Paeds · clinical-pharmacology-and-therapeutics
Drug interactions and medication reconciliation
Also known as Drug-drug interactions in children · Cytochrome P450 interactions · Medication reconciliation · Best Possible Medication History · Polypharmacy in children
A fellowship approach to drug interactions and medication reconciliation in children covering cytochrome P450 induction and inhibition, pharmacodynamic additive toxicity, developmental changes in drug handling that shift interaction risk by age, the Best Possible Medication History, and the structured reconciliation of every medicine across admission, transfer and discharge.
On this page
Study tools
Your progress
Saved on this device.
Practise this topic
Target exams
Red flags
- A child started on a macrolide or azole antifungal while already taking tacrolimus, ciclosporin or theophylline without a planned interaction check
- Rifampicin added to a child on oral contraceptives, warfarin or anticonvulsants without anticipating loss of efficacy
- Two serotonergic agents co-prescribed, such as an SSRI with tramadol or linezolid
- An admission or discharge medicines list built from a single source without verifying with the family and the community pharmacy
- A complex, technology-dependent child with five or more medicines and no pharmacist-led reconciliation at transition
- Phenytoin dosed through continuous enteral feeds without holding feeds around the dose
Life stages
Care settings
Clinical exam formats
Board mappings
- General and Community Paediatrics
- Current 2026 PREP curriculum — Learning Objective 2.4.4: Assess and manage infants, children and young people requiring safe prescribing across transitions of care
- Current 2026 PREP curriculum — Learning Objective 2.2.1: Recognise, prioritise and manage an acutely ill infant, child or young person including safe medication use
- Renewed curriculum for first-year trainees from 2027 — Learning goal 6: Clinical management – essential general paediatrics
- Renewed curriculum for first-year trainees from 2027 — Learning goal 9: Quality and safety, including medication safety
- Clinical Applications
- Medical Sciences
- Long Cases
- Short Cases
- 4. Professional skills and knowledge: Patient management
- 7. Patient safety, including safe prescribing
- 8. Quality improvement and patient safety
- General Paediatrics: Prescribes safely, anticipates drug interactions, and reconciles medicines at every transition of care
- Foundation of Practice (FOP)
- Theory and Science (TAS)
- Applied Knowledge in Practice (AKP)
- Clinical
- History
- Communication
- General Pediatrics Content Outline — Domain 10: Principles of Pharmacology and Medication Management
- General Pediatrics Content Outline — Domain 12: Quality, Safety and Systems Thinking
- General Pediatrics Content Outline — Universal Task 4: Management and Treatment
- Systems-Based Practice 1: Coordination of Care and Medication Reconciliation
- Patient Safety/Quality Improvement 1: Medication Safety
- Practice-Based Learning and Improvement 2: Quality Improvement Methods
- Medical Knowledge 2: Diagnostic and Therapeutic Decision Making
- Medical Expert
- Collaborator
- Pediatrics: Core EPA #5 — Recommending and Initiating Pharmacologic Interventions
Overview & Definition
A teenager on long-term tacrolimus after a liver transplant who is prescribed fluconosal for oral thrush and presents a week later with tremor and rising tacrolimus levels; a preschool child whose theophylline toxicity is unmasked by a five-day course of erythromycin; a complex child discharged on twelve medicines of which three are unintentionally duplicated — these are the faces of drug interactions and failed reconciliation at the bedside. A drug interaction is a clinically meaningful change in the effect or concentration of one drug caused by another drug, food, or substance, and most clinically important interactions are predictable from a knowledge of drug metabolism and pharmacodynamics. [1] [5]
Medication reconciliation is the formal process of creating the most accurate possible list of everything a child actually takes and comparing that list against every new prescription at each transition of care. The list is called the Best Possible Medication History, and it is built from at least two sources: the family interview, the community pharmacy record, the general practitioner summary, and any transfer letter or prior discharge summary. Reconciliation is not a clerical task; it is the structured check that catches the interacting medicine, omitted medicine, duplicated medicine, and the wrong dose before they reach the child. [7] [8]
From first prescription to safe transition
- 1
1 · Anticipate
Before prescribing, ask which enzyme metabolises each drug, and whether the new drug induces or inhibits it. Check the interaction against the child's age and organ function.
- 2
2 · Collect the BPMH
At admission, build the Best Possible Medication History from at least two sources, including name, dose, route, frequency, last dose, and adherence for every medicine, including over-the-counter and herbal products.
- 3
3 · Compare
Reconcile the BPMH against every new order. Flag omissions, duplications, wrong doses, wrong frequencies, and interactions for resolution with the prescriber.
- 4
4 · Communicate
At transfer and discharge, produce a verified, reconciled list. Explain changes to the family in plain language and confirm the community pharmacy and GP receive the updated plan.
- 5
5 · Monitor and review
For high-risk combinations, plan therapeutic drug monitoring and clinical review. Set the point at which the interaction will be reassessed.
References12ShowHide
- [1]Li T, Hu B, Ye L, et al. Clinically Significant Cytochrome P450-Mediated Drug-Drug Interactions in Children Admitted to Intensive Care Units International journal of clinical practice, 2022.PMID 36081809
- [2]de Wildt SN, Kearns GL, Leeder JS, et al. Cytochrome P450 3A: ontogeny and drug disposition Clinical pharmacokinetics, 1999.PMID 10628899
- [3]Emoto C, Johnson TN Cytochrome P450 enzymes in the pediatric population: Connecting knowledge on P450 expression with pediatric pharmacokinetics Advances in pharmacology (San Diego, Calif.), 2022.PMID 35953161
- [4]Lu H, Rosenbaum S Developmental pharmacokinetics in pediatric populations The journal of pediatric pharmacology and therapeutics : JPPT : the official journal of PPAG, 2014.PMID 25762871
- [5]Faria J, Solverson M, Faria M, et al. Potential Cytochrome P450 Drug-Drug Interactions among Pediatric Patients Undergoing Tonsillectomy Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery, 2019.PMID 30105930
- [6]Feudtner C, Dai D, Hexem KR, et al. Prevalence of polypharmacy exposure among hospitalized children in the United States Archives of pediatrics and adolescent medicine, 2012.PMID 21893637
- [7]Merandi J, Sapko M, Catt C, et al. Medication Reconciliation Pediatrics in review, 2017.PMID 28044039
- [8]Sheth S, Bialostozky M, Hollenbach K, et al. Standardizing Medication Reconciliation in a Pediatric Emergency Department Pediatrics, 2024.PMID 38273780
- [9]Adducchio S, Grant ED, Fonseca LD, et al. Reducing Discharge Medication Reconciliation Errors at a Pediatric Neurology Inpatient Unit Neurology. Clinical practice, 2024.PMID 38524835
- [10]Carroll AR, Johnson JA, Stassun JC, et al. Health Literacy-Informed Communication to Reduce Discharge Medication Errors in Hospitalized Children: A Randomized Clinical Trial JAMA network open, 2024.PMID 38227315
- [11]Davis T Paediatric prescribing errors Archives of disease in childhood, 2011.PMID 21109509
- [12]Glanzmann C, Frey B, Meier CR, et al. Analysis of medication prescribing errors in critically ill children European journal of pediatrics, 2015.PMID 25899070