PRESCRIPTION AUDIT
K.G.P. Children Hospital & Jajodia Reserach Institute,
Baroda
(Clinical Meetings on 6.2.1986, 6.3.1986, 1.5.1986 and 5.2.1987)

Ref: Academy Today Submitted by -

1986, 4, 2 : 36-37 & Arun Phatak

1987, 5, 1:23-25 Baroda

A. Diarrhoea
The following prescriptions need no comment except that although they are true, one finds it hard to believe that some consultant pediatricians wrote him!

I K.J.P. 6mo.s 8.4 kg

Severe dysentery for 6 hours on 31.12.1985 stool showed 80-100 pus cells, 50-60 RBCs and few macrophages per H.P. field. Given SYNASTAT susp., SREPTO-MAGMA susp, FUDONE liquid and Inj. GENTAMYCIN. Next day the child was seen by another pediatrician who discontinued all medicines except synastat (co-trimoxazole). The chid was given breast feeding, rice and moong kanji, banana and apple and was well in 2 days. There was really no need to give five antimicrobials simultaneously - co-trimozazole, Streptomycin, furazolidine, metronidazele and gentramycin. Incidentally the child had received 5 mg b.d. gentamycin because the parents bought the ‘Pediatric’ strength.

II V.M. 5mo. 6.5 kg

Frequency of liquid stools (8-10) for 1 day. Given on 16.11.85 WALAMYCIN susp., PESULIN-O, BACTRIM susp. Next day the child was given LYKASTREP srp., GRAMONEG syp. and FURAPECT susp. The child received colistin, phthalyl sulphathiazole with opium and co-trimoxazole on the first day and chloramphenicol streptomycin, nalidixic acid and furazolidine on the second day. On the third day the child was seen by another pediatrician who stopped all the antimicrobials and Advised O.R.S., diet and pectin Kaolin mixture. The child recovered within 3 days.

III. A.A.S. 8 mo 6.5 kg

Chronic ‘diarrhoea’ for 1 month. Variable consistency-loose liquid. During the 1 month period (3.8.85 to 14.9.85), the child received the following "anti-diarrhoeals" - LOMOFEN, LINOPEC, SPERIDEX, IODIZOL, GRAMONEG, PESULIN-O, SERUTAN, GENTAMYCIN, KALTIN, ENDAR, PANKREON, PRIMSPOR, vitazyme, SEPTRANPARAXIN. Thus over 43 days child received ten different anti-microbials furazolidine, cephalexin, di-iodohydroxyquinoline, metronidazole, nalidixic Acid, phthalyl sulphathiazole, gentamycin, contrimoxazole, chloramphenicol - some of them repeatedly! The child had gained only 200 gm, weight (6.3 kg i.e. 80% level on 3.5.86, 6.5 kg i.e. 75% level on 14.9.85). On 14.9.85 the child was seen by another pediatrician who discontinued the digestive drops and advised diet (milk-curd, rice, moong, banana, apple). The child (and the parents) gradually settled over a period of 2 weeks. The child started gaining weight from 6.5 kg on 14.9.85 (75% level) to 8 kg (82% level) on 2.12.85 and 9 kg. (90% level) on 1.3.86.

B. Bulged Fontanelle

U.P.s. 5 mo. 7.150 kg

had grequency of stool of 2 days duration. Was advised by a Pediatricina GRAMONEG and FLAGYL on 11.2.86. Two days later (13.2.86) seen by another Pediatrician - frequency was slightly reduced but anterior fontanelle was bulged. Stool examination (done on 1st day) did not reveal any evidence of bacterial infection. Child alert, active and playful, no dehydration. All medicines stopped and the child managed with ORS and diet. The child was well within 4 days and the anterior fontanelle no more bulged.
H/o acute diarrhoea treated with GRAMONEG and QUGYL on 4.1.86. The child had developed bulged fontanelle on 6.1.86 C.S.F. examination did not reveal any abnormality. The A.F. bulge disappeared after the diarrhoea was controlled.
Important points from the discussions on this case -
Antimicrobial therapy was certainly not indicated at least at the time of the 2nd episode.
benign intracranial hypertension (pseudotumor cerebrei) is a known side effect of nalidixic acid. It starts developing in 2-3 days of the onset of treatment and may last for long period causing headache, vomiting, papilloedema, VI N. paralysis.
nalidixic Acid should be used in infants with great caution and only if absolutely necessary.

C. Golden Treatment

D M P (11-1/2 mo.Male) had diarrhoea on 25.10.86. A general practitioner treated him and then sent him to a consultant pediatritian on 28.10.1986 evening. The child was admitted and advised the following treatment.

Inj. 5% glucose with 0.2 N saline 500 ml to be followed by Inj. Derilyte P250 ml (actually only 1/2 pint was given as the needle slipped)

Inj. Anxol (2 ml) 2 amp. given overnight (yet the drip could not be maintained).

Inj. Ampicillin (250 mg)

Oriprim susp. 3/4t.s.f. t.d.s.

Streptomagma susp. 1 t.s.f. t.d.s.

Combizol - F 1/2 t.s.f. t.d.s.

Tab. Loperamide 1/4 t.d.s.

Tab. Avomin 1/2 b.d. s.o.s. for vomitting - not gi ven

Electrol, sugar-salt water, tea-coffee in dilute milk.

The parents were visiting relatives in another town. In the morning (as I.V. drip could not be maintained) they took the child to their home town. Their pediatrician managed the child at home. He discontinued all treatment except O.R.S. (electral, rice-moong, kanji, bananas) and advised pecti-Kaolin mixture as a placebo. The child recoverd completely within three days.

Points to Ponder.

