Introduction to paediatric pharmaceutical care Workbook

Introduction to paediatric pharmaceutical care

Workbook

Introduction to paediatric pharmaceutical care Workbook

© 2009 NHS Education for Scotland (Pharmacy)

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1

Introduction to paediatric pharmaceutical care Workbook

How to use the workbookThis workbook is intended to be your own personal notebook, to assist your professional development by allowing you to:

record your responses to exercises in the blank spaces provided. •

apply your learning through completion of the four case studies on pages 31 to 42 •

compare your answers with suggested responses contained on pages 43 to 58•

make notes and jot down ideas and action points you may wish to follow up at a later •

stage on page 59.

When you see this pencil icon in the main text, you are being asked to complete an activity. As you turn to the relevant page in this workbook, you will find the activity repeated, with space below to record your response. We recommend that you complete the activities in the order and at the time they appear in the text, since they will help to reinforce the learning in that particular section. You will find that the practical tips and learning points from them will prove extremely valuable in your day to day work as they allow you the opportunity to put your learning into practice.

You may wish to then check your answers against the suggested responses, once you have completed all those in any given chapter, before moving on to study a new topic. Unless you are being asked to reflect on your own practice, you will find suggested responses to most of the activities.

The workbook provides a cross reference system of page numbering, to allow you to find suggested responses easily, and to return to the main text quickly.

Electronic workbook

The workbook is available to download from the NES website (www.nes.scot.nhs.uk/pharmacy). While we expect most learners to use the printed workbook, this provides additional flexibility for those who may prefer to utilise the electronic version.

Those pharmacists seeking accreditation may be required in the future to demonstrate that they have completed this knowledge based course by completing and submitting their workbook. The Word version would allow this to be done electronically.

Continuing professional development

There is a page set aside in this workbook (page 59) to allow you to note down any specific learning needs which arise as you study each chapter. Alternatively, you may opt to enter these directly onto your RPSGB personal CPD record. If you find the information you need is not in the text, you can use the further reading section listed in the Appendix on page 211, or check the websites listed in the package to see if there are any which might help you fill these gaps.

Multiple choice questionnaire

On completion of the package, the multiple choice questionnaire at the end of the workbook should then be attempted and returned to the NES Pharmacy Office, either as a paper copy or electronically via the NES pharmacy website (see page 60 for further details).

If you are not resident in Scotland, you should return your completed MCQ to the appropriate centre for pharmaceutical postgraduate education.

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Paediatric pharmaceutical care

1 Introduction Activity 1.1 (page 8)

List several examples from your practice where dosage dilemmas for children have arisen.

Write your answer here:

Activity 1.2 (page 10)

Now try the same calculation for an average six month old baby, Michael. Use the BNF-C to obtain the information you require.

Weight:

Surface area:

Using the percentage method:

Using the mg/kg method:

Suggested answer page 43

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2 Medication and its forms Activity 2.1 (page17)

Read the following paper: McIntyre, J., Conroy, S., Avery, A., Corns, H. and Choonara, I. (2000) ‘Unlicenced and off label prescribing of drugs in general practice’. Arch Dis Child 2000; 83: 498-501. To access the paper please go to www.nes.scot.nhs.uk/pharmacy/paediatrics/Start.pdf and click on ‘Activity Links’.

Audit your patient medication records for children over the past year. Identify 10 off-label and 4 unlicensed prescription drugs and list the potential risks and problems that arose for each one in relation to the patient or any of the health professionals

Child details (age, weight, etc.):

Drug:

Problems:


Drug:

Problems:


Drug:

Problems:


Drug:

Problems:

4



Drug:

Problems:


Drug:

Problems:


Drug:

Problems:


Drug:

Problems:


Drug:

Problems:

5



Drug:

Problems:


Drug:

Problems:


Drug:

Problems:


Drug:

Problems:


Drug:

Problems:

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Consider what medicines you would expect to see used for Susan, a three year old asthmatic girl weighing 12kg who has a chest infection.

Make recommendations for suitable preparations and dosages for her. Log whether the medicine is used in a licensed, unlicensed or off-label way.



Joseph, a 14 year old boy comes into the pharmacy with his mum. He has an allergy to benzoates and needs to have some OTC pain medicine. Find and list the relevant E numbers and chemical names for benzoates. List two suitable formulations, stocked in your pharmacy, that could be used for Joseph.



Caroline, a nine year old girl, is allergic to eggs, shellfish and nuts. Her mum brings a prescription for Naseptin cream for her to the pharmacy. Is this medicine okay for Caroline?


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3 Information sources Activity 3.1 (page 29)

What information sources would you look at to find the answer to the following question?

“A baby suffering from neonatal abstinence requires an oral morphine dose of 160 micrograms four times daily. This strength of morphine is not commercially available and it is going to take a week to obtain a supply from a ‘specials’ manufacturer. How do you prepare an extemporaneous morphine solution?”



What additional questions would you need answered if you were asked, “What is the dose of trimethoprim for a nine year-old boy?”



a What additional questions would you need answered if you were asked, “Can Exorex be used in pregnancy?”


b What information sources would you look at to find the answer to the following question? “Is metronidazole safe to take in pregnancy?”



What additional questions would you need answered in the following situation? A breastfeeding mother has been prescribed sertraline for post-natal depression. The baby is experiencing muscle spasms. Could this be related to the sertraline?


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Which oral vitamin K preparation is recommended for use in cholestasis of pregnancy?


4 Pregnancy and the first month of life


A pregnant woman who does not take milk or dairy products requires supplementation with calcium and vitamin D. Advise on a preparation suitable for her to use.



What problems may be seen in a baby where the mother has taken the following drugs late in pregnancy?

a Nitrofurantoin

b Ibuprofen


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A woman who is 24 weeks pregnant is seeking advice on treatment of constipation. She occasionally took senna tablets pre–pregnancy. Note down what further information you would need. What would you advise?



Read the CSM warning on sodium valproate. (Current Problems in Pharmacovigilance September 2003. (http://www.mhra.gov.uk/Publications/Safetyguidance/CurrentProblemsinPharmacovigilance/CON007449 To access the paper please go to www.nes.scot.nhs.uk/pharmacy/paediatrics/Start.pdf and click on ‘Activity Links’. How does this affect your practice? What steps do you need to take next? Record your plan and outcome.


Read NICE Guideline CG 45 Ante-natal and post-natal mental health: clinical management and service guidance. To access the paper please go to www.nes.scot.nhs.uk/pharmacy/paediatrics/Start.pdf and click on ‘Activity Links’. List three medicines suitable for use to treat depression during pregnancy. List one antidepressant medicine that should be avoided in pregnancy.


www.nes.scot.nhs.uk/pharmacy/paediatrics/Start.pdf

www.nes.scot.nhs.uk/pharmacy/paediatrics/Start.pdf

http://www.mhra.gov.uk/Publications/Safetyguidance/CurrentProblemsinPharmacovigilance/CON007449

http://www.mhra.gov.uk/Publications/Safetyguidance/CurrentProblemsinPharmacovigilance/CON007449

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Calculate the prophylactic dose of Sytron required for a premature baby born at 33 weeks gestation who is now 10 weeks old and currently weighs 3.85kg.



Mrs A. has epilepsy and is attending the pre-pregnancy clinic. She is currently on carbamazepine 400mg twice a day and lamotrigine 100mg twice a day.

a Discuss the problems with this drug regime in pregnancy and any treatment changes that may be considered.

Mrs A. has now had her baby and is still on the drug therapy above. She is breastfeeding and in need of contraception.

b What options are open to her?


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What information would you give a parent who is worried about their child receiving the MMR vaccine?


5 Childhood issues


Using the Green book, work out the current immunisation schedule from birth to the teenage years. It is available online at www.immunisation.nhs.uk (To access the paper please go to www.nes.scot.nhs.uk/pharmacy/paediatrics/ start.pdf and click on ‘Activity Links’)


http://www.nes.scot.nhs.uk/pharmacy/paediatrics/start.pdf

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Write a care plan for a school pupil with asthma. Choose a young patient on your PMR system, or one who has been admitted to your hospital ward. Once completed, discuss it with the pupil and their family/carers. You may wish to use the exemplar care plan. To access the paper please go to www.nes.scot.nhs.uk/pharmacy/paediatrics/Start.pdf and click on ‘Activity Links’.



Look at your PMRs for children who are on long-term medicines for chronic conditions. Make a list of the medicines which contain sugar and check with your wholesale supplier whether sugar-free alternatives are available for each of these medicines.


