Pediatric pharmacists’ perspectives on essential skills and activities for community pharmacists caring for pediatric patients: A mixed-methods study

Abstract

Background:

Provision of care to pediatric patients represents a set of unique challenges for pharmacists. Pharmacists practising in pediatric-specialty areas (acute care or ambulatory) have unique perspectives on approaches to pediatric care that can be shared to support pharmacists less familiar with this group of patients in providing effective, patient-centred care.

Methods:

This was a mixed-methods study using data from pharmacist interviews to quantify and qualitatively describe the approaches to care most commonly reported by pediatric-specialty pharmacists when asked to provide advice to pharmacists on providing pharmaceutical care to infants and children. Data were coded in duplicate using an inductive approach, and discrepancies were resolved by consensus. The number of times a theme (or subtheme) was mentioned and the number of pharmacists who mentioned it were used as markers of the relative importance of the content.

Results:

The themes (and subthemes) that emerged as most important were clinical activities (dose checks, considering indication, using up-to-date height/weight), caregiver counselling (demonstrating measurement, discussing administration), medication safety (using consistent concentrations of liquids), compounded medications (risks of, use of caution), adherence (formulation considerations, palatability), avoiding use of over-the counter products (except analgesics/antipyretics) and use of external supports (colleagues, caregivers, resources).

Conclusions:

We present a collated and prioritized list of practical approaches for pharmacists to use when caring for pediatric patients across the spectrum of practice. Can Pharm J (Ott) 2020;153:xx-xx.

Introduction

Children comprise almost a quarter of the population in North America, and approximately half have used at least one prescription medication in the past year.^1-3 Pediatric patients have up to a threefold higher rate of adverse drug events (including drug errors and adverse drug reactions) compared with adults, and dosing errors are the most common medication error in children.^4,5 Although the importance of preventing medication errors in children is well known, interventions to do so are not, particularly outside of institutional settings.⁶

Knowledge Into Practice.

• This study compiles a list of practical advice regarding patient-centred pediatric pharmacy care, based on interviews with pediatric-specialty pharmacists.

• Some of the main points include performing appropriate dose checks, ensuring accurate measurement, risks associated with compounding and how to avoid them and the importance of formulation selection.

• These approaches can be incorporated into clinical practice across the spectrum of practice environments and can also be used to guide pediatric training and education of pharmacists.

Mise En Pratique Des Connaissances.

• Cette étude compile une liste de conseils pratiques concernant les soins pharmaceutiques pédiatriques centrés sur le patient, sur la base d’entretiens avec des pharmaciens spécialisés en pédiatrie.

• Parmi les principaux points figurent la réalisation de contrôles de doses appropriés, comment assurer des mesures précises, les risques associés à la composition et la manière de les éviter, ainsi que l’importance du choix de la formulation.

• Ces approches peuvent être intégrées à la pratique clinique dans toute la gamme des environnements de pratique et peuvent également être utilisées pour guider la formation pédiatrique et l’enseignement des pharmaciens.

There are many contributing factors to pediatric medication errors, including high rates of off-label use and poor availability of appropriate dosage forms.^7-9 Additionally, community pharmacists may not be comfortable with pediatric medication use. A 2016 survey indicated that only 58% to 64% of community pharmacists were comfortable (scored 5-7 out of 7 on a comfort scale) filling prescriptions for common pediatric medications (amoxicillin, morphine and prednisone) and 91% were interested in more pediatric education.¹⁰ Surveys of pharmacy curriculum in North America revealed an average of 15 to 22 hours of required classroom time, limited availability of elective pediatric courses (offered by 33%-61% of faculties) and very few students (6%-20%) completing pediatric-specific experiential education.^11,12 A study evaluating medication-related pediatric visits to the emergency department found that 1 in 12 visits were preventable and most were associated with adverse drug reactions, subtherapeutic dosages or nonadherence.¹³ These findings highlight the importance of pharmacists optimizing pediatric medication use across the continuum of care.

