Abstract
Colleges of pharmacy provide varying amounts of didactic and clinical experiential hours in pediatrics therapeutics, resulting in variability in the knowledge, skills, and perceptions of new graduates toward the pharmacist role in providing care to pediatric patients. The Pediatric Pharmacy Association continues to endorse a minimum set of core competencies for all pharmacists involved in the care of hospitalized pediatric patients of all ages. To that end, we have updated our 2015 Position Statement.
Keywords: pharmacist, pharmacy education, professional competence
Background
Pediatric patients are not merely small adults when it comes to medication selection, dosing, and administration. They undergo significant growth and physiologic changes over time, resulting in variations in pharmacokinetic and pharmacodynamic parameters. Additionally, pediatrics is a heterogeneous population and can include individuals of varying weights and sizes, from the premature infant weighing 600 g to the adolescent athlete weighing several hundred pounds. As a result of legislative actions for pediatric drug development and research, significant progress has been made with regard to the number of medications that have been “formally” studied in the pediatric population and the timeliness of study initiation. These efforts have resulted in more than 600 medications containing new pediatric information in labeling since 1997.1 Although improving, there is still a need for pediatric studies to determine efficacy, optimal dosing, pharmacokinetics, or adverse effect profiles of many medications. Although the number of medications with pediatric labeling has increased, when studies in neonates, infants, children and/or adolescents are lacking, common practice is to extrapolate information from adult studies; hence, off-label prescribing is still commonplace. Reported rates of off-label medication use vary and are influenced by many factors, including practice setting and patient age.2–6
The Joint Commission recommends that pharmacists with pediatric expertise be available or on call at all times for the care of hospitalized pediatric patients and should be assigned to high-risk areas, including the neonatal intensive care units, pediatric critical care units, and pediatric hematology/oncology units.7 Unfortunately, the availability of pharmacists with pediatric expertise remains limited. Although colleges of pharmacy provide varying amounts of didactic and clinical hours in pediatrics, the exposure across programs is inconsistent and leads to variability in the knowledge, skills, and perceptions of new graduates toward the provision of care to pediatric patients. In a survey by Prescott et al,8 the mean number of didactic hours related to pediatric topics in Doctor of Pharmacy programs was 21.9 ± 22.9 hours, with a range of 1 to 153 hours. A limited number of pharmacists pursue formal advanced training in pediatrics through completion of residencies or fellowships, which are optional following licensure. Currently, there are about 49 first-year postgraduate pharmacy residencies (postgraduate year [PGY]-1) and 66 American Society of Health-System Pharmacists–accredited second-year postgraduate residency (PGY-2) programs between free-standing and non–free-standing children's hospitals.9 Training and competencies around pediatric patients may be limited in residency programs not associated with children's hospitals, depending on the institution. In 2015, the Pediatric Pharmacy Association (PPA) published a position paper regarding minimum core competency for those in pediatric pharmacy practice.10 This paper serves as an update.
Rationale and Recommendations
As a result of the limited number of pharmacists formally trained in pediatrics, extensive on-the-job training is often necessary to achieve a minimum level of competency for hospital pharmacists who will care for neonates, infants, and children. This is in addition to training focused on the development of general clinical and organizational skills, such as those used in the pharmacists' patient care process, which is applicable across all ages of patients and pharmacy settings.11 Any pharmacist caring for pediatric patients in a hospital setting should demonstrate proficiency in core knowledge and skills before practicing independently. Pharmacists who have not completed residency training in a pediatric facility may have to gain this minimal level of competency through institution-based on-the-job training programs. Currently, there are no suggested minimal competencies for entry-level pharmacists caring for hospitalized children. Table 1 provides suggested topics for skill and knowledge development for entry-level pharmacists caring for hospitalized pediatric patients. Although this is not an exhaustive list, it may give employers some guidance on content to include in their programs. Employers should evaluate what services their institutions offer and try to match their minimal competencies to encompass those areas. For example, an institution whose sole pediatric population is in the neonatal intensive care unit should direct their training to the minimal competencies necessary to care for neonates.
Table 1.
Suggested Knowledge Topics and Skills for Pharmacists Caring for Hospitalized Pediatric Patients
| Basic Topics for All Pharmacists |
| Normal vital signs for age |
| Normal laboratory values and associated calculations (e.g., CrCl, IBW) for age |
| Weight-based dosing and calculations |
| Common pathogens and empiric antibiotic regimens for children |
| Fluid selection and calculations of replacement and maintenance requirements |
| Appropriate dosage form selection |
| Appropriate routes of medication administration and volumes |
| Key Potentially Inappropriate Drugs in Pediatrics (KIDs List)15 |
| Appropriate pediatric information resources |
| Knowledge of clinical practice guidelines that include pediatric patients (e.g., community-acquired pneumonia, anticoagulation) |
| Developmental pharmacokinetics |
| Additional Topics* |
| Intravenous drug administration devices and techniques |
| Improving medication palatability, oral drug administration devices and techniques |
| Total parenteral nutrition |
| Therapeutic drug monitoring (e.g., vancomycin, aminoglycosides) |
| Pharmacogenomics |
| Pediatric/neonatal advanced life support16–18 medication dosing and preparation |
| Medications and human milk |
| Communicating with children and caregivers |
CrCl, creatinine clearance; IBW, ideal body weight
* Based on services provided at a respective institution.