Contact your local school and ask for a copy of their policy on medicines. What issues does this policy raise for you when you supply medicines for children?


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The mother of a 10 year old claims that lactulose alone does not help his constipation. What would you recommend?


6 Constipation and diarrhoea


A prescription for a three-year-old is written as “Movicol 2 sachets daily”. What would you do?



Look at the rehydration solutions you have available in your pharmacy. List the contents in 1000ml of solution when made up as described and compare them.

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List the symptoms of dehydration that you may see in an infant or child.



Jennifer, a two year old girl has been unwell for two days with diarrhoea. Her mum asks what you would advise for her as she is now vomiting too. On questioning mum, you consider that Jennifer has gastroenteritis and is at risk of dehydration. How would you advise her?


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7 Asthma


Mrs A presents a prescription for a salbutamol inhaler for her eight year old son. You notice from the PMR that he received one six weeks ago. On asking Mrs A how often he uses it, she tells you he uses it most mornings on waking and also during sports at school. What would you recommend?



A four year-old girl was admitted to hospital with a severe asthma attack, her second in eight weeks. She needed nebulised salbutamol, oral prednisolone and intravenous aminophylline.

a What side effect is common to all three drugs and should be monitored for?

The child is to be discharged on salbutamol and beclometasone inhalers via a spacer. The beclometasone is an addition to therapy.

b What step of the BTS/SIGN guidelines is she now on?

c List three reasons why a spacer is recommended for use with a steroid MDI.

d What counselling points would you cover prior to discharge?

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8 Diabetes


What palatable liquid glucose sources might be used for children requiring an oral glucose tolerance test (OGTT)?



Using the BNF and other references, create a list of the various insulins (single and biphasic) available and their properties, particularly the length of action.


Diabetes UK has published a useful chart giving information about the types of insulin pens available in the UK. To access the paper please go to www.nes.scot.nhs.uk/pharmacy/paediatrics/Start.pdf and click on ‘Activity Links’ to familiarise yourself with the devices. Find out which devices children attending your hospital or community pharmacy use and why.

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a List what test strips, dipsticks or tablets are available on the drug tariff or in your hospital and what information they can provide.

b Check what meters are currently available (http://www.diabetes.org.uk. To access the link please go to www.nes.scot.nhs.uk/pharmacy/paediatrics/Start.pdf and click on ‘Activity Links’.) Review which ones are currently used by your patients or recommended by the local specialist service and why.

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9 EpilepsyActivity 9.1 (page110)

Using the BNF or BNF-C, list the antiepileptic drugs that are licensed for use in children. Of those, which are available in appropriate dosage forms?


Based on current recommendations, what is most appropriate AED for a four-year-old girl (16.8kg) with absence seizures? She is taking no other drug therapy and has no relevant medical history. What dose and formulation would be most appropriate?



Give four examples of drugs which can lower the seizure threshold and should be used with extreme caution in children with epilepsy.


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Consider the key pharmaceutical care issues in a child prescribed buccal or intranasal midazolam for the first time. What actions would you require to take for the following pharmaceutical care issues?

Pharmaceutical Care Plan

Issue Action Outcome

Verify dose correct and dose volume is practical for administration purposes.

Ensure patient’s carer understands how and when to administer the midazolam.

Ensure continuity of supply of midazolam.

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10 Pain and Sedation

Activity 10.1 (page 120) Find out and record which method of pain assessment is used in your hospital or in the community. In primary care settings you could ask the local pharmacy providing palliative care services or the district nurses.


Refer to standard reference sources such as the current edition of the British National Formulary for Children (BNF-C) and list the appropriate doses for the following analgesics in a six-year-old child.

paracetamol

ibuprofen

codeine

dihydrocodeine

morphine

diamorphine

diclofenac



Which of the following oral doses of paracetamol would be correctly prescribed for a six-year-old?

a 5mg/kg per dose 4 hourly – max 60mg/kg/24 hours

b 15mg/kg per dose 4 hourly – max 90mg/kg/24 hours

c 20mg/kg per dose 6 hourly – max 80mg/kg/24 hours


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Activity 10.4 (page 124) Work out the oral dose of morphine for acute pain in a six-year-old.


Activity 10.5 (page 125) A mother wants to buy ibuprofen for her five-year-old son who has just been discharged from hospital following surgery. He has been discharged on paracetamol liquid only and is still in pain. His dose is 180mg every 4-6 hours as required for pain. He has asthma and his mum says he weighs about 18kg. What action would you take and what counselling would you give?


Activity 10.6 (page 125) A ten-year-old girl is admitted to hospital after being involved in a road traffic accident. She has sustained multiple injuries including a fractured left femur. She has just returned from surgery after open reduction internal fixation to the left femur and her left arm has been placed in plaster. She is to be admitted to the children’s ward. She is distressed and appears to be in some degree of pain. What analgesia would you recommend in this child and how would you assess her pain control?


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Activity 10.7 (page 126) Compare the choice of sedatives used in hospital and community and consider why they differ. If applicable, find out which preparations are used in your hospital. Refer to the current edition of BNF-C for doses.


Activity 10.8 (page 127) A five-year-old boy is admitted to the paediatric intensive care unit with a suspected diagnosis of bacterial meningitis. He is currently intubated. A history was taken from his parents. They said he was well until a few hours previously when he suddenly started to complain of headaches and became confused and drowsy. His temperature was 40˚ C. He is not suitable for PCA and is receiving a morphine infusion of 20 micrograms/kg/hour. He is to start IV antibiotics with a plan for lumbar puncture and full blood count.

a Comment on his analgesic regime.

b How would you assess his pain control?

c What analgesia would you recommend for planned procedures?


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11 Childhood infectionsActivity 11.1 (page 136) Mrs A. brings her two year old daughter Lucy to your pharmacy asking for something to settle her. On questioning, she tells you that Lucy is very irritable, not feeding as normal and has a temperature. In addition a few days ago she had developed ‘cold’ symptoms. Lucy weighs 12kg.

a What do you advise?

Following consultation with her GP Mrs A. is advised to take her daughter to hospital for full assessment of symptoms. Whilst awaiting test results a provisional diagnosis of bacterial meningitis is made. It is decided to commence the infant on intravenous ceftriaxone.

b What is the rationale for using this antibiotic?

c What dose would you recommend the medical staff to prescribe? Are there any particular precautions regarding its administration?



a What agent is most commonly used for prophylaxis against respiratory syncytial virus (RSV) infection?

b Chemoprophylaxis is indicated for all close contacts of which meningeal pathogens?


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Activity 11.3 (page 141) What of the following statements about impetigo are true?

True False o o a Not a very contagious infection.

o o b Spontaneous cure can occur in 2-3 weeks.

o o c Oral antibiotics are the treatment of choice.


Activity 11.4 (page 142) What oral antibiotic therapy is advised in severe cases of otitis externa?


Activity 11.5 (page 145) a What is the most common pathogen that causes urinary tract infections (UTIs) in children?

b How long should a child be treated for a UTI that is not making them systemically unwell?


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Activity 11.6 (page 145) Mr C. has come to your pharmacy with his six year old son Tom. Tom has had coryzal symptoms for the last 4-5 days and now has a temperature of 38 degrees. Today he is ”breathing quicker” and seems miserable. Occasional coughing fits are not productive of any sputum.

a What are your initial thoughts and concerns?

b What advice do you offer Mr C?

c Tom is diagnosed as having a chest infection. What are the likely pathogens, taking into account Tom’s age, signs and symptoms?

d What antibiotic would you recommend as first line treatment and why?


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Activity 12.1 (page 152) Look up the signs and symptoms of Leigh’s disease on the website of NORD – the National Organization for Rare Disorders or the European Union sponsored Orpha.net (http://www.rarediseases.org or http://www.orpha.net). Go to the ‘Index of rare diseases’ and scroll down.

12 Metabolic disorders

Activity 12.2 (page 158) Mrs P presents a prescription for co-amoxiclav suspension for her 5 year old daughter who has a chest infection. She asks you to check the ingredients as her daughter has ‘PKU’.

a What is PKU?

b What excipients should be avoided in PKU?

c What would you recommend?


http://www.rarediseases.org

http://www.orpha.net

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Activity 12.3 (page 159) Can children with galactosaemia have medicines that contain sucrose? Give a reason for your answer.


Activity 12.4 (page 161) List the five enzymes involved in the urea cycle.


Check your dispensary stocks and list which liquid medicines contain aspartame.