Pharmacists working in specialized pediatric clinics or acute-care settings develop specific skills and knowledge through practice experience centred on this age group. Many of these pharmacists have received additional training focused on pediatric patients, either as formal experiential education or informally through on-the-job training. Through day-to-day interactions with pediatric patients and their drug-related issues, pharmacists practising in specialized pediatric and neonatal areas develop insight into useful approaches to these patients that can be applied across practice settings.

This project’s aim was to quantify and qualitatively describe the practice issues and approaches most commonly reported by pharmacists working within a pediatric-specialty setting when asked to provide advice to pharmacists on providing pediatric pharmaceutical care.

Methods

This was a mixed-methods, interview-based study using transcripts from interviews conducted for another purpose. The Alberta Health Services (AHS) pediatric pharmacy community of practice (CoP) is a group of approximately 60 pharmacists who provide clinical services for pediatric or neonatal acute care units or specialized pediatric ambulatory clinics within AHS. In November 2017, the chair of the CoP was asked to compile a list of “Top 10 Tips from Pediatric Pharmacists” for community pharmacists. To inform this list, several members of the CoP volunteered to be interviewed regarding advice they would offer to community pharmacists. Standardized interview questions were developed through discussion and consensus by 4 clinical practice leaders working in pediatrics and/or neonatology (see Appendix 1, available in the online version of this article). Interviews were then conducted with volunteer participants over the phone or in person by a pharmacy student. The interviews were transcribed verbatim. The current project was conceived after completion of the interviews, and use of the interview data was approved by the local conjoint health ethics review board.

The primary outcome was a description of the themes mentioned most frequently during the interviews. A secondary outcome was a description of the themes mentioned by the most pharmacists. These were used as markers for the relative importance of the themes and subthemes.

Transcripts from the interviews were separated into single, unified ideas by the student who completed the interviews. These individual statements were then coded by another pharmacy student into themes and subthemes using an inductive approach, with up to 3 subthemes assigned per statement.^14,15 The primary investigator repeated the coding, blinded to the students’ coding and themes. Coding discrepancies were discussed between the student and lead investigator until final consensus was reached.

The frequency of themes (the total frequency of all related subthemes) and the number of pharmacists discussing a theme were used as measures of the relative importance of themes (assuming more important advice would be mentioned more often and by more pharmacists). Excel (Microsoft 2013) was used to analyze the data. The final collated themes were presented to the CoP as a whole to assess agreement with the relative importance of the themes that had emerged. This discussion included members who had been interviewed as well as those who did not participate in the interviews.

Results

Twenty-three pharmacists volunteered to be interviewed; at the end of these interviews, the student interviewer and primary investigator agreed that thematic saturation had occurred. The pharmacist participants had 1 to 25 years of experience in pediatric practice and represented practitioners from pediatric-specialty ambulatory care clinics, pediatric acute care inpatient units and pediatric or neonatal intensive care units. The frequency of all themes and subthemes discussed during the interviews is presented in Table 1. When shown the collated results, the CoP members were in agreement with the analysis regarding the relative importance of the themes.

Table 1.

Themes and subthemes based on frequency mentioned in interviews (N = 23 interviews)

