Quiz Feedback: Medication errors/Cough and cold in children

Most people correctly selected the details that are recommended to be included on a prescription. This message seems to be well understood.
To help minimise the occurrence of medication errors, prescribers are encouraged to include the following details (where appropriate) when prescribing, especially for children:

• Weight in kg (include the date the weight was measured)
• Basis of dose i.e. mg/kg dose (ensure that weight-based dose does not exceed the recommended adult dose)
• Indication for medicine e.g. on prescriptions for paracetamol state “only for use in pain or fever”
• Specific instructions (avoid vague instructions such as “take as directed” or “when required”)

Abbreviations and symbols have historically and commonly been used in prescribing but this practice is no longer recommended. This may account for the 18% of respondents who incorrectly indicated that abbreviations should be included on a prescription. Using abbreviations and symbols can be a source of confusion and misinterpretation e.g. HCT is used for both hydrocortisone and hydrochlorothiazide, O.D can be mistaken for Q.I.D or BD.

Ibuprofen is not considered a first line analgesic/antipyretic medicine because of its association with increased risk of GI bleeding in addition to renal toxicity and aspirin-like sensitivity reactions. The recommendations when prescribing ibuprofen for children are:

• For infants and children the usual oral dose is 20 mg/kg/day, in divided doses
• If the child is over 7 kg and has a severe condition, this can be up to 30 mg/kg/day
• In children weighing less than 30 kg, the total daily dose should not exceed 500 mg
• Always use the lowest effective dose, for the shortest possible duration, and preferably administer after food

A reasonable oral dose for a nine-year-old child would usually be 200 mg, three to four times per day (as selected by 34% of respondents). However in the example above, the child weighs less than 30kg, so the total daily dose should not exceed 500 mg. So for this child, the most appropriate of the three dose options would be 100 mg ibuprofen, three to four times daily.

Paracetamol is the preferred first-line analgesic for children for fever and mild to moderate pain as it has few adverse effects when dosed correctly. However, serious and sometimes even fatal liver toxicity can occur with acute and chronic overdose, so for this reason it is prudent to take time to calculate or look up safe dosing regimens when prescribing paracetamol for children.

The weight-based dose for paracetamol in children is generally 10–15 mg/kg, every four to six hours (maximum of four doses in 24 hours). The BNF for children (BNFc) gives age-based dose regimens and recommends a paracetamol dose for children 6–12 years of 250–500 mg every 4–6 hours (maximum 4 doses/24 hours).

In the example above, a conservative approach would be to follow BNFc recommendations and prescribe 250- 500 mg paracetamol, every four to six hours (as selected by 57% of respondents). However as the child weighs over 40 kg, it would be acceptable to prescribe a regular adult dose, therefore 500 – 1000 mg paracetamol, every four to six hours is the most appropriate dose in this situation (as selected by 43% of respondents).

In the example above the child weighs 25 kg, so using the 10-15 mg/kg dosing regimen, this would work out as 250-375 mg, every four to six hours. The BNFc recommends a paracetamol dose for children aged six to 12 years of 250-500 mg, every four to six hours. Therefore, if it is inferred that the prescriber intended the dose to be 250 mg paracetamol, every four to six hours, then this is the correct dose based on the child’s age and weight (although 28% of respondents disagreed with this).

The errors with the prescription are; trailing zero used (which could be misinterpreted as 50 mL instead of 5 mL), brand name used (Paracare) instead of generic name (paracetamol), clear instructions for use and maximum daily dose not given (all potentially leading to misinterpretation and medication error).

Ideally the prescription would be better written as: Paracetamol 250 mg/5mL, 5 mL to be given, every four hours, as required for pain or fever, maximum of four doses per day.

Although the majority of children with an acute cough presenting to general practice are likely to have a viral upper respiratory tract infection (URTI), the possibility of a more serious problem should be considered. Other serious causes of acute cough e.g. pneumonia, pertussis, foreign body inhalation should be considered and excluded if possible, especially in coughs that persists.

A cough associated with a very sudden onset or a history of choking may suggest inhalation of a foreign body, particularly in younger children.

Neonatal onset of cough can indicate some serious causes e.g aspiration, congenital malformation, cystic fibrosis, primary ciliary dyskinesia, infection.

