The 5th annual conference of the Neonatal and Paediatric Pharmacists Group (NPPG) was held at the Midland hotel in Derby from November 12 to 14. One hundred and forty pharmacists from Great Britain, Ireland, Norway, New Zealand, Italy, France, Sweden and Oman gathered to participate in workshops, poster sessions and plenary sessions covering a wide range of topics. Mr Peter Mulholland (senior pharmacist, Southern General hospital, Glasgow) reports
Opening the plenary session, Professor MIKE CULLEN (consultant pharmacist, Derby), described how pharmacy had progressed over the past 20 years from being a task orientated profession to a profession which put its emphasis on the patient. Paediatrics was a priority area in health care that was often overlooked, and as a result there were too few paediatric pharmacists for the potential roles. However, pharmacists should not wait until resources were provided but should grab opportunities as they arose and sort out the resources later. If pharmacists did not take an active role in patient care they might as well just continue with drug supply, said Professor Cullen. There were many roles for paediatric pharmacists, as any review of subjects in The Pharmaceutical Journal over the past 18 months made clear. Among these were: |
Mike Cullen: too few paediatric pharmacists |
It was up to pharmacists to become involved in all agenda which involved children.
Professor Cullen went on to say that a recent EC ruling stated that hospital pharmacy was not a specialisation. However, it followed that paediatric pharmacy could be designated a specialism. What now needed to be developed was a training pathway similar to that found in medicine for paediatric specialists.
In the discussion that followed, Dr MALCOLM PARTRIDGE (chairman, NPPG) noted that the group had picked up on many of the listed topics and wondered whether it would be better to adopt a European approach to the development of paediatric pharmacy. Professor Cullen said that he felt that, as 40 per cent of hospital pharmacists in Europe were based in the UK, it would be better to focus on the UK initially, concentrating on the links already established with the Royal College of Paediatrics and Child Health, and then roll out into Europe.
Many drugs used in paediatrics are used "off label" or have to be reformulated into a suitable preparation. Speaking about current controversies in paediatrics, Dr RICHARD MORTON (consultant paediatrician, Derbyshire children's hospital) detailed the use of botulinum, melatonin, midazolam, baclofen and methylphenidate in current paediatric practice.
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Richard Morton: pharmacists have an important role in ADHD |
Sleep disturbance was common in neurologically impaired children, especially if they also had visual impairment. This was a major problem for both the child and carers. Melatonin was the product of choice and was cheap, but it remained unlicensed. Patients needed to be assessed and started with trial doses, increasing if necessary. If treatment was successful, then the general practitioner should be encouraged to continue the treatment.
Attention deficit hyperactivity disorder (ADHD) was estimated to affect 5 per cent of children in the US. In the UK, where stricter diagnostic criteria were used, it was estimated that 1 per cent of children were affected by the disorder. Dr Morton said that methylphenidate was the drug treatment of choice. However, even though it was licensed for the treatment of ADHD in children, problems could arise when treatment was continued in the community, as many GPs were unwilling to continue its prescription. The requirement to take the medicine after meals meant that schools often had to be involved in the patient's treatment, and this was an area where pharmacists had an important role to play.
In the discussion that followed, Mr STEVE TOMLIN (Guy's and St Thomas's NHS trust) said that the use of sustained release methylphenidate, which was available in the US, would solve the need for the medication to be given at school, but, because of Controlled Drug regulations, it was difficult to import.
Opening the second session, Miss CATHERINE HALL (Royal Victoria infirmary, Newcastle upon Tyne) presented a case involving drug treatment of a foetus in utero by administration of medication to the mother. A baby with supraventricular tachycardia had been treated in late pregnancy by administration of amiodarone to the mother. When the baby had been born, the mother had stopped taking the amiodarone and wanted to breast feed. As amiodarone had a long half life, there had been concerns about the continued transfer of amiodarone into the breast milk. Most cases in the literature concerned breast feeding in mothers who continued to take amiodarone. The decision had been made to allow the baby to breast feed with monitoring of thyroid function, and measurement of amiodarone concentration in the breast milk. The case highlighted the considerations needed with in utero drug administration when drugs could continue to have an effect after birth and cessation of treatment. This was an example of how new challenges continued to arise for pharmacists involved in neonatal medicine.
Mrs CHRISTINE NYE (Jessop hospital, Sheffield) presented a case of Bartter syndrome. The case highlighted the need for close collaboration between hospital and community pharmacists when children were transferred into the community on unusual preparations.
