title: Manipulation of drugs to achieve the required dose is intrinsic to paediatric practice but is not supported by guidelines or evidence.
abstract: BACKGROUND
  A lack of age-appropriate formulations can make it difficult to administer medicines to children. A manipulation of the dosage form may be required to achieve the required dose. This study aimed to describe medicines that are manipulated to achieve the required dose in paediatric practice.
  
  
  METHODS
  A structured, undisguised observational study and postal survey. The observational study investigated drug manipulations occurring in clinical practice across three sites. The questionnaire, administered to a sample of paediatric nurses throughout the UK, surveyed manipulations conducted and nurses' experiences and views.
  
  
  RESULTS
  The observational study identified 310 manipulations, of which 62% involved tablets, 21% were intravenous drugs and 10% were sachets. Of the 54 observed manipulations 40 involved tablets with 65% of the tablets being cut and 30% dispersed to obtain a smaller dose. 188 manipulations were reported by questionnaire respondents, of these 46% involved tablets, 12% were intravenous drugs, and 12% were nebuliser solutions. Manipulations were predominantly, but not exclusively, identified in specialist clinical areas with more highly dependent patients. Questionnaire respondents were concerned about the accuracy of the dose achieved following manipulations and the lack of practice guidance.
  
  
  CONCLUSIONS
  Manipulations to achieve the required dose occur throughout paediatric in-patient settings. The impact of manipulations on the efficacy of the drugs, the accuracy of the dose and any adverse effects on patients is not known. There is a need to develop evidence-based guidance for manipulations of medicines in children.
authors.affiliation: Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool L12 2AP, UK. roberta.richey@alderhey.nhs.uk
authors.forename: Roberta H
authors.initials: RH
authors.lastname: Richey
authors.forename: Utpal U
authors.initials: UU
authors.lastname: Shah
authors.forename: Matthew
authors.initials: M
authors.lastname: Peak
authors.forename: Jean V
authors.initials: JV
authors.lastname: Craig
authors.forename: James L
authors.initials: JL
authors.lastname: Ford
authors.forename: Catrin E
authors.initials: CE
authors.lastname: Barker
authors.forename: Anthony J
authors.initials: AJ
authors.lastname: Nunn
authors.forename: Mark A
authors.initials: MA
authors.lastname: Turner
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D004304:Dosage Forms; D004333:Drug Administration Routes; D011307:Drug Prescriptions; D019317:Evidence-Based Medicine; D019538:Health Care Surveys; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D010372:Pediatrics; D017410:Practice Guidelines as Topic; D057184:Practice Patterns, Nurses' / Q000706:statistics & numerical data*; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011795:Surveys and Questionnaires; D006113:United Kingdom; D055815:Young Adult
chemical_list: D004304:Dosage Forms