BNF for Children 2011-2012

BNFC 2011–2012 1.2 Antispasmodics and other drugs altering gut motility 39Child 1 month–2 yearsBody-weight under 4.5 kg dose as for neonateBody–weight over 4.5 kg 2 ‘doses’ mixed with feeds (orwater, for breast-fed infants) when required (max. 6 timesin 24 hours)Note Not to be used in preterm neonates, or where excessivewater loss likely (e.g. fever, diarrhoea, vomiting, high roomtemperature), or if intestinal obstruction. Not to be used withother preparations containing thickening agentsSafe PracticeEach half of the dual sachet is identified as ‘onedose’. To avoid errors prescribe with directions interms of ‘dose’Topal c (Fabre)Tablets, alginic acid 200 mg, dried aluminium hydroxide30 mg, light magnesium carbonate 40 mg withlactose 220 mg, sucrose 880 mg, sodium bicarbonate40 mg (low Na + ). Net price 42-tab pack = £1.67Cautions diabetes mellitus (high sugar content)Dose. By mouthChild 12–18 years 1–3 tablets chewed 4 times daily(after meals and at bedtime)1.2 Antispasmodics andother drugs altering gutmotilityDrugs in this section include antimuscarinic compoundsand drugs believed to be direct relaxants of intestinalsmooth muscle. The smooth muscle relaxant propertiesof antimuscarinic and other antispasmodic drugs maybe useful in irritable bowel syndrome.The dopamine-receptor antagonist domperidone stimulatestransit in the gut.AntimuscarinicsAntimuscarinics (formerly termed ‘anticholinergics’)reduce intestinal motility. They are occasionally usedfor the management of irritable bowel syndrome but theevidence of their value has not been established andresponse varies. Other indications for antimuscarinicdrugs include asthma and airways disease (section3.1.2), motion sickness (section 4.6), urinary frequencyand enuresis (section 7.4.2), mydriasis and cycloplegia(section 11.5), premedication (section 15.1.3), palliativecare (p. 19), and as an antidote to organophosphoruspoisoning (p. 33).Antimuscarinics that are used for gastro-intestinalsmooth muscle spasm include the tertiary amine dicycloverinehydrochloride and the quaternary ammoniumcompounds propantheline bromide and hyoscinebutylbromide. The quaternary ammonium compoundsare less lipid soluble than atropine and so are less likelyto cross the blood-brain barrier; they are also less wellabsorbed from the gastro-intestinal tract.Dicycloverine hydrochloride may also have some directaction on smooth muscle. Hyoscine butylbromide isadvocated as a gastro-intestinal antispasmodic, but itis poorly absorbed; the injection may be useful in endoscopyand radiology.Cautions Antimuscarinics should be used with cautionin children (especially children with Down’s syndrome)due to increased risk of side-effects; they should also beused with caution in autonomic neuropathy, hypertension,conditions characterised by tachycardia(including hyperthyroidism, cardiac insufficiency, cardiacsurgery), pyrexia, and in children susceptible toangle-closure glaucoma. Antimuscarinics are not usedin children with gastro-oesophageal reflux disease,diarrhoea or ulcerative colitis. Interactions: Appendix1 (antimuscarinics).Contra-indications Antimuscarinics are contra-indicatedin myasthenia gravis (but may be used to decreasemuscarinic side-effects of anticholinesterases—section10.2.1), paralytic ileus, pyloric stenosis, and toxic megacolon.Side-effects Side-effects of antimuscarinics includeconstipation, transient bradycardia (followed by tachycardia,palpitation and arrhythmias), reduced bronchialsecretions, urinary urgency and retention, dilatation ofthe pupils with loss of accommodation, photophobia,dry mouth, flushing and dryness of the skin. Side-effectsthat occur occasionally include nausea, vomiting, andgiddiness; very rarely, angle closure glaucoma mayoccur.DICYCLOVERINE HYDROCHLORIDE(Dicyclomine hydrochloride)Cautions see notes aboveContra-indications see notes above; child under 6monthsPregnancy not known to be harmful; manufactureradvises use only if essentialBreast-feeding avoid—present in milk; apnoeareported in infantSide-effects see notes aboveIndication and doseSymptomatic relief of gastro-intestinal disorderscharacterised by smooth muscle spasm. By mouthChild 6 months–2 years 5–10 mg 3–4 times daily15 minutes before feedsChild 2–12 years 10 mg 3 times dailyChild 12–18 years 10–20 mg 3 times dailyMerbentyl c (Sanofi-Aventis) ATablets, dicycloverine hydrochloride 10 mg, net price100-tab pack = £4.84; 20 mg (Merbentyl 20 c ), 84-tabpack = £8.14Syrup, dicycloverine hydrochloride 10 mg/5 mL, netprice 120 mL = £1.77Note Dicycloverine hydrochloride can be sold to the publicprovided that max. single dose is 10 mg and max. daily dose is60 mgCompound preparationsKolanticon c (Peckforton)Gel, sugar-free, dicycloverine hydrochloride 2.5 mg,dried aluminium hydroxide 200 mg, light magnesiumoxide 100 mg, simeticone 20 mg/5 mL, net price200 mL = £2.21, 500 mL = £3.35DoseChild 12–18 years 10–20 mL every 4 hours whenrequired1 Gastro-intestinal system