Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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BNFor ENF?
- Trevor H Batt (23 September 2005)
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Prescribing in pediatric population: a research priority?
- Dr. Naseem A. Qureshi (24 September 2005)
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BNF calculator for estimating creatinine clearance is unsafe in children.
- Naima Smeulders, Nas Al-Jafari and Rowena Hitchcock (7 April 2006)
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A safe pediatric prescription
- khalid alkhouly (7 April 2008)
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Trevor H Batt, Formulary/Interface Pharmacist Torfaen Local Health Board, Block C, Mamhilad House, Mamhilad Park Estate, Pontypool, Torfaen NP4 0Y
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The publication of the BNF for Children is undoubtedly a significant step forward for this area of medicines use and the forthcoming UK distribution to all prescribers is laudable. The distribution in Wales is not due till the end of October at the earliest. This apparently will lag a little behind the distribution in England. This makes it all the more frustrating that the online version is for England only. I hope this does not herald the beginning of differential access to prescribing information across the UK and the BNF becoming the ENF. Competing interests: None declared |
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Dr. Naseem A. Qureshi, Specialist Senior Registrar POBox.4545, Department of Psychiatry, Rashid Hospital, Dubai, UAE.
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Sir, This editorial by Marcovitch(1) is an eye opener for all concerned prescribers with regard to pediatric population, however they can not solve the problems of off-label and unlicensed drug prescribing in children. Unfortunately, the usual trend is that the new drugs are more often subjected to rigorous trials in adult population and the encouraging results are applied in child population without any drug trials in this specific population, look for example psychotropic drugs in particular SSRIs and atypical antipsychotics. This trend needs overall change in order to ensure safety of pediatric population worldwide. Reference: Harvey Marcovitch. Safer prescribing for children. BMJ 2005; 331: 646 -647 Address: POBox.4545, Rashid Hospital, Dubai, UAE Fax.0097143113222 Competing interests: None declared |
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Naima Smeulders, SpR Paediatric Surgery Department of Paediatric Surgery and Urology, John Radcliffe Hospital NHS Trust, Oxford, OX3 9DU., Nas Al-Jafari and Rowena Hitchcock
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It is tempting to calculate the glomerular filtration rate (GFR) in children, in whom the accurate measurement of GFR is challenging. The BNF for children fails to spell out the hazards of estimations based on the Schwartz formula. 1 Renal impairment is overlooked, where serum creatinine is not raised.2 In addition, the BNF Extra offers a serum creatinine, age and sex-based calculator on-line without comment on its use in children.3 We compared creatinine clearance estimated by Schwartz formula and BNF Extra calculator from contemporaneous serum creatinine to laboratory GFR (by single injection 2 sample 99Tc-DTPA methodology) in 114 paediatric urology patients aged 1-14 years (Figure 1).
Figure 1.
The Schwartz formula identified patients with a laboratory GFR <80 ml/min/1.73m2 with 91% specificity but only 60% sensitivity. Schwartz missed those in whom the remaining number of functioning nephrons was sufficient for a normal serum creatinine. As this group of patients, nevertheless, requires special attention, including the use of medicines, the formula is unsafe. The on-line BNF calculator overestimated creatinine clearance in every case (Figure 2): mean overestimate 82 ml/min/1.73m2, range 4.5 to 156 ml/min/1.73m2. It should therefore never be used in children.
Figure 2.
In reply to Dr Marcovitch, who comments that the BNF for children has been validated against emerging evidence, guidelines on best practice and advice from a network of clinical experts, we would caution the use of either of these mechanisms for estimations of GFR in children.4 We suggest that the BNF Extra on-line calculator should exclude its use in children. Nas Al-Jafari, F2 Trainee in Paediatric Surgery, Naima Smeulders, Specialist Registrar in Paediatric Surgery and Rowena Hitchcock, Consultant Paediatric Surgeon and Urologist. Department of Paediatric Surgery and Urology, John Radcliffe Hospital NHS Trust, Oxford, OX3 9DU. naima.smeulders@btopenworld.com References: 1 Costello, I ed. BNF for children. London: Pharmaceutical Press, 2005:12-13. 2 Seikaly MG, Browne R, Bajaj G, Arant BS Jr. Limitations to body length/serum creatinine ratio as an estimate of glomerular filtration in children. Pediatr Nephrol1996; 10:709-11. 3 BNF Extra. Calculators: Creatinine clearance. 2005 http://www.bnf.org/bnf/extra/current/noframes/450019.htm (accessed 17 March 2006) 4 Marcovitch H. Safer prescribing for children. BMJ 2005;331:646-47. FIGURES 1 and 2 emailed to Sharon Davies Competing interests: None declared |
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khalid alkhouly, General Surgeon 10 Woodland Hill, Perth Andover, NB, E7H 5H5
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The majority of healthcare staff is highly motivated individuals who work together as a team to achieve the best outcomes for their patients. Pediatric prescription is one of the most sensitive issues, not only to the pediatricians and general practitioners, but also to the junior staff who may need to be supervised in their practice till they get the precise indications, formulations and dosages. Health professionals have put in place a range of systems and checks to prevent errors. Periodic healthcare system review limits the incidence of error, so that if an error occurs its damaging effects are minimized. However, recent experience has shown that in certain situations those safeguards have not been adequate and have failed to prevent serious error and harm to patients. Too often, incident enquiries have been characterized by passive learning –where lessons are identified but not carried through into practice. A more open culture, in which errors can be reported and discussed, mechanisms for ensuring the lessons are put into practice. Mistakes do occasionally occur and in the great majority of cases the causes of serious errors stretch far beyond the actions. Learning organization must be locally driven by health professionals and managers at the front line of patient care. Competing interests: None declared |
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