RCPCH Focus newsletter - Spring 2017

Fo us RCPCH

RCPCH celebrates 21 years of achievement in paediatrics This year we will celebrate all of the achievements in paediatrics over the past two decades. We will also reflect on the efforts of our members in founding and growing our College. We have a number of planned activities and dates for your diary including an online roll of Presidents and Spence Medal Winners, an RCPCH history book, a 21st Birthday Ball at Conference 2017 and a 21st Birthday table top book.

important resource for researchers of medical, health and social history and those with an interest in medical education.

RCPCH Conference 2017 is taking place in Birmingham from 24-26 May with a 21st birthday theme. Themed quizzes, health tips for delegates and a video montage of 21 top tips from children and young people will be showcased.

On Thursday 25 May during Conference 2017, the 21st Birthday Ball will be a dazzling event and will feature live music and a performance from a children’s choir. Bookings are open to members and guests.

SPRING 2017

Launched on 28 February, the online roll of past Presidents and Spence Medal Winners acknowledges the vital contribution of many since the RCPCH was established in 1996. It provides biographical information and is an

Children and young people have been involved in our birthday celebrations through an art competition. Shortlisted entries will be used throughout the year online and in publications, with the winning picture to be framed and displayed in the reception of our London office.

Wish us a happy birthday on Twitter using #RCPCHbirthday and stay tuned for more updates. We hope you will get involved in the celebrations.

Read more: www.rcpch.ac.uk/21birthday

FEATURING

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From the President Launch of the State of Child Health report Release of BSPGHAN report

Stroke - not just a disease of the elderly

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RCPCH Progress: Paediatric curriculum for excellence

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Career Grade Careers Guidance Service celebrates its first year

10 Get involved in the State of Child

Health campaign

We hope you enjoy your new and improved Focus newsletter!

President

RCPCH continues to lead the way in child health 21 years on

As we go to print, the Royal College of Paediatrics and Child Health has ‘come of age’. On 28 February, we will be 21 years old. We’ve come a long way from the time when George Frederick Still, Donald Paterson and colleagues founded the British Paediatric Association in 1928.

We’re also “leading the way in child health”; I hope many of you will have heard or read about our UK State of Child Health report in the press and broadcast media when it launched at the end of January. The report brings together 25 metrics of child physical and mental health, including data on specific conditions such as asthma, diabetes and epilepsy, health promotion, and risks to health such as obesity, and not being breast-fed. We make a number recommendations for national action, and actions for each of the four UK nations. The report is a landmark for the RCPCH and has already drawn offers of support and collaboration from over a hundred organisations, securing our position as the leading voice on child health. You can read more about the findings of the report, the launch events and next steps on page 4.

The critical situation of our health services, the NHS, public health, primary care, and social care shows no sign of abating. We are deep in one of the worst periods for the NHS on

record. I urge you to take heart; we are privileged to be members of the finest profession in the world, but with this comes responsibility to safeguard the care our patients receive and to advise Government wisely and well.

Though morale has taken a battering, I’m proud that paediatricians are still committed to paediatrics, and are not afraid from speaking truth to power.

We will be releasing a series of short reports on the “State of Child Health Services” in the coming months. The first will be on workforce issues and we will be making strong recommendations on what is required to ensure the child health workforce is valued, supported, and strengthened.

We will be making sure the report gets into the corridors of power, and coupled with the clear messages in State of Child Health on the need to safeguard the nation’s health by investing in children, we hope it will gain traction.

The other area we’re focusing on is Sustainability and Transformation Plans

Its aims were “the advancement of the study of paediatrics and the promotion of friendship amongst paediatricians”. Our founders were of their time in many respects, such as their refusal to admit women into their ranks until 1945, but they were visionary in recognising that childhood disease required special study, and was a science unto itself. We now have over 17,500 members in the UK and abroad; our training programmes and examinations are a byword for quality around the world; we’re strengthening the science and research basis of paediatrics and child health; and we have a growing media and political profile.

The RCPCH has many members and fellows in the United Arab Emirates; RCPCH President Professor Neena Modi with members and fellows, Abu Dhabi, February 2017

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(STP). We’re making representations about our concern that the majority of STP provide little or no evidence that the needs of infants, children and young people have been taken into consideration. We need to hear from members, in particular from STP leads, about their experiences locally; please do write and let me know how the plans are being implemented in your area, and the impact they are having on children’s services.

