BNF for Children
What's different about the BNF for Children compared with the BNF?
BNF for Children contains information on the use of drugs for neonates, infants, children and adolescents. It is based on information derived from Medicines for Children and the BNF, combined with information from other sources such as hospital paediatric formularies, research studies and systematic reviews.
Whereas the 'standard' BNF deals with the use of medicines for individuals of all ages, BNF for Children is able to focus specifically on the use of medicines in children. This allows it to deal with the drug management of childhood conditions more extensively and it also allows a greater discussion of the unlicensed use of medicines. BNF for Children includes advice on drugs used for rare metabolic disorders and on specialist neonatal and paediatric interventions.
Entries on individual drugs give an indication of the licensed status of the drug and if specialist expertise is required for use in children. Recognising that 'adult' conditions may also be relevant to younger individuals, BNF for Children includes, in drug entries, advice on the use of medicines during pregnancy and whilst breast-feeding.
BNF for Children does not include information on the drug management of conditions such as dementia, which affect older people and are dealt with by the BNF.
Who should use BNF for Children?
BNF for Children is for use by all health professionals, in all sectors of healthcare, who are involved in prescribing, administering or managing medicines used for children. The resource is also very well suited to professional training. When used for making clinical decisions, it should be interpreted in the light of professional knowledge and supplemented by specialist literature if necessary.
How often will BNF for Children be published?
BNF for Children will be published annually in July. Digital versions will be available simultaneously or shortly after publication of the book.
What age groups does BNF for Children cover?
BNF for Children covers the use of drugs in children of all ages from newborn infants, including those born prematurely to individuals aged 18 years.
Who produces the BNF for Children?
The BNF for Children is produced by the BNF Publications editorial team under the supervision of a Paediatric Formulary Committee. A network of expert clinical advisers provide advice and information on current best practice. The names of all individuals who have contributed can be found in the Preface. BNF for Children is published under the joint imprint of the British Medical Association, the Royal Pharmaceutical Society of Great Britain, the Royal College of Paediatrics and Child Health, and the Neonatal and Paediatric Pharmacists Group.
Why is there an overlap in the age bands in BNF for Children?
The use of age bands in the presentation of doses can be confusing. In BNF for Children, a dose for, say, 'Child 1–8 years' means that the dose may be used from the child's 1st birthday to the 8th birthday and the next band, say, 'Child 8–12 years' applies between a child's 8th and 12th birthdays.
The age bands apply to children of average size and in practice the clinician will use the age bands in conjunction with other factors such as the severity of the condition being treated and the child's size in relation to the average size of children of the same age.
Why are some drugs not included?
Many drugs used in children are used outside their licence and they may not have been studied in adequate detail in children. BNF for Children includes information on drugs when there is sufficient evidence for the drug to be considered relatively safe and effective in children.
For some drugs information is very scarce and their use may be limited to specialist centres and by clinicians with specialist expertise and knowledge of these drugs. In such cases, until the evidence is better established, BNF for Children omits information about the drugs.
How should I reference the BNF for Children?
The Uniform Requirements for Manuscripts Submitted to Biomedical Journals (http://www.icmje.org), formerly referred to as the Vancouver convention, is preferred by many medical journals. The style for referencing the BNFC using the Uniform Requirements for Manuscripts is as follows:
Paediatric Formulary Committee. BNF for Children [edition year]. London: BMJ Publishing Group, RPS Publishing, and RCPCH Publications; [year of publication]
Why is the printed BNFC available before the digital versions?
Our primary focus is to publish the printed BNFC since it is this version that is used most extensively. The electronic versions of the BNFC are derived from the same database as the one we use for the paper copy. However, a number of tasks are required to adapt the database output for the electronic versions. These tasks are undertaken once the paper version has been sent away for printing. Unfortunately, this results in the electronic versions appearing shortly after the printed book.
How often is BNFC data updated?
Whilst the central BNFC data is updated once a year, the other pages on the website are updated on a more regular basis. The BNFC text is compiled with the help of a network of expert clinical advisers under the authority of the Paediatric Formulary Committee (comprising representatives of the three publishers and the Department of Health). This allows the publication to provide impartial, authoritative and practical advice and ensures that the BNFC remains reliable. BNFC's clinical advisers, the Paediatric Formulary Committee and the editorial team work together to:
The rigour and consultative nature of this process limit the frequency with which the BNFC text can be updated and certainly preclude a monthly production cycle. However, as indicated above, the BNFC website is able to provide any vital information that comes to light between editions.