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13 Adverse drug reactions

Activity 13.1 (page 166) From your own experience, give an example of a type A reaction and a type B reaction.

Activity 13.2 (page 169) List three predisposing factors to the development of an ADR.


Activity 13.3 (page 175) The CHM / MHRA updates health professionals about topical drug safety issues through its bulletin Drug Safety Update. This is issued monthly and can be accessed via the MHRA website. It alerts health professionals to problems with medicines and provides advice on the ways medicines may be used more safely.

Copies of current and previous editions can be found on the MHRA website http://www.mhra.gov.uk. Take a look at this website now and find the article on:

Over-the-counter cough and cold medicines in children

Note the main issues discussed in this article.

Activity 13.4 (page 176) Consider each of the following suspect case scenarios. Should a yellow card be completed?

yes no o o a Eczematous skin rash in a nine year old child after three weeks’ treatment with etanercept o o b 15 year old girl became pregnant despite using emergency contraceptive (Levonelle).

o o c Baby born at 36 weeks gestation to mother who had taken venlafaxine throughout pregnancy. Baby had signs of agitation and poor feeding.

o o d Child prescribed lacosamide for seizures complains of mood swings and irritability

o o e Interstitial nephritis develops in a child shortly after completing a course of amoxicillin


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14 Nutrition

Activity 14.1 (page 180) Calculate the daily fluid maintenance requirement of a 23kg child.


Activity 14.2 (page 182) How would you advise a new mother who is struggling to breastfeed her baby?


Activity 14.3 (page 187) Calculate the basic daily nutritional requirements of an 8.5kg infant on day three of parenteral nutrition following abdominal surgery.


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Activity 14.4 (page 188) The same 8.5 kg infant as in the activity 14.3 develops a serious wound infection two days later and an abdominal surgical drain shows increased losses. Indicate how these factors might influence the infant’s daily nutritional requirements in terms of the following constituents:

Fluid requirement: o increased

o no change

o decreased

Energy requirement: (glucose & fat) o increased

o no change

o decreased

Electrolytes: sodium requirement o increased

o no change

o decreased

Electrolytes: potassium requirement o increased

o no change

o decreased


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Case Study: Josh

In general, what do you make of this baby’s condition?

What further information do you need?

Current medication:

Abidec vitamin drops 0.6ml once daily

Folic Acid Liquid 50 micrograms (0.1ml) once daily

Sytron 0.5ml twice daily

Infant Gaviscon 1 dose with feeds

Carobel 1 scoop/100ml milk

Ranitidine liquid 3mg (0.2ml) three times daily

Nystatin liquid 100 000units/ml 1ml four times daily

Nystatin cream topically sparingly four times daily with nappy changes.

Josh was born prematurely at 32/40 weeks gestation with recurrent apnoeas and significant GORD. He was discharged from hospital on the above medicines. Mum has handed in a prescription for all of the medicines except the nystatin preparations. She has given up breastfeeding and is asking about how to give the medicines – Carobel and Gaviscon in particular. Mum is anxious as she has received a card for the baby’s vaccinations and wants information about this too.

Sex: Male

Age: born at 32/40 weeks gestation.

Now seven weeks old (39 weeks corrected gestation age).

Birth weight: 1.82kg

Current weight: 3.3kg

Height: not known.

Test results: nil of note.

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What educational advice would you give this parent?

What complicating factors may be present?


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Case Study: Debbie

A What step of the Asthma BTS/SIGN Guidelines is Debbie on?

B What comments do you have on the GP’s observations of Debbie?

C After admission to hospital, what action would be appropriate to manage Debbie’s symptoms?

D What complicating factors may be present?

Current medication:

Budesonide Turbohaler 200micrograms 1 puff twice daily

Salbutamol Accuhaler 200micrograms 1 puff when required for wheeze

Debbie was taken to her GP with increasing shortness of breath and wheeze for last 3 days and a productive cough with yellow sputum. Six months ago, she was diagnosed with asthma.

The GP’s observations were:

PEFR 60-67 (normally 150-160)•

increased respiratory rate•

tachycardia•

difficulty completing sentences•

temp 38.8˚C.•

Sex: Female

Age: 5 years.

Weight: 17.2kg

Height: 1.1m

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F What signs would indicate that Debbie is responding to treatment?

G Since Debbie’s PEFR has increased to 122, she is discharged four days after admission. What medication should Debbie receive on discharge?

H Debbie is due to receive her pre-school immunisations next week. Her mum asks if it is alright for her to receive them?

E Debbie is prescribed: Nebulised salbutamol 2.5mg 1-2 hourly as required Prednisolone 40mg once daily (oral) Cefotaxime 900mg twice daily (intravenous) Paracetamol 250mg 4-6 hourly as required for pain/fever

Progress report: Debbie responded well to treatment. Intravenous antibiotics were discontinued and oral treatment initiated. Prednisolone was discontinued after 3 days. As Debbie was responding well to treatment, arrangements were made for discharge.

What oral antibiotic(s) would be appropriate for Debbie?

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I Now complete a self management and pharmaceutical care plan in light of what you know about Debbie. One issue and action has been entered already to illustrate how your plan should look.


Issue Ensure appropriate management of acute asthma

Action Compare Debbie’s management against BTS/SIGN Guidelines

Outcome According to BTS/SIGN guidelines, Debbie has acute severe asthma.

Management is in accordance with the guidelines except that they recommend that inhaled steroids are continued during oral treatment to improve compliance and Debbie’s budesonide has been discontinued.


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Case Study: Sarah

A Sarah seems to be showing symptoms of hyperammonaemia. What factors may have caused her ammonia level to rise?

B There are probably several questions you would like to ask about Sarah and her current treatment. Note them down.

C Mum ensures that she is responsible for Sarah’s medicines, and is adamant that she takes them daily as instructed. How would you check compliance?

Sarah has been admitted to hospital complaining of drowsiness and vomiting. Her ammonia level was 432mmol/l (usual level <70mmol/l).

Her past medical history showed a urea cycle disorder – OTC Heterozygote (Ornithine Transcarbamylase) Deficiency. She has moderate learning difficulties, delayed development and a reduced concentration span. There were three admissions to hospital in the previous three weeks.

Current drug treatment:

Sodium phenylbutyrate 250mg/ml, 13mls tds

L-arginine 10% w/v, 7mls tds. Current dietary restrictions:

Protein restricted, with a calorie supplement.

Sex: Female

Age: 10 years.

Weight: 32kg

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D This is a difficult situation as essentially it is Mum who is not complying. Discuss the ethical issues. How could you use this information constructively?

E Sarah is admitted from A&E to one of the acute paediatric medical wards, as her ammonia level is >250mmol/l. What treatment would you expect to be initiated to manage this acute phase?

F Four hours later Sarah’s ammonia level was re-checked. Ammonia level = 210 mmol/l. As it is still > 200 mmol/l what might you suggest to reduce it?

G Four hours later the ammonia was re-checked and was down to 96 mmol/l. Sarah seems brighter and has not vomited since admission to the ward. The medical staff decide to stop her IV infusions and want to see if she can tolerate her oral medicines before discharge. Unfortunately her L-arginine has expired. The dispensary is very busy and it would take at least three hours for the extemporaneous liquid to be dispensed. What other options would you suggest as the pharmacy only keeps 500mg tablets and the 60% w/v ampoules for injection?

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K You receive an outpatient prescription for Sarah in the dispensary for her new preparations, Sodium phenylbutyrate, one yellow and one white scoop (3.85g) qds, and L-arginine 500mg tabs, 2 tabs tds. What might you consider doing to improve her compliance?

H If Sarah is usually on L-arginine 10% w/v 7mls tds, what would be the equivalent volume of the 60% solution for injection, or the nearest number of tablets that you would suggest to the medical staff?

i Mum insists that Sarah won’t take tablets and the injection is prescribed. On discharge the sodium phenylbutyrate is increased to 500mg/kg/day, and the L-arginine to 100mg/kg/day as she has grown. Sarah was followed up at an outpatient appointment two weeks after discharge to check her ammonia level and to discuss her multiple recent admissions. Her ammonia level was high again. After some negotiation, Mum agrees to try Sarah on L-arginine tablets and sodium phenylbutyrate granules. Why are the granules a better choice of product?

J At the appointment the consultant is addressing many problems. Do you think the main problem is concordance or compliance?

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L What is the licensed status of the new preparations? How would you check the licensed status of the products, and obtain further information? Discuss how you would source these products?