“Parents know their child best”, so any reasonable concern that persists, despite reassurance, should be seriously considered and other causes for cough investigated.

These concepts seem well understood by respondents.

Habit (psychogenic) cough is estimated to be the cause of persistent cough in children in 3–10% of cases. Diagnosis should only be made after other causes have been excluded, such as a transient or chronic tic disorder or Tourette’s syndrome.

Features of habit cough include:

• A dry harsh cough, repetitive and often reproducible on request
• Often begins with an URTI, which then persists
• Cough can occur at any time, can decrease during enjoyable activities, disappear at night, and can be disruptive to others while the child seems oblivious to it
• The child may have a history of psychosocial problems such as abuse, anxiety, school phobia or depression

These concepts seem well understood by respondents.

In general investigations are not required for children with acute cough who are likely to have a diagnosis of a viral URTI, which will be the majority of cases presenting to general practice.

Spirometry can be useful for investigating a chronic dry cough in a child who is old enough to master the technique (usually school age). However normal results do not exclude a diagnosis of asthma.

A chest x-ray may provide useful information in a child with chronic cough, abnormal chest signs or history of aspiration e.g. possible foreign body inhalation (although a normal chest x-ray does not exclude this possibility).

Sputum collection is often not useful as most young children swallow their sputum and are unable to produce a sample of sufficient quality for analysis. If a sample can reliably be collected, sputum analysis may be useful for older children with a chronic wet cough. This point appears to have caused some confusion, with 29% of respondents.

Paracetamol can be considered first-line for the treatment of pain and fever. Ibuprofen is also effective for pain and fever, but is considered, especially in children, to be a second-line alternative to paracetamol. Parents/carers can sometimes perceive that paracetamol and ibuprofen if effective separately will be even more effective when used together. Advice to parents should be:

• To use paracetamol as first-line and to only add in ibuprofen to the regimen if there is no response to paracetamol and to NOT routinely use paracetamol and ibuprofen together
• Not to use paracetamol for the specific purpose of preventing febrile convulsion

Other advice for managing fever at home includes not under-dressing or over-wrapping the child. Although selected by 17% of respondents, “tepid sponging” is not an effective method for reducing fever and causes distress to most children, therefore it is no longer recommended (See Correspondence, “Tepid sponging”, BPJ 30, August 2010 for more information). Keeping up regular fluids and checking for deterioration in the child’s overall condition is essential for parents/carers.

A 2008 Cochrane review found that antitussives, antihistamines, antihistamine/decongestant combinations and antitussive/bronchodilator combinations were no more effective than placebo in alleviating symptoms of cough and cold. Medsafe recommends that cough and cold preparations containing medicines such as antihistamines, antitussives, expectorants and decongestants should not be used in children aged less than six years.

Beta-2 antagonists e.g. salbutamol, have not been shown to reduce the incidence or severity of cough in children with acute cough, with no airflow obstruction.

Infection with the common cold can affect children and adults differently, therefore products which may be effective for adults do not necessarily work in the same way for children. It is acknowledged that the placebo effect may play a significant role in the anecdotal success and popularity of using cough and cold preparations.

Many cough and cold preparations contain either a CNS depressant e.g. promethazine or a CNS stimulant e.g. phenylephrine. This can lead to adverse CNS effects, even following recommended doses, such as sedation, psychomotor impairment, insomnia, tremor and hyperexcitability.

These concepts seem well understood by respondents.

Although widely used, most cough and cold preparations are not effective at reducing symptoms related to cough and cold in children. Paracetamol is recommended as the first-line treatment for pain and fever associated with cough and cold. Saline drops or spray may be used as a nasal decongestant, particularly in younger children and infants. Although there is a lack of clinical evidence of effectiveness, honey is regarded as a safe treatment to trial for a child, aged over one year with cough and cold. Honey should not be used in children younger than one year, due to the very rare association of honey with infant botulism. There is no evidence that echinacea prevents occurrences of cold.

One of the most important things that parents can do for their child with cough and cold, is to provide a “healthy home” environment i.e. a warm, dry and smoke-free house, and provide general care such as encouraging rest, adequate fluid intake and keeping the child clothed warmly.

These concepts seem well understood by respondents.