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Medicines information services UK Teratology Information Service
Information on any aspect of drug therapy can be Information on drug and chemical
obtained from Regional and District Medicines Informa- exposures in pregnancy 0844 892 0909
tion Services. Details regarding the local services pro-
vided within your Region can be obtained by telephon-
ing the following numbers. Medicines for Children information leaflets
Medicines information for parents and carers.
www.medicinesforchildren.org.uk
England
Birmingham (0121) 424 7298
Bristol (0117) 342 2867 Patient Information Lines
Ipswich (01473) 704 431 NHS Direct 0845 4647
Leeds (0113) 206 5377
Leicester (0116) 255 5779
Poisons Information Services
Liverpool (0151) 794 8113/4/5/7
UK National Poisons Information
(0151) 794 8206 Service 0844 892 0111
London
Guy’s Hospital (020) 7188 8750
(020) 7188 3849 Travel Immunisation
(020) 7188 3855 Up-to-date information on travel immunisation
Northwick Park Hospital (020) 8869 2761 requirements may be obtained from:
(020) 8869 3973 National Travel Health Network and Centre (for
Newcastle (0191) 282 4631 healthcare professionals only) 0845 602 6712
(09.00–12.00 and 14.00–16.30 hours weekdays)
Southampton (023) 8079 6908/9
Travel Medicine Team, Health Protection Scotland
(0141) 300 1130 (14.00–16.00 hours weekdays)
Wales
Cardiff (029) 2074 2979 www.travax.nhs.uk (for registered users of the NHS
website Travax only)
(029) 2074 2251
Welsh Assembly Government (029) 2082 1318
(09.00–17.30 hours weekdays)
Scotland
Department of Health and Social Services (Belfast)
Aberdeen (01224) 552 316
(028) 9052 2118 (weekdays)
Dundee (01382) 632 351
(01382) 660 111
Extn 32351 Information on drug therapy relating to dental
Edinburgh (0131) 242 2920 treatment can be obtained by telephoning:
Glasgow (0141) 211 4407 Liverpool (0151) 794 8206

Northern Ireland
Sport
Belfast (028) 9063 2032
Information on substances currently permitted or
(028) 9063 3847 prohibited is provided in a card supplied by UK Anti-
Doping.
Republic of Ireland Further information regarding medicines in sport is
Dublin Dublin 473 0589 available from: www.ukad.org.uk
Dublin 453 7941 Tel: (020) 7766 7350
Extn 2348
[email protected]

United Kingdom Medicines Information Pharma- Telephone numbers and email addresses of manu-
cists Group (UKMIPG) website facturers listed in BNF Publications are shown in the
www.ukmi.nhs.uk Index of Manufacturers
BNF
for children
2011–2012
Published by Distribution of BNFCs
BMJ Group The UK health departments distribute BNFCs to NHS
Tavistock Square, London WC1H 9JP, UK hospitals, doctors, and community pharmacies.
In England, BNFCs are mailed individually to NHS
Pharmaceutical Press doctors, pharmacists, and non-medical prescribers
Pharmaceutical Press is the publishing division of the who have prescribing responsibility for children; for
Royal Pharmaceutical Society extra copies or changes relating to mailed BNFCs,
1 Lambeth High Street, London, SE1 7JN, UK contact the DH Publications Orderline:
Tel: 0300 123 1002
RCPCH Publications Ltd In Scotland email:
5–11 Theobalds Road, London WC1X 8SH, UK [email protected]
In Wales, telephone the Business Services Centre:
Copyright # BMJ Group, the Royal Pharmaceutical Tel: (01495) 332 000
Society of Great Britain, and RCPCH Publications Ltd In Northern Ireland email:
2011 [email protected]

ISBN: 978 0 85369 959 0

The BNF for Children is for use by health profes-
ISSN: 1747–5503 sionals engaged in prescribing, dispensing, and
administering medicines to children. It has been
Printed by CPI Clausen & Bosse, Leck, Germany prepared under the guidance of the Paediatric
Formulary Committee.
Typeset by Xpage
BNF for Children has been constructed using robust
A catalogue record for this book is available from the procedures for gathering, assessing and assimilating
British Library. information on paediatric drug treatment. It is, how-
ever, expected that the reader will be relying on
All rights reserved. No part of this publication may be appropriate professional knowledge and expertise
reproduced, stored in a retrieval system, or transmitted to interpret the contents in the context of the cir-
in any form or by any means, without the prior written cumstances of the individual child. BNF for Children
permission of the copyright holder. should be used in conjunction with other appropriate
and up-to-date literature and, where necessary, sup-
plemented by expert advice. Information is also
Material published in the BNF for Children may not available from Medicines Information Services (see
be used for any form of advertising, sales or publicity inside front cover).
without prior written permission. Each of the classi-
fication and the text are protected by copyright and/ Special care is required in managing childhood
or database right conditions with unlicensed medicines or with
licensed medicines for unlicensed uses. Responsibil-
ity for the appropriate use of medicines lies solely
Paper copies may be obtained through any bookseller or with the individual health professional.
direct from:

Pharmaceutical Press
c/o Macmillan Distribution (MDL)
Brunel Road
Houndmills
Basingstoke
RG21 6XS
UK
Tel: +44 (0) 1256 302 692
Fax: +44 (0) 1256 812 521
Email: [email protected]
www.pharmpress.com

For all bulk orders of more than 20 copies:

Email: [email protected]
Tel: +44 (0) 207 572 2266

Pharmaceutical Press also supplies BNF for Children in

digital formats suitable for standalone computers and
intranets, and for use on mobile devices.
BNFC 2011–2012 iii

Contents
Preface.................................................................................................................................. iv
Acknowledgements ................................................................................................................ v
BNF Staff............................................................................................................................... vi
How BNF for Children is constructed.................................................................................... ix
How to use BNF for Children................................................................................................. xi
Changes for this edition .................................................................................................... xvii
General guidance................................................................................................................... 1
Prescription writing................................................................................................................ 4
Supply of medicines .............................................................................................................. 6
Emergency supply of medicines ............................................................................................ 8
Prescribing Controlled Drugs ................................................................................................. 9
Adverse reactions to drugs................................................................................................. 12
Prescribing in hepatic impairment...................................................................................... 14
Prescribing in renal impairment ......................................................................................... 14
Prescribing in pregnancy .................................................................................................... 16
Prescribing in breast-feeding.............................................................................................. 16
Prescribing in palliative care .............................................................................................. 17
Prescribing in dental practice ............................................................................................. 22
Drugs and sport.................................................................................................................. 23
Emergency treatment of poisoning .................................................................................... 24
Notes on drugs and Preparations
1: Gastro-intestinal system........................................................................................ 35
2: Cardiovascular system ........................................................................................... 73
3: Respiratory system .............................................................................................. 133
4: Central nervous system ....................................................................................... 169
5: Infections ............................................................................................................. 242
6: Endocrine system................................................................................................. 348
7: Obstetrics, gynaecology, and urinary-tract disorders ......................................... 393
8: Malignant disease and immunosuppression ....................................................... 414
9: Nutrition and blood.............................................................................................. 442
10: Musculoskeletal and joint diseases .................................................................... 499
11: Eye ....................................................................................................................... 517
12: Ear, nose, and oropharynx ................................................................................... 534
13: Skin ...................................................................................................................... 550
14: Immunological products and vaccines................................................................. 599
15: Anaesthesia ......................................................................................................... 628
Appendices and indices
Appendix 1: Interactions.................................................................................................. 655
Appendix 2: Borderline substances ................................................................................. 743
Appendix 3: Cautionary and advisory labels for dispensed medicines........................... 788
Appendix 4: Intravenous infusions for neonatal intensive care ...................................... 791
Dental Practitioners’ Formulary ........................................................................................ 794
Nurse Prescribers’ Formulary............................................................................................ 796
Non-medical prescribing ................................................................................................... 799
Index of manufacturers..................................................................................................... 800
Index................................................................................................................................. 811
Medical emergencies in the community .................................................... Inside back cover
iv BNFC 2011–2012

