Manipulations of Oral Medications in Paediatric Neurology and Oncology Care at a Swedish University Hospital: Health Professionals' Attitudes and Sources of Information.

Rania Kader,Mattias Paulsson,Gunnar Liminga,Gustaf Ljungman

doi:10.3390/pharmaceutics13101676

Abstract

Oral administration of medications to children requires age-appropriate dosage forms and strengths. In this study, we: (i) assessed the extent of oral dosage form manipulations, (ii) documented how it is carried out, and (iii) examined the attitudes and sources of information regarding the handling from healthcare professionals. Prospective reviews of electronic records, ward observations, and clinician surveys were performed at a paediatric neurology ward and a paediatric oncology ward in Sweden during April to May of 2018. Approximately 15% of oral medications were manipulated for the studied patient group (median age 12.9 years in oncology, 5.8 years in neurology) with approximately 30% of the patients having an enteral feeding tube. Manipulations were performed both to obtain an appropriate dose from, for example, a fraction of the original tablet or to obtain a powder that could be used to prepare a slurry for administration through enteral feeding tubes. Risks identified were related to patient safety such as cross contamination, suboptimal absorption/pharmacokinetics and inaccurate dose. When examining the working environment of nurses, we observed safe handling of hazardous substances but the nurses occasionally experienced stress and a fear of making mistakes due to absence of information. Paediatricians experienced a lack of time to search for proper information on manipulations. As a step towards improving safety in paediatric medication, we suggest the introduction of clinical pharmacists into the team and further evaluating the possibilities of using more ready-to-administer medications with necessary product information and pharmacovigilance support.

Highlights

Medication dosing in paediatric patients is challenging due to the extensive variation in patient weight in addition to changes in metabolic capacity, distribution sites and organ function [1]
It can be noted that electronic health record (EHR) software often contains a computerized physician order entry (CPOE) module that allows for easy dose scaling of orders based on a mg/kg approach that relies on the availability of scalable formulations such as oral suspensions for safe administration
The administered oral medications were given to 79 patients, predominantly older than 2 years with a median age of 12.9 years (Oncology, ward A) and 5.8 years (Neurology, ward B), Table 1

Summary

Introduction

Medication dosing in paediatric patients is challenging due to the extensive variation in patient weight in addition to changes in metabolic capacity, distribution sites and organ function [1]. For intravenous medications, scaling of dose based on, for example, body surface area or body weight is often feasible, but for oral administration, paediatricians frequently resort to licensed, fixed-dose tablets, developed for the adult population. Some oral solutions are marketed that allow for on-label dose scaling and improvements in availability are being made [2], but challenges persist [3]. It can be noted that electronic health record (EHR) software often contains a computerized physician order entry (CPOE) module that allows for easy dose scaling of orders based on a mg/kg approach that relies on the availability of scalable formulations such as oral suspensions for safe administration.

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