1. Use metric dosing for prescribing and dispensing
Historically there have been a number of common errors in dosing, specifically confusion between millilitres and teaspoons. Before dispensing, pharmacists should double-check that the directions on the label match the original prescription.21
2. Prescribe, dispense and demonstrate with 5 mL or 10 mL syringes
When demonstrating how to draw up and administer medicine to a child, use 5 mL or 10 mL syringes and match the required dose to the appropriate sized syringe.15 Ensure the parent/carer understands how to read incremental markings; trial data suggest more errors in administration by carers occur with 2.5 mL and 7.5 mL dose amounts compared with 5 mL dose amounts.16
3. Dispense and demonstrate administration with oral, not parenteral, syringes
At times children may be sent home with an IV cannula in place. Oral syringes have specially engineered hubs that cannot be easily or securely connected to standard IV lines, preventing accidental administration through the IV route. In addition, clearly demonstrate to the parent/carer that oral medicines are for oral use only.22
4. Use a combination of text and pictograms to support low health literacy
Adults with low health literacy may be more likely to find millilitre-dosing difficult. Evidence shows that demonstrating medicine dosage using a combination of text and pictograms results in fewer errors. This includes use of teachback/showback, drawings or pictures of the dose and dose demonstrations and providing dosing tools with millilitre units.15
5. Ensure parents/carers know that overdose and toxicity can occur with paracetamol
It is important that parents/carers are aware that despite being widely available without a prescription, paracetamol is a medicine and overdose can occur.23 Some reasons for overdose include dosing every 4 hours over a 24-hour period, resulting in six doses in total; more than one parent/carer administering medicine; and misreading the label.20
Many of the cases of accidental exposure to paracetamol reported to PIC occurred when a bottle was left on the bench or bedside table after dosing, or sometimes left with the cap off.20
When recommending paracetamol for pain relief in children and infants younger than 12 years of age, ensure that parents/carers know the following facts.23
- Paracetamol comes in different formulations and strengths for different ages – choose the correct paracetamol product for the child's age.
- They should keep track of all medicines that are given to the child. This helps prevent accidental overdose through coadministration of medicines that contain the same ingredient, for example paracetamol.16
- There is a potential for liver damage with misuse and overdose of paracetamol, and there are no early signs of hepatotoxicity. Phone the PIC immediately if an overdose is suspected.
- It is important to keep a current record of the child's weight. The recommended dose of paracetamol for children is based on ideal body weight (15 mg/kg).
- The maximum recommended dosage for children, which is 15 mg/kg every 4–6 hours to a maximum of 1 gram, and no more than 4 doses in a 24-hour period, should never be exceeded.
6. Provide intensive support to families whose children are taking NTIDs
Drugs with a narrow therapeutic index (NTIDs) include clonidine, warfarin, carbamazepine, digoxin, phenytoin, tacrolimus and theophylline.18 For some NTIDs, errors within an even smaller range (< 20% deviation) may be clinically significant and additional intervention strategies are important to reduce errors.16 With infants, the millilitre dosing of these medicines can be less than 1 mL, so clear education with a 1 mL syringe is essential.