Preface BNFC aims to provide information suited to the

needs of the clinician and recognises that, although
BNF for Children aims to provide prescribers, pharma- this edition represents a considerable advance in the
cists and other healthcare professionals with sound up- content and presentation of information on the
to-date information on the use of medicines for treating paediatric use of medicines, further changes will be
children. necessary. Comments from healthcare professionals
are therefore very welcome and should be sent to:
A joint publication of the British Medical Association,
the Royal Pharmaceutical Society of Great Britain, the British National Formulary Publications, Royal Phar-
Royal College of Paediatrics and Child Health, and the maceutical Society of Great Britain, 1 Lambeth High
Neonatal and Paediatric Pharmacists Group, BNF for Street, London SE1 7JN.
Children (‘BNFC’) is published under the authority of a [email protected]
Paediatric Formulary Committee.
Many areas of paediatric practice have suffered from The contact email for manufacturers or pharmaceut-
inadequate information on effective medicines. BNFC ical companies wishing to contact BNF publications
addresses this significant knowledge gap by providing is [email protected]
practical information on the use of medicines in children
of all ages from birth to adolescence. Medicines for
Children (RCPCH Publications Ltd) and the British
National Formulary itself form the basis for BNFC.
Information in BNFC has been validated against emer-
ging evidence, best-practice guidelines, and crucially,
advice from a network of clinical experts.
Drawing information from manufacturers’ literature
where appropriate, BNFC also includes a great deal of
advice that goes beyond marketing authorisations (pro-
duct licences). This is necessary because licensed indi-
cations frequently do not cover the clinical needs of
children; in some cases, products for use in children
need to be specially manufactured or imported. Careful
consideration has been given to establishing the clinical
need for unlicensed interventions with respect to the
evidence and experience of their safety and efficacy;
local paediatric formularies, clinical literature and
national information resources have been invaluable in
this process.
BNFC has been designed for rapid reference and the
information presented has been carefully selected to aid
decisions on prescribing, dispensing and administration
of medicines. Less detail is given on areas such as
malignant disease and the very specialist use of medi-
cines generally undertaken in tertiary centres. BNFC
should be interpreted in the light of professional knowl-
edge and it should be supplemented as necessary by
specialised publications. Information is also available
from Medicines Information Services (see inside front
cover).
It is vital to use the most recent edition of BNFC for
making clinical decisions. The more important changes
for this edition are listed on p. xvii.
The website (bnfc.org) includes additional information
of relevance to healthcare professionals. Other digital
formats of BNFC—including intranet and versions for
mobile devices—are produced in parallel with the
printed version.
BNFC 2011–2012 v
Acknowledgements The BNF for Children has valuable access to the Mar-
tindale data banks by courtesy of S. Sweetman and staff.
J. E. Macintyre and staff provided valuable technical
The Paediatric Formulary Committee is grateful to assistance.
individuals and organisations that have provided advice
and information to the BNF for Children. C. Adetola, N. Bansal, J.J. Coleman, S. Foad, E.H.
Glover, T. Hamp, A. Holmes, J. Humphreys, J.M.
James, E. Laughton, H.M.N. Brady, R.M. Patel, J. Rey-
The principal contributors for this edition were: nolds, and E.J. Tong provided considerable assistance
I.H. Ahmed-Jushuf, M.N. Badminton, S. Bailey, T.G. during the production of this edition of BNF for Chil-
Barrett, D.N. Bateman, G.D.L. Bates, H. Bedford, M.W. dren.
Beresford, R.M. Bingham, I.W. Booth, L. Brook, K.G.
Brownlee, R.J. Buckley, M. Burch, I.F. Burgess, A. Cant,
L.J. Carr, R. Carr, E.A. Chalmers, T.D. Cheetham, A.J. Xpage have provided assistance with typesetting devel-
Cotgrove, J.B.S. Coulter, B.G. Craig, S.M. Creighton, J.H. opment and related production processes.
Cross, A. Dhawan, P.N. Durrington, A. Durward, A.B.
Edgar, J.A. Edge, D.A.C. Elliman, N.D. Embleton, P.J.
Goadsby, P.W. Golightly, J. Gray, J.W. Gregory, P. Grin-
gras, J.P. Harcourt, P.J. Helms, C. Hendriksz, R.F.
Howard, R.G. Hull, H.R. Jenkins, S. Jones, B.A. Judd,
C.J.H. Kelnar, P.T. Khaw, J.M.W. Kirk, P.J. Lee, T.H. Lee,
S. Lewis-Jones, E.G.H. Lyall, A. MacDonald, D.J.
Macrae, P.S. Malone, A.Y. Manzur, S.D. Marks, D.F.
Marsh, A.G. Marson, K.A. Matyka, P.J. McKiernan,
L.M. Melvin, E. Miller, R.E. Morton, C. Moss, P. Mulhol-
land, C. Nelson-Piercy, J.M. Neuberger, K.K. Nischal,
C.Y. Ng, L.P. Omerod, J.Y. Paton, G.A. Pearson, M.M.
Ramsay, I.A.G. Roberts, J. Rogers, K.E. Rogstad, P.C.
Rubin, J.W. Sander, N.J. Scolding, M.R. Sharland, N.J.
Shaw, G.J. Shortland, O.F.W. Stumper, M.R.J. Sury, A.G.
Sutcliffe, A. Sutherland, A.M. Szarewski, E.A. Taylor,
A.H. Thomson, M.A. Thomson, J.A. Vale, J.O. Warner,
D.A. Warrell, N.J.A. Webb, A.D. Weeks, R. Welbury, W.P.
Whitehouse, C.E. Willoughby, C. Wren, A. Wright, M.M.
Yaqoob, Z. Zaiwalla, and S.M. Zuberi.

Members of the British Association of Dermatologists’

Therapy & Guidelines Subcommittee, D.A. Buckley, L.C.
Fuller, J. Hughes, S.E. Hulley, J. Lear, A.J. McDonagh, J.
McLelland, N. Morar, I. Nasr, S. Punjabi, M.J. Tidman,
S.E. Haveron (Secretariat), and M.F. Mohd Mustapa
(Secretariat) have provided valuable advice.

Members of the Advisory Committee on Malaria Pre-

vention, R.H. Behrens, P.L. Chiodini, F. Genasi, L. Good-
yer, A. Green, D. Hill, G. Kassianos, D.G. Lalloo, G.
Pasvol, S. Patel, M. Powell, D.V. Shingadia, C.J.M.
Whitty, M. Blaze (Secretariat), and V. Smith (Secretariat)
have provided valuable advice.

Members of the UK Ophthalmic Pharmacy Group have

also provided valuable advice.
R. Suvarna and colleagues at the MHRA have provided
valuable assistance.

Correspondents in the pharmaceutical industry have

provided information on new products and commented
on products in the BNF for Children. NHS Prescription
Services has supplied the prices of products in the BNF
for Children.

Numerous doctors, pharmacists, nurses and others have

sent comments and suggestions.
vi BNFC 2011–2012

BNF Staff Digital Development Editor

Philip D. Lee BSc, PhD

Managing Editor: Knowledge Creation

John Martin BPharm, PhD, MRPharmS Digital Development Assistants
Robert C. Buckingham BSc
Michelle Cartwright
Jennifer L. Palmer FdSc
Assistant Editors
Leigh-Anne Claase BSc, PhD
Bryony Jordan BSc, DipPharmPract, MRPharmS Terminologist
Sarah Peck BSc
Colin R. Macfarlane BPharm, MSc, MRPharmS
Paul S. Maycock MPharm, DipPharmPract,
MRPharmS Head of Production
Claire L. Preston BPharm, PGDipMedMan, John Wilson
MRPharmS
Rachel S. M. Ryan BPharm, MRPharmS Senior Production Editor
Shama M. S. Wagle BPharm, DipPharmPract, Linda Paulus
MRPharmS

BNF Publishing Director

Duncan S.T. Enright MA, PGCE, MInstP, FIDM
Staff Editors
Sejal Amin BPharm, MSc
Angela K. Bennett MPharm, DipPharmPract Managing Director, Pharmaceutical Press
Robert Bolick BA, MA
Shena S. Chauhan BPharm, MRPharmS
Susan E. Clarke BPharm, DipClinPharm, MRPharmS
Kristina Fowlie MPharm, PGCertPharmPract, Senior Medical Adviser
MRPharmS Martin J. Kendall OBE, MB, ChB, MD, FRCP, FFPM
Belén Granell Villen BSc, PGDipClinPharm
Manjula Halai BScChem, MPharm
Emma E. Harris MPharm, DipPharmPract,
MRPharmS
Amy E. Harvey MPharm, PGDipCommPharm
Amber F. Lauder BPharm, PGCertPharm
Angela M. G. McFarlane BSc, DipClinPharm,
MRPharmS
Sarah Mohamad MPharm
Elizabeth Nix DipPharm(NZ), MRPharmS
Sanjay Patel BPharm
Vinaya K. Sharma BPharm, MSc, PGDipPIM,
MRPharmS
Katie E. Walters MPharm, PGCertPharmPract,
MRPharmS

