Meds use in children

• Hydrocortisone


  A corticosteroid that is essential for the management of adrenal insufficiency, severe acute asthma and acute hypersensitivity reactions in paediatrics
• Careful dosing of hydrocortisone in children

  • Required to avoid serious adverse effects and toxicity
  • Long-term use poses several challenges for healthcare professionals and patients, particularly in relation to the choice of formulation and ease of administration of appropriate doses
• Oral formulations of hydrocortisone available in the UK

  • Tablets
  • Soluble tablets
  • Oral suspensions
  • Granules in capsules
• Pharmacists' role


  • Advise on the safe use of an appropriate hydrocortisone formulation, including switching and providing counselling to help manage difficult dose administration at home
  • Ensure patients, parents and carers can recognise the signs and symptoms of adrenal insufficiency
  • Advise on prescribing alternative formulations during temporary supply shortages
• Hydrocortisone is most commonly used in children to treat primary adrenal insufficiency, which is caused by congenital adrenal hyperplasia (CAH) and Addison's disease
• CAH affects around 1 in 15,000 children in the UK, while the prevalence of Addison's disease in children is around 1 in 10,000 for the whole population
• Ideal paediatric hydrocortisone formulation

  • Should satisfy high dose reproducibility, practicality, safety, low cost, and have a licensed status
  • It is unlikely that any one formulation will meet all criteria, so a balance of benefits and risks should be made in relation to the child's individual circumstances
• Excess dosing of hydrocortisone causes symptoms of cortisol excess, while under-dosing is associated with symptoms of cortisol insufficiency, which can be life-threatening
• Children with adrenal insufficiency require daily doses of 8–10mg/m2 of hydrocortisone, while those with CAH require higher doses of 10–15mg/m2
• In 2018, the MHRA issued a drug safety update, advising that prescribers and pharmacists should only consider use of licensed hydrocortisone products for adrenal replacement therapy
• Tablets


  • Concerns have been highlighted around the reproducibility of doses when splitting or dispersing them in water
  • Halving the 10mg tablet to give 5mg doses appears to provide relatively consistent dosing
• Soluble tablets


  Produce a true solution rather than a dispersion, potentially offering more accurate dosing over tablets
• Oral suspensions


  Many current suspensions no longer use the cypionate ester of hydrocortisone, but rather hydrocortisone acetate or micronised hydrocortisone base, providing doses bioequivalent to tablets
• Granules in capsules


  Provide an accurate and reproducible dosing option, suitable for children who cannot swallow tablets or those requiring doses not in multiples of 2.5mg
• The MHRA issued a drug safety update in February 2021, advising that parents or carers should be informed of the need to be extra vigilant for symptoms of adrenal insufficiency when switching children from hydrocortisone tablets to Alkindi granules
• Pharmacists can offer to demonstrate how to prepare doses, and provide useful counselling points for patients starting hydrocortisone or switching formulations
• Prescribing errors affect around 13% of paediatric prescriptions
• Paediatric medication errors - prescribing errors

  • Some of the most important threats to patient safety in children
  • Can have lethal consequences
• Errors occur more frequently in children than in adults and may be up to three times more likely to cause harm
• Prescribing error


  A clinically meaningful prescribing decision or prescription that reduces the probability of treatment being timely and effective, or increases risk of harm when compared with generally accepted practice
• Steps in the prescribing process


  • Patient assessment
  • Medication choice (via shared decision making with the patient)
  • Prescription writing
  • Information provision
  • Monitoring
• Paediatric prescribing errors are common, with a UK multicentre study identifying errors in 13.4% of 'medication orders' in hospitalised children
• Up to 22% of children in primary care may have received an incorrect prescription
• Most errors are intercepted prior to or during administration and do not impact patients
• The most severe errors have catastrophic outcomes, with 29 fatal paediatric medication errors reported in UK newspaper articles over an eight-year period
• The economic burden of prescribing errors is significant, with an estimated 66 million potentially clinically significant medication errors occurring in England annually, with an associated cost of £98m
• Types of paediatric prescribing errors

  • Incomplete prescriptions
  • Inappropriate use of abbreviations
  • Dosing errors (including tenfold errors)
• High-risk areas of paediatric prescribing

  • Care for neonates (particularly in neonatal care unit settings)
  • The process of medication dosing
  • Specific drug types (e.g. opiates, benzodiazepines, insulin)
• The Swiss cheese model of accident causation


  Systems have multiple layers designed to prevent errors, but each layer has holes. When these holes align, errors occur.
• Capability-Opportunity-Motivation-Behaviour (COM-B) model


  For a behaviour to occur, an individual must have capability, opportunity and motivation
• Causes of prescribing errors in children include factors specific to prescribing for children, in addition to causes of error in adult settings
• Most errors occur in the context of multiple factors, such as haphazard working environments, poor communication, and individual shortcomings
• Paediatric-specific causes of errors

  • Individualised dosing and calculations
  • Off-licence prescribing
  • Different medication formulations
  • Communication with children and parents
  • Inexperience with working with children
• Individualised dosing


  Prescribing a specific dose for each patient based on weight, and the consequent requirement to perform calculations
• Individualised dosing is the most frequently cited cause of prescribing errors
• Individualised dosing leads to error

  • Prescribers find calculations challenging, often making errors even in controlled classroom settings
  • Most prescribers appear susceptible, particularly when distracted, contradicting the belief that this represents incompetence within a minority
  • Some errors occur because some calculations are particularly complex, while others are 'slips', such as misplaced decimal points
  • Errors also happen when prescribers fail to adjust doses as children grow; do not recognise that children are overweight or underweight; or act on incorrect weight measurements
• While electronic prescribing (EP) has the potential to prevent errors related to individualised dosing and calculations, evidence suggests that they continue to occur even after its implementation
• Off-licence prescribing


  A common practice in children, owing to a lack of paediatric evidence regarding medication use
• Off-licence prescribing is associated with increased risk of error
• Off-licence prescribing


  • Places additional responsibilities on prescribers to choose suitable formulations, especially when using extemporaneous preparations — compounding ingredients to prepare an unlicensed medicine for an individual patient in accordance with a prescription — yet clear information on these formulations may be limited