M What potential problems are posed in the use of unlicensed medicines?

N Four days after commencing on the new products Sarah is refusing to take the sodium phenylbutyrate granules. (One yellow (medium) scoop = 2.9g, and one white (small) scoop = 0.95g, therefore 3.85g qds) The community pharmacist phones you for advice, as Mum wants her previous extemporaneous liquid dispensed. Should she increase the ‘old’ dose (13mls tds 250mg/ml)? What would you suggest?

O What would be the ‘new’ dose of the 250mg/ml sodium phenylbutyrate liquid?


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Case Study: Katie

A What is your general opinion of Katie, given the test results shown here ?

Katie was brought to the accident and emergency department. She was vomiting and complaining of abdominal pain. She also had a headache.

Past medical history:

Congenital adrenal hyperplasia

Recurrent urinary tract infections

Reflux nephropathy

Enuresis

Test results:

Urea (3.3-6.0 mmol/l) = 8.2

Sodium (135-145mmol/l) = 145

Potassium (3.5-5.0mmol/l) = 4.2

Current medication:

Fludrocortisone 100micrograms in the morning and 50micrograms at night

Prednisolone 1.5mg twice daily

Trimethoprim 100mg at night

First impressions:

Katie was diagnosed with acute appendicitis and admitted to the Surgical Ward with a view to proceeding to theatre for an appendectomy.

Sex: Female

Age: 15 years.

Weight: 42kg

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B You would probably like to find answers to several questions regarding Katie’s current treatment. Note these here.

C It is planned that Katie will undergo a surgical procedure. What changes, if any, would you recommend be made to her medication and what monitoring should be undertaken postoperatively?


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D Now complete the Pharmaceutical Care Plan in light of what you know about Katie




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Suggested answers 1. Introduction Activity 1.2 (page 2) Michael is six months old. He weighs 7.7kg and has a body surface area of 0.4 metres squared. Percentage method: Dose is 0.227 x 800 = 181.6mg. Use 180mg = 4.5ml of 200mg/5ml susp Mg/kg method: Dose is 11.4 x 7.7kg = 87.78mg. Use 88mg = 2.2ml of 200mg/5ml susp

2. Medication and its forms


Beclometasone inhaler via volumatic and mask. Dose: 100 microgram bd (licensed). •

Salbutamol inhaler via volumatic and mask. Dose: up to 10 puffs 4 hourly prn for wheeze (off label dose – •

licensed maximum is 8 puffs per day.

Benzylpenicillin. Dose: 300mg (25mg/kg/dose) qds IV bolus (licensed). •

Followed when improved by:

Amoxicillin syrup (125mg/5ml). Dose: 5ml tds to complete 7 day course in total (licensed). •

Paracetamol syrup (120mg/5ml). Dose: 180mg (15mg/kg/dose) 4 hourly prn for pyrexia/pain, •

max qds (licensed).

Ibuprofen syrup (100mg/5ml). Dose: 60mg 6 hourly prn for pyrexia/pain (licensed). •


The following E numbers relate to benzoates:

E210 Benzoic acid

E211 Sodium benzoate

E212 Potassium benzoate

E213 Calcium benzoate

E214 Ethyl hydroxybenzoate

E215 Sodium ethyl para-hydroxybenzoate

E216 Propyl hydroxybenzoate

E217 Sodium propylhydroxybenzoate

E218 Methyl hydroxybenzoate

E219 Sodium methylhydroxybenzoate


Naseptin cream is not suitable as it contains nut oil. An alternative is Bactroban nasal ointment. Counsel also on frequency of use. Naseptin requires four times a day application whereas Bactroban only requires 2-3 times daily.

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3. Information sources


Formulation in Pharmacy Practice• (Woods)Pediatric Drug Formulations• (Nahata)UK Formulary of Extemporaneous Preparations• St Mary’s Pharmaceutical UnitHandbook of Pharmaceutical Excipients•


What is the indication for trimethoprim?•

What is the approximate weight of the child?•

Is the child taking any other medicines?•

Does the child have any other significant medical history?•

Does the child prefer to take liquid or tablets? •

Activity 3.3a (page 7)

Is this a general enquiry or patient specific?•

How many weeks pregnant is woman?•

What is the indication for Exorex?•

Where will the Exorex be applied, what is the size of the area and how often will it be applied?•

Has woman already used Exorex during pregnancy?•

Have any other medicines been tried for this indication? Give details.•

Any medical problems during her pregnancy?•

Is this her 1st pregnancy? If not, did she have any problems in previous pregnancies and were the babies healthy?•

Is there a family history of malformations or recurrent abortions?•

Any significant medical history?•

Any significant drug history? •

Activity 3.3b (page 7)

BNF (Appendix 4)•

Medicines for Children•

Drugs in Pregnancy and Lactation• (Briggs)Therapeutics in Pregnancy and Lactation• (Lee)www.spib.axl.co.uk•

The National Teratology Information Service may also provide useful information.

BNF and Medicines for Children have very limited information on medicines use in pregnancy but are the most likely reference sources to be held in a community pharmacy. To provide an accurate answer more specialist reference sources such as the three listed above should be used.


What age is the baby?•

Did the baby have any problems at birth e.g. pre-term?•

What dose of sertraline is mum taking?•

How long has she been taking sertraline?•

When did the muscle spasms start in relation to mum commencing sertraline?•

Does the baby have any medical problems?•

Is the baby on any medication?•

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4. Pregnancy and the first month of life Activity 4.1 (page 8)

Water soluble form of vitamin K i.e. menadiol as its absorption is not dependent on bile acid.


Calceos has 500mg calcium plus 10 micrograms colecalciferol and Adcal-D3 has 600mg calcium plus 10 micrograms of colecalciferol (source: BNF).


Nitrofurantoin – possibility of haemolytic anaemia in the newborn infant due to immature erythrocyte enzyme systems.


Ibuprofen – may prolong labour and increase neonatal bleeding. May result in premature closure of ductus anteriosus.


It is best to use a non-stimulant laxative such as ispaghula husk or lactulose. Advise to increase fibre in diet, fluid intake and light exercise. A faecal softener such as docusate sodium could be considered.


The following antidepressants have not been shown to be teratogenic – tricyclics, fluoxetine (licensed), paroxetine, sertraline, citalopram, fluvoxamine. There is most experience with tricyclics but data is increasing all the time with SSRIs. Reboxetine or MAOIs should be avoided in pregnancy.


Try monotherapy if it will control epilepsy. Carbamazepine has been associated with congenital abnormalities. Lamotrigine is the favoured drug but it is relatively new and the true incidence of any problems associated with this medicine isn’t known. It is important that the regimen controls the epilepsy.


Normally, if breastfeeding, a progesterone contraceptive would be chosen but this is not suitable as she is on an enzyme inducing drug. Combined oral contraceptives reduce milk production, so a barrier method of contraception is recommended.

Activity 4.8 (page10)

Dose requirement is 1-2mg/day of iron. For a 3.85kg baby between 0.7-1.4ml per day is needed. As a rough guide, 0.2ml/kg to the nearest 0.1ml would be given, i.e. 0.8ml sytron. Some baby units use a fixed dose.

5. Childhood issues Activity 5.1 (page 11)

You should ask what specific concerns the parent has about MMR so that you can address these issues. It may be useful to find out where they have obtained their information from. They may have obtained information from non medical sites on the Internet in which case you can direct them to suitable sites. The website, www.immunisation.nhs.uk/vaccines/MMR, is useful, provides information on the diseases and has details of all the research that has been carried out on MMR.

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You should give information about the diseases and the risks of not vaccinating their child. Explain that these diseases are rare in this country because of the immunisation programme, but still present in other parts of the world. Infection with these diseases produces illnesses of varying severity lasting between 2-10 days. They can also be associated with serious complications including death. Rubella is harmful to an unborn baby.

You should outline that although there was research published linking MMR vaccination with autism and bowel disorders, there have been many more studies which have not found any link. Remind them that MMR is endorsed by many independent organisations such as the Royal College of Paediatrics and Child Health.

There are information leaflets on MMR available which you can give to parents.


The current immunisation schedule can be found in the BNF or on www.immunisation.nhs.uk. The website would have any changes made to the schedule since the publication of the BNF.


Policies will vary from school to school and also in the amount of detail that is given. It is recommended that all medication for children is appropriately labelled. This may require you to dispense a quantity of medication into a separate container for school use or to dispense an additional prescription, e.g. additional inhaler for school use. Where appropriate you can advise on when to take doses to avoid the need to take medication to school.