Editorial Assistants
Rebecca S. Bastable BA, BTEC
Cristina Lopez-Bueno BA

Senior BNF Administrator

Heidi Homar BA

Managing Editor: Digital Development and Delivery

Cornelia Schnelle MPhil
BNFC 2011–2012 vii
Paediatric Formulary Dental Advisory
Committee Group
2010–2011 2010–2011
Chair Chair
Warren Lenney David Wray
MD, FRCP, FRCPCH, DCH MD, BDS, MB ChB, FDSRCPS, FDSRCS Ed,
F MedSci
Committee Members
Jeffrey K. Aronson
MA, MBChB, DPhil, FRCP, FBPharmacolS, FFPM
Committee Members
Neil A. Caldwell
BSc, MSc, MRPharmS Christine Arnold
BDS, DDPHRCS, MCDH
Ian Costello
BPharm, MSc, MRPharmS Barry Cockcroft
BDS, FFDS (Eng)
Martin G. Duerden BMedSci, MB BS, DRCOG,
MRCGP, DipTher, DPH Duncan S.T. Enright
MA, PGCE, MInstP, FIDM
Simon Keady
BSc, MRPharmS, SP Amy E. Harvey
MPharm, PGDipCommPharm
Martin J. Kendall
OBE, MB, ChB, MD, FRCP, FFPM (Chair, Content Martin J. Kendall
Strategy Committee) OBE, MB, ChB, MD, FRCP, FFPM
James H. Larcombe Lesley P. Longman
MB, ChB, FRCGP, DipAdvGP BSc, BDS, FDSRCS Ed, PhD
E. David G. McIntosh Sarah Manton
MB BS, MPH, PhD, FAFPHM, FRACP, FRCPCH, BDS, FDSRCS Ed, FHEA, PhD
FFPM, DRCOG, DCH, DipPharmMed John Martin
Neena Modi BPharm, PhD, MRPharmS
MB, ChB, MD, FRCP, FRCPCH Michelle Moffat
Matthew J. Thatcher BDS, MFDS RCS Ed, M Paed Dent RPCS, FDS (Paed
MB BS, FRCS, DRCOG, DMRD Dent) RSC Ed
David Tuthill MB, BCh, FRCPCH Rachel S.M. Ryan
William G. van’t Hoff BPharm, MRPharmS
BSc, MB, MD, FRCPCH, FRCP
Edward R. Wozniak
BSc, MB BS, FRCP, FRCPCH, DCH Secretary
Arianne J. Matlin
Executive Secretary MA, MSc, PhD
Heidi Homar
BA

Executive Secretary
Heidi Homar
BA

Advice on dental practice

The British Dental Association has contributed to
the advice on medicines for dental practice through
its representatives on the Dental Advisory Group.
viii BNFC 2011–2012

Nurse Prescribers’
Advisory Group
2010–2011
Chair
Nicky A. Cullum (until November 2010)
PhD, RGN
Molly Courtenay (from December 2010)
PhD, MSc, Cert Ed, BSc, RGN

Committee Members
Fiona Culley
LLM, RN, BSc, Cert Ed
Duncan S.T. Enright
MA, PGCE, MInstP, FIDM
Penny M. Franklin
RN, RCN, RSCPHN(HV), MA, PGCE
Belén Granell Villen
BSc, PGDipClinPharm
Margaret F. Helliwell
MB, BS, BSc, MFPHM
Bryony Jordan
BSc, DipPharmPract, MRPharmS
Martin J. Kendall
OBE, MB, ChB, MD, FRCP, FFPM
Fiona Lynch
BSc, MSc, RGN, RSCN
John Martin
BPharm, PhD, MRPharmS
Wendy J. Nicholson
BSc, MA, Cert Ed, RGN, RSCN
Jill M. Shearer
BSc, RGN, RM
Rabina Tindale
RN, RSCN, BSc, DipAEN, PGCE
Vicky Vidler
MA, RGN, RSCN
John Wright

Executive Secretary
Heidi Homar
BA
BNFC 2011–2012 ix
How BNF for Children chapter for thorough review. These planned reviews aim
to verify all the information in the selected sections and
is constructed to draft any amendments to reflect current best prac-
tice.
Staff editors prepare the text for publication and under-
BNF for Children (BNFC) is unique in bringing together
take a number of checks on the knowledge at various
authoritative, independent guidance on best practice
stages of the production.
with clinically validated drug information, enabling
healthcare professionals to select safe and effective
medicines for individual children.
Information in BNFC has been validated against emer-
Expert advisers
ging evidence, best-practice guidelines, and advice from BNFC uses about 80 expert clinical advisers (including
a network of clinical experts. BNFC includes a great deal doctors, pharmacists, nurses, and dentists) throughout
of advice that goes beyond marketing authorisations the UK to help with the production of each edition. The
(product licences or summaries of product characteris- role of these expert advisers is to review existing text
tics). This is necessary because licensed indications and to comment on amendments drafted by the staff
frequently do not cover the clinical needs of children; editors. These clinical experts help to ensure that BNFC
in some cases, products for use in children need to be remains reliable by:
specially manufactured or imported. Careful considera- . commenting on the relevance of the text in the
tion has been given to establishing the clinical need for context of best clinical practice in the UK;
unlicensed interventions with respect to the evidence . checking draft amendments for appropriate inter-
and experience of their safety and efficacy. pretation of any new evidence;
Hundreds of changes are made between editions, and . providing expert opinion in areas of controversy or
the most clinically significant changes are listed at the when reliable evidence is lacking;
front of each edition.
. advising on areas where BNFC diverges from sum-
maries of product characteristics;
Paediatric Formulary Committee . advising on the use of unlicensed medicines or of
licensed medicines for unlicensed uses (‘off-label’
The Paediatric Formulary Committee (PFC) is respon-
use);
sible for the content of BNFC. The PFC includes a
neonatologist and paediatricians appointed by the . providing independent advice on drug interactions,
Royal College of Paediatrics and Child Health, paed- prescribing in hepatic impairment, renal impair-
iatric pharmacists appointed by the Royal Pharmaceut- ment, pregnancy, breast-feeding, neonatal care, pal-
ical Society of Great Britain and the Neonatal and liative care, and the emergency treatment of pois-
Paediatric Pharmacists Group, doctors appointed by oning.
the BMJ Publishing Group, a GP appointed by the In addition to consulting with regular advisers, BNFC
Royal College of General Practitioners, and representa- calls on other clinical specialists for specific develop-
tives from the Medicines and Healthcare products Reg- ments when particular expertise is required.
ulatory Agency (MHRA) and the UK health depart-
BNFC also works closely with a number of expert bodies
ments. The PFC decides on matters of policy and
that produce clinical guidelines. Drafts or pre-publica-
reviews amendments to BNFC in the light of new
tion copies of guidelines are routinely received for
evidence and expert advice. The Committee meets
comment and for assimilation into BNFC.
every 6 months and each member also receives proofs
of all BNFC chapters for review before publication.

