Why neonatology pharmacy is fascinating and demanding

The role of the CMRIC is to bring people together to work on improving children’s medicines – making the most of the small number of specialists in children’s medicines across the country, explains Mr Tomlin.

Mr Tomlin’s interest in paediatric medicine started during his pre-registration training when he realised that little was known about the use  of medicines in very young patients.  A couple of fatal incidents early in his career impressed upon him the importance of having sufficient information about the medicines and a thorough understanding of the clinical situation. Such incidents made him think hard about how to use his knowledge to improve the working systems “and that’s … really been the focus of my career”, he reflects.

Neonatology became his special interest because neonates are physiologically different from adults and this can have profound effects on the way in which drugs are handled.

The challenges of parenteral feeding for pre-term babies

Parenteral nutrition solutions represent some of the most complex products that are administered to patients. “A bag of parental nutrition is about 50 different drugs; 50 different elements and we throw them all in a bag together ……..  and the importance of getting it right is huge – both from a clinical point of view and from a manufacturing point of view”, says Mr Tomlin. Managing parenteral nutrition draws upon “all of those bits that you went to university and learned. It’s the chemistry, it’s the pharmaceutics, it’s the clinical aspect – and it’s how all of those interact together”, he says.

Mr Tomlin advocates the use of standardised products in neonatal practice.   Standardised parenteral nutrition products provide correctly balanced quantities of nutrients and avoid the need for potentially risky additions.  Intravenous and oral medicines can also be standardised.  “It doesn’t mean it works for everybody but it does allow you then to concentrate on the smaller proportion that can’t use the standards – and therefore get it right. ….  It’s not about saying that ‘one size fits all’. Just because you’re standardising a concentration you can still give whatever dose that you want”, he explains.

How standardisation of pharmaceutical products helps in neonatology

Effective use of standardised products in neonatology depends on expert knowledge of both the clinical situation and the pharmaceutics of the products. When it comes to parenteral nutrition, “I do believe you can maintain and correctly handle neonates on very few standard bags”, says Mr Tomlin.

Safe prescribing of parenteral nutrition requires expert knowledge of both the clinical situation and the pharmaceutics of the products and, in many ways, it represents the pinnacle of prescribing by pharmacists.  “We should be ensuring that the right people are prescribing – the people who understand the product and how it’s being used – and that’s where we [pharmacists] come in”, he says.

What does a consultant neonatal pharmacist do?

As Director of the Children’s Medicines Research and Innovation Centre (CMRIC) at Great Ormond Street Hospital for Children in London, Steve Tomlin now uses his experience of hands-on patient care to shape research and innovation in children’s  medicines. He acknowledges that his skills in patient care are no longer being used at the bedside but his past experiences are now underpinning his efforts to change things for the better at a national level, he says.

He recommends a career in paediatric pharmacy because it demands knowledge of chemistry,  pharmaceutics, the law and many other things including in- depth skill sets.  However, he also advises young pharmacists not to rush because a broad experience of pharmacy practice is always an asset. Furthermore, “the bit that I think defines whether you will be good ….. is having that questioning mind and it’s where I would advocate that research, education and practice are all part of the package.  …. So, it’s that all-rounded approach that I think is really important. Keep an inquiring mind throughout your career right from day one”, he says.

About Steve Tomlin

Steve Tomlin is Director of the Children’s Medicines Research and Innovation Centre (CMRIC) at Great Ormond Street Hospital for Children in London. He is  also the professional lead of the Neonatal and Paediatric Pharmacists’ Group (NPPG) and the vice-chair of the Joint Medicines Committee at the Royal College of Paediatrics and Child Health (RCPCH)

The Children’s Medicines Research and Innovation Centre is concerned with advancing practice for children’s medicines both in terms of improving medicines themselves and improving the usage and effectiveness of medicines in practice.

Read and watch the full series on our website or on YouTube.

Mr Tomlin – a consultant paediatric clinical pharmacist by trade – acknowledges that his skills in patient care are no longer being used at the bedside but “I think there’s also a time when you can see the bigger picture that needs sorting out and you …. think, ‘well, who’s going to [do it]’?” In fact, he is able to make use of his lifetime experience of paediatric medicine in his current role. “I hope I still understand what is happening at the bedside because of being part of a team, hearing their stories, getting involved if I need to.  … Yes –  my ‘hands-on’ [role] on an individual basis has been lost at the ward level”. However, his past experiences are now underpinning his efforts to change things for the better at a national level, he says.

A career in paediatric pharmacy?

In some ways “the only true pharmacy is paediatric pharmacy”  because it demands knowledge of chemistry,  pharmaceutics, the law and many other things including in- depth skill sets.  A career in paediatric pharmacy has much to recommend it but  “the one thing I would say to anybody coming through is not to rush”, says Mr Tomlin.  He himself worked in adult medicine and in mental health for a time. “I still look back on those [experiences] and I think the broader your background training is, the better. Have a bit of everything because then you can talk to everybody about different aspects. You don’t have to specialise immediately”.