Theme	Subtheme	Total
Clinical (22/23 interviews)	Tips related to dose checks (general, adult maximum, age, adjust for growth, organ function, weaning)	34
	Assessing indication of therapy	16
	Ensuring current weight/height for dosing	13
	Encouraging to use electronic medical record resources	9
	Checking medical history	8
	Checking for drug interactions	7
	Using full scope of pharmacist practice	7
	Performing appropriate and complete follow-up	6
	Assessing medication history	6
	Including an assessment of allergies/intolerances	4
	Checking for contraindications	3
	Ensuring seamless care	3
	Ensuring measurability of different medications (i.e., small volumes)	3
	Reviewing laboratory work as part of assessment	2
	Using the same clinical process as would for adults	2
	Providing information specific to hazardous medications	1
	Total clinical	124
Counselling (20/23 interviews)	Including information on correct measurement of medications	20
	Including information on administration of medication	17
	Ensuring accuracy of drug information provided	7
	General counselling tips	5
	Including discussion on dosage during counseling	4
	Including information on storage of medications	4
	Including stop/start dates and duration of therapy in discussion of medication schedule	4
	Ensuring counselling provided to the right patient	2
	Counselling on drug safety	2
	Providing direction on what to do when doses are missed	2
	Total counselling	67
Adherence (23/23 interviews)	Use most appropriate formulation	15
	Address palatability of medications	13
	Provide medication schedule with consideration of child and family’s schedule	9
	Maintain empathy/cultural sensitivity with parents/caregivers	5
	Consider the child’s preference/encourage their involvement	5
	Consider reminders/technology/blister packs	4
	Consider volume of liquid/concentration/ensure accuracy of measuring devices	3
	Address cost of medications/coverage issues	1
	Total adherence	55
Use of external supports (16/23 interviews)	Encouraging use of pediatric dosing references (guidelines/online resources)	17
	Encouraging collaboration with other pharmacists	16
	Encouraging collaboration with physicians	5
	Encouraging collaboration with parents	11
	Total external supports	49
Safety (23/23 interviews)	Ensuring appropriate/correct concentrations of medications	26
	Using caution with combination products (i.e., multiple combination products)	7
	Ensuring dosing by weight	6
	Checking for right drug	2
	Checking for age cut-offs for doses and medications	1
	Total safety	42
Compounding (16/23 interviews)	Labelling compounded medication (i.e., mg and mL)	7
	Use of reputable recipe for compounding	9
	Caution related to risks of compounding	16
	Total compounding	32
OTC medications (23/23 interviews)	Only use select over-the-counter products (i.e., ibuprofen and acetaminophen)	6
	Avoidance of all over-the-counter products	5
	Total OTC medications	11

The most frequent theme discussed was “Clinical Activities,” coded a total of 124 times and mentioned by 22 (96%) pharmacists. More specifically, the most frequent subthemes included tips on completing dose checks (reported 34 times by 78% of pharmacists), assessing the dose in the context of the specific indication (reported 16 times by 57% of pharmacists) and ensuring a current weight and height (reported 13 times by 44% of pharmacists). Statements representative of this theme included the following:

Make sure the dosing is appropriate for the child’s age and weight.

[Doses are] typically weight based and therefore, you need a weight to properly check the doses.

Doses are usually weight based so over time may need to titrate up doses as the child grows.

Dose per weight, but make sure not to exceed [the flat] adult dose.

Lots of medications are off-label in [pediatrics] . . . confirm that you know what it’s being used for.

Patient counselling was the second most frequently reported theme, mentioned 67 times by 20 (87%) pharmacists. Ensuring parents are counselled on accurate measurement (reported 20 times by 65% of pharmacists) and administration (reported 17 times by 70% of pharmacists) of medications were the most frequently reported subthemes. Specific advice included providing caregivers with proper measuring devices, physically showing how to measure the dose of liquids, medication administration techniques, as well as counselling on general drug information, dosing, safety, storage and what to do when doses were missed (Table 1).

Parents struggle with . . . measurement—show them how to measure, draw line on syringe, or whatever makes it easiest for them to measure accurately.

Ensure that parents know how much of the medication to give and what the concentration of the medication is.

Dispense correct measuring devices and provide instructions on shaking meds and proper storage.

Offer syringes and bottle lid adapters for measuring liquids.

Adherence advice was requested as a specific question and so mentioned by all 23 pharmacists. The most commonly reported advice for adherence included formulation and palatability considerations (reported 10 times).

Discuss taste with parents. Sometimes liquid formulations taste worse than tablets.

Don’t underestimate ability to take capsules at a young age.

Can give kids a popsicle before their dose [to freeze taste buds] or mix the dose in pudding/applesauce/yogurt.