Sources of BNFC information

Dental Advisory Group BNFC uses a variety of sources for its information; the
The Dental Advisory Group oversees the preparation of main ones are shown below.
advice on the drug management of dental and oral
conditions; the group includes representatives from Summaries of product characteristics BNFC
the British Dental Association. receives summaries of product characteristics (SPCs)
of all new products as well as revised SPCs for existing
products. The SPCs are a key source of product infor-
Editorial team mation and are carefully processed, despite the ever-
increasing volume of information being issued by the
BNFC staff editors are pharmacists with a sound under-
pharmaceutical industry. Such processing involves:
standing of how drugs are used in clinical practice,
including paediatrics. Each staff editor is responsible . verifying the approved names of all relevant ingre-
for editing, maintaining, and updating specific chapters dients including ‘non-active’ ingredients (BNFC is
of BNFC. During the publication cycle the staff editors committed to using approved names and descrip-
review information in BNFC against a variety of sources tions as laid down by the Medicines Act);
(see below). . comparing the indications, cautions, contra-indica-
Amendments to the text are drafted when the editors tions, and side-effects with similar existing drugs.
are satisfied that any new information is reliable and Where these are different from the expected pat-
relevant. The draft amendments are passed to expert tern, justification is sought for their inclusion or
advisers for comment and then presented to the Paed- exclusion;
iatric Formulary Committee for consideration. Addition- . seeking independent data on the use of drugs in
ally, for each edition, sections are chosen from every pregnancy and breast-feeding;
x BNFC 2011–2012

. incorporating the information into BNFC using ing the Prescription only Medicines Order. Official com-
established criteria for the presentation and inclu- pendia such as the British Pharmacopoeia and its
sion of the data; addenda are processed routinely to ensure that BNFC
. checking interpretation of the information by two complies with the relevant sections of the Medicines
staff editors before submitting to a senior editor; Act.
changes relating to doses receive an extra check; BNFC maintains close links with the Home Office (in
. identifying potential clinical problems or omissions relation to controlled drug regulations) and the Medi-
and seeking further information from manufacturers cines and Healthcare products Regulatory Agency
or from expert advisers; (including the British Pharmacopoeia Commission).
Safety warnings issued by the Commission on Human
. careful validation of any areas of divergence of
Medicines (CHM) and guidelines on drug use issued by
BNFC from the SPC before discussion by the Com-
the UK health departments are processed as a matter of
mittee (in the light of supporting evidence);
routine.
. constructing, with the help of expert advisers, a
Relevant professional statements issued by the Royal
comment on the role of the drug in the context of
Pharmaceutical Society of Great Britain are included in
similar drugs.
BNFC as are guidelines from bodies such as the Royal
Much of this processing is applicable to the following College of Paediatrics and Child Health.
sources as well.
BNFC reflects information from the Drug Tariff, the
Scottish Drug Tariff, and the Northern Ireland Drug
Expert advisers The role of expert clinical advisers in Tariff.
providing the appropriate clinical context for all BNFC
information is discussed above. Pricing information NHS Prescription Services
provide information on prices of medicinal products
Literature Staff editors monitor core medical, paed- and appliances in BNFC. BNFC also receives and pro-
iatric, and pharmaceutical journals. Research papers cesses price lists from product suppliers.
and reviews relating to drug therapy are carefully pro-
cessed. When a difference between the advice in BNFC Comments from readers Readers of BNFC are
and the paper is noted, the new information is assessed invited to send in comments. Numerous letters and
for reliability and relevance to UK clinical practice. If emails are received during the preparation of each
necessary, new text is drafted and discussed with expert edition. Such feedback helps to ensure that BNFC
advisers and the Paediatric Formulary Committee. provides practical and clinically relevant information.
BNFC enjoys a close working relationship with a num- Many changes in the presentation and scope of BNFC
ber of national information providers. have resulted from comments sent in by users.

Systematic reviews BNFC has access to various Comments from industry Close scrutiny of BNFC by
databases of systematic reviews (including the the manufacturers provides an additional check and
Cochrane Library and various web-based resources). allows them an opportunity to raise issues about BNFC’s
These are used for answering specific queries, for presentation of the role of various drugs; this is yet
reviewing existing text and for constructing new text. another check on the balance of BNFC advice. All
Staff editors receive training in critical appraisal, litera- comments are looked at with care and, where necessary,
ture evaluation, and search strategies. Reviews pub- additional information and expert advice are sought.
lished in Clinical Evidence are used to validate BNFC
advice. Virtual user groups BNFC has set up virtual user
groups across various healthcare professions (e.g. doc-
Consensus guidelines The advice in BNFC is tors, pharmacists, nurses). The aim of these groups will
checked against consensus guidelines produced by be to provide feedback to the editors and publishers to
expert bodies. A number of bodies make drafts or pre- ensure that BNF publications continue to serve the
publication copies of the guidelines available to BNFC; it needs of its users.
is therefore possible to ensure that a consistent message
is disseminated. BNFC routinely processes guidelines Market research Market research is conducted at
from the National Institute for Health and Clinical regular intervals to gather feedback on specific areas of
Excellence (NICE), the Scottish Medicines Consortium development, such as drug interactions or changes to
(SMC), and the Scottish Intercollegiate Guidelines Net- the way information is presented in digital formats.
work (SIGN).
BNFC is an independent professional publication
Reference sources Paediatric formularies and refer- that is kept up-to-date and addresses the day-to-
ence sources are used to provide background informa- day prescribing information needs of healthcare
tion for the review of existing text or for the construction professionals treating children. Use of this resource
of new text. The BNFC team works closely with the throughout the health service helps to ensure that
editorial team that produces Martindale: The Complete medicines are used safely, effectively, and appropri-
Drug Reference. BNFC has access to Martindale infor- ately in children.
mation resources and each team keeps the other
informed of significant developments and shifts in the
trends of drug usage.

Statutory information BNFC routinely processes

relevant information from various Government bodies
including Statutory Instruments and regulations affect-
BNFC 2011–2012 xi
How to use BNF for Children
BNF for Children (BNFC) provides information on Finding information in BNFC
the use of medicines in children ranging from neo- BNFC includes a number of aids to help access relevant
nates (including preterm neonates) to adolescents. information:
The terms infant, child, and adolescent are not used . Index (p. 811), where entries are included in alpha-
consistently in the literature; to avoid ambiguity betical order of non-proprietary drug names, pro-
actual ages are used in the dose statements in prietary drug names, clinical conditions, and pre-
BNFC. The term neonate is used to describe a new- scribing topics. A specific entry for ‘Dental
born infant aged 0–28 days. The terms child or Prescribing’ brings together topics of relevance to
children are used generically to describe the entire dental surgeons. The page reference to the drug
range from infant to adolescent in BNFC. monograph is shown in bold type. References to
drugs in Appendices 1 and 3 are not included in the
In order to achieve the safe, effective, and appropriate main Index;
use of medicines in children, healthcare professionals . Contents (p. iii), provides a hierarchy of how infor-
must be able to use BNFC effectively, and keep up to mation in BNFC is organised;
date with significant changes in each new edition of
BNFC that are relevant to their clinical practice. How to . The beginning of each chapter includes a classified
Use BNF for Children is aimed as a quick refresher for hierarchy of how information is organised in that
all healthcare professionals involved with prescribing, chapter;
monitoring, supplying, and administering medicines for . Running heads, located next to the page number on
children, and as a learning aid for students training to the top of each page, show the section of BNFC that
join these professions. While How to Use BNF for is being used;
Children is linked to the main elements of rational . Thumbnails, on the outer edge of each page, show
prescribing, the generic structure of this section means the chapter of BNFC that is being used;
that it can be adapted for teaching and learning in
different clinical settings. . Cross-references, lead to additional relevant infor-
mation in other parts of BNFC.

Finding dental information in BNFC

Extra signposts have been added to help access dental
Structure of BNFC information in BNFC:
The Contents list (on p. iii) shows that information in
. Prescribing in Dental Practice (p. 22), includes a
BNFC is divided into:
contents list dedicated to drugs and topics of rele-
. How BNF for Children is Constructed (p. ix); vance to dentists, together with cross-references to
. Changes for this Edition (p. xvii); the prescribing notes in the appropriate sections of
. General Guidance (p. 1), which provides practical BNFC. For example, a review of this list shows that
information on many aspects of prescribing from information on the local treatment of oral infections
is located in chapter 12 (Ear, Nose, and Oro-
writing a prescription to prescribing in palliative
care; pharynx) while information on the systemic treat-
ment of these infections is found in chapter 5 (Infec-
. Emergency Treatment of Poisoning (p. 24), which tions). Further guidance for dental practice can be
provides an overview on the management of acute found in the BNF.
poisoning;
. Side-headings, in the prescribing notes, side-head-
. Classified notes on clinical conditions, drugs, and ings facilitate the identification of advice on oral
preparations, these notes are divided into 15 chap- conditions (e.g. Dental and Orofacial Pain, p. 199);
ters, each of which is related to a particular system
of the body (e.g. chapter 3, Respiratory System) or . Dental prescribing on NHS, in the body of BNFC,
to an aspect of paediatric care (e.g. chapter 5, preparations that can be prescribed using NHS form
Infections). Each chapter is further divided into FP10D (GP14 in Scotland, WP10D in Wales) can be
classified sections. Each section usually begins identified by means of a note headed ‘Dental pre-
with prescribing notes followed by relevant drug scribing on NHS’ (e.g. Aciclovir Oral Suspension,
monographs and preparations (see fig. 1). Drugs p. 323).
are classified in a section according to their phar-
macology and therapeutic use;
. Appendices and Indices, includes 4 Appendices Identifying effective drug treatments
(providing information on drug interactions, border-
line substances, cautionary and advisory labels for The prescribing notes in BNFC provide an overview of
dispensed medicines, and intravenous infusions for the drug management of common conditions and facil-
neonatal intensive care), the Dental Practitioners’ itate rapid appraisal of treatment options (e.g. epilepsy,
Formulary, the Nurse Prescribers’ Formulary, Non- p. 215). For ease of use, information on the management
medical Prescribing, Index of Manufacturers, and of certain conditions has been tabulated (e.g. acute
the main Index. The information in the Appendices asthma, p. 136).
should be used in conjunction with relevant infor- Advice issued by the National Institute for Health and
mation in the chapters. Clinical Excellence (NICE) is integrated within BNFC
xii BNFC 2011–2012