Did the child really need hospitalisation and parenteral fluids?

Why were five different antimicrobials used when not even one was required?

How much did the parents spend for a condition which could have been easily treated by a general practitioner.

The first pediatrician displays on his prescription paper, patient carried file (and perhaps on his board) that he is M.D. GOLD MEDALIST. Should not the University ask him to return the gold medal?

D Brain Tonics

Two prescriptions were presented.

A.A.S., a 15 months old male child was seen by a SENIOR PROFESSOR OF PEDIATRICS. the child was diagnosed as a case of cerebral palsy with microcephaly and ? kernicterus. In addition to the physio-therapy, the child was given BRENTO and NORMABRAIN for 1-1/2 months and then was given BRENTO and ENCEPHABOL for one month.

S.M., a 3 year old male child was seen by a NEUROSURGEON heading a Department of neurosurgery and having a long list olf degrees, fellowships and titles. The child was diagnosed as a case of Cerebral Palsy. The child was advised THYROID, ENCEPHABOL and BETHADOXINE for more than 6 months and then advised to continue THYROID and BETHADOXINE while ENCEPHABOL was replaced by NORMABRAIN.
During discussion it was observed that it was observed that it is a common practice amongst doctors to give some ‘Brain tonics’ to any child who has developmental retardation. The parents are made to spend, without any justification, Rs. 100-200 every month for these drugs. This is adding insult to injury - the parents who are already under emotional, social and physical strain should not be made to shoulder additional economic burden. Instead, they should be advised to save the money by recurring deposits and other ways for the child’s future.
Dr. B.P. Udwadia, formerly Professor of Pharmacology (Govt. Medical College, Surat) and presently Medical Director, Sarabhai Chemicals, Baroda was invited to give his comments on ‘brain Tonics’ in general. We give here some salient points from his talks.
A wide variety of drugs are being prescribed with a hope to improve the cerebral function related to learning, memory, analysis as well as various neurological and mental functions. These can be classified into certain groups for discussion.

(a) Vitamins
Except at extreme (high or low) blood levels, the brain has an ultrastable environment of vitamins. In certain conditions (some retarded children, meningitis) the transport mechanism is reduced or suppressed but the utility of high dose vitamin therapy is yet to be established.

(b) Glycerophosphates
It was presumed that these will be assimilated by CNS and help its function. To-date there is no evidence to support this assumption.

(c) Cholinergic Drugs.
Clinical trials have shown no improvement in CNS function. Physostigmine helps only an Alzheimer’s disease.

(d) Vasodilators
Cerebral autoregulation takes care of cerebral blood flow over a wide range of B.P. and oxygen saturation. Drugs have little appreciate and sustained effect on the cerebral blood flow. There is no selective cerebral vasolidation and the general effect may steal and divert the blood away from the affected areas. Most of the clinical trials are poorly designed and their results are equivocal.

(e) Nootropics
These are claimed to provide selective improvement of higher telencephalic integrative activities. These are as many clinical trials reporting ‘no impovement’ as those reporting ‘improvement’.

(f) Hormones
Vasopressin may have an effect on mood and arousal. Thyroid should be used only when deficiency is proved. otherwise there are no benefits and there may be some ill-effects.

(g) Other Drugs
With the declining credibility of vasodilator drugs, the interest is new drugs like hexobonidino, betahistine etc. has remained isolated.

(h) Miscellaneous Therapy

(i) Hyperbaric oxygen at 2.5 atoms. has been tried (90 mins/day - 15 days) results were equivocal.

(ii) Anticoagulant treatment also has been suggested. benefit remains unproven and carries risk of hemorrhage particularly in elderly and debiliated patients.

(iii) Oxpentifylline or pentoxyfylline a xanthine derivative reduces viscosity of blood and improves red cell flexibility. Few trials show subjective improvement. Most trials are faulty in design and erroneous in statistics calculations. Trials for I.A.A. has faults in design of trial and error in statistical calculations (data upto 1981).

(I) Problems in E.E.G. Intepretation:

Problems in interrogation:

(i) Wide interindividual variability make criteria for normality difficult.

(ii) Recordings indicate synchronous involvement of large areas of underlying cortex (6 Cms²) - cortical activity only.

(iii) The EEG changes of cerebral dysfunction also occur due to metabolic processes - liver failure, hypoglycemia.

Quotable Quotes

We heard with growing horror the evidence about the efficacy of these drugs.

I started being interested, then surprised, then shocked. Shocked by the gross misuse of the double-blind randomised controlled trial.

Increasing sensory input, paying more attention to the child and decreasing or discontinuing CNS active drugs produces more improvement than addition of new drugs.

MEDICAL AUDIT FOR RATIONAL TREATMENT
Phatak A.T. and Desai H.K.

Indian Pediatrics, 1987, 24:325-329

A routine analysis of the records of the inpatients revealed that almost all the children suffering from gastroenteritis had received one or more antimicrobials. Four honorary consultants pediatricians managed the patients independently. The work system did not allow dictatorial method. Pooled records of the four consultants were presented regularly in the monthly clinical meetings and discussed openly by all present to focus the attention on the use of antimicrobials, antimotility drugs, digestives and binding agents (group audit). The practice was continued for a period of nine months. This was followed by presenting the records of individual doctors without disclosing the identity (individual audit) and the effect studied over a period of two months. The overall rate of non-indicated use of antimicrobials fell significantly from 38.8% to 25% after the group audit and further to 11.71% after the individual audit (10 0% in the case of two consultants). The use of antimotility drugs and on digestives was also reduced significantly (from 45.9% to 15.3% and from 43.6% to 14.4%, respectively). The use of binding agents, however increased significantly