If you suggest mixing the medication in with food, recommend a small volume so the child gets the whole dose.

Give parents tips on how to teach their child to swallow . . . put tablet far back in mouth, take with lots of water, practice with [increasing size of candies].

Give the kid some options about medication administration—it makes them feel involved and sometimes makes children more willing to take it.

Having external support, whether from collaboration with hospital pharmacists, using online resources, guidelines or electronic medical records (reported 49 times by 16 pharmacists), was a final common theme noted.

You can phone the hospital pharmacists if you have any questions.

Don’t be afraid to call prescriber for questions; it will ensure patient safety and help you learn.

Talk to parents and ask them lots of questions (especially patients on chronic meds)—parents are very knowledgeable about their children’s medications.

BC Children’s [pedmed.org] is free online access; Lexicomp has a great neonatal dosing section.

If you have questions about indications—check [provincial electronic medical record] for a discharge summary.

Medication safety was mentioned specifically in the interview questions, and so some component of drug safety was coded 42 times and discussed by all pharmacists. The most commonly reported component of safety was related to concentrations of liquid medications (reported 26 times by 78% pharmacists). Ensuring dispensing of the proper concentration, documentation of this concentration in the medical record and making sure a consistent concentration is dispensed (or educating caregivers if not) were also recorded 26 times throughout the interviews and by 78% of pharmacists.

Be conscious of mg vs mL, especially when medications are being transferred.

Put both mg and mL amounts on [the label instructions].

Parents often confuse volumes with dosages.

Related to this, compounded medication was another frequent theme throughout the interviews. In total, compounding was discussed by 70% of pharmacists and was coded 32 times. The most common subtheme of compounding was related to safety risks of compounding medications (reported 16 times).

Make sure that the concentration is the same in hospital; try to only use [hospital’s] recipes just for continuity of care.

Different stores compound and carry different concentrations of medications. This can lead to a lot of confusion.

When you put compounds in [the provincial electronic medical record], it’s very helpful to add the concentration (put it on the [label instructions]).

Utilize the [provincial health authority] compounding database—it’s free and evidence based.

Advice on use of over-the-counter (OTC) products was also requested in a separate question. The most commonly reported advice included avoidance of all or most OTC products (mentioned 10 times) and being cautious of combination products (reported 5 times).

Don’t suggest [OTCs]. I do not recommend any.

Stick with analgesics for fever and pain only.

Parents use different products and do not realize that a lot of them contain the same ingredients.

Be aware that sometimes doses on the bottle aren’t always the most appropriate; always double check with another source.

Discussion

A significant amount of literature has highlighted the importance of reducing pediatric medication errors in the community to prevent hospital admissions, complications or therapeutic failures due to nonadherence, but few studies have explored how pharmacists can prevent these errors.^4,9,13,16,17 This study attempted to fill this gap by seeking insight from pharmacists working in pediatric-specialty practices. This information may be useful for pharmacists entering a pediatric practice or those who practise in an adult-dominated setting and see pediatric patients only occasionally, or it may be used to guide pediatric pharmacy training or curriculum development.

The most highly discussed subtheme throughout the interviews was related to dose checking. Many medications are understudied in pediatric patients, and off-label use of medications in children is common: up to 31% in ambulatory settings and 78% in inpatient settings.^7,8 This makes accessing information on appropriate dosing of medications in children challenging for pharmacists and prescribers. Access to pediatric-specific resources (e.g., LexiComp) may be limited; therefore, pharmacists need to advocate for access to these resources with their employers. Another resource that pharmacists should not overlook is collaboration with other pharmacists, physicians and parents. Acute-care pharmacists should make efforts to reach out to community pharmacists when discharging patients with specific medication needs, and community pharmacists should not hesitate to reach out to hospital pharmacists with questions or concerns in these situations.