prescribing notes if appropriate. Summaries of NICE In order to select safe and effective medicines for
technology appraisals, and relevant short guidelines, individual children, information in the prescribing
are included in pink panels. BNFC also includes advice notes must be used in conjunction with other pre-
issued by the Scottish Medicines Consortium (SMC) scribing details about the drugs and knowledge of the
when a medicine is restricted or not recommended for child’s medical and drug history.
use within NHS Scotland.
Figure 1 Illustrates the typical layout of a drug monograph and preparation
records in BNFC
BNFC How to use BNFC xii
DRUG NAME U In the case of compound preparations, the indica-
tions, cautions, contra-indications, side-effects, and
Cautions details of precautions required and also
interactions of all constituents should be taken into
any monitoring required
account for prescribing.
Counselling Verbal explanation to the patient of spe-
cific details of the drug treatment (e.g. posture when When no suitable licensed preparation is available,
taking a medicine) details of preparations that may be imported or
Contra-indications circumstances when a drug formulations available as manufactured specials or
should be avoided extemporaneous preparations are included.
Hepatic impairment advice on the use of a drug
in hepatic impairment
Renal impairment advice on the use of a drug in Drugs
renal impairment Drugs appear under pharmacopoeial or other non-
Pregnancy advice on the use of a drug during proprietary titles. When there is an appropriate
pregnancy current monograph (Medicines Act 1968, Section
Breast-feeding advice on the use of a drug dur- 65) preference is given to a name at the head of that
ing breast-feeding monograph; otherwise a British Approved Name
Side-effects very common (greater than 1 in 10) (BAN), if available, is used.
and common (1 in 100 to 1 in 10); less commonly The symbol U is used to denote those prepara-
(1 in 1000 to 1 in 100); rarely (1 in 10 000 to 1 in tions considered to be less suitable for prescribing.
How to use BNFC

1000); very rarely (less than 1 in 10 000); also Although such preparations may not be considered
reported, frequency not known as drugs of first choice, their use may be justifiable
Licensed use shows if drug unlicensed in the in certain circumstances.
UK, or ‘off-label’ use of drug licensed in the UK
Indication and dose
Details of uses and indications Prescription-only medicines A
. By route This symbol has been placed against preparations
that are available only on a prescription from an
Child dose and frequency of administration
appropriate practitioner. For more detailed infor-
(max. dose) for specific age group
mation see Medicines, Ethics and Practice, Lon-
. By alternative route don, Pharmaceutical Press (always consult latest
edition).
Child dose and frequency
The symbols 23KL indicate that the
Administration practical advice on the adminis- preparations are subject to the prescription require-
tration of a drug ments of the Misuse of Drugs Act. For advice on
prescribing such preparations see Prescribing Con-
1
Approved Name (Non-proprietary) A trolled Drugs, p. 9.
Pharmaceutical form, sugar-free, active ingre-
dient mg/mL, net price, pack size = basic NHS
price. Label: (as in Appendix 3) Preparations not available for NHS
1. Exceptions to the prescribing status are indicated by a prescription D
note or footnote.
This symbol has been placed against preparations
that are not prescribable under the NHS. Those
Proprietary Name (Manufacturer) A D prescribable only for specific disorders have a
Pharmaceutical form, colour, coating, active footnote specifying the condition(s) for which the
ingredient and amount in dosage form, net price, preparation remains available. Some preparations
pack size = basic NHS price. Label: (as in which are not prescribable by brand name under
Appendix 3) the NHS may nevertheless be dispensed using the
Excipients include clinically important excipients
Electrolytes clinically significant quantities of electrolytes brand name provided that the prescription shows
Note Specific notes about the product e.g. handling an appropriate non-proprietary name.

Preparations
Preparations are included under a non-proprietary Prices
title, if they are marketed under such a title, if they Prices have been calculated from the basic cost
are not otherwise prescribable under the NHS, or if used in pricing NHS prescriptions, see also Prices
they may be prepared extemporaneously. in BNFC, p. xvi for details.
BNFC 2011–2012 xiii
A brief description of the clinical uses of a drug can ments should be made, and the child should be mon-
usually be found in the Indication and Dose section of its itored adequately. The general principles for prescribing
monograph (e.g. ibuprofen, p. 503); a cross-reference is are outlined under Prescribing in Hepatic Impairment
provided to any indications for that drug that are cov- (p. 14) and Prescribing in Renal Impairment (p. 14).
ered in other sections of BNFC. Information about drugs that should be avoided or
The symbol U is used to denote preparations that are used with caution in hepatic disease or renal impair-
considered by the Joint Formulary Committee to be less ment can be found in drug monographs under Hepatic
suitable for prescribing. Although such preparations Impairment and Renal Impairment (e.g. fluconazole,
may not be considered as drugs of first choice, their p. 301). However, if a class of drugs (e.g. tetracyclines,
use may be justifiable in certain circumstances. p. 274) share the same recommendations for use in
hepatic disease or renal impairment, this advice is
presented in the prescribing notes under Hepatic
Impairment and Renal Impairment and any advice
Drug management of medical that is unique to a particular drug in that class is
emergencies included in its individual drug monograph.
Guidance on the drug management of medical emer-
gencies can be found in the relevant BNFC chapters (e.g.
treatment of anaphylaxis is included in section 3.4.3). A Prescribing for patients who are
summary of drug doses used for Medical Emergencies
in the Community can be found in the glossy pages at
pregnant or breast-feeding
the back of BNFC. Algorithms for Newborn, Paediatric Drug selection should aim to minimise harm to the
Basic, and Paediatric Advanced Life Support can also be fetus, nursing infant, and mother. The infant should be
found within these pages. monitored for potential side-effects of drugs used by the
mother during pregnancy or breast-feeding. The general
principles for prescribing are outlined under Prescribing
in Pregnancy (p. 16) and Prescribing in Breast-feeding
Minimising harm in children with co- (p. 16). The prescribing notes in BNFC chapters provide
morbidities guidance on the drug treatment of common conditions
The drug chosen to treat a particular condition should that can occur during pregnancy and breast-feeding (e.g.
have minimal detrimental effects on the child’s other asthma, p. 133). Information about the use of specific
diseases and minimise the child’s susceptibility to drugs during pregnancy and breast-feeding can be
adverse effects. To achieve this, the Cautions, Contra- found in their drug monographs under Pregnancy and
indications, and Side-effects of the relevant drug should Breast-feeding (e.g. fluconazole, p. 301). However, if a
be reviewed, and can usually be found in the drug class of drugs (e.g. tetracyclines, p. 274) share the same
monograph. However, if a class of drugs (e.g. tetracy- recommendations for use during pregnancy or breast-
clines, p. 274) share the same cautions, contra-indica- feeding, this advice is amalgamated in the prescribing
tions, and side-effects, these are amalgamated in the notes under Pregnancy and Breast-feeding while any
prescribing notes while those unique to a particular drug advice that is unique to a particular drug in that class is
in that class are included in its individual drug mono- included in its individual drug monograph.
graph. Occasionally, the cautions, contra-indications,
and side-effects may be included within a preparation
record if they are specific to that preparation or if the
preparation is not accompanied by a monograph.
Minimising drug interactions
Drug selection should aim to minimise drug interac-
The information under Cautions can be used to assess tions. If it is necessary to prescribe a potentially serious
the risks of using a drug in a child who has co-morbid- combination of drugs, children should be monitored
ities that are also included in the Cautions for that appropriately. The mechanisms underlying drug inter-
drug—if a safer alternative cannot be found, the drug actions are explained in Appendix 1 (p. 655).
may be prescribed while monitoring the child for
adverse-effects or deterioration in the co-morbidity. Details of drug interactions can be found in Appendix 1
Contra-indications are far more restrictive than Cau- of BNFC (p. 656). Drugs and their interactions are listed
tions and mean that the drug should be avoided in a in alphabetical order of the non-proprietary drug name,
child with a condition that is contra-indicated. and cross-references to drug classes are provided where
appropriate. Each drug or drug class is listed twice: in
The impact that potential side-effects may have on a
the alphabetical list and also against the drug or class
child’s quality of life should also be assessed. For
with which it interacts. The symbol . is placed against
instance, in a child who has constipation, it may be
interactions that are potentially serious and where com-
preferable to avoid a drug that frequently causes con-
bined administration of drugs should be avoided (or
stipation. The prescribing notes in BNFC may highlight
only undertaken with caution and appropriate monitor-
important safety concerns and differences between
ing). Interactions that have no symbol do not usually
drugs in their ability to cause certain side-effects.
have serious consequences.
If a drug or drug class has interactions, a cross reference
to where these can be found in Appendix 1 is provided
Prescribing for children with hepatic or
under the Cautions of the drug monograph or pre-
renal impairment scribing notes.
Drug selection should aim to minimise the potential for
drug accumulation, adverse drug reactions, and exacer-
bation of pre-existing hepatic or renal disease. If it is
necessary to prescribe drugs whose effect is altered by
hepatic or renal disease, appropriate drug dose adjust-
xiv BNFC 2011–2012

