‘Only nurses with relevant knowledge, competence, skills and experience in nursing children should prescribe for children. This is particularly important in primary care (e. g. out of hours, walk-in clinics and general practice settings). Any one prescribing for a child in these situations must be able to demonstrate competence in prescribing for children and refer to another prescriber when working outside their level of expertise or level of competence. ’ The Nursing and Midwifery Council standards of proficiency for nurse and midwife prescribers’ (NMC, 2006)
This would be a time when I as a prescriber would consider myself as working outside of my level of expertise, due to my client group being above the age of 18. Therefore it is my aim in this paper to evidence my awareness of the differences in prescribing for children and adults. Learning outcomes covered: 5 & 8. Medicines undergo a rigorous amount of testing, including pre-clinical trials and clinical trials, before they are licensed to be used in adult medicine. This procedure however does not necessarily apply to child medicines, having not necessarily been tested within the child age group.
Until relatively recently there was a widespread reluctance to conduct clinical trials of medicines used in the treatment of children. This was due to a number of factors including ethical concerns, and the practical difficulties of conducting trials in children, together with commercial/financial considerations. As a result, most medicines have only been tested for safe and effective use in the adult population and there are comparatively few medicines on the market which are specifically licensed for the treatment of children.
This in turn results in many medications being prescribed off label in this group. Contra-indications, precautions, adverse reactions and drug interactions can vary considerably in a child than an adult. The Commission on Human Medicines (CHM) Expert Advisory Group on Pediatric Medicines (PMEAG) was established in 2006. It replaces the Committee on Safety of Medicines (CSM) Paediatric Medicines Working Group (PMWG) which was established in July 2000.
Its remit is to advise the CHM on the safety, quality and efficacy of medicines for paediatric use, and on the implementation of the Department of Health/MHRA paediatric strategy, the EU paediatric worksharing project, and the European regulation on medicines for paediatric use (Regulation (EC) No 1901/2006). The National Prescribing Centre recognize some fundamental differences in the absorption, distribution and excretion of medicines between adults and children. The differences are published in the National Prescribing Centre’s bulletin, produced by MeReC Bulletin Volume 11, Number 2, 2000.
Over many years, there has been debate upon debate about the responsibility in child prescribing. Is it their age, intelligence /understanding, law, the parent/legal guardian? The Gillick test was passed in 1985, this test was widely used to determine when a child, irrespective of age and mental capacity is capable of making a decision about their treatment. Lord Fraser debated the use of this test with regard to prescribing contracecptives for the under 16’s. The Fraser guidelines were introduced and work alongside the Gillick test as a framework in prescribing for children.
Lord Scarman was involved in the passing of these policies, he stated, “… whether or not a child is capable of giving the necessary consent will depend on the child’s maturity and understanding and the nature of the consent required. The child must be capable of making a reasonable assessment of the advantages and disadvantages of the treatment proposed, so the consent, if given, can be properly and fairly described as true consent. ” Lord Scarman 1985. The debate continues today, there is a vast amount of literature with regards to prescribing for a child and the taking of responsibility.
The Childrens Act 2004 clearly defines all ethical, social, psychological, physical, emotional legal areas in which to guide the safe guarding of all minors. Every Child Matters document’, or ECM for short, is a UK government initiative that was launched in 2003. It is one of the most significant policy initiative and development programmes in relation to children and children’s services of the last decade. It has been the title of three government papers, leading to the Childrens Act 2004.
Every Child Matters covers children and young adults up to the age of 19, or 24 for those with disabilities. Its main aims are for every child, whatever their background or circumstances, to have the support they need to be: SSafe HHealthy EEnjoy/achieve EEconomic PPositive Each of these areas has a framework attached, the outcomes require multi-agency partnerships working together to achieve them. This initiative for me highlights the need to be focused on your patient, not necessarily what the parent/guardian or carer wants, but the needs of the patient.
At times, a prescriber may feel under pressure to prescribe, as this would please the parent/guardian/carer, it is therefore important to remind ourselves of our professional code of conduct. This leads on to the financial implications of prescribing, when prescribing for a child, it must be considered whether the child will have difficulty taking this medication or will dislike it so much they will refuse, considering concordance is likely to reduce waste and unnecessary expenditure {NPC, 2007}.
Reference List
- Penny Lovatt {2010} Legal and ethical implications of Non-Medical prescribing. Nurse Prescribing 2010 Vol 8 No 7 NMC
- Code of Professional Conduct: standards for conduct, performance and ethics {2008} Medicines Matter 2006 Seedhouse D (1998) Ethics: The Heart of Health Care. John Wiley:Chichester www. legislation. gov. uk/ukpga/2004/31
- British Paediatric Association and the Association of the British Pharmaceutical Industry. Licensing medicines for children: a report of the joint working party of the British Paediatric Association and the Association of the British Pharmaceutical Industry on the development of medicines for children.
- London: BPA, 1996. BMA, Royal Pharmaceutical Society of Great Britain, Royal College of Paediatrics and Child Health, and Neonatal and Paediatric Pharmacists Group. BNF for Children. London: British Medical Journal Publishing Group, Royal Pharmaceutical Society Publishing, and Royal College of Paediatrics and Child Health Publications, 2006.
- MeReC Bulletin Volume 11, Number 2, 2000 Wheeler R 2006 Gillick or Fraser? A plea for consistency over competence in children: British Medical journal 332 {8 April}:807.