Intended for healthcare professionals


A prescription for better prescribing

BMJ 2006; 333 doi: (Published 31 August 2006) Cite this as: BMJ 2006;333:459

Don’t forget the children!

The Editorial by Aronson et al (1) highlights the fact that medical
students and junior doctors are unprepared for prescribing drugs for the
patients they need to care for. When these patients are babies and
children this problem is even more pronounced since these patients are at
higher risk of prescribing errors than adults (2) and have fewer internal
reserves to compensate if they occur. In children there is no such thing
as a standard dose, most need to be calculated on an individual patient
basis taking into account gestational and postnatal age, weight and/or
body surface area. Drug selection and doses need to take into account the
dynamic changes in pharmacokinetic and pharmacodynamic maturity of the
patient and the potential for drug toxicity which can be different to
adult patients. The need to use drugs which are unlicensed or off label
for the majority of paediatric patients in hospital (3,4) and a
significant proportion in the community (5) also means that suitable
licensed products and prescribing information are not always readily

Education and competency assessment for all healthcare professionals
prescribing for children is therefore paramount. This is currently being
delivered by a number of centres around the UK. We have established this
through the Co-operative of Safety of Medicines in Children (COSMIC)
scoping study which aims to identify and analyse interventions used to
reduce errors in the calculation of paediatric drug doses. This is a joint
project between the University of Nottingham and the School of Pharmacy
and Institute of Child Health, University of London. The project has been
funded by the Patient Safety Research Programme, Department of Health and
will report its findings at the end of this year. However we have
established that this education and training can take many different
approaches, use different teaching methods and may or may not assess
prescribing competency. We agree that a national syllabus and competency
assessment programme is needed. We would support the proposal by Dr
Aronson (6) that research is needed to establish current practice,
identify gaps and to propose a minimum set of standards. This must include
the unique challenges presented by the paediatric patient and therefore
must involve paediatricians, paediatric clinical pharmacists and
paediatric clinical pharmacologists.

Sharon Conroy, Lecturer in Paediatric Clinical Pharmacy,

Mark Anderson, Specialist Registrar in Paediatric Clinical

Helen Sammons, Consultant Paediatrician, Associate Professor in Child

Academic Division of Child Health,
Derbyshire Children’s Hospital,
University of Nottingham


1. Aronson JK, Henderson G, Webb DJ, Rawlins MD. A prescription for
better prescribing. BMJ 2006;333:459-60.

2. Kaushal R, Bates DW, Landrigan C, McKenna KJ, Clapp MD, Federico
F, Goldmann DA. Medication errors and adverse drug events in pediatric
inpatients. JAMA 2001;285:2114-20

3. Conroy S. McIntyre J. Choonara I. Unlicensed and off label drug
use in neonates. Arch. Dis. Child. Fetal Neonatal Ed. 1999;80:F142-145

4. Conroy S, Choonara I et al. Unlicensed and off label drug use in
paediatric wards in different European countries. BMJ 2000;320:79-82

5. McIntyre J, Conroy S, Corns H, Avery A, Choonara I. Unlicensed and
off label prescribing of drugs in general practice. Arch Dis Child

6. Aronson JK, Barnett DB, Ferner RE, Ferro A, Henderson G, Maxwell
SR, Rawlins MD, Webb DJ. Poor prescribing is continual. BMJ 2006;333:756

Competing interests:
None declared

Competing interests: No competing interests

16 October 2006
Sharon Conroy
Lecturer in Paediatric Clinical Pharmacy
Mark Anderson, Helen Sammons
Academic Division of Child Health, Univ of Nottingham, Derbyshire Children's Hospital, DE22 3DT