Selecting the dose body surface area-standardised dose is multiplied by the

child’s body surface area. The child’s body surface area
The drug dose is usually located in pink panels within
can be estimated from his or her weight using the tables
the Indication and Dose section of the drug monograph
for Body Surface Area in Children located in the glossy
or within the Dose section of the preparation record.
pages at the back of the print version of BNFC.
Doses are linked to specific indications and routes of
administration. The dose of a drug may vary according The doses of some drugs may need to be adjusted if
to different indications, routes of administration, age, their effects are altered by concomitant use with other
body-weight, and body-surface area. When the dose of a drugs, or in patients with hepatic or renal impairment
drug varies according to different indications, each (see Minimising Drug Interactions, and Prescribing for
indication and its accompanying dose is included in a Children with Hepatic or Renal Impairment).
separate pink panel (e.g. aciclovir, p. 322). The dose is Wherever possible, doses are expressed in terms of a
located within the preparation record when the dose definite frequency (e.g. if the dose is 1 mg/kg twice
varies according to different formulations of that drug daily, a child of body-weight 9 kg would receive 9 mg
(e.g. amphotericin, p. 305) or when a preparation has a twice daily). Occasionally, it is necessary to include
dose different to that in its monograph. Occasionally, doses in the total daily dose format (e.g. 10 mg/kg
drug doses may be included in the prescribing notes for daily in 3 divided doses); in these cases the total daily
practical reasons (e.g. doses of drugs in Helicobacter dose should be divided into individual doses (in this
pylori eradication regimens, p. 42). The right dose example a child of body-weight 9 kg would receive
should be selected for the right age and body-weight 30 mg 3 times daily).
(or body surface area) of the child, as well as for the right
indication, route of administration, and preparation. Most drugs can be administered at slightly irregular
intervals during the day. Some drugs, e.g. antimicrobials,
are best given at regular intervals. Some flexibility
Doses in BNFC are usually assigned to specific age
should be allowed in children to avoid waking them
ranges; neonatal doses are preceded by the word
during the night. For example, the night-time dose may
Neonate, all other doses are preceded by the word
be given at the child’s bedtime.
Child. Age ranges in BNFC are described as shown
in the following example: Special care should be taken when converting doses
Child 1 month–4 years refers to a child from 1 from one metric unit to another, and when calculating
month old up to their 4th birthday; infusion rates or the volume of a preparation to admin-
ister. Conversions for imperial to metric measures can
Child 4–10 years refers to a child from the day of
be found in the glossy pages at the back of BNFC.
their 4th birthday up to their 10th birthday.
Where possible, doses should be rounded to facilitate
However, a pragmatic approach should be applied to administration of suitable volumes of liquid prepara-
these cut-off points depending on the child’s physio- tions, or an appropriate strength of tablet or capsule.
logical development, condition, and if weight is
appropriate for the child’s age.

For some drugs (e.g. gentamicin, p. 278) the neonatal

dose varies according to the postmenstrual age of the Selecting a suitable preparation
neonate. Postmenstrual age is the neonate’s total age Children should be prescribed a preparation that com-
expressed in weeks from the start of the mother’s last plements their daily routine, and that provides the right
menstrual period. For example, a 3 week old baby born dose of drug for the right indication and route of
at 27 weeks gestation is treated as having a postmenstr- administration.
ual age of 30 weeks. A term baby has a postmenstrual
age of 37–42 weeks when born. For most other drugs, In BNFC, preparations usually follow immediately after
the dose can be based on the child’s actual date of birth the monograph for the drug which is their main ingre-
irrespective of postmenstrual age. However, the degree dient. The preparation record (see fig. 1) provides infor-
of prematurity, the maturity of renal and hepatic func- mation on the type of formulation (e.g. tablet), the
tion, and the clinical properties of the drug need to be amount of active drug in a solid dosage form, and the
considered on an individual basis. concentration of active drug in a liquid dosage form.
The legal status is shown for prescription only medi-
Many children’s doses in BNFC are standardised by cines and controlled drugs; any exception to the legal
body-weight. To calculate the dose for a given child status is shown by a Note immediately after the pre-
the weight-standardised dose is multiplied by the child’s paration record or a footnote. If a proprietary prepara-
weight (or occasionally by the child’s ideal weight for tion has a distinct colour, coating, scoring, or flavour,
height). The calculated dose should not normally this is shown in the preparation record. If a proprietary
exceed the maximum recommended dose for an adult. preparation includes excipients usually specified in
For example, if the dose is 8 mg/kg (max. 300 mg), a BNFC (see p. 2), these are shown in the Excipients
child of 10 kg body-weight should receive 80 mg, but a statement, and if it contains clinically significant quan-
child of 40 kg body-weight should receive 300 mg tities of electrolytes, these are usually shown in the
(rather than 320 mg). Calculation by body-weight in Electrolytes statement.
the overweight child may result in much higher doses
Branded oral liquid preparations that do not contain
being administered than necessary; in such cases, the
fructose, glucose, or sucrose are described as ‘sugar-
dose should be calculated from an ideal weight for
free’ in BNFC. Preparations containing hydrogenated
height.
glucose syrup, mannitol, maltitol, sorbitol, or xylitol are
Occasionally, some doses in BNFC are standardised by also marked ‘sugar-free’ since there is evidence that they
body surface area because many physiological phe- do not cause dental caries. Children receiving medicines
nomena correlate better with body surface area. In containing cariogenic sugars, or their carers, should be
these cases, to calculate the dose for a given child, the advised of appropriate dental hygiene measures to pre-
BNFC 2011–2012 xv
vent caries. Sugar-free preparations should be used Children and their carers should be advised if treatment
whenever possible. is likely to affect their ability to perform skilled tasks
Where a drug has several preparations, those of a (e.g. driving).
similar type may be grouped together under a heading Cautionary and advisory labels that pharmacists are
(e.g. ‘Modified-release’ for theophylline preparations, recommended to add when dispensing are included in
p. 143). Where there is good evidence to show that the preparation record (see fig. 1). Details of these labels
the preparations for a particular drug are not inter- can be found in Appendix 3 (p. 788).
changeable, this is stated in a Note either in the Dose
section of the monograph or by the group of prepara-
tions affected. When the dose of a drug varies according Monitoring drug treatment
to different formulations of that drug, the right dose Children should be monitored to ensure they are achiev-
should be prescribed for the preparation selected. ing the expected benefits from drug treatment without
In the case of compound preparations, the prescribing any unwanted side-effects. The prescribing notes or the
information of all constituents should be taken into Cautions in the drug monograph specify any special
account for prescribing. monitoring requirements. Further information on mon-
Unlicensed preparations that are available from ‘Special itoring the plasma concentration of drugs with a narrow
order’ manufacturers and specialist importing compa- therapeutic index can be found in the Pharmacokinetics
nies are included (e.g. midazolam buccal liquid, p. 639). section or as a Note under the Dose section of the drug
The availability of an extemporaneous formulation of a monograph.
drug is shown after its other preparations (e.g. captopril,
p. 102).
Identifying and reporting adverse drug
reactions
Clinically relevant Side-effects for most drugs are
Writing prescriptions included in the monographs. However, if a class of
Guidance is provided on writing prescriptions that will drugs (e.g. tetracyclines, p. 274) share the same side-
help to reduce medication errors, see p. 4. Prescription effects, these are presented in the prescribing notes
requirements for controlled drugs are also specified on while those unique to a particular drug in that class
p. 9. are included in its individual drug monograph. Occa-
sionally, side-effects may be included within a prepara-
tion record if they are specific to that preparation or if
the preparation is not accompanied by a monograph.
Administering drugs
Side-effects are generally listed in order of frequency
Basic information on the route of administration is
and arranged broadly by body systems. Occasionally a
provided in the Indication and Dose section of a drug
rare side-effect might be listed first if it is considered to
monograph or the Dose section of a preparation record.
be particularly important because of its seriousness. The
Further details, such as masking the bitter taste of some
frequency of side-effects is described in fig. 1.
medicines, may be provided in the Administration sec-
tion of a drug monograph (e.g. proguanil, p. 336). Prac- An exhaustive list of side-effects is not included for
tical information is also provided on the preparation of drugs that are used by specialists (e.g. cytotoxic drugs
intravenous drug infusions, including compatibility of and drugs used in anaesthesia). Recognising that hyper-
drugs with standard intravenous infusion fluids, method sensitivity reactions can occur with virtually all medi-
of dilution or reconstitution, and administration rates cines, this effect is generally not listed, unless the drug
(e.g. co-amoxiclav, p. 263). The Administration section carries an increased risk of such reactions. BNFC also
is located within preparation records when this informa- omits effects that are likely to have little clinical con-
tion varies according to different preparations of that sequence (e.g. transient increase in liver enzymes).
drug (e.g. amphotericin, p. 305). If a class of drugs (e.g. The prescribing notes in BNFC may highlight important
topical corticosteroids, p. 559) share the same adminis- safety concerns and differences between drugs in their
tration advice, this may be presented in the prescribing ability to cause certain side-effects. Safety warnings
notes. issued by the Commission on Human Medicines
Information on intravenous infusions for neonatal inten- (CHM) or Medicines and Healthcare products Regula-
sive care can also be found in Appendix 4, p. 791. tory Agency (MHRA) can also be found here or in the
drug monographs.
Adverse Reactions to Drugs (p. 12) provides advice on
Advising children (and carers) preventing adverse drug reactions, and guidance on
reporting adverse drug reactions to the MHRA. The
The prescriber, the child’s carer, and the child (if appro- black triangle symbol T identifies those preparations in
priate) should agree on the health outcomes desired and BNFC that are monitored intensively by the MHRA.
on the strategy for achieving them (see Taking Medi-
cines to Best Effect, p. 1). Taking the time to explain to
the child (and carers) the rationale and the potential
adverse effects of treatment may improve adherence.
For some medicines there is a special need for counsel-
ling (e.g. recognising signs of blood, liver, or skin dis-
orders with carbamazepine); this is shown in Counsel-
ling statements, usually in the Cautions or Indication
and Dose section of a monograph, or within a prepara-
tion record if it is specific to that preparation.
xvi BNFC 2011–2012