How is the BNFC funded?
The BNFC is entirely funded from sales made by the joint publishers, the BMJ Publishing group, RPS Publishing, and RCPCH Publications. The great bulk of sales are of the printed version and made to the Department of Health for distribution within the NHS. The publishers also sell the publication in both printed and electronic formats in the UK and the rest of the world.
How do I get permission to reproduce information from the BNFC?
Permission to reproduce material from the BNFC is granted in certain circumstances and should be sought from
BNF Publications,Please note that the publishers do not permit the reproduction of any part of the BNFC for promotional purposes.
Many websites provide information on medicines. What's special about BNFC.org?
BNFC.org includes the entire content of the BNF for Children, which is widely regarded by doctors, pharmacists and other healthcare professionals as an up to date and highly authoritative information resource on medicines prescribed in the UK. BNFC.org also includes supplementary information of relevance to those with an interest in the effective use of medicines in children.
A Paediatric Formulary Committee (comprising representatives of the three publishers and the Department of Health) is responsible for the content of the BNFC - this allows the publication to provide impartial, authoritative and practical advice.
Find out about how the BNFC is constructed.
Can the BNFC office offer advice about the treatment of my child's specific condition?
We regret that we are unable to comment on individual cases and we cannot enter into correspondence with patients (or their relatives). These matters are best dealt with by properly qualified professionals who are familiar with all the circumstances surrounding the case.
Whereas the BNFC tries to give the best possible advice on treatment, there are sometimes special circumstances when the doctor may want to deviate from this advice.
Corresponding with the BNFC
The BNFC receives a great many comments and it is not always possible to acknowledge each one or to specify what action the BNFC will take in response. However, we are very grateful for the comments and we will consider each comment carefully. The comments which the BNFC is most likely to respond to are those received from the intended audience of the BNFC (healthcare professionals dealing with medicines), especially when there is definite concern about the correct use of medicines. Before making an enquiry to the editorial department, the BNFC also expects healthcare professionals to have checked other sources of information, including a medicines information centre. More advice about this is available on our Contact Us page.
Readers of the BNFC should note that the BNFC is an aide memoire (for use by practitioners with a high level of background knowledge about medicines) and the BNFC cannot be exhaustive in its coverage. Supplementary information is available from the summaries of product characteristics of individual products and from works such as Martindale: the complete drug reference as well as from medicines information centres.
Why are herbal and homeopathic remedies not included in the BNFC?
We appreciate that such an expansion of the BNFC would enable practitioners to access various options from a single volume. However, to expand the BNFC in this way is unlikely to be practicable currently.
The infrastructure of the BNFC (the Paediatric Formulary Committee, the clinical advisers and the editorial staff) has been set up to possess special expertise and knowledge on the use of conventional medicines. Such a structure enables the BNFC to provide authoritative information. In order to provide reliable and authoritative information on homeopathic or herbal medicines, it would be necessary to set up a parallel structure with specific expertise in complementary medicine. It would be very difficult to achieve this and to include all the information in one volume which provides advice on the selection of both types of medicines would add a further level of complexity. In short, we feel that it is best for the BNFC to focus on what it does best! To expand its scope could risk devaluing the product.
A particular difficulty with complementary medicines is that there are no nationally recognised standards to govern the quality (or even identity) of the products. Therefore, it is not possible to describe the clinical effects of these products reliably.
Nevertheless, we are sympathetic to healthcare professionals' needs and we are looking into ways of providing information on complementary medicines without compromising the core content of the BNFC.
Why has the BNFC changed the names of some drugs? Why does the BNFC use adrenaline and not epinephrine?
European law requires the use of the Recommended International Non-proprietary Name (rINN) for medicinal substances. In most cases the familiar British Approved Name (BAN) and the rINN are identical. Where they were different the BANs have been amended to conform to the rINNs. The only exception to this is adrenaline and noradrenaline.
Adrenaline and noradrenaline are the terms used in the titles of monographs in the European Pharmacopoeia and are thus the official names in the member states. For these substances the British Pharmacopoeia shows the European Pharmacopoeia names and the rINNs (epinephrine and norepinephrine respectively) at the head of the monographs; the BNFC uses a similar style.
The list of commonly used substances whose names have been affected by the name change is available on BNF.org.