I also want to thank everyone who participated in the first of what will be six monthly surveys put together by the RCPCH Trainee’s Committee to monitor the impact of the new contract. Please do continue to participate; we need objective information in order to advocate effectively.

Many of you will be aware that the paediatric curriculum has been under review. The new revised curriculum will be presented to the General Medical Council later this year and if approved will be implemented around autumn 2018. It moves away from the current ‘tick box’ list of competences

We’ve come a long way from the time when George Frederick Still, Donald Paterson and colleagues founded the British Paediatric Association in 1928.

to 11 “Learning Outcomes” for each training level, based on the General Medical Council’s “Generic Professional Capabilities”. A supporting syllabus will provide guidance on how each learning outcome can be evidenced. It is intended to provide a more flexible framework than at present, with an emphasis on the quality rather than the quantity of evidence.

Our 21st birthday celebrations are kicking off; do get involved! I look forward to seeing many members at our 21st Birthday Ball at RCPCH Conference 2017 in May. Other things to look out for include Alan Craft and Keith Dodds’ fascinating book on the history of the RCPCH, bringing together contributions from previous Presidents, Officers, members, staff, and friends of the RCPCH. We’ve also produced a table top book, illustrated by children and young people that includes 21 top tips for paediatricians, celebratory descriptions of 21 advances in paediatrics over the last 21 years, and 21 wishes for child health, from high profile individuals.

Read more about planned activities in our birthday year: www.rcpch.ac.uk/21birthday

PROFESSOR NEENA MODI president@rcpch.ac.uk

Notes Members are invited to submit ideas for content (for planning purposes). Please send proposals only to focus@rcpch.ac.uk Editors: Jo Ball Michael Giardino

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Your RCPCH

State of Child Health report launches across UK Our landmark State of Child Health report was launched in January to widespread acclaim from stakeholders across the health and children’s sectors, politicians, the media and other key decision-makers. The report finds that inequality is damaging our children’s lives, with those from the most deprived backgrounds experiencing much worse health compared to the most affluent.

State of Child Health brings together data for the first time on 25 measures of the health of UK children. Measures range from specific conditions such as epilepsy, diabetes and asthma, risk factors for poor health like obesity and low rates of breastfeeding, to child deaths. Across almost all indicators, children from the poorest backgrounds are trailing behind their richer peers.

Bold and brave action is needed to tackle these unacceptable inequalities and improve the health of all our nation’s children. Since there isn’t one solution to address all problems, we launched

our report alongside a wide range of key recommendations for governments across the UK. These include: •

Each UK Government to develop a child health and wellbeing strategy, coordinated, implemented and evaluated across the nation

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Each UK Government to adopt a ‘child health in all policies’ approach

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UK Government to introduce a ban on the advertising of foods high in saturated fat, sugar and salt in all broadcast media before 9pm

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Each UK Government to develop cross-departmental support for breastfeeding; this should include a national public health campaign and a sector wide approach that includes employers, to support women to breastfeed

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A reversal of public health cuts in England, which are disproportionately affecting children’s services

The report and our recommendations were launched at events in the Houses of Parliament, National Assembly for Wales and Scottish Parliament. We had hoped to do the same in the Northern Ireland Assembly, but unfortunately due to a snap election we were forced to postpone our plans until later in the year.

There was widespread media coverage, including the front page of the Guardian, BBC Radio 4 Today Programme, BBC

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6 O’clock news, editorials in the Lancet and BMJ, as well as front pages of the Herald, Scotsman, Daily Mail (Scotland) and Western Mail (Wales).

An enthusiastic mix of politicians, Government officials, key sector stakeholders, RCPCH members and young people attended our launch events, with many committing to working with us on future campaigns.

In the Scottish Parliament, First Minister Nicola Sturgeon welcomed the report the day of the launch. The task now is to continue the momentum and push for policy change.

State of Child Health involved staff and members from across the RCPCH, including Policy, Research, Media and External Affairs, the National Offices and Digital and Creative Media.

See page 10 for details on how to get involved in future State of Child Health campaigning activity.

Young people’s views on the state of child health In 2016, our Children and Young People’s Engagement team spoke with over 300 children and young people about “the state of child health”.