Ensuring appropriate measurement and administration of medications was another prominent topic during the interviews. It was commonly advised that physically showing caregivers how to measure medication and educating caregivers on doses and concentrations (and the distinction) are important for both patient safety and therapeutic efficacy. The most common errors reported to poison centers in the United States involving children younger than 5 years were due to caregiver dosing errors caused by confusion in units of measurement.¹⁸ Dose preparation errors were the most frequently reported errors in newborns recently discharged from hospital.¹⁹ Recent data indicate that 50% of doses measured by caregivers using a dosing spoon are done incorrectly, suggesting the need to use oral syringes, particularly for smaller doses.^20,21 These findings further emphasize the importance of this role for pharmacists.

Appropriate medication formulations for children are often unavailable, necessitating manipulation of dosage forms that can contribute to errors.^8,9 The risks of compounding were frequently brought up throughout the interviews, with suggestions to compound only when absolutely necessary and to use extreme caution when doing so. The risks associated with pediatric compounded medications were emphasized in a recent study where 71 pediatric patients discharged with prescriptions for 99 compounded medications experienced a total of 256 problems, 9 of which were considered major.⁹ These included administration errors and a median delay in drug delivery of 24 hours (maximum delay 12 days).⁹ Pharmacists need to know how to access standard recipes (which may include contacting acute-care centers for recipes to ensure continuity of care) and the importance of standardized checking processes when compounding. Additionally, pharmacists need to be hyperaware of the potential for errors with concentration changes; caregiver education along with ensuring that labels state dose, concentration and volume may help mitigate this risk.

Tips on improving pediatric medication adherence were also discussed throughout the interviews. Nonadherence to medications in pediatric patients with chronic conditions has been attributed to be the greatest cause of treatment failure, and parents have indicated that palatability of antibiotic therapy is one of the most important factors related to their child’s medication, following efficacy and safety.^22,23 Pharmacists play a vital role in choosing appropriate formulations for children. Pharmacists should be aware of the palatability of medications and the volume of liquid required for doses and should consider whether the child can take a full, split or crushed tablet (or be taught to do so). Some recommendations for improving palatability of medications (e.g., freezing taste buds with frozen treats, mixing in small amounts of palatable food immediately prior to administration) can be found in resources like “Helping Medications Taste Better” through the Children’s Hospital of Eastern Ontario website.²⁴ Additionally, pharmacists and caregivers should involve the child when choosing medication formulations and administration techniques and should provide a medication schedule tailored to the family’s schedule to further support adherence.

Although these data come from pharmacists working in multiple centers, the data are limited to pharmacists practising within one health system and so may not be relevant in other jurisdictions. Likewise, pharmacists who do not specialize in pediatric practice may have other useful perspectives on the most important things to know about pediatric medication use that we have not captured with the current interviews, so external validity cannot be guaranteed. However, internally, the collated results were discussed with the CoP as a whole and there was overall agreement that the common themes from the interviews represented those most important for pediatric pharmacy care. This information could be used in the development of standardized training or education regarding pediatric pharmacy practice. The creation of cases or laboratory activities that incorporate these topics may provide an efficient way to cover important pediatric issues in a practical manner. Future research could center on whether medication errors reported in children follow similar themes.

It is also worth noting that although pediatric practice offered an excellent lens for these skills to be highlighted, none of the skills are limited to the care of children. Certainly dose checking, collaborative practice, complete counselling and appropriate compounding practices are expectations of all pharmacists and are included in the Standards of Practice for Pharmacists in most jurisdictions. Pediatric patients’ vulnerability to medication errors offers ideal illustrative examples of the risks associated when standards of practice are not followed.

Conclusions

Pharmacists who specialize in caring for children have a unique perspective and key insight into approaches for optimizing pediatric pharmaceutical care. By gathering the opinions of practitioners from multiple sites and clinical areas, we have gained a broad range of practical advice and suggested activities that pharmacists can use across the spectrum of practice. The information presented may help pharmacists develop greater comfort in caring for pediatric patients and may guide the development of a practical pediatric pharmacy curriculum that will support both adult and pediatric medication use. ■