Nurse Practitioner's Role in Prescribing for Children

A Nurse Practitioner currently undertaking the Independent Nurse and Supplementary Nurse Prescribing Course is required to critically analyse and evaluate history taking, clinical assessment and appropriate referral for children, recognising the unique physiological and anatomical difference between neonates, children and young people having considered the legal, cognitive, emotional and physical differences between children and adults.

The Nurse Practitioner should consider as a nurse prescriber that history taking provides the opportunity to observe the child-parent interaction (Bickley and Szilagyi, 2013). However, as well as observation, communication plays a vital role as well in every aspect of consultation particularly in young people (Nuttal and Ruth-Howard, 2011). Furthermore, Nolan (2007) mentions that communication is both verbal and non-verbal requiring special skills, taking into account the child or young person’s stages of development (Nursing and Midwifery (NMC), 2004). 

The Nurse Practitioner is currently based in adult nursing however in line with the course; it is a requirement to demonstrate the differences between prescribing for adults and children. In consultations with children, parents play a role as historian and take part in describing the child’s symptoms to the practitioner (Nuttal and Ruth-Howard, 2011). It is important to gain valid consent prior to assessment, examination and initiation of treatment in line with the child’s best interest (Williams and Perkins, 2011) in accordance to the Children’s Act 1989. However, patients under the age of 16 are not deemed autonomous adults; therefore, decisions for their healthcare require the parents or guardians to be involved in making decisions requiring consent (Department of Health (DH), 2001). Nevertheless, the concept of the Gillick’s competent child under the age of 16,  who is deemed competent enough to give consent as an autonomous adult if considered mature enough to understand the proposed clinical treatment and procedure is also a challenge for the practitioner (Hunter and Pierscionek, 2006). Furthermore, once the child is determined as Gillick competent, the practitioner is likely to respect the child’s autonomy in the same fashion as for any adult. Blair (2011) on the other hand, argues that Gillick competence also means that a child at no specific age can consent to treatment, depending on the degree of the condition and treatment. However, the DH (2001) implies that despite the child being deemed competent, it is still best practice to encourage children to involve their families in decision-making. Therefore, the practitioner should never assume that a child with a learning disability is not competent to make decisions , as most children are, provided with information given in a way they can understand, supporting the decision making process (DH, 2001).

Although medication may have significant risks, it is essential that when making the decision to prescribe medication for children and young people in partnership with the practitioner and parents/guardians, that the benefits of the treatment outweigh the risks (Caldwell 2011), enabling the best possible health outcome to be achieved (DH, 2004). In view of this, children must be closely monitored when given medications, ensuring the expected benefits are not compromised by unwanted side effects. The British National Formulary (BNF) and British National Formulary for Children (BNFc) (2015) clearly stress those children, particularly neonates respond differently compared to adults.

According to the World Health Organization (WHO 2007), it is important to assess the changes that occur from birth to adolescence. In addition, one of the variations between children and adult is the dynamic process of maturation such as the developmental changes in physiology, which affects the pharmacology in terms of its efficacy, toxicity and dosing regimen. The nurse prescriber should review all the literature and understand that the drug toxicity is increased in children, therefore it is crucial that dosages are calculated (BNF, 2015).

The commonly used approaches for dose adjustment is based on body weight (mg/kg) and the age of the child, taking into account the changes due to developmental growth within each age group (Cella et al 2010). Therefore, the nurse prescriber should recognise that drug doses are occasionally calculated based on body surface area, as this parameter is possibly more accurate than body weight particularly in cases of narrow drug therapeutic index (Morris 2010).