Four themes emerged from the views of children and young people: •

Communication: “Please include me in what is being said. Listen to me more” - child, Glasgow 2016

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Personal, Social and Health Education: “Have more stuff here in college then it is more

confidential. Good to have someone separate from family to talk to” - young person, Biggleswade 2016 •

Mental Health: “Schools have careers advisors, so why not mental health advisors?” young person London 2016

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Poverty: “If the housing is bad then you have problems with mould / damp and then have health problems” - young person London 2016

Eight young people who either

had a representative role with the UK Youth Parliament or had health care experience took part in launch events to share their stories through a new Fixers film.

Young people are currently involved in creating a digital badge looking at the impact of poverty on child health which will be available through the & Us® Network.

Contact and_us@rcpch.ac.uk to find out more.

EMMA SPARROW CYP Engagement Manager

[In my film] I talked about how mental health is something we all have. it’s exactly like physical health in the way that if you don’t look after your health it will suffer.

- young speaker, London 2017

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Research

Improving paediatric gastroenterology, hepatology and nutrition services Public Health England’s NHS Diagnostic Service Atlas report provided powerful evidence of variability in healthcare across the country. Changes in commissioning arrangements for specialist care have put pressure on pathways of care becoming fragmented for children with gastroenterology, liver and complex nutrition needs across the UK.

We remain committed towards making the NHS a better place for children, so when one of the College’s largest special interest groups, the British Society for Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN), approached the College early in 2016 to develop a key set of quality service standards, the opportunity to collaborate was warmly welcomed.

In order for children to receive equitable access to high quality care as close to home as possible, the nine service standards have been built around the requirement for specialist paediatric gastroenterology, hepatology and nutrition services to provide the full portfolio of services within a clinical network. This will ensure that children with suspected acute illness will be cared for in networks that are operational to provide rapid access to all aspects of nursing and medical care 24 hours a day, seven days a week.

care will be achieved as a result of services being commissioned, planned and delivered through managed clinical networks. These networks will not only improve and standardise the quality of care across the UK, but they will provide significant opportunities for clinical research, training and shared learning that will enhance the skills and practical development of gastroenterologists, hepatologists and nutrition care experts.

The standards will be launched at the RCPCH Conference in Birmingham during the BSPGHAN symposium on Wednesday 24 May 2017 from 2-5:45pm.

View the report: www.rcpch.ac.uk/pghan DR JOHN FELL Quality Standards Working Group Chair, BSPGHAN MELISSA ASHE Project Officer, RCPCH

We maintain that the most effective mechanism for improving clinical outcomes and reducing variation in

Meds IQ is growing Meds IQ (www.medsiq.org) is celebrating the 21st birthday of RCPCH with a new layout and content structure on its website.

We rebuilt our content categories to make it easier for users to navigate and created a new content section focussed on medicines administration. We continue to receive submissions of resources – care bundles, drug charts, dosage calculators and local quality improvement projects - making our library ever more robust and useful to child health professionals.

We have continued to grow the numbers of our Meds IQ Champions and engage with them through our regular activities, most notably our eBulletin and bi-monthly webinar.

Both have been useful forums to share local solutions to common

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issues such as double-checking of prescriptions, minimising interruptions in prescribing and quality assurance for drug dosage calculators.

In 2017, we are planning to further grow our resource library and user community, to enable even more practice sharing, innovation development and channelling user experience into wider advocacy on safety issues. Our aim is that Meds IQ supports local improvement and becomes a hub for paediatric medication safety expertise and advice at the highest level, helping to reduce the rate of medication error for children and young people.

KASIA MUSZYNSKA Quality Improvement Manager

Stroke - not just a disease of the elderly Stroke is a devastating disease, affecting several hundred children and young people in the UK each year, and is often thought of as a disease of the elderly.

be a more clinical-focussed guideline accompanied by a parent version of the guideline ensuring that families can be informed of what to expect and when.

This guideline raises awareness that strokes do occur in children and young people and there are interventions that can make a difference. These are set to challenge both commissioners’ and clinicians’ responses relating to the care of childhood stroke in the UK. Key messages include:

Over the last 15 years there have been improvements in the recognition of the incidence and consequences of childhood stroke, mirroring the transformation of medical and societal attitudes and treatment pathways in adults. However, while stroke in adults is now considered a medical emergency, childhood stroke lags behind.

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The first clinical guideline on stroke in childhood was published in 2004, and one of its major conclusions was the need for more research.

