Safe drug administration is every bit as important as safe and effective drug prescribing.

Neonatal prescribing: It is important to consider the practicalities of drug administration when prescribing, and to avoid prescribing absurdly precise doses that cannot realistically be measured. Such problems arise with particular frequency when body weight enters into the calculation. It is difficult to measure volumes of less than 0.05 ml even with a 1 ml syringe, and anyone who prescribes a potentially dangerous drug without first working out how to give it must inevitably carry much of the responsibility if such thoughtlessness results in an administrative error. Guidance on this is given in the individual drug monographs, with advice on prior dilution where necessary.

Equal thought should also be given to the timing and frequency of drug administration. Because many drugs have a relatively long neonatal elimination ‘half-life’, they only need to be given once or twice a day. More frequent administration only increases the amount of work for all concerned and increases the risk of errors creeping in. Parents are also more likely to give what has been prescribed after discharge if they are not asked to give the medicine more than twice a day!

Length of treatment: Remembering to stop treatment can be as important as remembering to start it. Neonatal antibiotic treatment seldom needs to be continued for very long. Treatment should always be stopped after 36–48 hours or sooner if the initial diagnosis is not confirmed. Babies with meningitis, osteitis and staphylococcal pneumonia almost always need 2–3 weeks’ treatment, but 10 days is usually enough in septicaemia. Few babies need to go home on treatment; even anticonvulsants can usually be stopped prior to discharge (cf. the monograph on phenobarbital). Babies are often offered respiratory stimulants like caffeine for far longer than is necessary. Few continue to need such treatment when they are more than 32 weeks gestation: it should, therefore, usually be possible to stop all treatment at least 3 weeks before discharge. In the case of some widely used nutritional supplements (such as iron and folic acid), there was probably never any indication for starting treatment in the first place given the extent to which most artificial milks are now fortified (cf. the monograph on pre-term milk).

Storage before use: Most drugs are perfectly stable at room temperature (i.e. at between 5 and 25 °C) and do not require specialised storage facilities. Temperatures above 25 °C can be harmful, however, and some drugs are damaged by being frozen, so special thought has to be given to transport and dispatch. Some drugs are best protected from direct daylight, and, as a general rule, all drugs should be stored in a cupboard and kept in the boxes in which they were dispensed and dispatched. Indeed, in a hospital setting, all drugs are normally kept under lock and key.

Hospital guidelines usually specify that drugs for external use should be kept in a separate cupboard from drugs for internal use. Controlled drugs, as specified in the regulations issued under the UK Misuse of Drugs Act 1971, must be kept in a separate cupboard. This must have a separate key, and this key must remain under the control of the nurse in charge of the ward at all times. A witnessed record must be kept of everything placed in, or taken from, this cupboard and any loss (e.g. due to breakage) should be accounted for. Medical and nursing staff must comply with identical rules in this regard.

Special considerations apply to the storage of vaccines. Many of these are damaged if they are not kept at between 4 and 8 °C at all times – even during transit and delivery (no mean feat in many resource poor or underdeveloped countries). A range of other biological products, such as the natural hormones desmopressin, oxytocin, tetracosactide and vasopressin, need to be stored at 4 °C. The same goes for cytokines, such as erythropoeitin (epoeitin) and filgrastim, and surfactants of animal origin. The only other widely used neonatal drugs that need to be stored at 4 °C are amphotericin, atracurium, dinoprostone, soluble insulin, lorazepam and pancuronium, and even here the need to maintain such a temperature all the time is not nearly as strict as it is with vaccine storage. Many oral antibiotic preparations have only a limited shelf life after reconstitution. The same goes for a number of oral suspensions prepared for neonatal use ‘in house’. The ‘shelf life’ of all these preparations can be increased by storage at 4 °C. Drugs that do not need to be kept in a ward refrigerator should not be so stored.

All the drugs mentioned in this compendium that require special storage conditions have their requirements clearly indicated in the relevant drug monograph – where no storage conditions are specified it can be taken that no special conditions exist.

Continued retention of open vials: Glass and plastic ampoules must be discarded once they have been opened. Drug vials can generally be kept for a few hours after they have been reconstituted, as long as they are stored at 4 °C but, because they often contain no antiseptic or preservative, it becomes increasingly more hazardous to insert a fresh needle through the cap more than two or three times, or to keep any open vial for more than 6–8 hours. It is, therefore, standard practice to discard all vials promptly after they have been opened (with the few exceptions specifically mentioned in the individual monographs in Part 2).

Drug dilution: Many drugs have to be diluted before they can be used in babies because they were formulated for use in adults. In addition, dilution is almost always required when a drug is given as a continuous infusion. Serious errors can occur at this stage if the dead space in the hub of the syringe is overlooked. Thus if a drug is drawn into a 1 ml syringe up to the 0.05 ml mark, the syringe will then contain between 0.14 and 0.18 ml of drug. If the syringe is then filled to 1 ml with diluent, the syringe will contain three times as much drug as was intended!

To dilute any drug safely, therefore, draw some diluent into the syringe first, preferably until the syringe is about half full, and then add the active drug. Mix the drug and diluent if necessary at this stage by one or two gentle movements of the plunger, and then finally make the syringe up to the planned total volume with further diluent. In this way the distance between two of the graduation marks on the side of the syringe can be used to measure the amount of active drug added.

While this may be adequate for 10-fold dilution, it is not accurate enough where a greater dilution than this is required. In this situation it is necessary to use two syringes linked by a sterile three-way tap. The active drug is drawn up into a suitable small syringe and then injected into the larger syringe through the side port of the tap. The tap is then turned so as to occlude the side port and diluent added to the main syringe until the desired total volume is reached.

Detailed guidance is given in Part 2 of this compendium on how to reconstitute each drug prior to administration, and how to handle drug dilution whenever this is called for. This can be found under the heading ‘Supply’ or ‘Supply and administration’ in each drug monograph.

Giving drugs by mouth