How to use the BNF for Children (BNFC)

Quick reference guide

The quick reference guide is for pharmacists, pre-registration trainees, other healthcare professionals and students. It is a tool to support learning and is not intended for use by patients.

It outlines how to find information in the BNFC. Scenarios and further sources of support to help you use the BNFC are included.


Why is this guidance important to you?

The BNF for Children (BNFC) is a clinically validated guide which aims to provide authoritative, independent guidance on best practice, and enable safe medication use in children up to their 18th birthday. It contains key information relating to medicines and covers areas such as licensing, handling, prescribing, dispensing, administration and monitoring of medication.

The BNFC is intended for use by healthcare professionals, including pharmacists and is a joint publication of the Royal Pharmaceutical Society, the British Medical Association, the Royal College of Paediatrics and Child Health and the Neonatal & Paediatric Pharmacists Group.

This guidance will help pharmacists use the BNFC more effectively, particularly when they undertake clinical checks and provide advice. 


How to access the BNFC

The BNF for Children is updated monthly online via MedicinesComplete and NICE Evidence Services, and via the NICE BNF mobile app, with the print edition revised annually, ensuring that the work remains at the forefront of practice. Additional digital formats include Formulary Complete (the unique locally hosted formulary management tool), and a PDA version or apps for mobile devices as well as being part of many clinical systems.

It remains vital to use up-to-date information on prescribing and dispensing medicines effectively and safely. Each print edition expires when a new print edition is published.


How is the information in the BNFC structured?

Information in the BNF is divided into a number of sections namely:

  • How the BNF for children is constructed
  • How to use the BNF for children
  • Changes for this edition
  • General guidance
  • Emergency treatment of poisoning
  • Notes on drugs and preparations
  • Appendices and indices

What symbols should I be aware of before looking at the BNFC? 

The symbols below indicate the legal status of the preparation against which they are placed:

bnfc-1

The symbols below indicate that a product is less suitable for prescribing or is not prescribable under the NHS respectively: 

bnfc-2

Other symbols to be aware of include:

The black dot symbol (●) is placed against interactions that are potentially serious and where concomitant administration of the drugs involved should be avoided (or only undertaken with caution and appropriate monitoring).

The black triangle symbol (▲) identifies newly licensed medicines that require additional monitoring by the European Medicines Agency. Such medicines include new active substances, biosimilar medicines, and medicines that the European Medicines Agency considers require additional monitoring. Remember all reactions in children should be reported, even if the black triangle has been removed.


What information can I find in the general guidance section of BNFC?

This section provides practical information on many aspects of prescribing including:

  • Prescription writing requirements for children
  • Emergency supply of medicines
  • Prescribing controlled drugs
  • Adverse reactions to drugs including reporting
  • Prescribing for special groups of patients, for example those with hepatic or renal impairment, in pregnancy, breast-feeding and palliative care patients
  • Prescribing in dental practice
  • Drugs and sport

What does the 'Emergency Treatment of Poisoning' section cover?

This section provides an overview of the general management of acute poisoning as well as information relating to management of poisoning from specific drugs e.g. paracetamol.


How is information in the section 'Notes on Drugs and Preparations' arranged?

This section is divided into 15 Chapters relating to either a body system, e.g. cardiovascular, or certain element of medical care e.g. infections. These chapters are:

  • Gastro-intestinal system
  • Cardiovascular system
  • Respiratory system
  • Central nervous system
  • Infections
  • Endocrine system
  • Obstetrics, gynaecology, and urinary-tract disorders
  • Malignant disease and immunosuppression
  • Nutrition and blood
  • Musculoskeletal and joint diseases
  • Eye
  • Ear, nose and oropharynx
  • Skin
  • Immunological products and vaccines
  • Anaesthesia

These chapters are subdivided into classified sections. Within each section the drugs are grouped according to their pharmacology e.g. beta-adrenoreceptor blocking drugs or therapeutic use e.g. laxatives. At the start of each section are prescribing notes.


What are prescribing notes?

The prescribing notes provide a summary of treatment options for common conditions, and where appropriate include information on relevant guidelines issued by National Institute for Health and Care Excellence (NICE). Advice issued by the Scottish Medicines Consortium relating to use of medicines in NHS Scotland is also contained here when a medicine is restricted or not recommended for use within NHS Scotland.

