Rational prescribing is challenging in neonatology. Drug utilization studies help identify and define the problem. We performed a review of the literature on drug use in neonatal units and describe global variations. We searched databases (EMBASE, CINAHL and Medline) from inception to July 2020, screened studies and extracted relevant data (two reviewers). The search revealed 573 studies of which 84 were included. India (n = 14) and the USA (n = 13) reported the most. Data collection was prospective (n = 56) and retrospective (n = 26), mostly (n = 52) from one center only. Sixty studies described general drug use in 34 to 450,386 infants (median (IQR) 190 (91–767)) over a median (IQR) of 6 (3–18) months. Of the participants, 20–87% were preterm. The mean number of drugs per infant (range 11.1 to 1.7, pooled mean (SD) 4 (2.4)) was high with some reporting very high burden (≥30 drugs per infant in 8 studies). This was not associated with the proportion of preterm infants included. Antibiotics were the most frequently used drug. Drug use patterns were generally uniform with some variation in antibiotic use and more use of phenobarbitone in Asia. This study provides a global perspective on drug utilization in neonates and highlights the need for better quality information to assess rational prescribing.

Purpose To describe drug utilisation patterns in neonatal units. Methods Retrospective observational cohort study using data held in the National Neonatal Research Database (NNRD) for neonatal units in England and Wales including infants born at 23 to 44 weeks’ gestational age (GA) from 01 January 2010 to 31 December 2017. Results The cohort included 17,501 (3%) extremely preterm infants; 40,607 (7%) very preterm infants; 193,536 (31%) moderate-to-late preterm infants; and 371,606 (59%) term infants. The number of unique drugs received by an infant (median (IQR)) increased with decreasing GA: 17 (11–24) in extremely preterm, 7 (5–11) in very preterm, 3 (0–4) in moderate-to-late preterm, and 3 (0–3) in term infants. The two most frequently prescribed drugs were benzylpenicillin and gentamicin in all GA groups, and caffeine in extremely preterm. Other frequently used drugs among preterm infants were electrolytes, diuretics and anti-reflux medications. Among infants <32 weeks’ GA, the largest increase in use was for surfactant (given on the neonatal unit), caffeine and probiotics, while domperidone and ranitidine had the largest decline. Conclusion Antibiotics, for all GAs and caffeine, among preterm infants, are the most frequently used drugs in neonatal medicine. Preterm infants are exposed to a high burden of drugs, particularly antibiotics. Changing patterns in use reflect the emergence of evidence in some areas but several non-evidence-based drugs continue to be used widely. Improvements are needed to ensure rational drug use on neonatal units. Registration ClinicalTrials.gov (NCT03773289). Date of registration 21 Dec 2018.

Aim To evaluate the usefulness of dose-banding in reducing prescribing errors in a paediatric A & E department Method Dose banding is a process where the dose is determined within defined ranges or bands, based on the age or weight of the child depending on the medication. Dose bands are often used in prescribing cytotoxic agents through an agreement between pharmacists and clinicians. A previous audit conducted in paediatric A&E over one week identified a 28.7% prescribing error rate;19% of all errors were dosing errors. The intention of this study was to apply dose-banding to selected medications prescribed in the paediatric A&E to evaluate its usefulness in reducing prescribing errors.A dose-banding schedule was created using BNFC 2013-2014, in agreement with a paediatric A&E consultant and a senior paediatric pharmacist. This included analgesics and antibiotics most commonly prescribed in the paediatric A&E department (paracetamol, ibuprofen, morphine, amoxicillin, co-amoxiclav, clarithromycin, erythromycin, azithromycin). A standard operating procedure was written, training was provided and a one week run-in period was implemented to ensure all A&E staff were aware of the dose-banding schedule. All paediatric A&E prescriptions written over two consecutive weeks were included; this was achieved by asking nursing staff to photocopy every prescription issued, morning and night, during this time period. All prescriptions were screened retrospectively for prescribing errors using a streamlined version of a validated data collection tool. Prescriptions written under Patient Group Directions (PGDs) were exempted from dose-banding, but were included in the analysis. Results A total of 590 medication orders (MOs) from 428 prescriptions were screened for different types of prescribing errors over two consecutive weeks. Of these, 450 (76.3%) were doctor MOs and 140 (23.7%) were PGD MOs. A total of 225 (38.1%) MOs contained a prescribing error, giving an overall prescribing error rate of 37.9%. Allergy status was missing in 36 (6.1%), date of birth (DOB) was missing in 98 (16.6%) and the patient name was missing in 88 (14.9%) MOs. Dosing errors occurred in 38 (6.4%) MOs.Of the 450 MOs written by doctors, 194 followed the dose banding schedule and none of these resulted in an incorrect dose; 114 MOs were not written according to the dose bands -and 22 of these had an incorrect dose; 142 MOs were written for drugs that were not included in the dose-banding schedule, and 2 of these had an incorrect dose. Of the 140 MOs from PGDs, 14 had an incorrect dose. Conclusion Overall the dose-error rate for MOs written by doctors was 24 out of 256 (9.4%) for non-dose banded drugs versus 0% for dose-banded drugs. The error rate for PGD MOs was 10%. The results suggest that dose-banding may be a useful strategy to help reduce prescribing errors in paediatrics.

ObjectiveTo describe the diagnosis and treatment of patent ductus arteriosus (PDA) in infants born at <32 weeks’ gestational age (GA) in England and Wales between 2010 and 2017.Study designRetrospective cohort study using routinely recorded data from the National Neonatal Research Database of infants born at <32 weeks admitted to neonatal units in England and Wales from 2010 to 2017.ResultsAmong 58 108 infants born at <32 weeks’ GA, 28.3% (n=16 440) had a PDA diagnosed clinically or with echocardiographic confirmation. Of these, 34.8% (n=5721; 9.8% of total <32 weeks’ infants included) had PDA treatment including 7.6% (n=1255) with indomethacin, 23.5% (n=3857) with ibuprofen and 5.6% (n=916) with surgical closure. The highest incidence of PDA was among infants born at 24 and 25 weeks’ GA (70.2% and 70.8%, respectively), decreasing to 6.1% among infants born at 31 weeks’ GA. The percentage of infants with a PDA increased over the study period (25.5% in 2010 to 28.5% in 2017). The percentage of infants who received ibuprofen or indomethacin or had PDA surgery decreased from 41.3% in 2010 to 33.7% in 2017, with an increase in use of ibuprofen from 20.2% to 27.3% while use of indomethacin decreased from 20.0% to 8.8%. Surgical closure of PDA decreased from 9.1% to 3.0%. Indomethacin was used for median (IQR) 3 (2–5) days while ibuprofen was given for 3 (2-4) days, at a median of 8 and 10 days after birth, respectively; surgical treatment was used later at 33 (24–45) days after birth.ConclusionsIbuprofen is the preferred drug and surgical interventions are becoming less frequent for PDA closure among very preterm infants in England and Wales.Trial registration numberNCT03773289.