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Prescribing for children

While all the foregoing advice on avoiding medication errors applies to both children and adults, special care is needed when prescribing, preparing and administering drugs to children.

Drugs that are relatively innocuous in adults may have adverse effects in children. Variations in height, weight and body mass can make them more susceptible; or they may quickly accumulate toxic levels as a result of slower metabolism and excretion.

At MPS we see many examples of errors occurring because a doctor failed to check the appropriateness of a drug and its route of administration for children or infants, or to prescribe the correct dose.

We have also seen tragic cases (such as the one recounted in the case report below) in which infants have died or been seriously and permanently impaired because doses of drugs were miscalculated or a decimal point misplaced.

We see many examples of errors occurring because a doctor failed to check the appropriateness of a drug and its route of administration for children or infants, or to prescribe the correct dose

Case report

An overworked doctor, who had been on duty for 11 hours overnight while deputising for a colleague on leave, was asked to see a premature infant with biventricular heart failure. He was not normally responsible for the care of premature infants, but he prescribed digoxin to be given intramuscularly and calculated (by mental arithmetic) that the dose should be 0.6 mg.

Just as he was settling down for a well-earned rest, the ward nurse phoned to ask whether the dose shouldn’t be 0.06 mg as she had had to open two ampoules. Without thinking, he told her to “Give it as I ordered”.

An hour later he was called to the ward because the baby had suffered a cardiac arrest.

Advice for safer paediatric prescribing

  • Refer to a paediatric formulary when appropriate and always seek advice from colleagues if you are not sure.
  • When writing a prescription, include the child’s age and write the exact dose in weight and (if liquid) volume required for administration.
  • Always calculate doses on paper and get a competent colleague to check your arithmetic.
  • When writing dosage, take special care in placing the decimal point and putting a zero in front of it.
  • If you are prescribing in very small amounts of less than 1 milligram, prescribe in micrograms (written out – not abbreviated) to avoid confusion over the placing of decimal points.
  • When prescribing for a child, it is particularly important to give the parents all relevant information such as:
    • the name of the drug
    • the reason for the prescription
    • how to store and administer the drug safely (if appropriate)
    • common side-effects
    • how to recognise adverse reactions.
Remind [parents] of the importance of storing drugs in their labelled containers, and well out of children’s sight and reach
Parents must always be warned about side-effects, particularly those that will be distressing to the child (eg, alopecia with cytotoxic drugs). It is also helpful to remind them of the importance of storing drugs in their labelled containers, and well out of children’s sight and reach.