Children and adults differ in a way in how the body handles a drug and varies between different stages of childhood (Morris 2010).  According to Anderson and Holford (2013), the process of distribution, absorption, metabolism and elimination determines the time course of concentration. Neonates have a much lower gastric secretion compared to adults however; the oral absorption of medicines in older infants and children is similar to that in adults (Schoor, 2006). Furthermore, the volume of distribution of medicine differs from premature babies, neonates, infants and young children in comparison to an adult. This is because there is an increased extracellular fluid compartment in neonates, requiring a greater initial dosage than older children (Anderson and Holford , 2013). In addition to Anderson and Holford, (2013) there is an increased permeability of blood brain barrier, reduced fats and muscles in neonates, and a dramatic increase in metabolic rate happens from 5-15years thus, compared with adults, children may require higher doses based on mg/kg and increased its dosing frequency. The glomerular filtration rate (GFR) and renal tubular function in neonates are immature until about 6 months when it reaches adult levels (Schoor, 2006). Therefore, the medicines that are excreted in the kidney have the tendency to be accumulated in neonates and young infants. Equally important WHO (2007) stipulates that there is a greater significance in the excretion capacities of neonates, infant and children as there is a poorer hepatic metabolism and renal capacity.

There are factors to consider when it comes to prescribing for children. These are; certain drugs may be inappropriate in use for children, for example, the use of tetracycline antibiotics for children is contraindicated (Thorp, 2008). The drug is absorbed into growing teeth and harmful for bone growth leading to yellow staining of the teeth (Morris, 2010). In view of prescribing for children, the prescriber needs to be aware of the connection between variable tastes of medicines and adherence, thus the involvement of both children and families is necessary in choosing treatments for successful outcomes (Bagueley et al 2012).  Medication comes in different preparation such as tablet, liquid, injectable or rectally. Specifically, a liquid preparation encourages dental caries; hence, the recommendation of dental hygiene is essential. Whenever possible the use of sugar free preparation is favourable (BNFC 2015).  One of the markers of a good practice is seeking professional assistance from the pharmacist, who in turn contributes to the effectiveness and safe usage of the medicines in children, DH (2004).

BNFc (2015) suggested that children ought to be prescribed a preparation that suits their daily routine with the right dose, right route and right indication. When children reach school age, children may have to take their prescribed medicine to school so consideration of the dosing timing matters, so as not to disrupt the treatment process by missing the dose. A written parent’s agreement to allow school staff to give the medicine to the child is required (Department for Education and Skills/DH 2005). 

Some simple precautionary measures are required to ensure safe prescribing in children, for instance, always check the child’s age and if possible the child’s weight and pay particular attention to the calculated doses with decimal point when writing a prescription, review dosage, its side effects and contraindication for less familiar drugs. Extra care should also be taken when prescribing off label medication (Morris 2010). Off label medications are drugs prescribed outside their license indications with respect in dosage, age or route (Pandolfini and Bonati, 2005). Unlicensed drugs are commonly used in children compared to adults, as there is less information obtained on the efficacy of the drug due to children being excluded in clinical trials (Morris, 2010).

It is essential to check if the child is allergic to any medication by checking with the parents and the child’s history (Blair 2011). In the same way, with the guidance of best practice, emphasized by the DH (2005) a clear allergy status documented in patient records must be available when prescribing medicines for both children and adults. The nurse prescriber should ensure documentation is clear and detailed in patient’s records to facilitate continuity of care and at all times, respect their right to privacy and confidentiality (NMC 2015). Furthermore, the child or young person should be informed how and why information is shared with other healthcare professionals involved in their care (Blair 2011) to achieve quality of care.

Only nurses with knowledge, competency and experience in dealing with children can prescribe for children, particularly in a situation such as out-of-hours, walk-in clinics and general practice. Should the prescriber encounter instances whereby they are working outside their level of competence and expertise, a referral to another qualified children’s prescriber is necessary (NMC 2006).

In conclusion, dealing with children and young adults requires special skills. A comprehensive history taking and assessment in partnership with the parents/guardian in gathering information helps the practitioner to formulate a plan in achieving a holistic approach in the child’s care package.  The nurse prescriber should have knowledge of the different stages of the child’s developmental process, which plays an important role in prescribing of medicines for children. The aim of safeguarding a child’s best interest at all times prevents unwanted adverse reactions or side effects that can be detrimental to the child. In all aspect of care, proper documentation is also important to safeguarding and continuity of care. In the same way, the practitioner’s level of competence and enhanced skills in dealing with neonates, children and young adults should be in line with the standard of safe practice.

