The sixth annual Neonatal and Paediatric Pharmacists Group conference, in Liverpool from September 29 to October 1, was attended by 140 pharmacists from the United Kingdom, Ireland, Australia, New Zealand and Scandinavia
Researchers need to be organised before they start searching for evidence
on which to base practice, the meeting heard. Dr STEVEN RYAN (consultant paediatrician,
Alder Hey hospital) said that probably the best known evidence based medicine
group was the Cochrane Collaboration, whose logo was based on the evidence in
trials of the benefit of antenatal steroids for the foetus. The group’s
original meta-analysis proved that the treatment was safe and effective and
was the first, and possibly best, example of evidence based paediatrics.
Qualitative questions were harder to answer than quantitative ones. What was
needed was a well-structured question based on the acronym PICO — P, patient
or problem; I, intervention or exposure; C, comparison; and O, clinical outcome.
An example would be the question “In an eight-year-old boy with migraine
(P) does prophylaxis with pizotifen (I) compared with placebo (C) reduce the
frequency of headaches (O)?
Researchers should do no more work than necessary, always checking to see if
the question had been answered before. However, the answer found might not be
what was wanted. For example, the first 10 studies involving children in the
latest edition of the Cochrane database included five with positive results
(three on the use of antibiotics in upper respiratory tract infection, one on
bronchodilators in bronchiolitis and another on penicillamine in retinopathy
of prematurity), none of which were in routine use in practice. There were two
negative studies on the use of caffeine versus theophylline in neonatal apnoea,
but most sites used caffeine because of its safer therapeutic profile.
It was important not to overlook reference sources closer to home, such as the
BNF or ‘Medicine for children’, which might hold the answer. Researchers
also had to ask whether the evidence was any good. There could be bias from
the inclusion of positive studies only or the omission of foreign language articles.
Sedation — how is more important than what
Dr ANDREW BOWHAY (consultant anaesthetist, Alder Hey hospital) said that, when
considering sedation, safety was more important than the choice of agent.
The aims of sedation were to: minimise pain and discomfort; control behaviour;
create amnesia; and minimise negative psychological responses to treatment.
For non-painful procedures, sedation options included non-pharmacological methods
such as play, guided imagery and distraction. The different levels of sedation
ranged from conscious sedation, where protective reflexes were maintained to
deep sedation, which was just above the level of general anaesthesia.
At least two trained people had to be involved: one had to be competent to use
the technique, to carry out appropriate monitoring and to manage complications;
the other should be solely responsible for the patient.
Sedation was contraindicated in: patients with a post conceptual age of less
than 45 weeks; abnormality of upper airway; abnormality of respiratory centre;
raised intra-cranial pressure; respiratory disease; renal or hepatic dysfunction;
risk of pulmonary aspiration of gastric contents; and epilepsy if the patient
was prone to multiple seizures.
For non-painful sedation midazolam or diazepam could be used. For painful procedures
Entonox or a combination of morphine and midazolam (either oral or intravenous)
could be used. The combination of ketamine and midazolam (again either oral
or I/V) was unpredictable and produced sedation heading towards general anaesthesia.
Among other agents, trimeprazine had gone out of fashion and droperidol was
always used in combination due to its side effects. Chloral hydrate could give
deep sedation in high doses but care was needed because of its extended effect.
Quinalbarbitone was used at the Alder Hey for magnetic resonance imaging scans,
but its long half-life could demand an overnight stay.
Morphine was the mainstay for analgesia. Entonox had a quick onset and short
duration but could cause distension in gas filled cavities in the body. Ketamine
produced intense analgesia but led to a dissociated state, causing dysphoria
on waking. It was a chiral mixture and one enantiomer was responsible for each
effect (analgesia and dysphoria), so a chiral fraction version might be introduced.
Dr Bowhay concluded that there was no ideal regime for sedation and that safe
sedation depended on safe monitoring and the use of established guidelines.
During discussion, Dr Bowhay agreed that benzodiazepines might have a protective
effect in epileptics. He added that major tranquillisers could have odd effects
and that ketamine could make the epilepsy worse. It would be difficult to deal
with a patient who started fitting while in an MRI scanner.
So far as community dentists were concerned, Dr Bowhay felt that practitioners
needed to have the knowledge to deal with any complications, especially if they
were not used to dealing with patients who had stopped breathing.
It was unfortunate that the recently published National Health Service plan
made no reference to paediatrics in general or to paediatric pharmacy in particular,
Dr CAMPBELL DAVIDSON (medical director, Alder Hey hospital) said.
Looking back over 30 years of change in paediatric practice and at the potential
for the future of paediatric pharmacy, Dr Davidson said that the challenge for
pharmacists was to promote the specialty and the major contribution that pharmacists
make to patient care. Among advances in the past 30 years were a decrease in
spina bifida due to increased ante-natal uptake of folic acid and decreases
in measles and mumps due to MMR vaccine. However the debate around prevention
still raged, an example being the use of chickenpox vaccine in the United States
but not in the United Kingdom.
Dublin poster wins travel bursary
The NPPG travel bursary was awarded for a poster entitled “From the paediatric hospital to the community pharmacy — an aid to seamless care” by Siobhan Moriarty and Jane Fanning (Our Lady’s hospital for sick children, Dublin). They carried out a three-month audit of calls received from, and made to, community pharmacists and carers with a concurrent audit of discharge prescriptions. All items for which information was requested or provided to a pharmacist or which potentially could be prescribed on discharge were included. The outcome was a booklet of information on the availability of about 70 products and the formulation of 24 oral liquids and topicals. A trouble shooting guide to help deal with all prescriptions from the hospital, information sources routinely used by the pharmacy department and the compounding of extemporaneous products was also included.