Manipulations of Oral Medications in Paediatric Neurology and Oncology Care at a Swedish University Hospital: Health Professionals’ Attitudes and Sources of Information

Abstract

Oral administration of medications to children requires age-appropriate dosage forms and strengths. In this study, we: (i) assessed the extent of oral dosage form manipulations, (ii) documented how it is carried out, and (iii) examined the attitudes and sources of information regarding the handling from healthcare professionals. Prospective reviews of electronic records, ward observations, and clinician surveys were performed at a paediatric neurology ward and a paediatric oncology ward in Sweden during April to May of 2018. Approximately 15% of oral medications were manipulated for the studied patient group (median age 12.9 years in oncology, 5.8 years in neurology) with approximately 30% of the patients having an enteral feeding tube. Manipulations were performed both to obtain an appropriate dose from, for example, a fraction of the original tablet or to obtain a powder that could be used to prepare a slurry for administration through enteral feeding tubes. Risks identified were related to patient safety such as cross contamination, suboptimal absorption/pharmacokinetics and inaccurate dose. When examining the working environment of nurses, we observed safe handling of hazardous substances but the nurses occasionally experienced stress and a fear of making mistakes due to absence of information. Paediatricians experienced a lack of time to search for proper information on manipulations. As a step towards improving safety in paediatric medication, we suggest the introduction of clinical pharmacists into the team and further evaluating the possibilities of using more ready-to-administer medications with necessary product information and pharmacovigilance support.

3D Printing of Pediatric Medication: The End of Bad Tasting Oral Liquids?—A Scoping Review

“…Studies conducted in a children's hospital in the Netherlands and pediatric wards in a German hospital show that manipulation was necessary for 37% of oral medicine prior to administration [7,8]. Similar studies conducted in Norway and Sweden found a lower manipulation prevalence of 17% and 15.5%, respectively, for orally administered pediatric medicines [5,6]. The lower manipulation rate could be explained by a difference in the definition of drug manipulation.…”

“…Manipulation of marketed drugs, e.g., crushing or splitting tablets or diluting a solution, often holds two specific reasons, namely, to acquire the needed dosage strength, or to adapt an unsuitable dosage form, i.e., poor swallowability or palatability of the dosage form. A combination of these reasons also occurs [5][6][7][8].…”

‘Working outside the box’—an interview study regarding manipulation of medicines with registered nurses and pharmacists at a Swedish paediatric hospital

“…Examples of manipulations include the splitting of tablets, crushing and dissolving tablets in liquids, opening capsules and cutting suppositories 1 . Most studies on the manipulation of medicines in the paediatric setting are observational studies for short time periods with results ranging from 10% to 57% of all administrations being manipulated 2–5 . A study conducted in a Swedish paediatric university hospital concluded that there is still a lack of suitable dosage forms and strengths for paediatric patients 6 …”

Manipulated Oral and Rectal Drugs in a Paediatric Swedish University Hospital, a Registry-Based Study Comparing Two Study-Years, Ten Years Apart

“…The frequencies of manipulated doses, including those made to facilitate drug administration, ranged from 11% in adolescents to 64% in toddlers, with an overall average frequency of 16% [ 9 ]. These results contradict earlier reports where children older than six years have the highest frequency of manipulations [ 7 ].…”