Information for classes of drugs that share the same recommendations with regards to cautions, contra-indications, side-effects, use in pregnancy, breast-feeding, renal impairment and hepatic impairment is presented in the prescribing notes.

Important safety concerns and differences between drugs with regards to their ability to cause side-effects are highlighted in this section.

For practical reasons drug doses and administration information is sometimes included in the prescribing notes in tabular form e.g. table of asthma treatment.


What information can I find in a drug monograph?

A typical drug monograph entry contains information under the following headings:

Drug name - Pharmacopoeial or other non-proprietary titles are used. For non-proprietary titles the International Non-proprietary Name (INN) or the British Approved Name (BAN), if available, are used.

Cautions - Outlines precautions to be exercised for patients with co-morbidities listed and details of monitoring to be undertaken if applicable. If specific for a preparation this information is included under the preparation.

Contra-indications - Administration of the drug should be avoided in the circumstances listed. If this is unique to an individual preparation, information will be included under the individual preparation.

Hepatic impairment - Advice on whether caution is to be exercised or if the drug is to be avoided in this group of patients. It also highlights any monitoring requirements or dosage adjustments required in these patients.

Renal impairment - Advice on whether caution is to be exercised or if the drug is to be avoided in this group of patients. It also highlights any monitoring requirements or dosage adjustments required in these patients.

Pregnancy - Provides advice unique to the use of the drug in patients who fall in this category. 

Breast-feeding - Provides advice unique to the use of the drug in patients who fall in this category.

Side-effects - These are arranged broadly by body systems and in order of decreasing frequency. Rare serious side-effects are occasionally listed first if it is considered to be particularly important because of its seriousness. Effects that are likely to have little clinical consequences are not listed and only drugs with increased risk of hypersensitivity reactions have hypersensitivity as a side-effect included in this section.

Licensed use – Shows if a drug is unlicensed in the UK ('unlicensed'), or if a drug is licensed in the UK but not for use in children ('off-label'use).

Indication and dose – The drug dose is usually located in pink panels within the Indication and Dose section of the drug monograph. Doses specific to formulations or preparations are listed under the individual preparation.

Many children's doses in BNFC are standardised by body-weight. Occasionally, some doses in BNFC are standardised by Body Surface Area.

Wherever possible, doses are expressed in terms of a definite frequency (e.g. if the dose is 1mg/kg twice daily, a child of body-weight 9kg would receive 9mg twice daily). Occasionally, some doses are in the total daily dose format (e.g. 10mg/kg daily in three divided doses); in these cases you should remember to divide the total daily dose into individual doses (in this example a child of body-weight 9kg would receive 30mg three times daily).

At the end of the monograph a list of preparations of the drug is included. Preparations are listed by approved name or proprietary name. Information on pack sizes, formulations available and the manufacturer of the product is contained in this section .This section also contains basic net prices for products to provide an indication of relative cost. Under proprietary names, specific notes regarding excipients, handling precautions, clinically important electrolytes contained in the preparation and conditions for which the preparation can be prescribed, may be stipulated.

Counselling statements for medicines that have special counselling requirements are usually located either in the caution or dose section of the monograph, or if specific for a preparation, under the individual preparation entry.


What information is contained in the appendices and indices?

Appendix one - Provides information on drug interactions.  Medicines are listed by non-proprietary names and arranged in alphabetical order. Where appropriate, cross references to interactions linked to drug classes are made.

Interactions with the black dot symbol (●) indicates a potentially serious interaction.

Appendix two – Borderline substances, includes details on foods which may be prescribed on FP10, GP10 (Scotland), or WP10 (Wales). Contain tables of approved enteral feeds and nutritional supplements. It includes separate tables for specialised formulae as well as details on feed supplements, feed additives, and foods for special diets and nutritional supplements for metabolic diseases.

Appendix three - Contains details of cautionary and advisory labels that pharmacists are recommended to add to dispensing labels for dispensed medicines.

Appendix four - Provides practical information on intravenous infusions for neonatal intensive care.

The BNFC includes the Dental Practitioners’ Formulary and Nurse Prescribers’ Formulary. It contains information regarding non-medical prescribing. A list of manufacturers and their contact details, together with email addresses, is also included.

Yellow cards are included (in the back of the print format). Pharmacists can use these to report any adverse drug reactions.

A list of useful numbers and websites for different organisations including medicines information services, poisons information services and travel health information services is also available (inside the front cover of the print format).