Turning to paediatrics, he says, “There is something about the fact that they are a vulnerable population; there is something wonderful about being involved with children and carers and on the whole the multidisciplinary team for paediatrics are very friendly people”.

“I think that that would be my advice to anybody – make the most of every experience. The bit that I think defines whether you will be good ….. is having that questioning mind and it’s where I would advocate that research, education and practice are all part of the package.  …. So, it’s that all-rounded approach that I think is really important. Keep an inquiring mind throughout your career right from day one”, he says.

About Steve Tomlin

Steve Tomlin is Director of the Children’s Medicines Research and Innovation Centre (CMRIC) at Great Ormond Street Hospital for Children in London. He is  also the professional lead of the Neonatal and Paediatric Pharmacists’ Group (NPPG) and the vice-chair of the Joint Medicines Committee at the Royal College of Paediatrics and Child Health (RCPCH)

The Children’s Medicines Research and Innovation Centre is concerned with advancing practice for children’s medicines both in terms of improving medicines themselves and improving the usage and effectiveness of medicines in practice.

Read and watch the full series on our website or on YouTube.

Standardised products offer a number of advantages and one important question is whether a single, standardised parenteral nutrition solution could be used for neonates.  Mr Tomlin argues that only a small number of standardised parenteral nutrition solutions are required and that adjustments can often be made separately e.g. as a separate infusion or an oral supplement.  Ideally, manipulation of  standardised parenteral nutrition infusions either on wards or in the pharmacy should be avoided to minimise the risk of microbial contamination or errors, he emphasises. “I do believe you can maintain and correctly handle neonates on very few standard bags”, he says.

Prescribing

Safe prescribing of parenteral nutrition requires expert knowledge of both the clinical situation and the pharmaceutics of the products and, in many ways, it represents the pinnacle of prescribing by pharmacists.  Moreover, this should take place within the framework of the multidisciplinary team that is caring for the patient.  It has been suggested that pharmacists might undertake some of the routine prescribing for neonates but Mr Tomlin argues strongly that “when the pharmaceutics are complex alongside the clinical position then [the prescribing is] probably best done by those who know about the pharmaceutics – the pharmacists”

Pharmacy prescribers

“Pharmacy is in a unique position, I think, in the UK ……  I actually think, bearing in mind what I’ve just been talking about, that it’s really useful to have pharmacist prescribing”, says Mr Tomlin.  From September 2026  all newly-qualified pharmacists will be “prescribing-ready”.  “That doesn’t mean they’re all going to come out and be prescribing everything from day one but “prescribing-ready”, which means as a workforce we are going to have a buildup of the number of people who are prescribing. That’s exciting from a professional point of view, really, really exciting”, he says.  Developments in technology and in the work of pharmacy technicians are also taking place and “therefore a lot of things that pharmacists have traditionally done will not disappear but certainly won’t be taking up as much of their time”, he adds.

“We should be ensuring that the right people are prescribing – the people who understand the product and how it’s being used – and that’s where we come in”, he concludes.

About Steve Tomlin

Steve Tomlin is Director of the Children’s Medicines Research and Innovation Centre (CMRIC) at Great Ormond Street Hospital for Children in London. He is  also the professional lead of the Neonatal and Paediatric Pharmacists’ Group (NPPG) and the vice-chair of the Joint Medicines Committee at the Royal College of Paediatrics and Child Health (RCPCH)

The Children’s Medicines Research and Innovation Centre is concerned with advancing practice for children’s medicines both in terms of improving medicines themselves and improving the usage and effectiveness of medicines in practice.

Read and watch the full series on our website or on YouTube.

Survival rates in premature babies

At the beginning of Mr Tomlin’s career babies born at 28 weeks’ gestation had a 50% survival rate but now this applies to babies born at 24 weeks’ gestation. This reflects the advances in care that have taken place over the past 30 years. These include ventilation, medicines and parenteral nutrition together with the development of much more holistic care than was given in the past, he explains.

Parenteral nutrition   

Parenteral nutrition (intravenous feeding) is an important element of neonatal care. Parenteral nutrition solutions represent some of the most complex products that are administered to patients. “A bag of parental nutrition is about 50 different drugs; 50 different elements and we throw them all in a bag together and we tweak them and we up some and we down some and yet some of those do interact – and the importance of getting it right is huge – both from a clinical point of view and from a manufacturing point of view ……… I think that’s what really enhanced my enthusiasm for delving into it, trying to understand it more both from a clinical point of view but also from a pharmaceutical point of view”, says Mr Tomlin.  Parenteral nutrition solutions are excellent growth media and micro-organisms can grow rapidly in them. For this reason, keeping the products sterile and avoiding manipulation (e.g. making additions) on the ward is critical. Managing parenteral nutrition draws upon “all of those bits that you went to university and learned. It’s the chemistry, it’s the pharmaceutics, it’s the clinical aspect – and it’s how all of those interact together.  Therefore, I think we have to make the most of all the skills that we learned”, he adds.