Our Clinical Standards Team has worked alongside a multi-professional guideline development group to produce up to date evidence-based clinical guidance on stroke in childhood. This new guideline, funded by the Stroke Association, and due to launch in May 2017, extends the scope to include identification, diagnosis, management and rehabilitation of both arterial ischaemic stroke (AIS) and haemorrhagic stroke (HS). This will

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Image provided by the Stroke Association

to long-term care

Most CYP with stroke can be identified using FAST (Face, Arms, Speech, Time) – this guideline flags the opportunity to extend the use of adult FAST criteria into the paediatric population and improve awareness of childhood stroke in FAST campaigns

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Brain scans should be performed within one hour of arrival at hospital in every child with a suspected stroke Rehabilitation begins at the point of diagnosis, and parents/family members should be involved at all stages from initial diagnosis through

The guideline highlights the lack of evidence and the need for further research – e.g. rehabilitation intervention trials in the paediatric stroke population.

The clinical guideline and parent information booklet will be launched at RCPCH Conference on Wednesday 24 May 2017 from 1:10-1:55pm.

Please join us in celebrating the launch of this timely and important guideline.

SARA HAVERON Clinical Guideline Coordinator, Stroke in Childhood

Global Supporting improvement in global child health is part of RCPCH’s institutional vision and mandate. Our Global Team is currently managing large multi-site programmes supporting improvement in clinical care for children in low-income countries in East and West Africa, the Middle East and Southeast Asia. Our work draws strongly on the WHOendorsed Emergency Triage Assessment and Treatment Plus (ETAT+) protocol.

Over the last five years, we have generated increasingly robust evidence of the impact of our work.

As a contribution to the College’s 21st birthday celebrations, we will produce an Impact Report, showing how the support of our members (and the larger grant-funded programmes we have secured from international donors) contribute to strengthening clinical care and improving child survival.

The report will incorporate data from current programmes in Sierra Leone, Kenya, Rwanda, Uganda, Myanmar and Palestine.

Watch this space for more information!

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Education and training

RCPCHProgress Paediatric curriculum for excellence

When the new curriculum for training is launched in 2018, it will not only support a better training experience for trainees, but will also better reflect current challenges in child health such as those highlighted in the RCPCH’s flagship report, State of Child Health (page 4).

The report delivers key messages about the health of children and young people in the UK. It draws attention not only to those illnesses associated with childhood but wider issues such as poverty, social inclusion, the use of alcohol and smoking, road traffic accidents and vulnerability. encourage practice which can help tackle these issues.

The updated curriculum will have a stronger emphasis on these issues

and will encourage practice to help tackle them. It will include new content related to global and environmental health, public health, increased attention to psychological well-being and mental health. There will be an increased emphasis on paediatricians providing evidencebased practice from medical research and it will explore social and economic issues.

Another change in the new curriculum will be a move to the provision of a more holistic management of the child.

Traditionally, it could be argued that the patient was sometimes seen as disease within a child. The new curriculum will challenge this by incorporating ‘the whole population

approach’, whereby the child will be seen first and foremost as a human being, bringing into account not only the illness, but a range of social, educational and economic factors.

This provides a wider holistic picture of the patient for the paediatrician to explore and manage.

The new curriculum will better reflect the needs of children through the addition of these wider areas.

The improved format will give both flexibility and focus to the trainee as they progress through their training programme, giving them the skills required to become paediatricians of the future.

YVONNE SAVAGE Quality and Standards Coordinator

RCPCH courses and events 2017 20 APR

MRCPCH Clinical Exam Preparation Course RCPCH London

21 APR

Child Protection: The professional witness in the courtroom Edinburgh

2 MAY

How To Manage: Gastroenterology - an approach to common GI presentations RCPCH London

3 MAY

Mentoring Skills training Edinburgh

6 JUNE

Effective Educational Supervision Edinburgh

6 JUNE

Safeguarding: Statement and Report Writing (Level 3) Belfast

* Dates correct at time of going to press. Limited places available.

Sign up to our Events and courses eBulletin at www.rcpch.ac.uk/sign-events-e-newsletter Access e-learning courses anytime on Compass at rcpch.learningpool.com View more courses and events at www.rcpch.ac.uk/courses

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Career Grade Careers Guidance Service celebrates its first year Along with the College’s 21st birthday, our Career Grade Careers Guidance Service is celebrating a milestone of its own.

day, wanting to change my work contact details and the phone happened to be picked up by someone who knew the service was about to be launched.

We understand that paediatricians at all stages of their careers are facing increasingly challenging times. While this can be due to pressures within the Health Service, we also know that incorporating a healthy work-life balance can be difficult.

