This is the second of a two-part series on paediatric cardiology. Part 1 was published in the May 2026 IPU Review.
In part two of this two-part series, we will cover:
Effective discharge planning must anticipate the practical challenges associated with medication supply and the transition from hospital to community care. This period of transition is particularly high-risk for medication errors in paediatrics, especially at the point of dispensing. A report by the US Poison Control Centre found that cardiovascular drugs, when compared to many other drugs, lead to higher fatality events in paediatrics (Joint Commission Preventing Medication Errors, 2008).
There are several reasons why children are particularly susceptible to harm from cardiology medication errors. One major challenge is the complexity of paediatric dosing, as doses may be calculated according to age, weight, or body surface area and can involve multiple calculations to determine the correct dose. This increased complexity raises the risk of calculation mistakes, particularly ten-fold dosing errors. In some cases, children may also be prescribed adult doses depending on the indication and patient profile, which can create further confusion.
Prescribing practices may also contribute to error risk. For example, the use of trailing zeros (for example, 1.0 mg) can be misinterpreted as 10 mg rather than 1 mg. In addition, doses that cannot be measured easily may present practical challenges in the community setting. Dose rounding can sometimes facilitate safer administration, such as enabling the use of a single oral syringe, but it must be undertaken carefully to maintain accuracy and safety. Where appropriate, dose rounding should remain within an acceptable margin (commonly 5 to 10 per cent) and always be guided by clinical judgement.
Another challenge is the availability of unlicensed medicines, which may not be routinely stocked in community pharmacies, and can be difficult to source, due to medicines shortages issues. This can result in delays to treatment, including delays involving time-critical cardiac medications.
There are also limitations in the evidence base and a lack of licensed paediatric dosing in manufacturers’ SPCs. Inconsistent presentation of dosing information, such as total daily doses versus divided doses, may cause confusion. Commonly used paediatric references such as BNF for children often recommend dose banding according to age rather than dosing as mg/kg, for example, oral flucloxacillin dosing for children two to nine years in a single age band despite large variations in weight in this cohort.
Another consideration is the lack of suitable paediatric formulations. Due to limited availability of licensed medicines for children, adult formulations are often modified to achieve appropriate doses. This may involve tablet splitting or crushing, dilution of injectable products, or preparation of extemporaneous suspensions which many pharmacists may not be familiar with. Each additional manipulation introduces further potential for error.
Transitions of care further compound these risks. Medicines initiated in acute settings — such as proton pump inhibitors started in intensive care — may be unintentionally continued after discharge without reassessment of their ongoing need.
Complexity of paediatric dosing:
The use of trailing zeros (for example 1.0 mg) can be misinterpreted as 10 mg rather than 1 mg.
Inconsistent presentation of dosing information, such as total daily doses versus divided doses in product SPC, may cause confusion
Modification of adult formulations to achieve appropriate doses. This may involve:
Transitions of care:
There is a high level of discharge liaison between the paediatric cardiology pharmacist at the Children’s Heart Centre (CHC) and primary care services to support a safe and seamless transition from hospital to home. Close collaboration between hospital pharmacy services and community pharmacies is essential to ensure continuity of care, safe medication use, and ongoing access to treatment following discharge. Practical considerations such as reimbursement, bridging supply, dose standardisation, product availability, and timing of administration must also be addressed to minimise the risk of medication errors and support continuity of care in the home setting.
This discharge support includes:
A key component of discharge planning is the provision of a bridging supply of medication to cover the period until community pharmacies can source ongoing stock. The CHC clinical pharmacist also supports reimbursement processes and acts as a liaison between the community pharmacy and cardiology team to facilitate timely completion of the necessary documentation. This helps ensure uninterrupted treatment for the patient while also supporting reimbursement for community pharmacies supplying specialist or unlicensed medicines.
To promote consistency and reduce the risk of error, the CHI pharmacy department provides guidance to community pharmacies on suitable paediatric products and brands. This is particularly important in paediatrics, where differences in formulation strength, concentration, bioavailability, or excipients between products may significantly affect safety, tolerability, and dosing accuracy. Maintaining the same formulation following discharge helps support continuity of care and minimises the risk of dosing or administration errors.
Given the increasing use of unlicensed medicines in paediatric cardiology, the CHI pharmacy department also play a critical role in assessing the quality, safety, and suitability of these products, including careful evaluation of excipients and formulation characteristics. The CHI pharmacy department can provide information on formulations that have previously been assessed for use in paediatric patient cohorts.
Ongoing communication between hospital and community pharmacists is therefore essential to support safe, effective, and consistent medication use for paediatric cardiology patients following discharge. There is a high level of discharge liaison between the paediatric cardiology pharmacist and primary care services to support a safe and seamless transition from hospital to home.
Clear, structured counselling for parents and carers is essential to ensure safe medication administration and supports adherence at home. Key information should include:
Medication adherence in paediatrics is complex and influenced by both the child and their caregivers. Factors such as dosing frequency, palatability, and practical challenges (for example, children spitting out or vomiting doses) can significantly impact treatment success. Strategies to improve adherence include simplifying regimens, reducing dosing frequency where possible, and considering alternative formulations. Children can often be taught to swallow tablets from a relatively young age, which may help avoid poorly tolerated liquid formulations. Other options such as dispersible tablets or granules may also be beneficial.
When evaluating a cardiac medication for use in a child in the community, a structured assessment is required to ensure safety, practicality, and continuity. Key considerations should include the formulation and strength of the medication and ensuring, where possible, that these remain consistent between hospital and home settings to minimise the risk of dosing and administration errors. The licensing status should also be reviewed, with additional measures applied to unlicensed medicines, such as assessment of product quality, excipient profile, bioavailability, and suitability for paediatric use.
Assessment of excipients is particularly important in paediatric patients, as certain excipients may have clinically significant effects in children. For example, high concentrations of sorbitol may cause diarrhoea, while some oral liquid formulations may contain alcohol as a diluent at concentrations that are unsuitable for paediatric use. The Neonatal and Paediatric Pharmacists Group (NPPG) has published a position statement that provides useful guidance for the assessment of unlicensed oral liquid formulations in paediatric practice. This guidance was updated in 2026 and is available at nppg.org.uk > Resources > Position Statements (also see ‘Medicines Optimisation’ article in the April 2026 IPU Review for further information on this topic).
Practical administration is another critical consideration with paediatric cardiology medications. This includes assessing whether a formulation can be safely manipulated, such as crushing tablets or opening capsules, whether liquid doses can be measured accurately using a single oral syringe, and whether the overall regimen is manageable for caregivers at home, particularly when multiple medicines or frequent daily dosing schedules are involved. Consideration should also be given to the therapeutic range of medications, especially those with a narrow margin of safety, such as Digoxin. In addition, some medicines are formulation or brand-specific, such as Aqumeldi (oral dispersible enalapril), where consistency of product is important to maintain dosing accuracy, efficacy, and safety.
Finally, parents and carers should be supported and educated on the safe administration of medicines to their child and safety-netting provided in case of any changes to strengths or regimens. The overall goal is to ensure that the prescribed medication is not only clinically appropriate, but safe, practical, and sustainable in the home setting.Bottom of Form
References available on request.
Aoibhe Frazer MPSI
Senior Pharmacist, Pharmacy Department, Children’s Health Ireland (CHI) Crumlin
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