By Nathan Ohiomokhare

Last year before the lockdown during a brief visit to Benin I visited a close friend, colleague and former classmate at the University Of Benin Teaching Hospital. She is a Deputy Director at the hospital and unit head at the Paediatrics Pharmacy Unit. One of the many things we talked about was the evolution of Clinical Pharmacy practice and inpatient Pharmaceutical care management. She spoke so passionately about her pediatrics unit and displayed a vast knowledge of drug therapy management in various pediatric conditions and then she expressed a need. She wished there is a specialty course in Pediatric Pharmaceutical care she could attend. I was so proud of her passion for Pediatric Pharmaceutical care. I recomended she check with one of the special centers between College of Medicine and Faculty of Pharmacy UNIBEN maybe they might point her in the right direction. Though I had never heard of any in Nigeria she may eventually need to do the certification online or abroad.

Pediatric Pharmaceutical care is a Clinical Pharmacy specialty that basicaly narrows down medication therapy management to specific age range of 0 to 12 years. Opara 2020 et al'., describes it as Pharmaceutical care in a heterogenous group with infants ageing from birth to 1 year and Children 1 to 12 years, and also includes neonates ageing from birth to 4 weeks and preterm babies. It is the provision of drug therapy (Pharmacotherapy) management to this specific age group based on their anatomical and physiologic peculiarities (age, body mass, organs at various stages of development and maturity, disease condition, genetic predisposition, pharmacodynamics and intersubject variability) with the ultimate purpose of achieving definite outcomes that improve quality of life. In plain English "you dont manage drug therapy for children the same way you manage for adults"

It explores dosage administrations and routes of administration based or peculiarities and disease conditions in children at various developmental stages.

Pediatric Pharmaceutical care is necessary because though studies show that Nigeria has ample supply of medications for primary care use, there is a deficiency of pediatric dosage forms for prescription only medications used for secondary and tetiary care. Consequently extemporanous reconstitution of prescribed medicines in the Pharmacy becomes necessary. Recostitution of pediatric medications is a highly sensitive but commonly overlooked area. Hospitals which take it seriously have had to locate a Pediatric Pharmaceutical Care unit within the Special Care Baby Unit (SCBU) and/or the Paediatrics Unit.

The American Society of Health-System
Pharmacists and the Pediatric Pharmacy Advocacy Group in 2018 published a gudeline titled "ASHP–PPAG Guidelines for Providing Pediatric Pharmacy Services in Hospitals and Health Systems" to guide Clinical Pharmacists in meeting the special needs of the pediatric population. This underscores the importance of Pediatric Pharmaceutical Care as a specialty in Hospital Pharmacy practice. This is because studies show the pediatric population is a more vulnerable group to Adverse Drug Reactions (ADRs) than the adult population, exhibit higher variability in Pharmacokinetic and pharmacodynamic profiles of drugs and have pharmacogenetic variations such as Glucose-6-phosphate dehydrogenase(G6PD) deficiency, short gut syndrome and lactose intolerance. There is also a lesser tendency for recipients to report ADRs either because they are too young to recognise the injury(children), are too young to communicate (Babies) or are not being monitored by a vigilant caregiver. Pediatric Pharmaceutical care specialty is important because many drugs that are safe for adults are not safe for children.

There is even the school of thought which intends to include unborn children in pediatric pharmaceutical care by trying to prevent genetic anomalies or irreversible damage to the unborn baby as a result of substances consumed by the mother during pregnancy. For example, an eight month pregnant mother taking Tetracycline capsules as antibiotic treatment for her infective cough will likely cause bone distortion in the child as a result of calcium/phosphorus chelation and Dental dysplasia (brownish/yellow coloring of teeth). There is neonatal death due to chloramohenicol induced "grey baby" syndrome and Kernicterus from taking Sulphonamides. So should this be included in paediatric pharmaceutical care or left to the OBGYN?

A recent study by Tareq 2017' et al'., insists that Pharmacists must have a baseline knowledge of Pharmaceutical care in pediatrics not only for the purpose of councelling care givers but also for dosage form reconstitution and inpatient interventions to correct medication errors that could result in ADRs (Adverse Drug Reactions) or suboptimal dosing.