Dr PETER ARLETT (ADROIT Pharmacovigilance Group, Medicines Control Agency) discussed the use of medicines "off label" in children and how the yellow card scheme could help to obtain safety data on drug use in this patient population. He said that the presence of a licensed product on the market did not preclude the use of an unlicensed medicine, if the clinician felt that the benefit outweighed the risk. However, effective safety monitoring systems needed to be in place. A key part of this was the yellow card scheme (recently extended to all community pharmacists) which was an immediate report on current clinical use and would flag problems quicker than any other database. Hospital pharmacists were now reporting more serious adverse drug reactions than hospital doctors. This was a role that paediatric pharmacists could develop for "off label" medicine use. |
Peter Arlett: hospital pharmacists reporting more serious ADRs than hospital doctors |
Reporting on the recent launch of Medicines for Children, the national paediatric formulary produced jointly by the Royal College of Paediatrics and Child Health and the NPPG, Mr TONY NUNN (director of pharmacy, Alder Hey Children's hospital, Liverpool) said that the editorial board was looking towards electronic publication for future editions and that the formulary could only develop if feedback was received by users.
The NPPG launched its web site (www.nppg.demon.co.uk ) one year ago. Mr PETER MULHOLLAND (senior pharmacist, Southern General hospital, Glasgow) presented details of the site's progress and future plans. The site currently consisted of a variety of information sources for group members, both within the site and on the wider internet. Plans for the coming year included the creation of a database of member interests to progress further the work already undertaken by special interest groups within NPPG, and the collation and publication of protocols used within paediatric pharmacy across the UK. The site would also become a repository for information on any paediatric pharmacy research work being undertaken by group members.
Miss AMANDA CLARKSON (academic division of child health, Derbyshire children's hospital) presented a report on a pilot scheme to establish a regional monitoring service for paediatric adverse drug reactions (ADRs). It had been set up in October, 1998, to raise awareness and stimulate the reporting of ADRs, and involved 20 hospitals in the Trent region. A modification to the yellow card ensured that all reports were sent to the pilot scheme before onward transmission to the MCA. Preliminary results showed a large increase in reporting, with the most common drugs associated with suspected adverse reactions being topical local anaesthetics, anticonvulsants, antibiotics, vaccines and inhaled steroids. The pilot was to run for three years.
Neonatal medicine is one of the most challenging areas facing pharmacists and was the subject of two research presentations. Mrs ROISIN LANNIGAN (Royal hospital for sick children, Glasgow) presented a paper on the evaluation of current neonatal dosage guidelines for gentamicin. A variety of dosing schedules were used throughout the UK but, using a prediction model, none was found to be entirely satisfactory. Work was being undertaken to validate an alternative dosage schedule.
Miss LOUISE GALLARD (Guy's and St Thomas's NHS trust) presented a paper on the safety and efficacy of ibuprofen in patent ductus arteriosus. A licensed product was available for this treatment (indomethacin) but it was known to have a range of side effects, including decrease in cerebral blood flow, oxygen delivery and blood volume. Ibuprofen injection was available as a named patient import from Germany and a trial of its use had been undertaken. Results showed that it appeared to be as effective as indomethacin, with fewer side effects. However, numbers were small and further data collection was required to substantiate the results.
Miss PENNY FLETCHER (Chelsea and Westminster hospital) presented a poster on a quality improvement in service development, involving pharmacist transcription of paediatric surgical day case discharge medicines from protocols. Prior to the introduction of the service, day case elective surgical patients had to endure long waiting times for discharge medicines (TTAs). Prescriptions did not receive a clinical check by the paediatric pharmacist, were commonly for a small range of medicines, often written after the patient was ready to go home and arrived in the pharmacy over lunchtime. Protocols developed jointly by medical and pharmacy staff were introduced. On the morning of surgery, the pharmacist completed a pharmaceutical care information sheet after discussion with the parent and child and transcribed the TTAs onto the computerised prescribing system. This was printed and signed by medical staff, then sent to the pharmacy. Results showed that delay to discharge was reduced from a mean of two hours to zero (ie, all TTAs ready at time of discharge) and that all TTA prescriptions arrived in the pharmacy well before lunch (ie, when the department was fully staffed).
The conference also incorporated workshops which covered many aspects of paediatric and neonatal pharmaceutical care.
A workshop on paediatric epilepsy discussed the rationale behind treatment and the use of new treatments. Fosphenytoin has recently been launched in the UK. It has a different dosage schedule to phenytoin injection, with the dose being quoted in terms of phenytoin equivalents. While this is not a problem in adult wards, where a complete changeover to fosphenytoin is likely to have happened, in paediatric wards, where there might be an age range from 0 - 12 years, this can lead to confusion as both preparations need to be stocked, with their differing dosage schedules. Its licence is another example of how the impact of a new medication on paediatrics is not always considered before marketing.
The NPPG conference continues to expand, with an increasing number of countries being represented each year. It demonstrates that pharmacists internationally face similar problems and acts as a forum for networking between professionals in the challenging field of neonatal and paediatric pharmaceutical care.
Session for new pharmacistsNew for the 1999 conference was a session aimed at new paediatric pharmacists which took place before the beginning of the main conference. Subjects covered included life stages, developmental pharmacology, kinetics and drug related problems, medication errors, calculations, communicating with patients and reference sources. Thirty participants from a variety of countries attended the session. |