“I felt totally unjudged by the person at the College about my decision regarding my career. I was offered a discussion with a careers advisor, with no pressure. I didn’t take up the offer immediately, but I knew it was there when I was ready.

We recognise the importance of developing support for career grade paediatricians who may be facing The junior doctor contract dispute difficult situations or simply has continued to who be the focuswant of to proactively manage theirand careers. considerable public media over the lastCareers months.

Theattention RCPCH Career Grade Guidance entering its A newService, wave of now strikes was announced second year, is ainnetwork of careers by the BMA September, following advisors who areby all members experienced the rejection of the paediatricians support negotiatedavailable contract,to and the any fellow paediatrician would like statement by thewho health secretary advice help. thatand/or it will be imposed nonetheless.

A dispute is always best resolved An experienced consultant through mature and honest discussion. paediatrician who used the service I have called upon both parties to gives their view: withdraw from entrenched positions “I first outnegotiations. about the careers andfound resume guidance service by accident - and I’m very glad I did. I had perused the internet on many occasions while I was going through the process of making the most difficult decision in my career to date. But nothing was available.

There were avenues for trainees and for doctors in difficulty, but I didn’t really meet the criteria. I rang the College one

“A few months later I was able to have a completely confidential chat with someone experienced and understanding. felt able to talk openly In this difficult Itime it might help about my situation, both in andisout of to remember that paediatrics work.

Andalways it gavebeme hope, hopeand that and will a wonderful I rewarding had made profession. the right decision, Traineeshope can that there options,other perspective count on were consultants, senior on what the options were, and how I staff, colleagues, family and friends could pursue them. Most importantly to provide support.

Consultants were and unexpectedly for me,inthere was a once trainees, although a very glimmer sparkle differentofera, and as I walked out of the meeting - something I had previously trainees will one day be seniors. I lost professionally. hope today’s trainees will use the ex “Iownership remain confident thatashould I see the of shaping future health career advisor on they the other side of an service in which will be proud to interview panel in patient the future, thatand our work, and where health discussions would remain separate. That wellbeing will be place was very important to me. I also knew that I could come back at any stage if I needed to.”

I was able to have a completely confidential chat with someone experienced and understanding.

I felt able to talk leagues, family about and friends to provide openly my support. Consultants were once situation, both and trainees, although in a veryin different era, out and trainees will one day be of work.

And it seniors. I hope today’s trainees will use gave me hope, hope the experi that I had made the leagues, family and friends to provide right decision, support.

Consultants were hope once trainees, although in a very that there were different era, and trainees will one day be options, perspective seniors.

I hope today’s trainees will use the on experiences and of what thereflections options PROFESSOR NEENA MODII could were, and how president@rcpch.ac.uk pursue them.

Register for the service today: www.rcpch.ac.uk/careers-advice SARAH FELLOWS Education and Professional Development Lead

- Consultant Paediatrician

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Your views

Get involved with the State of Child Health The State of Child Health report has now been launched and disseminated to politicians, decision-makers and stakeholders across the country, but so what? What’s next for our campaign to improve child health across the UK? Immediately following the report launch, we were approached by over 100 organisations who want to work with us on various campaigns. Nearly 50 supportive comments were issued to the media by organisations and individuals across the country, ranging from other royal colleges, health charities, interest groups and politicians. We also had a 200% increase in engagement on our social media channels with over 100,000 impressions on Twitter and Facebook.

All this certainly hints at a huge degree of support for child health issues.

What we now need is a groundswell of support for our key recommendations to ensure that Governments across the UK will introduce policies that will ensure healthier outcomes for infants,

children and young people. As noted elsewhere, this is a wide-ranging report drawing together evidence on 25 key indicators of child health in the UK – this is potentially 25 different child health campaigns! We at the College simply cannot achieve all that needs to be done alone, which is why we have been busy since the report launch identifying key stakeholders to work with on various campaigning activity in the weeks, months and possibly even years to come.

From breastfeeding to vaccinations, inequalities to public health services, we will continue to be vocal on our report’s key findings and calls to action, building on the momentum of the nationwide launch. But many voices are better than one, and through working together we can most effectively put pressure on UK Governments to enshrine our recommendations in policy and legislation.

MARGARET DONNELLAN Public Affairs Lead

Get involved We won’t just be working with other Royal Colleges, health organisations and politicians.

