B – BNF for Children
The British National Formulary (BNF) was first published in 1949 as a result of war-time formularies, with new editions being published every 3 years until the mid-1970s (Wade, 1993). Then, the pharmaceutical industry began to publish the Monthly Index of Medical Specialities (MIMS) every month, providing more up-to-date information for doctors – no non-medical prescribers then! However, the BNF format was re-evaluated and re-formed, and new editions have been published every 6 months since 1981. This new format included drug monographs for all licensed medications, as well as some unlicensed drugs and, since 1999, NICE (then the National Institute of Clinical Excellence) has been using the BNF to create guidelines alongside evidence-based practice (Ogden, 2017).
In 2005, the British National Formulary for Children (BNFc) (Paediatric Formulary Committee, 2023) was launched. Paediatric health professionals know that caring for children is challenging in a variety of ways, and that they are not just ‘little adults’. Children – especially neonates – differ greatly to adults in their response to drugs. In the neonatal period, for example, the risks of toxicity are increased by a reduced drug clearance, so a working knowledge of differing pharmacokinetic changes as children grow and develop is paramount. Yet, most children's doses of medications are still extrapolated from adult drug studies (O'Hara, 2016).
A lack of paediatric clinical trials has been recently highlighted and, because of this many drugs used in children – and again, especially in neonates – is often ‘off-label.’ The term ‘off-label’ is used to describe licensed medications for unauthorised indications – like age groups, dose, dosage forms, or routes of administration (Belayneh et al, 2022). Off-label use is seen commonly in prescribing for children, sometimes up to 95% of all inpatients (Meng et al, 2022).
Fewer licensed medications for children also result in a reduced amount of adequate formulations suitable for children. Specialised paediatric centres – until 2005 – formed their own formularies, including major London hospitals, Liverpool, and the north of England (Kendall and Mehta, 2006).
Medicines for Children was launched by the Royal College of Paediatrics and Child Health (RCPCH) and the Neonatal and Paediatric Pharmacy Group (NNPG) in 1999 (Kendall and Mehta, 2006). It was used throughout hospitals in secondary and tertiary care, but uptake in primary care was not so successful. Therefore, in 2005, the BNFc was born after a call for a paediatric specific editorial team was made to ensure regular and clinically evidence-based practice.
The BNFc – in contrast to the BNF – is published annually, every September. The editors do stress that it is important to use the most up to date BNFc in clinical practice, and any changes made can be found in new published editions, in a specific section. Similar to the BNF in that cautions, contraindications and side effects are listed, the BNFc also focuses on drug dosages specific to age, body weight and, at times, body surface area (Novak, 2006). Again, this means not forgetting neonates, where drug dosages can vary between premature infants and term babies, or from a week-old baby to a 4-week-old baby.
Recognition is also given (where relevant) to the most appropriate formulation for a child, depending on their age and age-appropriate pharmacokinetics. For example, when referring to antibiotics, older children may be able to switch from intravenous antibiotics to oral antibiotics more readily than neonates can, due to variable absorption in the neonatal period. Knowledge of adverse effects of medications in the developing child is also noted: dexamethasone, for example, should not be used in neonates with chronic lung disease due to the potential for adverse neurological events (Joint Formulary Committee, 2023), or the lowest dose of prednisolone should be used where clinically relevant due to its known growth suppressing effects (Allen, 2015).
Replacing Medicines for Children with the BNFc to maintain clinically evidence-based standards in line with the RCPCH and NPPG was clearly the way forward (Elias-Jones and Rylance 2005). Yet, it is not just the paper version that is used in clinical practice; in line with the BNF, the BNFc is also available digitally, either offine or via an app, which is fully functional online. It is easy to switch between the two, and the ‘adult’ BNF is colour-coded blue, and the BNFc pink to represent children (Porter, 2022).
Drug monographs are easily accessible, including detail on action statements, dose and indications, and unlicensed use. One principle advantage of the digital format is that clinical content is updated monthly, and this has been heralded as preferable by medical and non-medical prescribers alike, ensuring clinical accuracy and reducing medico–legal risk. Teaching non-medical prescribing students does now focus on not just the paper version, but also how to navigate the digital version, imperative for a time-restricted pharmacology exam.
The success of the BNFc has clearly been demonstrated by its constant need for updating and expansion of drugs that are included, and both the BNF and the BNFc continue with their monthly newsletter, where health professionals can sign up to receive emails, enabling them to keep up to date with the latest drugs and any significant changes made. There is no doubt that the BNFc is here to stay, and it is exciting to envisage where the next steps will be taken. The next A–Z article – C – will be focusing on concordance.