The care plan should include the following information:

Child’s details, e.g. name, date of birth.•

Explanation of asthma and description of symptoms and an indication of severity of the condition in the individual child.•

Medication – for asthmatics, the only medication they should require at school is their reliever inhaler, i.e. short-acting •

beta2 agonist. The name of the medicine (generic and trade name where appropriate), the strength of the inhaler, the type of inhaler and any device used should be written on the care plan.Dose – the number of puffs to take and when to take them. Some children may need to take their inhaler prior to exercise •

and this should be recorded on the care plan. There may need to be a reference to multidosing (i.e. up to 10 puffs per dose) should the individual child require this.Whether the child has their own inhaler or, if not, where it is kept.•

Whether the child is able to administer the medication themselves or requires assistance.•

Treatment of acute attack and emergency contact details. •

6. Constipation and diarrhoea


Movicol Paediatric Plain is the next line of treatment.


You need to confirm the preparation required with the prescriber since the recommended product for this child would be Movicol Paediatric Plain sachets.


GES solution offered as frequent sips. To contact GP if no improvement by next morning.


Dry or sticky mouth.•

Sunken eyes.•

Low or no urine output, concentrated urine appears dark yellow.•

No tear production.•

Sunken fontanelles• † (the soft spot on the top of the head) in an infant.Lethargic or comatose (with severe dehydration). •

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Activity 7.2 (page 15)Could recommend child uses salbutamol inhaler prior to exercise. However exercise induced asthma is usually an indicator •

of poor control of asthma.May be some trigger in the house which could be removed e.g. pets in bedroom, smoker in house etc.•

Inhaler technique should be checked.•

Short acting beta• 2 agonists should only be used intermittently – regular use indicates poor control.Should advise Mrs A to take child to GP or nurse/pharmacist-led asthma clinic for review.•


Hypokalaemia which can be increased in hypoxia, a common feature of acute severe asthma.


Step 2.

Activity 7.3c (page 15)

Reduced side effects.•

Greater deposition in lungs.•

No co-ordination of actuation and inhalation required.•

Activity 7.3d (page 15)

You should include the following:

salbutamol to be used as required (not regularly)•

beclometasone to be used regularly•

mouth should be rinsed afterwards•

ensure correct use of spacer device. •

8. Diabetes


The following could be used as sources of glucose for an OGTT: 23g Hypostop Gel contains 9.2g glucose; 200ml milk contains 10g glucose; lucozade contains 10g glucose; 90ml Coca-Cola contains 10g glucose; 15ml Ribena original contains 10g glucose. See the BNF for further information on oral glucose tolerance tests. You would require to calculate the appropriate volume.

9. Epilepsy


Sodium valproate, lamotrigine and ethosuximide are recommended in the SIGN guidelines as the most appropriate agents for the management of absence seizures. Monotherapy is preferred – therefore only one agent should be started initially.

Ethosuximide is less commonly used and is normally reserved for cases that are not adequately controlled by sodium valproate or lamotrigine. Lamotrigine is not licensed for use as monotherapy in children under 12 years (although it is used) therefore sodium valproate would be the most appropriate agent to start with. Medicines for Children recommends a starting dose of 12.5mg/kg twice daily which equates to 210mg for this patient. Sodium valproate is available in liquid form (200mg/5ml). For administration purposes a dose of 200mg would be appropriate.


Examples include sedatives such as haloperidol, antimalarials such as chloroquine, quinolone antibiotics (although rarely used in children) and anthelmintics such as piperazine.

7. Asthma

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Verify dose correct and dose volume is practical for administration purposes.

Check dose prescribed (child’s age and weight required) against recommendations in Medicines for Children.

Calculate volume for administration.

If impractical contact prescriber to discuss dose adjustment

Ensure patient’s carer understands how and when to administer the midazolam.

Discuss with patient’s carer.

Explain how and when to administer midazolam if required.

Provide written information if available.

Ensure continuity of supply of midazolam. Hospital Pharmacist should communicate with GP surgery and patient’s community pharmacy and advise on:

- supplier

- strength

- delivery/order times

- general info on medicine if required.

Advise patient and carer that medicine has to be ordered specially and that prescriptions should be requested in plenty of time to ensure they do not run out.

10. Pain and sedation Activity 10.2 (page 20)

Paracetamol PO 15mg/kg 4-6 hourly (maximum 90mg/kg in 24 hours)

Ibuprofen PO 100mg 6-8 hourly (maximum 20mg/kg in 24 hours)

Diclofenac PO 1mg/kg TID

Diclofenac IV infusion 300 micrograms – 1mg/kg once or twice daily

Codeine PO 0.5 to 1mg/kg 4-6 hourly

Dihydrocodeine PO 0.5 to 1mg /kg 4-6 hourly

Morphine IV bolus 100-200 micrograms/kg up to 6 times in 24 hours

Diamorphine IV bolus 75-100 micrograms/kg 4 hourly as necessary

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B is the correct answer: the dose you would give in most clinical situations is 15mg/kg per dose 4 hourly – max. 90mg/kg per 24 hours.


The oral morphine dose is 200-500 micrograms/kg. For a child weighing 20kg the dose would be 4mg to 10mg.


The mother would be advised that the dose of paracetamol could be increased and ibuprofen (if not contra-indicated) could be purchased for the child.

The paracetamol dose could be increased to 15mg/kg 4 hourly.

Ibuprofen can be given provided that the child has not previously shown hypersensitivity to aspirin or any NSAID. NSAIDs are contra-indicated if aspirin or any NSAID has precipitated attacks of asthma, although this occurs rarely in children.

Counselling:

The increased dose of paracetamol should be discussed and the dose rounded down to a suitable amount for the mother to measure. The importance of not exceeding the maximum dose should be emphasised and that no other products containing paracetamol should be given concomitantly. The doses could be given regularly for a few days to prevent the child experiencing breakthrough pain. The frequency could then be reduced to PRN.

If ibuprofen is not contra-indicated, then it should be explained that it can be given along with the paracetamol, again at the stated dose and dosage interval.

If the child still experiences pain after increasing the paracetamol dose and adding in ibuprofen, then the mother should go back to the GP who could prescribe other analgesia.


Morphine IV is the most commonly used opioid post operatively. Morphine intravenously by PCA would be an option for children 5 years and over. In PCA for children a background infusion of usually 4 micrograms/kg/hour is used. A lockout interval is set at 5 to 15 minutes. A loading dose is often given, usually in theatre, of 100-200 micrograms/kg over 30 minutes. Additional doses of 20 micrograms/kg can be triggered by the child. NCA would be an option if there was not time to explain to her about PCA or she did not understand how to operate it. In NCA a background infusion is used and extra doses can be triggered by the nurse. The background infusion is usually higher at about 20 micrograms/kg/hour and the lockout time is longer.

As the pain reduces and as she is able to tolerate oral medication, paracetamol and ibuprofen can be given. This can reduce the amount of opioid required.

Older children can self report about their pain and can use pain tools. A visual analog scale can be used with children > 7 years. A ‘Faces scale’ could also be used. Pain can be discussed with the child and her parents. The nursing staff can assess the pain by observation of behaviour. Physiological measures (heart rate, BP, respiratory rate) would be monitored but these can reflect stress rather than pain.


Midazolam is often the drug of choice for paediatric sedation in hospital. It can be used as part of premedication and for sedation prior to procedures lasting < 20 minutes. It has anxiolytic properties and has a quick onset of action. It would not be used for sedation in the community due to its short duration of action and its potential adverse effects. Children can experience severe disinhibition and restlessness. In general benzodiazepines would not be chosen as sedatives in community. They can be effective initially, but tolerance can develop and many have unacceptable side effects such as respiratory depression and dependence.

Chloral hydrate is sometimes used in the hospital prior to procedures lasting 20-60 minutes. The quality and duration of sedation can be variable and it has no anxiolytic effects. It may be prescribed for long-term and night sedation in the hospital and community but triclofos is preferred as it produces less gastric irritation.

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Children given sedatives in hospital have to be closely monitored for at least one hour afterwards with means to resuscitation available.

Alimemazine could be used as premedication in the hospital but does not have anxiolytic effects. It can cause increased crying and struggling. It may be seen in the community when prescribed for night sedation.


Appropriate analgesia and sedation are important for this child. For severe and predictable pain an opioid infusion is required. Morphine is the opioid of choice and the dosage range for continuous IV infusion is 20 to 30 micrograms/kg/hour for children > 6 months. The IV route is most common although the subcutaneous route has been used Fentanyl infusion would be an alternative.