Are there any useful tables or diagrams in the BNFC?

At the back of the print version, the BNFC includes:

  • Algorithms for newborn life support, paediatric basic life support and paediatric advanced life support ('glossy pages')
  • Body Surface Area in Children tables for estimating a child's body surface area from his or her weight ('glossy pages')
  • A summary of drug doses for use in medical emergencies in a community setting ('glossy pages')
  • Useful conversions for imperial and metric measurements are listed ('glossy pages')
  • A table shows the mean values for weight and height by age (and by gender) ('glossy pages')
  • Abbreviations and symbols (inside back cover).

Scenarios to help you practice using the BNFC

Scenario one – dose calculation by body-weight

Many children’s doses in BNFC are standardised by body-weight. For calculating a child’s dose multiply the dose (mg/kg) by the child’s weight (kg). The calculated dose should not normally exceed the maximum recommended dose for an adult.

Scenario – A doctor wants to prescribe oral azithromycin liquid for an ear infection. It is for a two year old, allergic to penicillin, weighing 12kg.

Find the dose in the current version of BNFC (within the Indication and dose section of the azithromycin monograph). Doses are linked to specific indications and routes of administration.

Dose*   By mouth

“Child over six months 10mg/kg once daily (max. 500mg once daily) for three days”

*Always use the current version of BNFC. The doses quoted in this quick reference guide are for illustration only.

Answer: Use the child’s weight (scenario – weight 12kg; age – two years).

Multiply the dose (10mg/kg) by the child’s weight (12kg).

Hence 120mg once daily for three days.

In this scenario azithromycin 200mg/5mL liquid is required (Scenario - dose 120mg=3mL). 

Scenario two – dose selection 

Some doses are shown in BNFC as “age bands”.

Scenario – A doctor wants to prescribe oral paracetamol for pyrexia. It is for a 12 year old weighing 38kg.

Find the dose in the current version of BNFC (within the Indication and dose section of the paracetamol monograph). Doses are linked to specific indications and routes of administration and, in this example, are provided for age ranges.

Dose*   by mouth

“Child 12-16 years 480-750mg every four to six hours (max. four doses in 24 hours)”

*Always use the current version of BNFC. The doses quoted in this quick reference guide are for illustration only.

Answer: Use the child’s age (scenario – age 12 years) and select the dose for the correct age range ie. 12-16 years

Hence 480-750mg every four to six hours (max four doses in 24 hours).

The prescription should state the formulation required and strength of that formulation.

In this scenario paracetamol liquid is required. Your advice would be as per BNFC that the child receives the most suitable strength of formulation ie. 250mg/5mL (Scenario - dose =10 to 15mL every four to six hours max. four doses in 24 hours) 

Scenario three – suitable formulations

It is important to ensure the child is given the correct formulation and that the formulation is the correct strength.

Scenario – A prescriber asks your advice on chlorothiazide for a three month old baby weighing 6kg. What dose and formulation should be prescribed?

Find the dose in the current version of BNFC.

Dose*   by mouth

“Child one to six months. 10-20mg/kg twice daily”

*Always use the current version of BNFC. The doses quoted in this quick reference guide are for illustration only.

Answer: The dose for the child is calculated by body weight (same method as scenario one).

Use the child’s weight (scenario – weight 6kg).

Multiply the dose (10mg/kg) by the child’s weight (6kg).

Hence scenario – dose = 60mg twice daily

The chlorothiazide monograph states “licensed use: not licensed” so it is not licensed.

Your advice would be as per BNFC that the child receives an unlicensed chlorothiazide oral suspension 250mg/5mL.

Chlorothazide oral suspension 250mg/5mL is required (scenario – dose = 60mg = 1.2mL twice daily).

For more scenarios on using the BNFC see “Where to go for further information”.

Further scenarios include dose calculation by Body Surface Area (scenario – chemotherapy induced nausea and vomiting); excipients and unlicensed medicines (scenario – suitable formulation of Phenobarbital liquid).

Where to go for further information

rps resources

  • Birmingham and Solihull RPS Local Practice Forum (LPF) support tools, include a presentation with further scenarios to help you practice using BNFC 

external resources

Details
   

Acknowledgement

Thanks to Birmingham and Solihull RPS Local Practice Forum, who contributed scenarios and provided advice on the quick reference guide.