How are the prices in the BNFC calculated?
Prices are included in the BNFC to allow comparison between products. They are not suitable for quoting to patients since they do not include elements such as container allowance and professional fees.
Prices in the BNFC are generally calculated from the net cost used in pricing NHS prescriptions. This information comes from NHS Prescription Services and is updated each edition. Suitable original packs or patient packs are usually priced as the basis for comparison, but the unit of 20 is still sometimes used for tablets and capsules particularly if a suitable patient pack is not available.
Where does the BNFC get its information?
Find out how the BNFC is constructed.
Why is there sometimes a discrepancy between a product SPC and the BNFC monograph?
The most important source of information on drug entries is the manufacturer's product literature (including Summaries of Product Characteristics and Patient Information Leaflets). However, the BNFC entries may not be entirely consistent with the manufacturers' literature because the entries are constructed according to internal editorial guidelines; the following examples illustrate how the BNFC 'rules' are applied:
Information from other sources (such as
journal articles, CSM statements and expert advice) may also be
incorporated into the BNFC drug entries.
For some drugs there is good reason to include indications or
doses that are inconsistent with those in the Summaries of Product
Characteristics. In such cases the BNFC verifies its information
with clinical literature and with expert advisers.
How does BNFC.org choose links to other websites?
The inclusion of links to other websites is at the discretion of BNF Publications. Criteria for linking to other websites include:
Is it safe to prescribe products containing arachis (peanut) oil where peanut allergy is known or suspected?
Oils obtained from nuts can be said to be "crude" or "refined". A report in 1998 from the Department of Health's Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment has advised that refined arachis oil does not contain allergenic peanut proteins. As Arachis Oil BP contains refined arachis oil it is unlikely to cause a reaction in those with peanut allergy.
A further distinction needs to be made between those substances (in topical products) that are associated with skin sensitisation and those which cause systemic reactions (e.g. anaphylaxis), such as peanut proteins. The list of sensitising excipients in section 13.1.3 of the BNFC includes only those substances that are associated with skin sensitisation; arachis oil is not thought to sensitise the skin.
However, the manufacturer should be contacted if it is essential to check details and the BNF or the product literature does not provide the necessary information.
The report of the Department of Health's Committee can be found on the Department of Health website.
How do I report a suspected adverse drug reaction?
Doctors, dentists, coroners, pharmacists, nurses, and patients are strongly encouraged to report suspected adverse drug reactions to the Committee on Safety of Medicines. Prepaid Yellow Cards are available for this purpose and may be found at the back of printed copies of the BNFC or complete a Yellow Card on-line.
Should I report all suspected adverse drug reactions?
For established drugs and vaccines all serious suspected reactions should be reported. These are reactions which are fatal, life-threatening, incapacitating, disabling, or which result in prolonged hospitalisation; they should be reported even if the reaction is well recognised.
Newer drugs and vaccines are subject to intense monitoring and they are denoted in the BNFC by the symbol 
. Healthcare professionals and patients are asked to report all suspected reactions, however minor, which could conceivably be attributed to these drug, even if causality is uncertain or other drugs are being given concurrently.
See the BNFC for more details about reporting adverse drug reactions.
Why has the caffeine monograph in BNFC changed from caffeine citrate to caffeine base?
The caffeine monograph was amended for BNFC 2009 to express caffeine as caffeine base rather than caffeine citrate because there is now a licensed product of caffeine base available. This change was made to minimise confusion and the potential for error when prescribing because the licensed preparation given to neonates is caffeine base. A note has been included to remind readers that the dose in BNFC is expressed as caffeine base and the different doses for caffeine base and caffeine citrate are highlighted in a safe practice box.
Why does the BNF for Children not recommend brand-name prescribing of modified-release opioids?
The BNFC has not seen any evidence to indicate that switching between brands of modified-release opioids that have the same release profile (e.g. between different brands of 12-hourly oral morphine, or between different brands of fentanyl patch) alters the therapeutic effect. Furthermore, when used in accordance with the product licence, there are no grounds for a clinical difference between brands of fentanyl patch.
A suggestion has been made that brand-name prescribing of opioids should be adopted on grounds of safety. However, the BNFC is not clear why modified-release opioids should be treated differently to other drugs commonly associated with medication errors (e.g. carbamazepine), or, indeed, other drugs in general. We have not seen any evidence to show that brand-name prescribing of modified-release opioids would have a significant impact on the incidence of medication errors associated with these preparations—if users of the BNFC know of such evidence, we would be pleased to consider it.
