The Pharmaceutical Journal
Vol 280 No 7492 p292
8 March 2008

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Working as a neonatal pharmacist

Caring for neonates is a fast-growing area of practice, as more babies survive despite being born at low gestational ages, says Maiya Ahmed

Careers series

Neonatal pharmacy is changing fast. Advances in care, including medicine use, mean that babies of an increasingly low gestational age are surviving, with those weighing less than 1kg now having an 80 per cent chance of living, compared with a 20 per cent survival rate 20 years ago.

Around one in eight babies born in the UK will be admitted to a neonatal unit because of an infection and will need intravenous antibiotics or breathing support and one in 40 will need neonatal intensive care. The unit at St Mary’s Hospital, London, where I work as specialist neonatal pharmacist, is a tertiary centre for neonatal intensive care.

As such, it has frequent referrals from hospitals that lack the capacity and staff to treat seriously premature babies or those with complex problems. The unit has 26 beds, including a high-dependency unit and a special care baby unit.

Since starting at St Mary’s I have produced a neonatal formulary, which is over 100 pages, covering all medicines commonly used, along with guidelines, such as pain protocols and guidance about infusions, parenteral nutrition and immunisation. Producing the document was rewarding and a great learning experience. It was checked and rechecked by various groups at the hospital to minimise the risk of errors.

There are major differences between the pharmaceutical care needed by neonates and that needed by paediatric patients. The clearance and excretion of drugs is problematic in neonates and their liver and kidney functions can fluctuate. This means that blood levels, particularly trough levels, need to be monitored closely to determine whether a drug is accumulating or being cleared effectively.

Assessing the degree of pain felt by neonates is difficult because severely premature babies may not have developed features, such as a high-pitched scream, that one looks for in paediatric patients. While older children can become involved in their own care neonates cannot. Methods of drug delivery also differ.

In neonates the oral route is often inappropriate, as is the peripheral route, because the friability of veins means a high risk of extravasation. Instead, single-lumen long central lines are used. Compatibility is therefore a key issue — more than one drug will often be present in the same line and contact times can be long because drugs have to be infused slowly. For paediatric patients, drugs can generally be infused more quickly and double or triple lumen central lines can be used.

The pharmacist’s role on a neonatal ward is similar to that on an adult or paediatric intensive care ward. The main aspects of the job are:

• Providing a clinical pharmacy service
• Providing input into parenteral nutrition services
• Developing a formulary
• Educating staff and parents
• Participating in the multidisciplinary team
• Providing input into maternity services

Advising on drug choice is a key to the role. The gestational age of the baby is important because the pharmacokinetics of drugs is different in neonates to other patients, so the dose or frequency of dosing needs to be adjusted. When I started at St Mary’s the nearest thing to a neonatal formulary was a folder in the baby unit, but nothing was referenced and it was hard to work out how much of a particular medicine to give.

Our new formulary has built on those of other trusts and the BNF. It is aimed at nurses, doctors and pharmacists. Since it has been used, we have noticed a reduction in errors. I would like to see a neonatal version of the BNF for Children that would be used in every hospital.

Some creams used in paediatrics cannot be used on neonates because their the skin is particularly permeable and there is a risk of systemic absorption. If chloramphenicol ointment is used topically, for example, the effects of a dose can be compared to the likely effects of an intravenous dose. Systemic absorption of eye drops is also an issue.

Most babies on the neonatal unit need parenteral nutrition at some point and significant pharmaceutical input is needed in its manufacture and prescribing. Several factors are significant, including: whether the baby has a long line or peripheral access; what the electrolyte levels are; and whether the baby can tolerate lipids. (Lipids are contraindicated after gut surgery or if the baby has jaundice.)

Enteral feeds encourage bowel and gut flora to develop. However, introducing feeds too quickly is associated with necrotising enterocolitis, a condition common in neonates. For this reason, the amount of feed is slowly titrated.

Hyperglycaemia and hypoglycaemia are also fairly common in neonates (especially those born to mothers with diabetes); with these conditions the glucose content of the parenteral nutrition must be changed and glucose levels and fluid balance monitored — a small volume of fluid can have a huge impact on the fluid balance of a neonate.

Educating junior doctors

The neonatal pharmacist plays an important role in educating junior doctors, who may not be aware of the different approaches needed to paediatric and neonatal patients. At St Mary’s the neonatal pharmacist attends the weekly multidisciplinary ward round with the doctors, nurses and dietitian. Medicines are often reviewed, so a pharmacist’s input is crucial. The pharmacist also attends the registrar-led, twice-daily ward rounds as necessary.

In many hospitals neonatal pharmacists are responsible for maternity wards. At St Mary’s a junior pharmacist covers these wards on a three-month rotation. The neonatal pharmacist helps train them and answer queries.

There is currently no formal pharmacy postgraduate education in neonatology, although some universities offer modules in paediatrics and intensive care as part of diploma courses in pharmacy practice.

The Neonatal and Paediatric Pharmacy Group holds an annual conference with workshops and lectures. It is a great place to learn and network. Information is also available from the British Association of Perinatal Medicine, the Royal College of Paediatrics and Child Health, BLISS, a premature baby charity, and the Thames Regional Perinatal Group