He should be observed closely for side effects. At least hourly readings of pulse rate, respiratory rate, sedation score and pain score are required.

Midazolam infusion may be required. Low doses may be adequate as he is already receiving an opiate. Metabolites of morphine can accumulate and lead to sedative effects. Midazolam and opioids are synergistic.


His pain control could be assessed by self reporting using a ‘Faces scale’. Behavioural assessment (crying, irritability) may also be useful as would observation/assessment by the parents and nurses. Physiological measures (BP, heart rate, respiratory rate) would be recorded but these can also reflect stress rather than pain.


For planned procedures IV boluses of morphine can be given. Midazolam IV boluses could also be given if required.

11. Childhood infections Activity 11.1a (page 23) The classic symptoms of meningitis – severe headache, neck rigidity, photophobia and other CNS manifestations are not always present in younger patients. Generally the younger the patient, the more atypical are the signs and symptoms, making diagnosis difficult. A non-blanching purpuric rash† can occur as a result of meningeal septicaemia. This is a highly characteristic sign of meningitis. Although this infant does not have a purpuric rash, she needs to be urgently referred to her GP for assessment of symptoms. If a non-blanching rash is present urgent referral to hospital is necessary.


Ceftriaxone is a 3rd generation cephalosporin antibiotic. It is commonly used for empirical treatment of bacterial meningitis prior to availability of culture results and antibiotic sensitivities.

Ceftriaxone (and cefotaxime) has good penetration into the CSF with good activity against common meningeal pathogens. In addition, it has an excellent safety record and resistance to penicillin antibiotics is increasing worldwide, reducing their suitability for empirical treatment.


High doses are recommended in the treatment of bacterial meningitis (including cases where meningitis is suspected).

The current dose indicated is 80mg/kg (Medicines for Children). At 12kg, the dose would be 960mg once daily.

Doses greater than 50mg/kg should be infused over 30 mins in a suitable diluent.


The agent most commonly used is palivizumab.


Haemophilus infuenza and Neisseria meningitides.

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a False – it is a very contagious infection.

b True – spontaneous cure can occur in 2-3 weeks.

c True – oral antibiotics are the treatment of choice.


Flucloxacillin (erythromycin if penicillin allergic). Activity 11.5a (page 24) Escherica coli.


A child should be treated for 5-7 days. Longer courses are recommended if systemically unwell and the use of shorter courses is not advocated in children.


It sounds as though an upper respiratory tract infection has moved down into Tom’s chest. The increased temperature and respiratory rate are consistent with a bacterial infection, as is Tom’s age.


Mr C should be advised to take Tom to the GP as soon as possible.


At Tom’s age, the most likely pathogens are S. pneumoniae and/or Mycoplasma pneumonia.

Activity 11.6d (page 25)

Broad spectrum cover with a penicillin or cephalosporin would be an appropriate first choice, augmented with a macrolide antibiotic, e.g. azithromycin if Tom fails to respond or if a Mycoplasma infection is suspected.

12. Metabolic disorders Activity 12.2a (page 26)

Phenylketonuria is an inborn error of metabolism involving a defect in the conversion of phenylalanine to tyrosine.


Patients should restrict the intake of phenylalanine, including the artificial sweetener, aspartame (L-aspartylphenylalanine).


Co-amoxiclav suspension contains aspartame and should be avoided.You should discuss with Mrs P and try to contact the GP/Doctor to suggest an alternative formulation (for example dispersible tablets) or alternative antibiotic.


Yes. They are unable to metabolise galactose. Sucrose is a disaccharide made up of glucose plus fructose. These children should avoid medicines containing the disaccharide lactose which is made up of glucose plus galactose.


Carbamylphosphate synthetase, ornithine transcarbamylase, arginase, arginosuccinate synthetase, arginosuccinate lyase.

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13. Adverse drug reactions Activity 13.2 (page 28)

You may have included any three of the following:

Extremes of age, multiple drug therapy, compromised or reduced organ function, intercurrent disease (e.g. HIV infection), serious illness (e.g. ICU patients), previous history of ADRs, race/genetics (e.g. G6PD deficiency), gender.


a Yes – report all paediatric reactions. In children, however, the reporting of all suspected reactions is strongly encouraged, even if the black triangle symbol has been removed, because experience in children may still be limited.

b Yes – therapeutic failure can be reported via yellow card scheme

c Yes – serious (possible neonatal withdrawal syndrome)

d Yes – black triangle drug and suspected reaction in a child

e Yes – serious suspected reaction in a child.

14. Nutrition Activity 14.1 (page 29)

1500ml + (3 x 20) = 1560ml

or

1500ml + (3 x 25) = 1575ml

Either answer is acceptable.


If it appears that the main difficulty is with coping with the demands or with social acceptance then referring her to her health visitor/midwife or a breastfeeding support group would be appropriate.

If the problem is related to having sore nipples and her symptoms are suggestive of thrush then referral to her GP would be appropriate. If confirmed then both she and the baby would require to be treated. Similarly if her symptoms are suggestive of mastitis then initial support from the midwife/health visitor relating to positioning of the baby for feeeding would be appropriate. If this has not helped then refer mum to her GP as she may require antibiotics.


Fluid = 100ml/kg x 8.5kg = 850ml

Nitrogen = 0.32g/kg x 8.5kg = 2.7g

Glucose = 16g/kg x 8.5kg = 136g

Fat = 3g/kg x 8.5kg = 25 g

Sodium = 3mmol/kg x 8.5kg = 25mmol

Potassium = 2.5mmol/kg x 8.5kg = 21mmol

Calcium = 0.8mmol/kg x 8.5kg = 6.8mmol

Phosphate = 0.8mmol/kg x 8.5kg = 6.8mmol

Magnesium = 0.2mmol/kg x 8.5kg = 1.7mmol

53



Fluid (increased requirement)

Energy (increased requirement)

Electrolytes (sodium and potassium – increased requirement).

Case study – Josh (page 31)

Summary

This is a typical case of some of the medical and pharmaceutical problems seen in a baby born too soon. The main issues are summarised below and presented as a pharmaceutical care plan.

This new parent needs advice on the baby’s drug regime and reassurance regarding immunisations.

Nutrition

Josh is thriving despite his severe GORD and is growing appropriately. Mum needs reassurance regarding his vitamins and supplements and medicines for GORD and her decision to give up breastfeeding.

Candida Infection

The infection has now cleared up. Mum should be counselled regarding signs and symptoms of thrush infection in a baby in case of a recurrence. Reinforce need for sterilisation and hygiene issues to reduce risk of infection.

Immunisations

Mum needs advice on the immunisations in use and on the importance of immunising Josh, particularly since he was born prematurely. It is important that he is immunised at two months of age and not waiting until his age is corrected to when he was due and then adding two months (nearly 4 months of age).

Remember to advise on paracetamol cover for immunisations and advise on a suitable dose for Josh.



Verify mum’s comprehension Assess mum’s understanding of Josh’s condition, interpretation of symptoms and goals of treatment

Mum’s main concern is that Josh is still being a bit sick. Reassured.

Verify mum’s compliance with treatment for baby

Check with mum for any evidence of problems in maintaining compliance with medicine regimens

Josh is still a small baby with no set sleep pattern. Discussed with mum when medicines could be given over the day.

Modify treatment plan/drug choice

Discuss how Carobel and Gaviscon sachets should be administered now that mum is no longer breastfeeding.

Advised re adding medicines immediately before feeding and not when the bottles for that day are made. No longer need to be made into paste. Check mum’s sterilising technique.

Verify mum’s understanding of primary immunisation schedule

Test mum’s understanding of the immunisation schedule and importance of Josh being immunised on time and completing the course. Reinforce importance of paracetamol cover and advise suitable dose for Josh.

Advise on dose and counsel on use of oral dose syringe.

Modify mum’s expectations Discuss with mum that duration of treatment for medicines depends on Josh’s condition.

For follow up at next visit.

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Case study – Debbie (page 33)

A

Debbie’s current medication indicates that she is at step 2 of the Asthma BTS/SIGN Guidelines.

B

Debbie’s symptoms suggest an acute severe asthma exacerbation.

C

The BTS/SIGN Guidelines advise that children over 2 years be managed as follows:

If SpO2 <92% give oxygen.•

Frequent nebulised beta• 2 agonists. If symptoms are refractory to initial beta2 agonist treatment, add nebulised ipratropium bromide.

