If you go to any medication aisle of a store, you can find a wide selection of medications for pediatric patients. Everything from analgesics, cough and cold medications, and agents for gastrointestinal relief. Being a new parent myself, in learning the many ins and outs of infanthood, I did notice something that struck me as rather interesting, perhaps because of my background as an emergency medicine pharmacist, that called my attention.

On most over-the-counter medications for pediatric patients, particularly for oral liquid formulations, there is generally a single dose recommendation provided for any particular medication, given a weight range.  For example, this is the dosing range provided in the product labeling of ibuprofen for the branded formulation of Children’s Motrin® and Motrin Infant Drops®:

Yet, in the health-system setting, as we are so particular about ensuring that with documentation of the correct weight of the pediatric patient within the electronic medical record, we dose ibuprofen using a specific weight-based dose (generally 10 mg/kg/dose), rather than rely on this method for dosing the same medication.

Of course, from a practical standpoint, this makes the most sense, as our children are not regularly weighed when they are at home as opposed to obtaining an accurate weight when evaluated by a pediatrician in an inpatient or outpatient setting. But how many times have we heard of and/or been involved in situations where the weight was documented inaccurately (pounds versus kilogram) or the dosing of the medication prescribed was mg/kg/day instead of mg/kg/dose? You can also make the best pharmacotherapeutic recommendation for your sick pediatric patient, backed up by a complete and referenced in-house guideline for your team of providers (approved of course by the many committees at your institution), but the turnaround time in compounding the medication may not be all that feasible due to the individualization of the dose, limiting timely delivery and leading to potential delays in administration of therapy.

However, can this concept of dose banding, which is generally defined as dosing medications in patients based on a range (or ‘band’) of weights, with the dose generally falling within the middle of the band, be applied to the inpatient setting?

The concept of dose banding is not foreign in the inpatient setting. This strategy has been evaluated in pediatrics, particularly for antimicrobials and chemotherapeutic agents, and it has made headway in Europe over the past few years. In fact, the National Health Service (NHS) has actually advocated for the use of dose banding strategy for intravenous pediatric chemotherapeutic agents as a means to reduce drug waste, costs, and most importantly, errors in dosing these agents.1 Standardized doses have been proposed for these agents based on a band of predefined dose ranges with a given body surface area. Dose banding tables provided by the NHS are available here for a variety of chemotherapeutic agents, which can be used as a means to streamline chemotherapy for pediatric patients. In one evaluation of the effect of dose banding tables for chemotherapeutic agents, drug expenditures significantly decreased over the course of one year with this strategy,2 which can increase productivity within the department as a result of time freed for both extemporaneous compounding of the medication (as only standard doses would be required to be compounded) and clinical time, as errors are minimized and minimal intervention is needed in correcting the error (or worse, missing the error and treating the adverse reaction resulting from such an error later).

In addition, there was one evaluation conducted with prophylactic piperacillin-tazobactam in pediatric patients prior to surgery that also demonstrated minimal variations in the dosing recommendations of this agent when prescribed by a dose banding strategy relative to a mg/kg basis.3 In another evaluation of medications prescribed to pediatric patients in the emergency department, errors were minimized with dose banding strategies employed for a number of oral analgesic and antimicrobial therapies (our bread-and-butter classes of agents for this patient population in this acute setting).4

One may consider the pharmacokinetic implications (or lack thereof) with employing dose banding strategies for such agents. There are a number of evaluations that demonstrated minimal differences in pharmacokinetic parameters when dose banding strategies were used in pediatric patients versus dosing based on a mg/kg or mg/m2 basis.5-6 For some agents, a variance of 5% or less of the dose within the dose band versus standard mg/kg or mg/m2 dose may be acceptable.7 Of course, for agents with a narrow therapeutic index, one may not necessarily consider such a strategy to be utilized as a means to ensure that systematic toxicity is minimized with these particular agents while achieving the maximum therapeutic effect.

Overall, however, dose banding is an interesting concept that can make a multifaceted difference in the delivery of patient care, based on the numerous advantages highlighted above, and one that requires further evaluation for medications commonly used for the pediatric population in the inpatient setting.

References:

  1. Mayor S. National Health Service England introduces dose banding. Lancet Oncol 2016; 17(7):e271.
  2. Finch M, Masters N. Implications of parenteral chemotherapy dose standardisation in a tertiary oncology centre. J Oncol Pharm Pract 2018 [Epub ahead of print].
  3. Karande IS, Goff Z, Kewley J, et al. Dose-Banding of Intravenous Piperacillin-Tazobactam in Pediatric Surgical Inpatients. J Pediatr Pharmacol Ther 2017; 22(5):364-368.
  4. Al-Turkait A, Khan F. Can dose-banding help to reduce prescribing errors in a pediatric accident and emergency (A&E) department? Arch Dis Child 2015; 100(6):e1.26-e21.
  5. White-Koning M, Osborne C, Paci A, et al. Investigating the potential impact of dose banding for systemic anti-cancer therapy in the paediatric setting based on pharmacokinetic evidence. Eur J Cancer 2018; 91:56-67.
  6. Windscheif PM, Welsh R, Smith L, et al. Once daily gentamicin dose banding in newborns with signs of early onset neonatal sepsis (EONS), based on initial birth weight and gestational age. Arch Dis Child 2016; 101(9):e2.
  7. Plumridge RJ, Sewell GJ. Dose-banding of cytotoxic drugs: a new concept in cancer chemotherapy. Am J Health Syst Pharm 2001; 58(18):1760-1764.