There are periods of growth and development at different stages of childhood. During these periods, the organs, body systems and enzymes that handle drugs develop at different rates and respond to medicines differently. Therefore care should always be taken when prescribing for children.
It is often said that children are not 'mini-adults'. This is a useful reminder when prescribing that children need to be approached in their own specific way.
Choice of medicine
Compliance in children is influenced by the formulation, taste, appearance and ease of administration of a preparation. Although literature about non-compliance in children is limited, it is believed to be a widespread problem, similar to that reported in adults.
Parents are usually the best source of information on a child's capabilities. It is worth discussing the choice of preparation with both parent and child.
Sugar-free formulations should be used where available, and medicines needing injection should be avoided if possible. The oral route is the most convenient and preferable.
Liquid preparations may be necessary for younger children, although some may cope well with solid dosage forms while others might actually prefer them. To avoid dilution, oral syringes should be used for the administration of liquids.
Parents need to be discouraged from adding medicines to an infant feed. Interactions may occur with milk feeds in particular, and if the entire feed is not taken, a proportion of the dose will be lost.
Drug regimens should be tailored to a child's routine. In very young children who tend to sleep a lot and wake when hungry, it may not be possible to give the medicines as prescribed and so an alternative plan should be discussed with parents.
For older children, products that do not need to be administered during school hours are preferable, such as modified-release preparations or drugs with long half-lives. When administration during school hours is unavoidable, the school-time dose may be prescribed and supplied in a separate, labelled container.
The NSF for children offers guidance about administration of medicine in schools, but each school must develop its own guidelines for teachers and school nurses.
Most schools will request written permission from parents to administer the medicine and parents may wish to discuss this with their doctor. The use of individual healthcare plans, especially with chronic disease such as asthma, can be a useful way forward but these have yet to be widely implemented in practice.
Medicine is sometimes prescribed to children that has not been licensed for their use. When most medications are licensed or receive marketing authorisation they are only licensed for use in adults. This is most often because manufacturers do not test drug safety and efficacy in children.
Medicines prescribed for a child that are not licensed for that age group or for their health problem are referred to as 'off-label' while medicines that do not have a licence at all are 'unlicensed'.
One in 10 medicines prescribed in general practice are prescribed off licence and GPs are sometimes asked to continue prescribing unlicensed medicines started in hospital. The Medicines Act 1968 and European legislation make provision for doctors to use medicines in this manner.
However, individual prescribers are responsible for ensuring that there is adequate information to support the quality, efficacy, safety and intended use of a drug before prescribing it.
Children's doses should be calculated using weight, age or surface area and should not be extrapolated from adult doses. A paediatric formulary is the best resource to help make these calculations.
When writing a prescription for a child aged under 12 years of age, inclusion of their age is a legal requirement. It is good practice to state the patient's age in all prescriptions for children.
It is also important to state prescription strength. All prescriptions for children aged under 16 years or under 18 and in full-time education are exempt from charges.
Dr Whitburn is a GP registrar in Dursley, Gloucestershire
- Contact Sharon Pickett at GP Education at (020) 82674512 or email GPregistrar@haymarket.com
Prescribing for children
1. Taste, formulation, timing and method of administration should be considered.
2. Parents can be useful resources when making decisions about choice of medicine. Parent and child should be involved in medicine choice.
3. Use a paediatric formulary when calculating doses.
4. Avoid medicines that must be taken at school. If unavoidable have separate doses and liaise with school as needed. A care plan may be useful if medicine is needed as part of chronic disease management.
- British National Formulary for children www.bnfc.org/bnfc/
- The Royal College of Paediatrics and Child Health (RCPCH) www.rcpch.ac.uk
- The Neonatal and Paediatric Pharmacists Group (NPPG) www.nppg.scot.nhs.uk
- Medicines for Children - information for parents and carers from the Standing Medicines Committee of the RCPCH and the NPPG www.nppg.scot.nhs.uk/misc/parent_carer.DOC
- National Service Framework for Children, Young People & Maternity Services Standard 10: Medicines for Children and Young People, DoH and Department for Education and Skills, 2004.