Finding significant changes in a new falls outside a drug’s marketing authorisation (e.g.
edition naproxen, p. 505).

BNFC is published in July each year and includes lists of The absence of the Licensed Use statement from a drug
changes in a new edition that are relevant to clinical monograph indicates that the drug is licensed for all
practice: indications given in the monograph (e.g. zanamivir,
p. 327).
. The print version includes an Insert that sum-
marises the background to several key changes. A Prescribing unlicensed medicines or medicines outside
copy of the Insert can also be found at bnfc.org in their marketing authorisation alters (and probably
the section on Updates under ‘What’s new in increases) the prescriber’s professional responsibility
BNFC?’; and potential liability. The prescriber should be able to
justify and feel competent in using such medicines.
. Changes for this edition (p. xvii), provides a list of Further information can be found in BNF for Children
significant changes, dose changes, classification and Marketing Authorisation, p. 2.
changes, new names, and new preparations that
have been incorporated into a new edition, as well
as a list of preparations that have been discontinued Prices in BNFC
since the last edition. For ease of identification, the
Basic net prices are given in BNFC to provide an
margins of these pages are marked in pink;
indication of relative cost. Where there is a choice of
. E-newsletter, the BNF & BNFC e-newsletter service suitable preparations for a particular disease or condi-
is available free of charge. It alerts healthcare pro- tion the relative cost may be used in making a selection.
fessionals to details of significant changes in the Cost-effective prescribing must, however, take into
clinical content of these publications and to the way account other factors (such as dose frequency and
that this information is delivered. Newsletters also duration of treatment) that affect the total cost. The
review clinical case studies and provide tips on use of more expensive drugs is justified if it will result in
using these publications effectively. To sign up for better treatment of the patient, or a reduction of the
e-newsletters go to bnf.org/newsletter. To visit length of an illness, or the time spent in hospital. Prices
the e-newsletter archive, go to bnfc.org/bnfc/ have generally been calculated from the net cost used in
bnfcextra/current/450066.htm. pricing NHS prescriptions in October 2010. Prices gen-
erally reflect whole dispensing packs; prices for injec-
So many changes are made to each new edition of
tions are stated per ampoule, vial, or syringe. The price
BNFC, that not all of them can be accommodated in
for an extemporaneously prepared preparation has been
the Insert and the Changes section. We encourage
omitted where the net cost of the ingredients used to
healthcare professionals to review regularly the pre-
make it would give a misleadingly low impression of the
scribing information on drugs that they encounter fre-
final price.
quently.
BNFC prices are not suitable for quoting to patients
seeking private prescriptions or contemplating over-the-
counter purchases because they do not take into
Nutrition account VAT, professional fees, and other overheads.
Appendix 2 (p. 743) includes tables of ACBS-approved A fuller explanation of costs to the NHS may be
enteral feeds and nutritional supplements based on their obtained from the Drug Tariff. Separate drug tariffs
energy and protein content. There are separate tables are applicable to England and Wales, Scotland, and
for specialised formulae for specific clinical conditions. Northern Ireland; prices in the different tariffs may vary.
Classified sections on foods for special diets and nutri-
tional supplements for metabolic diseases are also
included. Extra resources on the BNFC website
While the BNFC website (bnfc.org) hosts the digital
content of BNFC proper, it also provides additional
resources such as Frequently Asked Questions and
Licensed status of medicines online calculators.
BNFC includes advice on the use of unlicensed medi-
cines or of licensed medicines for unlicensed applica-
tions (‘off-label’ use). Such advice reflects careful con-
sideration of the options available to manage a given
condition and the weight of evidence and experience of
the unlicensed intervention. Limitations of the market-
ing authorisation should not preclude unlicensed use
where clinically appropriate.
The Licensed Use statement in a drug monograph is
used to indicate that:
. a drug is not licensed in the UK (e.g. pyrazinamide,
p. 293);
. a drug is licensed in the UK, but not for use in
children (e.g. lansoprazole, p. 45);
. BNFC advice for certain indications, age groups of
children, routes of administration, or preparations
BNFC 2011–2012 xvii
Changes for this Combined oral contraceptives [preparations tabulated],
section 7.3.1
edition Progestogen-only contraceptive interactions, section
7.3.2.1 and section 7.3.2.2
Nocturnal enuresis, section 7.4.2
Significant changes Rapamune c tablets [0.5 mg tablet not bioequivalent to
The BNF for Children is revised yearly and numerous other strengths], section 8.2.2
changes are made between issues. All copies of BNF for G6PD deficiency [rasburicase and risk of haemolysis],
Children 2010–2011 should therefore be withdrawn and section 9.1.5
replaced by BNF for Children 2011–2012. Significant Calcium gluconate injection [MHRA advice], section
changes have been made in the following sections for 9.5.1.1
BNF for Children 2011–2012:
Drugs unsafe for use in acute porphyrias, section 9.8.2
How to use BNFC, p. xi
Aqueous cream [skin reactions when used as a leave-on
New symbols introduced throughout BNF for Children emollient], section 13.2.1
to identify Controlled Drug preparations in Schedules 2,
3, and 4, Prescribing Controlled Drugs Nappy rash, section 13.2.2
Ibuprofen poisoning, Emergency treatment of poisoning Sunscreens [International Nomenclature for Cosmetic
Ingredients, table added], section 13.8.1
Paracetamol poisoning [calculating the potentially toxic
dose ingested by obese children], Emergency treatment Immunisation Schedule, section 14.1
of poisoning Haemophilus type B conjugate vaccine and meningo-
Infliximab for Crohn’s Disease [NICE guidance], section coccal vaccines [in asplenia, splenic dysfunction, or
1.5 complement deficiency], section 14.4
Formoterol [MHRA/CHM advice], section 3.1.1.1 Influenza vaccines, section 14.4
Omalizumab [NICE guidance], section 3.4.2 Meningococcal vaccines, section 14.4
Fentanyl [counselling for the use of patches], section Pertussis vaccine [management of contacts], section
4.7.2 14.4
Epilepsy in pregnancy, section 4.8.1 Sedative and analgesic peri-operative drugs, section
15.1.4
Neonatal seizures, section 4.8.1
Local anaesthesia [section updated and reorganised],
Febrile convulsions, section 4.8.3 section 15.2
Nicotine dependence, section 4.10.2
Summary of antibacterial therapy [advice reformatted],
section 5.1, Table 1 Dose changes
Cystic Fibrosis, section 5.1, Table 1 Changes in dose statements introduced into BNF for
Children 2011–2012:
Meningitis, section 5.1, Table 1
Aciclovir [herpes simplex suppression], p. 322
Erysipelas and cellulitis, section 5.1, Table 1
Actiq c , p. 206
Prevention of pertussis, section 5.1, Table 2
ACWY Vax c , p. 615
Prevention of pneumococcal infection in asplenia or in
patients with sickle-cell disease, section 5.1, Table 2 AmBisome c , p. 306
Prevention of infection in open fractures, section 5.1, Amitriptyline [neuropathic pain], p. 185
Table 2 Ampicillin, p. 262
Urinary-tract infections [culture and sensitivity testing], Atorvastatin, p. 126
section 5.1.13
Atropine [premedication by intravenous injection in
Treatment of fungal infections: aspergillosis, section 5.2 neonates and intra-operative bradycardia in neonates],
HIV infection [initiation of treatment], section 5.3.1 p. 635
Antiretroviral drugs [doses included in their mono- Azathioprine [severe ulcerative colitis and Crohn’s dis-
graphs], section 5.3.1 ease], p. 54
Palivizumab [respiratory syncytial virus], section 5.3.5 Bendroflumethiazide, p. 77
Prophylaxis against malaria [recommendations for Mor- Cervarix c [alternative schedule], p. 611
occo and Turkmenistan removed], section 5.4.1 Cetirizine [dose and dose in renal impairment], p. 154
Dexamethasone [parenteral doses expressed as dexa- Ciprofloxacin, p. 254
methasone base], section 6.3.2
Co-amoxiclav [intravenous dose], p. 263
Somatropin for the treatment of growth failure in chil-
dren [NICE guidance], section 6.5.1 Colistimethate sodium (Colistin), p. 288