We can’t take this work forward without the support of our members. We need you to go out and speak to your colleagues, Trusts and local politicians about the report’s findings and recommendations. Tweet about the report on social media using the hashtag #childhealthmatters or write to your MP about a key area of interest – email public.affairs@ rcpch.ac.uk for a template letter.

You can also join our campaign, sign up for updates on activity, and indicate areas of particular interest on our website: www.rcpch.ac.uk/soch-updates Together we can make a positive change for children across the UK.

In the Twittersphere

The RCPCH’s twittersphere presence continues to gather pace with more than 11,600 followers. Here’s a highlight of our activity over the last few months, what’s coming up and how you can support us via our social media channels.

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#RCPCHbirthday

#childhealthmatters

Keep up to date with College activity

The RCPCH is celebrating its 21st birthday and we’ve been making a big splash. Not only are we celebrating the achievements of the College to date, but also the achievements that the field of paediatrics has brought to the UK. We hope you engage with us and join in the celebrations.

State of Child Health, our flagship report, has received much press and social media coverage since its release in January. We will continue to offer data and recommendations for the UK Government from the report throughout the year.

From the latest courses and events to the top child health news of the day, social media is the quickest way to keep up to speed.

Follow @RCPCHtweets on Twitter and visit our Facebook page at facebook. com/RCPCH

Committee news

Training matters The Trainee Committee has recently surveyed all trainees in the UK and received over 1000 responses. This survey will form a baseline from which we can monitor changes as the new junior doctor contract comes in from this spring.

The good news The majority feel motivated to work as a paediatric trainee (78.8%), the vast majority plan to complete their training in Paediatrics (90.2%) and an overwhelming majority want to work in a publicly funded, delivered and accountable health service (97.6%). Most also feel that they are able to learn while delivering clinical service, access study leave and attend local teaching.

A big birthday is always a good chance to take stock and reflect and the RCPCH’s 21st birthday presents just that opportunity. A lot has been said over the last couple of years about the challenging nature of the current training environment. But how bad actually are things on the ground?

Most concerning of all is that only a small group of trainees surveyed were hopeful about the future of paediatric training (41.4%).

Please be assured that the Trainee Committee hear this loud and clear and will be working tirelessly to safeguard the quality of paediatric training during contract introduction.

It is vital that paediatrics attracts and retains the very best doctors for a sustainable workforce for the next 21 years.

DAVID JAMES Chair, Trainees’ Committee www.rcpch.ac.uk/training-examinations

The worrying news Almost half of trainees surveyed do not feel that staffing levels where they worked were safe (41.4%). A significant proportion of trainees do not feel rested between shifts and there are considerable issues in securing desired annual leave.

Conference 2017

24-26 May 2017, Birmingham

In association with:

Conference 2017 is where paediatricians and child health professionals come together from around the world to share good practice, discover the latest in clinical research and hear from insightful speakers.

This is your opportunity to gain the skils and tools you need to help improve care in your clinical setting.

It’s also a great opportunity to meet old friends and make new contacts.

Wind down after a busy first day with the welcome drinks reception and make sure to reserve your seat at the very special RCPCH ball, a unique event that celebrates the College’s 21st birthday.

Explore the latest programme and register at www.rcpch.ac.uk/conf17

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BNF for Children 2016-2017

Guiding health professionals on all aspects of paediatric drug therapy

About the BNF for Children (BNFC) The BNFC provides essential, practical information to all healthcare professionals involved in the prescribing, dispensing, monitoring and administration of medicines to children.

Significant new content updates to the 2016-2017 edition include: ■ Updated guidance on the management of asthma, obesity, coeliac disease and irritable bowel syndrome ■ New safety information including: - Risk of abnormal pregnancy outcomes with sodium valproate and valproic acid - Risk of osteonecrosis of the external auditory canal with bisphosphonates - Risk of uterine perforation with intra-uterine contraception ■ Addition of new preparations including Orphacol® (cholic acid) and Intuniv® (guanfacine), and more ■ Significant dose changes including nystatin, diamorphine hydrochloride, colistimethate sodium, and more ■ Guidance on suspected or confirmed drug allergies Book: 978 0 85711 247 7 • September 2016 • £49.95

Order your print copy now – www.pharmpress.com/bnfc Online: For pricing information contact our sales team at pharmpress@rpharms.com

www.bnf.org

Pharmaceutical Press is the publishing arm of the