Oral corticosteroids.•

Aminophyline should be considered in an intensive care or high dependency unit setting. Some units may commence •

aminophyline if the child fails to respond to nebulised beta2 agonist and ipratropium bromide.

Antibiotics are not given routinely in acute severe asthma unless signs of infection are present.•

D

Debbie also has a temperature and a productive cough with yellow sputum. This suggests community-acquired pneumonia (CAP) requiring treatment with antibiotics.

E

Amoxicillin 125mg three times daily for 6 days

Clarithromycin 125mg twice daily for 6 days

F

Debbie’s temperature, white cell count and respiratory rate all returning to normal indicate she is responding to treatment.

G

Her discharge medications are:

Beclomethasone MDI 200micrograms 1 puff twice daily

Salbutamol MDI 100micrograms 10 puffs 4-6 hourly (to be reduced as per self management plan)

H

Mum should be advised that because prednisolone course was less than seven days and acute illness and fever have resolved there is no contraindication to immunisations.

55




Ensure appropriate management of acute asthma.

Compare Debbie’s management against BTS/SIGN Guidelines.

According to BTS/SIGN guidelines, Debbie has acute severe asthma.

Management is in accordance with the guidelines except that they recommend that inhaled steroids are continued during oral treatment to improve compliance and Debbie’s budesonide has been discontinued.

Ensure appropriate management of CAP.

Compare Debbie’s management against BTS Guidelines.

Cefotaxime is an appropriate antibiotic for management of CAP in this patient.

Amoxycillin and clarithromycin are appropriate oral alternatives and have been prescribed for an appropriate treatment duration.

Ensure all drug doses prescribed are appropriate for age and weight

Calculate recommended drug doses using a recognised drug fromulary and compare to prescribed doses

All doses prescribed at appropriate doses.

Ensure all drug doses prescribed are practical for administration purposes.

Calculate administration volumes for all drugs prescribed

Prednisolone 40mg

Give EIGHT prednisolone 5mg soluble tablets

Paracetamol 258mg

10.75ml of 120mg/5ml susp OR

5.16ml of 250mg/5ml susp

Advise dose change to either

240mg (10ml 120mg/5ml)

250mg (5ml 250mg/5ml) unlicensed

All other doses appropriate

Prompt review of inhaler inhaler therapy.

Inhalers on admission not in accordance with BTS/SIGN Guidelines. Discuss changing inhaler devices from turbohaler/accuhaler to MDI with spacer with medical staff and patient/carer.

Adjust patient/carer’s understanding of inhaler devices and self management of asthma.

Provide education to patient/carer regarding inhaler devices and self management plan.

Immunisation following steroids and acute ilness.

Review current advice on immunisation following steroids and acute illness.

Current advice is that immunisation should only be delayed if steroid therapy seven days or more or in acute illness.

Verify patient/carer’s understanding of medicines on discharge.

Discharge medication explained to child and carer.

Importance of completing antibiotic cource highlighted.

i

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Case study – Sarah (page 36)

A

Non-compliance; too much protein in her diet; illness (metabolic stress during infection, precipitating protein catabolism).

B

Who is in charge of Sarah’s medicines? Has she been taking them? What about at school/friend’s houses? Has she had a growth spurt recently? (Increased dose requirement.) Do friends/family know of her condition? Perhaps counselling issues? Has she been following her dietary instructions?

C

Phone the community pharmacist. The L-arginine 10% w/v solution has a seven day expiry, therefore needs to be dispensed weekly.

D

Community pharmacist explains that Sarah’s mother is very unreliable, often collecting the medicines 2-4 days late. The best course of action is to feed this information back to the Consultant. He can then discuss it with the family to try and improve concordance.

E

Intravenous (IV) fluids containing glucose (10% glucose, 0.45% sodium chloride – 90ml/kg/day)•

IV sodium phenylbutyrate 250mg/kg/day•

IV sodium benzoate 250mg/kg (90mins bolus) followed by 250mg/kg/day•

IV arginine 100mg/kg/day infusion. •

As she has been vomiting this ensures she gets the appropriate treatment quickly.

F

Continue with the IV infusion as the ammonia level is reducing with the current treatment. If no significant reduction, the dose of sodium phenylbutyrate could be increased to 500mg/kg/day, with the ammonia level being re-checked four hours later.

G

Give the injection orally or the equivalent dose of tablets. As a last resort you could contact the community pharmacist to see if they had some already prepared.

H

10% (10g/100ml = 100mg/ml)

7mls = 700mg. Total daily dose = 2100mg

Option 1 – injection is 60% w/v (60g/100ml = 600mg/ml)

700mg/600mg x 1 = 1.2mls tds

Option 2 – tablets are 500mg, 4 tablets per day = 2000mg.

I

There is very little evidence to support the extemporaneous liquid formulation, and the granules are licensed. Using the tablets and granules will mean that mum will not have to collect weekly prescriptions from the community pharmacist, perhaps improving compliance.

J

Concordance. The consultant is discussing the current clinical problem and is trying to encourage the family to agree to the treatment and advice being recommended. The rest of the family is not aware of Sarah’s condition so there are many social problems regarding diet to be addressed.

57


K

Counselling them on the new preparations. Supply appropriate information to the community pharmacist on how to order the new products. Phone the community pharmacist to explain the dose increase to avoid confusion.

L

L-arginine tablets are a pharmaceutical special and the sodium phenylbutyrate is a licensed product available from Orphan Europe. Contact the hospital pharmacist to find out more information, and for assistance in the ordering procedure.

M

Supply problems and delays. Difficulty in sourcing in primary care, therefore it is crucial to communicate information from secondary to primary care. GPs may be unsure/unhappy to prescribe a drug regarded to be too specialised (i.e. outwith their field/professional capacity). Some parents may be unhappy for their child to take an unlicensed drug.

N

Speak to the GP to get a prescription for the equivalent dose in liquid. Contact the consultant (if available) to double check.

O

Current dose is one yellow and one white scoop (3.85g) qds.

Sodium phenylbutyrate liquid dose is 3850mg/250mg x 1 = 15.4mls, therefore 15mls qds.

Case study – Katie (page 40)

A

Katie is possibly dehydrated as a consequence of her vomiting. This could help to explain her slightly elevated urea and sodium levels. It may also explain her headache.

Further laboratory investigations are needed to help confirm the above and exclude other reasons for the elevated results. She should have a plasma creatinine measurement taken, her urine output should be assessed (to exclude renal impairment) and a urine sample should be sent to microbiology to exclude UTI. Gastrointestinal bleeding should be excluded as a cause of the elevated urea; this could be determined by the use of FOB’s and by checking haemoglobin levels.

B

You would wish to check that the doses of her prednisolone and fludrocortisone were correct and that her UTI prophylaxis was appropriate in terms of the usual causative organism and the dose.

C

You would need to ensure that Katie received IV hydrocortisone peri- and post-operatively to prevent adrenal crisis in a patient with known adrenal suppression.

Fluid, electrolytes and blood glucose should be closely monitored as Katie has been maintained on long-term steroid therapy which may lead to fluid and sodium retention, potassium loss and glucose intolerance. In addition she will be surgically stressed which could aggravate glucose control postoperatively.

Her post-operative antibiotic cover should be appropriate to cover gut flora as well as E. coli since her oral trimethoprim may not be given postoperatively for a day or so.

Post-operative analgesia will need to be initiated using appropriate medicines at suitable doses for Katie’s age and weight.

Katie’s IV hydrocortisone should be converted to oral hydrocortisone 24 hours post-operatively and whilst the hydrocortisone is being gradually reduced her regular prednisolone maintenance therapy should not be re-started.

58


D



Assess possible causes for elevated urea.

Check laboratory results, request any additional tests required and discuss results with medical staff in light of their clinical impression.

Urine output and creatinine levels within normal limits. Urine sample clear. Gastrointestinal bleed excluded by medical staff by clinical examination. Dehydration identified.

Check fluid maintenance in light of hydration status and use of steroids.

Check fluids prescribed for volumes, glucose, sodium and potassium content.

Monitor electrolyte results.

Fluids prescribed to deliver 82ml/hour (equiv to 100% maintenance). Sodium and potassium content appropriate.

Modify treatment plan/drug choice in light of clinical condition/surgery.

Check that Katie is prescribed IV hydrocortisone to prevent adrenal crisis. Should then convert to oral steroid as soon as possible. May require discussion with endocrine team. Continue to monitor sodium levels and fluid balance.

