The National Patient Safety Team were approached to consider the risk of liquid phenobarbital preparations containing alcohol.
Phenobarbital, an anti-epileptic drug, is available in a range of strengths and dosage forms; some oral liquid preparations are considered inappropriate for children because of the alcohol content. The Royal College of Paediatrics and Child Health (RCPCH) and Neonatal and Paediatric Pharmacists Group (NPPG) recommend that unlicensed alcohol-free phenobarbital 50mg/5mL liquid is used in children.
A search of the National Reporting and Learning System identified 23 reports, over three years, describing confusion between different preparations of liquid phenobarbital.
Following these findings we worked in collaboration with partner organisations to develop and update guidance and resources including:
- Review of phenobarbital monographs in the BNF and BNFC and the Medicines For Children resource Phenobarbital for preventing seizures
- RCPCH and NPPG support to develop the NHSBSA Dashboard: Children’s Standard Liquid Concentration
- Rationalisation of the range of unlicensed liquid phenobarbital preparations listed in the Drug Tariff
- A webinar for the national medication safety officer network highlighting these concerns.
- Publication of Managing the risks if using liquid oral phenobarbital preparations’ (Specialist Pharmacy Service).
These new resources will support safer dosing and administration of phenobarbital in children.
Publication reference: PRN01208