Why doesn't the BNFC include more detail about drugs used for the management of malignant disease?
Chapter 8 of the BNFC includes information about the indications of cytotoxic drugs as well as some of the principal side-effects associated with them. Because oncology is an area that is likely to be managed by specialists, the BNFC does not include detail of chemotherapy regimens. Such information is best obtained from up-to-date specialist literature. In addition, many cancer treatments take place within the context of clinical trials and it is not possible to include the necessary information in the BNFC.
How does the BNFC decide which drug interactions to include and what criteria are used for determining their clinical significance?
Interactions in the BNFC are based on the Summary of Product Characteristics (SPCs), the medical literature and expert advice. The SPCs sometimes include 'theoretical interactions', not actually studied but predicted from knowledge of the cytochrome P450 isoenzymes involved in the drug's metabolism, the BNFC does not usually add such theoretical interactions (unless the manufacturer contra-indicates a particular combination).
As for the significance of drug interactions, those that are potentially hazardous are shown in bold type on a red background, (a 'black spot' is used in the printed version of the BNFC to denote a potentially hazardous interaction). It is not possible to define a type of interaction that will always be designated 'potentially hazardous'. For example, increased plasma concentration of one drug by another may be significant for a drug with a narrow therapeutic index, such as ciclosporin, but much less important for some other drugs. Interactions involving anticoagulants are often (but not always) designated 'potentially hazardous'.
The 'potentially hazardous' designation is not an indication of the likelihood of an interaction, but of how serious the potential effect could be if it occurred. Thus, combinations that might result in ventricular arrhythmia are designated 'potentially hazardous' even though it may occur very rarely.
Who decides on what cautionary advisory labels should be used?
The wording of the advisory and cautionary labels was originally recommended by a working party of the Royal Pharmaceutical Society of Great Britain. The BNF's Joint Formulary Committee has subsequently made some minor adjustments to the wording of the existing labels.
The label or labels for each preparation are recommended after careful consideration of the information available. However, it is recognised that in some cases the information on the recommended label may be either incomplete or open to a different interpretation.
The BNF will be grateful to receive any constructive comments on the labelling suggested for any preparation.
Should the suggested cautionary advisory labels always be used?
It is recognised that there may be occasions when pharmacists will use their knowledge and professional discretion and decide to omit one or more of the recommended labels for a particular patient. In this case counselling takes on even greater importance.
There may also be occasions when a prescriber does not wish additional cautionary labels to be used, in which case the prescription should be endorsed 'NCL' (no cautionary labels). The exact wording that is required instead should then be specified on the prescription.
What other digital versions of the BNF for Children will be produced?
Who will receive a printed copy of the BNF for Children?
All NHS staff and contractors in the UK who routinely receive a copy of the BNF receive a copy of the BNF for Children.
The UK health departments distribute BNFCs to NHS hospitals, doctors, surgeons, and community pharmacies. In England, BNFCs are mailed individually to NHS general practitioners and community pharmacies; contact the DH Publication Orderline on 08701 555 455 for extra copies or changes relating to mailed BNFCs. In Wales, telephone the Business Services Centre on 01495 332 000.
What arrangements have been made for digital access to BNF for Children content?
The official BNF for Children website is at http://bnfc.org and NHS England has mirrored the official BNFC website at www.bnfc.nhs.uk. Access to some of the content on these sites is restricted. Further information on the available options for access to BNFC online and the corresponding access control arrangements are available on the Digital BNF for Children page.
If I don't work for the NHS can I still have online access to BNF for Children?
If you live in the UK, then the full content of BNFC is available without charge at http://bnfc.org or www.bnfc.nhs.uk. Online access to BNFC is also available by subscription at www.medicinescomplete.com. Further information on the available options for access to BNFC online and the corresponding access control arrangements are available on the Digital BNF for Children page.
For details of organisational access please contact electronicinfo@rpsgb.org.
Do digital versions of the BNF and BNF for Children interoperate?
Presently the BNF and BNF for Children digital products do not interoperate. The subscription service at www.medicinescomplete.com provides the facility to search both the BNF and the BNF for Children simultaneously. Where additional paediatric dosage information is available, a link is provided from bnf.org to bnfc.org.
