Prescriptions for infants and young children present special risks and considerations for pharmacists and pharmacy technicians. The College has recently seen an increase in the number of complaints related to pediatric prescriptions. Pharmacy professionals must engage in appropriate care, consideration and collaboration to ensure patients can receive the intended benefit of their medication.
Common Scenarios Seen Through Complaints to the College
- Dispensing inappropriate volumes of medication that are not reasonably possible for infants or small children to consume.
- Using commercially available oral dexamethasone elixirs that contain a high percentage of alcohol.
- Improper reconstitution resulting in wrong strength.
- Lookalike, soundalike medications being mistakenly dispensed.
Learning from a Complaint to the College
A prescription for a commercially available solution of dexamethasone for a three-year-old child with croup was received by a pharmacy. The pharmacist prepared the dosage based on the child’s weight, noting no history of alcohol allergy and the parent’s insistence that the prescription was needed urgently. As a result, the volume of medication dispensed per dose was 70ml.
The child’s caregiver found the 70 ml, which had a bitter taste, impossible for the child to consume. The caregiver was very surprised to learn later that the dexamethasone elixir contains alcohol. This was not mentioned by the pharmacist, and no potential side effects were explained to them.
The caregiver later filed a complaint to the College. A panel of the Inquiries, Complaints and Reports Committee (ICRC) noted that there was no dispensing error, and the registrant acted in the best interest of the patient by providing the medication in a timely manner. However, they recommended that the pharmacist, in the future, give more consideration to the size of the dose and the format of a medication based on the patient’s age and needs.
Special Considerations for Pediatric Patients
Infants and children are considered “red flag” patients requiring additional care and attention when assessing the appropriateness of prescribed medication.
Pharmacy professionals are encouraged to consider the following elements to support optimal patient care.

Consider the whole picture of the patient. When assessing the prescription, ensure you consider all elements, including excipients, allergies, dose, dosage form and other factors. Engage with the child’s caregiver to understand the most appropriate formulation and consult with the prescriber as necessary. Consider whether alternatives are necessary, such as “dissolve and dose,” “crush and give” or compounding.

Check calculations. Pediatric patients often require individualized doses of medication based on the child’s age, weight, indication for use and dosage regimen. The need for calculations can introduce an additional source of error. Double check pediatric doses for accuracy and appropriateness. A best practice is to have another team member independently perform the calculation. Common calculation errors include mixing up pounds and kilograms, calculating total daily dose as a single dose and misplacement of a decimal point.

Follow the reconstitution instructions and inspect the final product. Pediatric medications, such as oral suspensions, often require reconstitution which is medication specific. This step can lead to errors such as incorrect water volume for mixing, forgetting to reconstitute, or overlooking stability after reconstitution (e.g., patient needs 14-day supply of antibiotics, but one bottle of their reconstituted antibiotic suspension is only stable for 10 days according to its product monograph).

Ensure informed decision-making. Pharmacy professionals have an ethical duty to provide patients/their caregivers with relevant and sufficient information regarding the potential risks and serious side effects associated with their medication. For instance, a patient’s caregiver should be counselled on the potential risk of intoxication with commercially available dexamethasone elixir when the prescription is first received. Patients/caregivers must have the opportunity to understand available options and make informed decisions, considering factors such as urgency of treatment and possible alternatives.

Do not dismiss caregiver concerns and questions. When concerns are raised, take the time to thoroughly address them. Ensure that pharmacy assistants and pharmacy technicians bring concerns or questions they receive to the attention of the pharmacist (instead of trying to address it themselves).

Be prepared to refer if you can’t compound. If a compounded preparation is determined to be the best alternative for a patient, the Designated Manager must ensure the pharmacy has the resources to safely and accurately prepare it. If this is not possible, registrants have an ethical obligation to make reasonable efforts to ensure continuity of care, such as referring the patient to a pharmacy with the necessary compounding standards in place.