From Mr N. A. Caldwell, MRPharmS, and Ms L. M. McClellan, MRPharmS
SIR,-We would like to express our concerns, through The Pharmaceutical Journal, about the problems created by glass ampoules in relation to non-parenteral administration in children.
A number of medicines are needed as liquid formulations to administer to children. Due to the lack of suitable liquid formulations, a "solution" is often sought by administering the injection via the oral or rectal route, or via gastrostomy or nasogastric tube. Within paediatric pharmacy a range of parenteral medicines are administered by alternative routes. Examples include:
We strongly believe that, if the medicine to be used is available as a glass ampoule, the product should be filtered in the pharmacy to remove fragments of glass and supplied in a ready-to-use form. This applies for products used in hospital and for outpatient use in the community. Decanting from single use ampoules, without preservative, to produce a supply of ready-to-use liquid medicine presents logistical problems for pharmacists.
Occasionally, with the full agreement of parents, we will supply glass ampoules of injectable solution with instruction to filter prior to administration. The alternative is to extrapolate product stability and provide extemporaneously prepared medicines, on a repeat basis, with parents having frequent visits to the pharmacy department for an ongoing supply of medicine, which sometimes may not have been used. They must also plan their visits to return before the product goes out of date. In addition, when medicines are required in an emergency setting, an expectation for parents or carers to filter the solution before administration or to withdraw a measured amount from a bottle is unrealistic.
There is currently much interest in the use of oral, buccal and nasal midazolam within paediatric and drug information circles, driven, perhaps, by ease of administration, or by the desire to overcome the embarrassment or stigma associated with the use of rectal diazepam by parents and teachers. Midazolam injection presented as a plastic "ampoule" would be a ready-to-use dose unit. If accessed with an oral syringe, this would avoid potential needle stick injury (and needle disposal problems) from use of filter needles by the general public.
We would urge all pharmaceutical companies to take note of this plea that plastic is best, and ask if anyone knows of any forthcoming changes in presentation of the medicines outlined above. We would also welcome our colleagues' considered opinions.
Neil A. Caldwell
Principal Pharmacist/Lecturer, Wirral Hospital NHS Trust/Liverpool John Moores University
Lesley McClellan
Drug Information Manager, Wirral Hospital NHS Trust