For example, at the National Hospital Abuja in Nigerias Federal Capital Territory the Pediatric Pharmacy unit is tasked with the responsibility of carrying out interventions. The Clinical Pharmacists :

  1. - recomend dose adjustments where necessary,
  2. - proactively intercept medication errors during prescription review and revert back to prescriber, (dosage calculation errors are known to be the most common sources of medication error)
  3. - Track patient adherence and persistence,
  4. - identify drug therapy problems based on known classifications, and
  5. - take appropriate action where necessary
  6. - educate parents and children themselves.

In all these clinical pharmacokinetic parameters such as age, weight, Body Mass Index(BMI), Renal function, Cardiovascular impairments, Drug elimination rates, Bioavailability, Volume of Distribution etc are considered. The pharmacist actually takes a wholistic picture of the situation and arrives at a care plan which will also involve the patients parents or care givers upon discharge. This is all done in collaboration with the entire inpatient management team at the hospital. Nurses are very fond of crosschecking and reviewing medication administration plans with the pharmacist and it is not uncommon for them to frequently seek clarification for routes and modes of administration. Post discharge the parents or caregivers also maintain close collaboration with the pharmacists and report on progress and any unwanted effects observed. Communication is maintained effectively via phone and wattsap chats which also enable sending photos and screen shots as visual aids.

In Pediatric Pharmaceutical care one thing is most improtant, VIGILANCE. Its simple, the Pharmacist must remain vigilant in prescription review, extemporaneous preparation or precribed medication reconstitution, medication administration, patient/care giver counceling and ADR monitoring. Hence Pharmacovigilance within the pediatric inpatient unit takes a different dimension. The Pharmacist is aware of common drug related problems identified with specific medicines and takes measures to look out for them.

Pharmacists should realise that after discharge and the patient becomes an outpatient the larger burden subsequently lies on the pharmacist who will be frequently contacted by the childs caregivers for clarification on various drug related issues.

Picture this : For a drug like Digoxin the optimal dose for a Baby may instantly kill an adult. We all observe that children are prescribed lower doses than adults. But do you know that children actually require higher drug doses than adults? Doses are determined on a milligram per kilogram (mg/kg) body weight basis. Anyways, that is a story for another day.

Let me know your thoughts by droping your comments below. As men of honour………!

References :

American Society of Health-System
Pharmacists, Inc., and the Pediatric Pharmacy Advocacy Group, 2018, ASHP–PPAG guidelines for providing pediatric pharmacy services in hospitals and health psystems. Am J Health-Syst Pharm. 2018; 75:1151–65.

DIGOXIN Pediatric Monographs, 2021, Copyright 2021, Medical Security Card Company, LLC, dowloaded at https://www.wellrx.com/digoxin/pediactric-monographs/ on 16th January 2021.

Enato E, 2020, lecture notes, Sukthankar V, Individualization of dosage regimen, Clinical Pharmacokinetics, Mpharm 2020, Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, University of Benin.

Moles.R, Carter. S, 2028, Pharmaceutical Care in Pediatrics, Springer Link, downloaded at https://link.springer.com/chapter/10.1007/978-3-319-92576-9_31. on 16th January 2021.

Opara A, 2020, lecture notes in Pediatric Pharmaceutical care, Pharmaceutical care, Mpharm 2020, Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, University of Benin.

Tareq L. Mukattash, Anan S. Jarab, […], and James C. McElnay, Pharmaceutical Care in Children, Sultan Qaboos University Medical Journal, downloaded at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6443271/ on 16th January 2021.


  1. Pediatric specialty is overdue considering the under five mortality in Nigeria and by extension subsaharan African .In particular the risk of a medication error occuring in a pediatric intensive care unit is often greater than in other clinical areas due to complexity of the necessary dose calculations and the manipulations required to prepare doses and complicated by the use of off label and non license drugs for pediatric drugs.
    In criticaly illed children meds are administered by intravenously and in most cases continuously and so the problems of compatibilities and fluids volume is needed to be monitored.
    Safety promotion is needed for neonates with low birth weight of whether they are 2kg neonates or teenagers weighing 100kg
    There is a need for a structured training in this are to cater for this all important need for knowledge gap filling

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