References:

• Anderson, B and Holford N. (2013) ‘Understanding dosing: children are small adults, neonates are immature children’, Archives of Disease in Childhood – British Medical Journal, 98, pp.737-744. doi: 10.1136/archdischild-2013-303720.
• Bagueley, D., Lim, E., Bevan, A., Pallet, A. and Faust, S. (2012), ‘Prescribing for children- taste and palatability affect adherence to antibiotics: a review’, Archives of disease in Childhood – British Medical Journal, 97, pp. 293-297. doi: 10.1136/arhdischild-2011-300909.
• Bickley, L. and Szilagyi, P (2013) Bate’s Guide to Physical Examination and History Taking. 11th edn. Philadelphia: Wolters Kluwer Health/ Lippincott Williams & Wilkin.
• Blair, K. (2011) Transforming Nursing Practice: Medicines Management in Children’s Nursing. Exeter: Learning Matters Ltd.
• British Medical Association and Royal Pharmaceutical Society (2015) British National Formulary for ChildrenLondon: BMJ Publishing Group Ltd.
• British Medical Association and Royal Pharmaceutical Society (2015) British National Formulary London: BMJ Publishing Group Ltd.
• Caldwell, N. (2011) ‘Prescribing for Children’, International Emergency Nursing,19, pp. 168-172.
• Cella, M., Knibbe, C., Danhof, M. and Della Pasqua O. (2010) ‘ What is the right dose for children?’, British Journal of Clinical Pharmacology, 70(4), pp.597-603. doi: 10.1111/j.1365-2125.2009.03591.x.
• Department of Health (2001) Seeking consent : working with children. Available at: http://webarchive.nationalarchives.gov.uk/20130107105354/http:/www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4067204.pdf  (Accessed: 06 June, 2015).
• Department of Health (2004) National Service Framework for Children, Young people and Maternity Services: Medicines for Children and Young People.  Available at: https://www.gov.uk/government/publications/national-service-framework-children-young-people-and-maternity-services (Accessed: 24 May 2015).
• Department for Education and Skills/Department of Health (2005) Managing Medicines in Schools and Early Years Settings. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/196479/Managing_Medicines.pdf  (Accessed: 25 May 2015).
• Hunter, D. and Pierscionek, B. (2006) ‘Research Ethics: Children, Gillick competency and consent for involvement in research’, J Med Ethics, 33 pp. 659-662. doi: 10.1136/jme.2006.018853.
• Morris, D. (2010) ‘Prescribing for children’, Independent Nurse, 2010(7). doi: http://dx.doi.org/10.12968/indn.2010.15.7.77625
• Nolan, Y. (2007) Working with Children and Young People. Oxford: Heinemann Educational Publishers.
• Nuttall, D. and Rutt-Howard, J. (2011) The Textbook of Non-Medical Prescribing. Oxford: Blackwell Publishing Ltd.
• Nursing and Midwifery Council (NMC) (2004) ‘Standards for competence for registered nurses’. London: NMC
• Nursing and Midwifery Council (NMC) (2006) ‘Standards of Proficiency for Nurse and Midwife Prescribers’. London: NMC
• Nursing and Midwifery Council (NMC) (2015) The Code: Professional standards of practice and behaviour for nurses and midwives. London: NMC
• Pandolfini, C and Bonati, M. (2005) ‘A literature review on off-label drug use in children’, European Journal of Paediatrics’, 164, pp. 552-558. doi: 10.1007/s00431-005-1698-8
• Schoor, J.V. (2006) ‘Prescribing for Children’, Professional Nursing Today, 10(6), pp. 26-29
• Thorp, C. (2008) Pharmacology for health care professions, Oxford: John Wiley & Sons,Ltd.
• Williams, C. and Perkins, R. (2011) ‘Consent issues for children: a law unto themselves?’ Continuing Education in Anaesthesia, Critical Care and Pain, 1(3), pp. 99-103.
• World Health Organization (2007) Promoting Safety of Medicines for Children. Available at: http://www.who.int/medicines/publications/essentialmedicines/Promotion_safe_med_childrens (Accessed: 15 May 2015).