Various training models could be used to gain competence in pediatric pharmacy practice. Possible options include self-directed learning modules, instructor-led learning, continuing education programming, experiential learning with a PGY-2–trained pediatric pharmacist, and case- or skill-based activities. Examples of some of these strategies have been published.12–14 Each of these approaches could involve the use of pre- and post-assessment tools to gauge the learner's understanding and ability to apply the material. Table 2 includes a list of resources that employers can use to develop training modules. Alternatively, these can be made available to entry-level pharmacists for self-directed learning. Professional organizations, such as the PPA, the American Society of Health-System Pharmacists, and the American College of Clinical Pharmacy, provide pediatric-specific programming, pediatric resources, and certificate programs that could be used by an institution or pharmacist individually or in addition to an institution's training modules.
Table 2.
Suggested Resources for the Development of Pediatric Pharmacy Competencies
| Resource | Reference | Advantages | Disadvantages |
|---|---|---|---|
| Pharmacy-specific pediatric textbooks | |||
| Advanced Pediatric Therapeutics | Eiland L, Todd T, eds. Advanced Pediatric Therapeutics. Pediatric Pharmacy Advocacy Group; 2015. | This book is intended for experienced practitioners and covers clinical controversies and cases for selected pharmacotherapeutic areas. | The textbook requires that pharmacists have a background knowledge of the pediatric diseases and therapeutic areas. |
| Theme Issue on Considerations in Management of Pediatric Patients | Am J Health-Syst Pharm. 2019;76(19):1451–1554. | Multiple overview topics geared toward individuals new to pediatric pharmacy. | Requires subscription to journal. |
| Pediatric Pharmacotherapy | Nahata M, Benavides S, eds. Pediatric Pharmacotherapy. 2nd ed. Lenexa, KS: American College of Clinical Pharmacy; 2020. | This general textbook was designed for the student learner and provides an overview of age- related pharmacokinetic changes, nutrition, and other miscellaneous disease states. | The textbook does not cover advanced topics for seasoned practitioners. The reference does not provide in-depth drug information. |
| Handbooks | |||
| Neofax | IBM Micromedex (Somers, NY) | Dosage reference specific to the neonatal population. | Available only online and as an app with subscription purchase. |
| Pediatric and Neonatal Drug Information Handbook | Taketomo CK, Hodding JH, Kraus DM, eds. Lexi-Comp’s Pediatric and Neonatal Dosage Handbook. 26th ed. Hudson, OH: Lexi-Comp; 2019. | The most comprehensive dosage reference for pediatric patients including information for all routes of administration. Also includes published recipes for compounding of extemporaneous formulations. | Electronic version updated frequently; dosage recommendations vary (e.g., mg/kg/dose versus mg/kg/day in divided doses). |
| The Harriet Lane Handbook | Kleinman K, McDaniel L, Molloy M. The Harriet Lane Handbook, 22nd ed. Philadelphia, PA: Elsevier Mosby; 2020. | Good reference for pediatric diseases and vital sign ranges. | Drug dosing information is limited. |
| The Teddy Bear Book: Pediatric Injectable Drugs | Phelps SJ, Hagemann TM, Lee KR, Thompson AJ, eds. The Teddy Bear Book: Pediatric Injectable Drugs. 11th ed. Bethesda, MD: American Society of Health System Pharmacists; 2018. | Excellent reference for IV medication preparation and administration (e.g., maximum concentrations, dosing); application available for electronic devices (Peds Inject). | Updated periodically. Does not provide in-depth disease info on pathophysiology, etiology, and/or treatment options. |
| Drugs, pregnancy, and breast milk | |||
| Drugs and Lactation Database (LactMed) | National Library of Medicine | Evidence-based information on medications in breast-feeding women, free app and online version available. | Updated periodically. |
| Drugs in Pregnancy and Lactation | Briggs G, Freeman R, Towers C, et al, Drugs in Pregnancy and Lactation. 12th ed. Philadelphia, PA: Wolters Kluwer; 2021. | Evidence-based information on medication in pregnancy and breast-feeding women; print and digital book available. | Updated periodically. |
| Medications and Mothers’ Milk | Hale TW. Medications and Mothers’ Milk New York, NY: Springer Publishing; 2019. | Evidence-based information on medications in breast-feeding women; digital version available. | |
Table 2.
Cont'd
| Resource | Reference | Advantages | Disadvantages |
|---|---|---|---|
| Pediatric-specific textbooks | |||
| Nelson Textbook of Pediatrics | Kliegman RM, St. Geme JW, eds. Nelson Textbook of Pediatrics. 21st ed. Philadelphia, PA: Elsevier Saunders; 2020. | Provides in-depth overview of pediatric diseases and stages of development. | Updated periodically; provides limited drug dosing information. |
| Red Book | https://redbook.solutions.aap.org/ or Red Book: 2021 Report of the Committee on Infectious Diseases. 32nd ed. Itasca, IL: American Academy of Pediatrics; 2021. | Publication of the American Academy of Pediatrics Committee on Infectious Diseases; provides disease and treatment option overviews for various pediatric infectious diseases | Provides limited drug dosing recommendations. |
Conclusion
Most entry-level pharmacists receive limited formal training in pediatric pharmacotherapy within their Doctor of Pharmacy curricula or via a PGY-1 that is not based in a children's hospital. Based on the pediatric population within their institutions, employers should establish a minimal level of competency for entry-level pharmacists caring for hospitalized pediatric patients. The PPA acknowledges that these minimal competency training programs are essential. However, at this time, PPA cannot endorse one program over another. The selection of a training program must be based on the institution's patient demographics, services offered, resources available, and time allotted for training programs.
ABBREVIATIONS
- PGY
postgraduate year
- PPA
Pediatric Pharmacy Association
Footnotes
Disclosures. Matthew R. Helms, BA, MA; mhelms@pediatricpharmacy.org
Adopted. Approved by the PPA Board of Directors on January 28, 2021.
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