Ensure antibiotic prophylaxis is appropriate and ideally would also be suitable for UTI prophylaxis.

IV hydrocortisone cover initiated for 24-48 hours.

Ensure that oral steroids are stopped initially but re-introduced as soon as possible at which time IV hydrocortisone should stop.

May require higher maintenance doses for a short period if still unwell and clinically stressed.

Cefotaxime and metronidazole used for prophylaxis; provides adequate cover for surgery and UTI.

Pain control. Ensure prescribed according to policy (age/weight banded doses etc).

Paracetamol and ibuprofen prescribed. Doses prescribed appropriately.

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Future learning needs

Use this page to jot down any ideas and action points you may wish to follow up at a later stage.

60


Multiple choice questionnaire

Congratulations – you have made it to the end of the package. However, we require one more task of you – to complete the attached self-assessment questionnaire. This allows you to test your understanding of the package and receive feedback on the answers.

Tick each answer as true or false. Tear off the answer sheet on the last page along the perforation and copy your ‘ticks’ on this sheet. Please take a few minutes of your time to add your comments about all aspects of the package on the back. Your comments allow us to improve future distance learning packages. Once completed with your name and address details, return it to:

NHS Education for Scotland (Pharmacy)

3rd Floor, 2 Central Quay

89 Hydepark Street

Glasgow G3 8BW

www.nes.scot.nhs.uk

Alternatively, you may wish to complete the MCQs online at the NES Pharmacy website. You will receive an instant score if you choose this method!

If you are not resident in Scotland, you should return your completed MCQ to the appropriate centre for pharmaceutical postgraduate education.

Please note there is no negative marking, so do attempt all the questions by ticking the appropriate true/false box.

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T F

1 Specific metabolic disorders include:

a phenylketonuria o o

b urea cycle disorders o o

c Reye’s syndrome o o

d galactosaemia. o o

2 Therapeutic approaches to treating metabolic disorders can include:

a increased glucose intake o o

b removal of toxins, for example, by peritoneal dialysis o o

c very large doses of vitamins o o

d correction of acidosis. o o

3 The following statements about pharmacokinetics are true:

a Infants experience increased oral absorption of phenobarbitone, phenytoin and

rifampicin compared to adults. o o

b Hepatically and renally cleared drugs have reduced plasma half lives in premature babies. o o

c Theophylline and anti-epileptic drugs often require to be given to older children in larger doses per kg than in adults. o o

d Renal excretion is the most important factor in assessing dosing in children. o o

4 Dose calculation:

a can be done using the percentage method and the mg/kg method o o

b using the mg/kg method takes account of surface area o o

c using the mg/kg method will give higher doses than the percentage method o o

d using the percentage method is far less accurate clinically than mg/kg method. o o

5 The Good Prescribing Code includes the following:

a Never prescribe without knowing the child’s allergy status. o o

b Writing mg, ng or iv is acceptable. o o

c Writing 75 micrograms is preferable to using 0.075mg. o o

d Only medication with no strength or with multiple components should be prescribed simply in ‘ml’. o o

6 The following statements about information sources are true:

a Sources of information are graded as first, second or third class. o o

b The Cochrane Database is an example of a primary reference source. o o

c When looking for medicines information, you would usually begin with a primary reference source. o o

d A very useful information source for all pharmacists to access is ‘Medicines in Children’. o o

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T F

7 The following statements about constipation are true:

a At 4 years, a child will normally pass one bowel motion per day. o o

b Girls are more likely to be affected than boys. o o

c Treating chronic constipation requires a flexible approach that includes counselling and use of behavioural therapy. o o

d Constipation can lead to impaction and encopresis. o o

8 The following statements about diarrhoea are true:

a Diarrhoea related to poor growth and sleeping should be investigated. o o

b The main risk with acute diarrhoea is dehydration and electrolyte disturbance. o o

c Anti-diarrhoeal drug therapy can be a useful adjunct in acute diarrhoea. o o

d Chronic diarrhoea lasting more than two weeks should be investigated to exclude conditions like coeliac or Crohn’s disease. o o

9 Prescriptions may be off-label in terms of:

a dose o o

b age of patient o o

c route of administration o o

d indication. o o

10 The following statements about prescribing unlicensed or off-label drugs are true:

a Explicit consent for use of such drugs should be obtained by parents/carers. o o

b A risk vs benefit review should be made on an individual patient basis. o o

c The doctor will always have raised the issue with the patient and therefore it will not be necessary for pharmacy staff to raise it. o o

d The patient information leaflet should not be supplied with the medicine. o o

11 The following drugs do not have a high risk of teratogenicity:

a Warfarin o o

b Captopril o o

c Cyclizine o o

d Sodium valproate. o o

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T F

12 Drugs in breast milk are:

a highly protein bound o o

b highly lipid solid o o

c of high molecular weight o o

d weak acids. o o

13 The following statements about vaccines are true:

a DTwP is associated with more reactions in babies than in older children. o o

b Children should have received five doses of polio by the time they are 18. o o

c Pneumococcal vaccine is part of the routine childhood immunisation programme. o o

d Vaccination should be postponed in a child with fever. o o

14 The following statements about children’s medicines are true:

a All medicines must be locked away at school. o o

b All children receiving medication at school should have a written health care plan. o o

c Only parents need to be counselled on children’s medication. o o

d Aspartame is not a suitable sweetening agent for all children. o o

15 In relation to the treatment of asthma in children:

a Steroid inhalers are first choice preventative therapy. o o

b Long-acting ß2 agonists can replace steroid if control is poor. o o

c Oral preparations are preferred over inhaled in younger children. o o

d Ipratropium bromide should never used. o o

16 The following statements about diabetes in children are correct:

a When using biphasic insulins three times daily, it is normal to give one half of the daily dose in the morning. o o

b Most children prefer insulin pens as they are simpler to use than insulin syringes. o o

c A glycosylated haemoglobin (HbA1c) of 7% usually reflects good glycaemic control over the previous two-three months. o o

d An unconscious patient with clammy skin and ‘fruity’ breath is likely to be hypoglycaemic. o o

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T F

17 In relation to the treatment of epilepsy in children:

a Rectal diazepam is the first choice treatment for CSE in children of all ages without intravenous access. o o

b The use of gapapentin should be limited to the treatment of West Syndrome because of the concerns over visual field defects in children. o o

c Lamotrigine is a suitable second line agent for the treatment of myoclonic epilepsy in children. o o

d The aim of epileptic drug management is to use the fewest number of antiepileptic drugs at the lowest effective dose possible. o o

18 Morphine is NOT usually given to children by the following routes:

a Epidural infusion. o o

b PCA. o o

c NCA. o o

d IM injection. o o

19 The following statements are correct:

a Flucloxacillin is advised in severe cases of otitis externa. o o

b Otitis media most commonly occurs in young infants. o o

c Ribavirin is most commonly used for prophylaxis against respiratory syncytial virus (RSV). o o

d In the treatment of pneumonia caused by mycoplasma, clarithromycin is often used. o o

20 The following statements about nutrition are correct:

a Weaning infants onto solids should not begin until the child is four months old. o o

b The use of vitamin drops is routinely recommended for breast-fed babies from six months of age. o o

c In parenteral feeding solutions, the percentage of calories provided as fat should be 20-40%. o o

d Nasogastric feeding is used when the GIT is normal but swallowing is impaired. o o

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MCQ answer sheet

1 a o o

b o o

c o o

d o o

2 a o o

b o o

c o o

d o o

3 a o o

b o o

c o o

d o o

4 a o o

b o o

c o o

d o o

5 a o o

b o o

c o o

d o o

6 a o o

b o o

c o o

d o o

7 a o o

b o o

c o o

d o o

8 a o o

b o o

c o o

d o o

9 a o o

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c o o

d o o

10 a o o

b o o

c o o

d o o

11 a o o

b o o

c o o

d o o

12 a o o

b o o

c o o

d o o

13 a o o

b o o

c o o

d o o

14 a o o

b o o

c o o

d o o

15 a o o

b o o

c o o

d o o

16 a o o

b o o

c o o

d o o

17 a o o

b o o

c o o

d o o

18 a o o

b o o

c o o

d o o

19 a o o

b o o

c o o

d o o

20 a o o

b o o

c o o

d o o

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Introduction to paediatric pharmaceutical care

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Address

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RPSGB Reg No.

Comments

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Introduction to paediatric pharmaceutical care Workbook

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