Open Access Open Badges Research article

Manipulation of drugs to achieve the required dose is intrinsic to paediatric practice but is not supported by guidelines or evidence

Roberta H Richey1*, Utpal U Shah123, Matthew Peak12, Jean V Craig4, James L Ford3, Catrin E Barker13, Anthony J Nunn15 and Mark A Turner56

Author Affiliations

1 Alder Hey Children’s NHS Foundation Trust, Eaton Road, Liverpool L12 2AP, UK

2 Cheshire, Merseyside & North Wales Medicines for Children Local Research Network, Eaton Road, Liverpool, L12 2AP, UK

3 School of Pharmacy & Biomolecular Sciences, Liverpool John Moores University, Byrom Street, Liverpool, L3 3AF, UK

4 Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, NR4 7TJ, UK

5 NIHR Medicines for Children Research Network Co-ordinating Centre, Institute of Child Health, University of Liverpool, Liverpool L12 2AP, UK

6 Liverpool Women’s Hospital NHS Foundation Trust, Crown Street, Liverpool L8 7SS, UK

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BMC Pediatrics 2013, 13:81  doi:10.1186/1471-2431-13-81

Published: 21 May 2013



A lack of age-appropriate formulations can make it difficult to administer medicines to children. A manipulation of the dosage form may be required to achieve the required dose. This study aimed to describe medicines that are manipulated to achieve the required dose in paediatric practice.


A structured, undisguised observational study and postal survey. The observational study investigated drug manipulations occurring in clinical practice across three sites. The questionnaire, administered to a sample of paediatric nurses throughout the UK, surveyed manipulations conducted and nurses’ experiences and views.


The observational study identified 310 manipulations, of which 62% involved tablets, 21% were intravenous drugs and 10% were sachets. Of the 54 observed manipulations 40 involved tablets with 65% of the tablets being cut and 30% dispersed to obtain a smaller dose. 188 manipulations were reported by questionnaire respondents, of these 46% involved tablets, 12% were intravenous drugs, and 12% were nebuliser solutions. Manipulations were predominantly, but not exclusively, identified in specialist clinical areas with more highly dependent patients. Questionnaire respondents were concerned about the accuracy of the dose achieved following manipulations and the lack of practice guidance.


Manipulations to achieve the required dose occur throughout paediatric in-patient settings. The impact of manipulations on the efficacy of the drugs, the accuracy of the dose and any adverse effects on patients is not known. There is a need to develop evidence-based guidance for manipulations of medicines in children.

Drug manipulation; Survey; Dosage forms; Children's medicines