BNF for Children 2011-2012

BNFC 2011–2012 1General guidanceMedicines should be given to children only when theyare necessary, and in all cases the potential benefit ofadministering the medicine should be considered inrelation to the risk involved. This is particularly importantduring pregnancy, when the risk to both mother andfetus must be considered (for further details see Prescribingin Pregnancy, p. 16).It is important to discuss treatment options carefullywith the child and the child’s carer (see also TakingMedicines to Best Effect, below). In particular, the childand the child’s carer should be helped to distinguish theadverse effects of prescribed drugs from the effects ofthe medical disorder. When the beneficial effects of themedicine are likely to be delayed, this should be highlighted.Taking medicines to best effect Difficulties inadherence to drug treatment occur regardless of age.Factors that contribute to poor compliance with prescribedmedicines include:. difficulty in taking the medicine (e.g. inability toswallow the medicine);. unattractive formulation (e.g. unpleasant taste);. prescription not collected or not dispensed;. purpose of medicine not clear;. perceived lack of efficacy;. real or perceived adverse effects;. carers’ or child’s perception of the risk and severityof side-effects may differ from that of the prescriber;. instructions for administration not clear.The prescriber, the child’s carer, and the child (if appropriate)should agree on the health outcomes desired andon the strategy for achieving them (‘concordance’). Theprescriber should be sensitive to religious, cultural, andpersonal beliefs of the child’s family that can affectacceptance of medicines.Taking the time to explain to the child (and carers) therationale and the potential adverse effects of treatmentmay improve adherence. Reinforcement and elaborationof the physician’s instructions by the pharmacistand other members of the healthcare team can beimportant. Giving advice on the management of adverseeffects and the possibility of alternative treatments mayencourage carers and children to seek advice ratherthan merely abandon unacceptable treatment.Simplifying the drug regimen may help; the need forfrequent administration may reduce adherence,although there appears to be little difference in adherencebetween once-daily and twice-daily administration.Combination products reduce the number ofdrugs taken but at the expense of the ability to titrateindividual doses.Drug treatment in children Children, and particularlyneonates, differ from adults in their response todrugs. Special care is needed in the neonatal period (first28 days of life) and doses should always be calculatedwith care; the risk of toxicity is increased by a reducedrate of drug clearance and differing target organ sensitivity.For guidance on selecting doses of drugs in children seeHow to Use BNF for Children, p. xiv.Administration of medicines to children Childrenshould be involved in decisions about taking medicinesand encouraged to take responsibility for using themcorrectly. The degree of such involvement will dependon the child’s age, understanding, and personal circumstances.Occasionally a medicine or its taste has to be disguisedor masked with small quantities of food. However,unless specifically permitted (e.g. some formulationsof pancreatin), a medicine should not be mixed withlarge quantities of food because the full dose might notbe taken and the child might develop an aversion tofood if the medicine imparts an unpleasant taste. Medicinesshould not be mixed or administered in a baby’sfeeding bottle.Children under 5 years (and some older children) find aliquid formulation more acceptable than tablets or capsules.However, for long-term treatment it may bepossible for a child to be taught to take tablets orcapsules.An oral syringe (see below) should be used for accuratemeasurement and controlled administration of an oralliquid medicine. The unpleasant taste of an oral liquidcan be disguised by flavouring it or by giving a favouritefood or drink immediately afterwards, but the potentialfor food-drug interactions should be considered.Advice should be given on dental hygiene to thosereceiving medicines containing cariogenic sugars forlong-term treatment; sugar-free medicines should beprovided whenever possible.Children with nasal feeding tubes in place for prolongedperiods should be encouraged to take medicines bymouth if possible; enteric feeding should generally beinterrupted before the medicine is given (particularly ifenteral feeds reduce the absorption of a particular drug).Oral liquids can be given through the tube provided thatprecautions are taken to guard against blockage; thedose should be washed down with warm water. When amedicine is given through a nasogastric tube to aneonate, sterile water must be used to accompanythe medicine or to wash it down.The intravenous route is generally chosen when amedicine cannot be given by mouth; reliable access,often a central vein, should be used for children whosetreatment involves irritant or inotropic drugs or whoneed to receive the medicine over a long period or forhome therapy. The subcutaneous route is used mostcommonly for insulin administration. Intramuscularinjections should preferably be avoided in children,particularly neonates, infants, and young children. However,the intramuscular route may be advantageous foradministration of single doses of medicines when intravenouscannulation would be more problematic orGeneral guidance