The launch of the first edition of the BNF for Children brings with it a commitment to providing cohesive, evidence-based information on medicines for children. In an interview for the Irish Pharmacy Journal, Julie Cronin spoke to its Senior Editor, Ian Costello, about the formulary and about the need for an increase in paediatric experience and expertise in the community.

The area of paediatric medicines has traditionally suffered from a dearth of coherent information, an emphasis on hospital-based expertise, and the absence of an integrated multidisciplinary approach to children's healthcare. As such, the publication of the BNF for Children (BNF-C) this month represents a major milestone for paediatric medicines. The formulary will be the first regularly updated publication in the area of paediatrics, it is designed for use by all healthcare professionals involved in the prescribing, dispensing and administration of medicines to children, and its style is firmly based on the familiar classifications of the BNF.

Ian Costello, editor of the BNF-C, is keenly aware that greater information provision on paediatric medicines is a necessity for pharmacists and other healthcare professionals. "Speaking from the perspective of information provision, there is a marked need for reliable sources of information," says Costello. "Information on paediatric medicine is in lots of different places, in lots of different formularies, presented in varying ways, of varying quality. In many instances, it is meant only for local use. The body of evidence is limited in paediatrics," he says.

Catering for the idiosyncrasies of paediatric medicines
Costello's experience in the area of paediatric pharmacy is extensive, with a stint as Chief Pharmacist at Birmingham Children's Hospital followed by employment as Clinical Lecturer and Research Fellow at the London School of Pharmacy. As one would expect, Costello's level of expertise is reflected throughout the highly organised management structure which has overseen the development of the BNF-C. The Paediatric Formulary Committee is composed of representatives nominated by its collaborating organisations - the Royal College of Paediatrics and Child Health, the Neonatal and Paediatric Pharmacists Group, the British Medical Association and the Royal Pharmaceutical Society - and is chaired by Dr. George Rylance, Consultant Paediatrician at the Royal Victoria Infirmary and advisor to the International Paediatric Association and the World Health Organisation, among others. A panel of expert advisors supports the work of the formulary's five editorial staff, providing expert opinion on each clinical area and advice for resolving problems. The editorial staff members are based at the BNF offices, enabling them to avail of the parent publication's expertise in editorial processes, layout and electronic products.

While the BNF-C is based on the classifications of the BNF, its layout has been adapted to meet the idiosyncrasies of paediatric medicines. Ian Costello explains this as follows: "In paediatrics, the pharmacist's role is more difficult. Issues include knowing what the most appropriate dose is and knowing how to monitor that dosing regimen. The effect and how a child handles the effect of the medicine can vary considerably within children of the same age. Then there is the formulations issue; what strengths, how reproducible is the dose, how are you going to ensure that it's made to a similar quality each time? While a larger body of work needs to be done to guarantee stability of dosage, the formulary includes guidelines to help people to apply certain criteria to guarantee that the formulation is made to a high standard. There are also recommendations on best practice to ensure criteria you apply to purchasing formulations and how to work with companies to guarantee quality."

The BNF-C is also distinct in its inclusion of information within its monographs that the BNF consigns to the appendices. Such information includes the use of drugs in pregnancy and during breastfeeding as well as hepatic and renal impairment. Supporting information on how to manage drugs will also be included within the monographs. Guidelines on measures to improve compliance and concordance are an additional feature.

Specifically, the range of information contained in the BNF covers:
• All medicines licensed for use in neonates, children and adolescents up to the age of 18.
• Medicines in common use.
• Unlicensed medicines for which there is good evidence.
• Information which is relevant to practitioners in primary, secondary and tertiary care.
• Monographs which give details about pregnancy, breastfeeding, hepatic and renal impairment as well as supporting information on the management of drugs.
• Best practice guidelines on extemporaneous preparations.

Championing paediatric pharmacy
According to Ian Costello, the BNF-C is only one step among many that need to be taken to guarantee the safe and effective use of medicines in the paediatric population.

"There's a real need for paediatric champions to get over some of the restrictions and barriers that are in place in this area and to coordinate and disseminate best practice," he says. In this regard, Costello was impressed by the work done by the Irish Centre for Continuing Education this spring in the area of Medicines for Children. (Over 850 pharmacists attended at the Centre's roadshow which traveled to 26 venues around Ireland). He describes the roashow as "an excellent initiative; something we would like to mirror in the UK in terms of its detail and quality."

"It's certainly unique in terms of any initiative I've seen around paediatrics in the community," Costello continues. "CPD in the UK is nowhere near as detailed or provided with the frequency that this roadshow has been." He underlines the need to build on the success of the ICCPE's module on Medicines for Children so that it can be "benchmarked and used as the base for a continued learning process to encourage the development of paediatric pharmacy practitioners in the community."

This growing need for a greater commitment of paediatrics experts to the community pharmacy setting is a major concern for Costello. "Paediatric experience has historically been based in secondary care, in the hospital setting. There's often an expertise gap in the community," he says. "The ICCPE roadshow is a big step forward in filling that gap. There's a need to keep the momentum going so that paediatric pharmacy practitioners become the norm in the community and that there is a seamless crossover between hospital and community settings."

In terms of future developments, Costello cites the "bigger body of work actively being produced in Britain by the NPPG" in the area of medicines information applied and produced in parent friendly format. For the time being, however, Costello recommends investment in the BNF-C as a key step towards guaranteeing the safe and effective usage of medicines in children. "I would encourage all pharmacists who deal with children and who dispense prescriptions for children to have this information source available to them," he says.

The British National Formulary for Children is published in print format at the start of September. It will be published in electronic format later in the year. It will be available in Ireland as per the BNF. Further information is available at www.bnf.org