Standardisation of products

Mr Tomlin advocates the use of standardised parenteral nutrition solutions in neonatal practice.  One important reason for this is that whereas other functions e.g. blood pressure are continuously monitored and alarms sound if there are major changes, for parenteral nutrition there are no alarms to tell the clinician about impending problems. Standardised parenteral nutrition products provide correctly balanced quantities of nutrients. Another important consideration is that the patients are very small and adjustments often require only very small amounts. “When you’re adding a tiny, tiny amount ….. trying to get that right is very, very hard and there are lots and lots of really good studies showing how inaccurate those are”, he explains.

“Whether it’s IVs or whether it’s oral I generally advocate for standardisation. It doesn’t mean it works for everybody but it does allow you then to concentrate on the smaller proportion that can’t use the standards – and therefore get it right. ….  It’s not about saying that ‘one size fits all’. Just because you’re standardising a concentration you can still give whatever dose that you want.  I think that is really important and so often the wrong messages get out there to do with standardisation. It’s understanding what is being standardised and why but all of the three standardisations that I’ve just talked about I think are absolutely important. …  There is a lot more work to do but that’s why I’m such an advocate”, he says.

About Steve Tomlin

Steve Tomlin is Director of the Children’s Medicines Research and Innovation Centre (CMRIC) at Great Ormond Street Hospital for Children in London. He is  also the professional lead of the Neonatal and Paediatric Pharmacists’ Group (NPPG) and the vice-chair of the Joint Medicines Committee at the Royal College of Paediatrics and Child Health (RCPCH)

The Children’s Medicines Research and Innovation Centre is concerned with advancing practice for children’s medicines both in terms of improving medicines themselves and improving the usage and effectiveness of medicines in practice.

Read and watch the full series on our website or on YouTube.

The role of the CMRIC is to bring people together to work on improving children’s medicines – making the most of the small number of specialists in children’s medicines across the country, explains Mr Tomlin.

Mr Tomlin’s interest in paediatric medicine started during his pre-registration training, part of which took place in a children’s hospital.  At that stage many things in adult medicine were ‘black and white’ – “Here’s the answer. This is what you do. This is the dose”, but things were very different in paediatrics. “There was a little drawer on my boss’s desk …. and you just pulled out a card and it just had a drug name and a dose – no reference – and that’s how we practised.  And it suddenly dawned on me how little we knew and therefore how exciting it was to be in a field where things were developing – and I think that’s what drew me into it”, he recalls.

At an early stage the death of an infant in a medicines-related incident underlined the importance of having sufficient information and a thorough understanding of the clinical situation. “A particular drug was wanted but that drug was needed in a particular salt. Nobody had picked up on the fact that the [available] salt was the problem. It was a theophyllinate salt as opposed to just an inert salt…….” he explains.  The post-incident review raised a number of important questions – “We knew the drug but it did we know all the formulations of that drug? Did we know how to get that drug into the baby? What were we monitoring? ……… It just dawned on me how little we really knew and I think it was possibly one of the things which really drew me into thinking this is a career that I want to do, despite the fact that it was very nerve-wracking at the time”, he says.

Later in his career a fatal incident  involving a contaminated parenteral nutrition solution further shaped his thinking.  “You’ve got a baby still in the in the next bed – next to the baby who died – what do you say to the parents? I was more senior then. I was the lead of the department and [these are] really hard conversations to have but it really focuses your mind on how critical our roles are and how important it is to understand all of the implications of both the products [and] the way they’ve been manufactured.”

Such incidents made him think hard about how to use his knowledge to improve the working systems “and that’s … really been the focus of my career”, he reflects.

Neonatology

Neonatology has been the focal point of Mr Tomlin’s career. He explains the contrast with adult medicine:  “It’s easy to give anybody one or two tablets, which is generally what the adult medicines are made up of. We count most adults as being the same size ……. we give one or two tablets to most adults. You can’t do that with neonates and I think it’s not just about the ….. dosing and the tablets. On the whole pharmacokinetics are similar in most people over the age of three years. …… It’s under three years when things really start to change with pharmacokinetics, blood-brain barriers, renal function, liver functions, the acidity of the gut  [and] the gut motility.  By the time you’re three years old most of those are very similar, although you don’t need the same dose because you’re not the same size, but the kinetics are very similar. But, under three years that starts changing – the smaller and smaller they get the more and more diverse that is. …. I think the thing that has really grabbed my career, I suppose, was premature babies because they’re not even supposed to be here ….  they’re still supposed to be inside”, he explains.

“I’ve concentrated my career on paediatrics as a totality, [but] if somebody was going to ask me my love it would be neonatology because I just think I think it’s fascinating”, he concludes.

About Steve Tomlin

Steve Tomlin is Director of the Children’s Medicines Research and Innovation Centre (CMRIC) at Great Ormond Street Hospital for Children in London. He is  also the professional lead of the Neonatal and Paediatric Pharmacists’ Group (NPPG) and the vice-chair of the Joint Medicines Committee at the Royal College of Paediatrics and Child Health (RCPCH)

The Children’s Medicines Research and Innovation Centre is concerned with advancing practice for children’s medicines both in terms of improving medicines themselves and improving the usage and effectiveness of medicines in practice.

Read and watch the full series on our website or on YouTube.