Recurrent vulvovaginal candidiasis [updated treatment Dexamethasone, p. 374

regimens], section 7.2.2 Dexamfetamine, p. 189
Combined hormonal contraceptive interactions, section Diazepam [intravenous dose for status epilepticus],
7.3.1 p. 232
xviii BNFC 2011–2012

Epilim Chronosphere c , p. 228 Salofalk c tablets, granules, and rectal foam, p. 51

Fersamal c , p. 444 Selenium sulphide [pityriasis versicolor], p. 584
Flucloxacillin [staphylococcal lung infection in cystic Sodium valproate, p. 227
fibrosis], p. 259 Sumatriptan [cluster headache], p. 213
Fludrocortisone acetate [mineralocorticoid replacement Symbicort c 100/6 [dose for children 6–12 years], p. 149
in adrenocortical insufficiency in neonates], p. 369
Temazepam, p. 639
Flumazenil [intravenous injection dose for reversal of
sedative effects of benzodiazepines], p. 647 Tiagabine [adjunctive treatment for focal seizures and
dose in hepatic impairment], p. 226
Foradil c [dose for children under 12 years], p. 138
Topiramate [focal seizures and Lennox-Gastaut
Fresh frozen plasma, p. 125 syndrome, migraine prophylaxis, and dose in renal
c
Fungizone [neonatal dose], p. 306 impairment], p. 226
Glycopyrronium [premedication at induction in children Tranexamic acid [prevention of excessive bleeding after
12–18 years and control of muscarinic side-effects of dental procedures by intravenous injection and menorr-
neostigmine in children 12–18 years], p. 636 hagia], p. 123
Hydralazine [intravenous infusion in neonates], p. 93 Trimethoprim, p. 255
Hydrocortisone [congenital adrenal hyperplasia and Valaciclovir, p. 323
adrenal hypoplasia, Addison’s disease, chronic mainte- Xylometazoline nasal spray, p. 542
nance or replacement therapy], p. 375
Zydol SR c , p. 211
Hydrocortisone [paediatric severe or life-threatening
acute asthma], p. 134 and p. 136
Indometacin [symptomatic ductus arteriosus], p. 130
Ipratropium [dose frequency for severe or life-threaten-
ing acute asthma in children 12–18 years], p. 134 and Classification changes
p. 136 Classification changes have been made in the following
Itraconazole [tinea capitis], p. 303 sections of BNF for Children 2011–2012:
Isoniazid, p. 255 Section 2.1.2 Phosphodiesterase type-3 inhibitors [title
Lansoprazole [dose in hepatic impairment], p. 45 change]

Levetiracetam [no dose adjustment when switching Section 4.7.1 Non-opioid analgesics and compound
between intravenous and oral therapy], p. 222 analgesic preparations [title change]

Macrogol Oral Powder, Compound [faecal impaction], Section 4.10.2 Nicotine dependence [new section]
p. 62 Section 5.2.1 Triazole antifungals [new sub-section]
Menveo c , p. 615 Section 5.2.2 Imidazole antifungals [new sub-section]
Mercaptamine, p. 492 Section 5.2.3 Polyene antifungals [new sub-section]
Meropenem, p. 273 Section 5.2.4 Echinocandin antifungals [new sub-sec-
Metronidazole, p. 296 tion]

Midazolam [neonatal dose for sedation in intensive Section 5.2.5 Other antifungals [new sub-section]
care], p. 638 Section 6.1.2 Antidiabetic drugs [title change]
Modigraf c , p. 437 Section 10.3 Drugs for the relief of soft-tissue inflam-
Morphine [intravenous injection and oral dose in chil- mation and topical pain relief [title change]
dren 12–18 years], p. 207 Section 10.3.2 Rubefacients, topical NSAIDs, capsaicin,
Movicol c [faecal impaction], p. 62 and poultices [title change]

Movicol c -Half [faecal impaction], p. 62 Section 13.2.1.1 Emollient bath additives and shower
preparations [title change]
Naloxone [intravenous infusion dose for overdosage
with opioids], p. 29 Section 15.1.4.1 Anxiolytics [title change]

Nifedipine [hypertensive crisis, acute angina in Kawa-

saki disease or progeria], p. 107
Nitrous oxide [maintenance of anaesthesia], p. 635
Paracetamol [severe postoperative pain by mouth and New Names
by rectum], p. 200 Colistimethate sodium [formerly Colistin], p. 288
Phenytoin sodium, p. 235 Dulcolax c Pico Liquid and Pico Perles [formerly
Prednisolone [corticosteroid replacement therapy], Dulcolax c Liquid and Perles], p. 61
p. 376 Hydrocortisone mucoadhesive buccal tablets [formerly
Prograf c , p. 437 Corlan c ], p. 544
Propranolol [migraine prophylaxis], p. 88 Laxido c Orange [formerly Laxido c ], p. 62
Retapamulin, p. 586 Oilatum c Junior bath additive [formerly Oilatum c
Junior emollient bath additive], p. 555
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