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Letter from the authors of "Improved Growth in Young Children with Severe Chronic Renal Insufficiency Who Use Specified Nutritional Therapy," which appeared on pages 2418–2426 of the November 2001 issue of JASN.

Johns Hopkins Medicine, Baltimore, Maryland;
University of Michigan, Ann Arbor, Michigan;
Montefiore Medical Center, Bronx, New York;
University of Alabama, Birmingham, Alabama

Regarding the homemade sodium solutions that we provided in the appendix to our article (1), use of these solutions began at our institution over 10 y ago after a pharmacy error resulted in an adverse event in a young child. It is estimated that medication errors occur in 6 of 100 orders in a pediatric inpatient pharmacy, and errors in dosing are frequent by parents (2,3). Potential errors can occur by the physician, pharmacy, and patient.

The controversy of homemade versus pharmacy-made solutions has also been under debate in the pediatric population with respect to the use of oral rehydration solutions. The error rate of homemade cereal-based rehydration solution was 3% when all ingredients were added and 1% in a premixed packet in a randomized clinical trial based in Boston (4). None of the mixing errors resulted in an adverse event.

Nevertheless, it is important to have personal, written instruction to the family and regular review and education of medication dosing. We carefully screen families to make sure that they are capable of mixing both their child’s formula and the sodium solutions correctly. If not, we have a pharmacy make up the sodium chloride or bicarbonate solutions. Since minimizing the risk to the patient is of utmost importance, we would recommend that a pharmacy-based solution be used in an industrialized nation. We would also suggest that the solution be kept at a standard concentration of 1 mEq of sodium chloride/1 cc so that frequent adjustments by dietician and physician can be made without the risk of further errors.

We previously made and tested our homemade salt solutions. However, in following these same instructions in 2001, we realize that the packaging of Arm and Hammer has changed, which would lead to errors in preparation of these home-based solutions if our original instructions were followed. Although our recent laboratory testing of the solution did not produce solutions of 1.7 mEq/cc sodium concentration as suggested, the inaccuracies with new packaging make it imperative that we revise our home-based solutions. In formulating a home-based regimen, local supplies, i.e., salt and bicarbonate sources and water constituents, all need to be considered. Our written outline is just an example and should not be used as a universal formula for a salt solution in any region or non-industrialized country.

Sincerely,

Rulan Parekh, William E. Smoyer, Joan L. Milne, David B. Kershaw, Aileen B. Sedman, Joseph T. Flynn, and Timothy E. Bunchman

References

1. Parekh RS, Flynn JT, Smoyer WE, Milne JL, Kershaw DB, Bunchman TE, Sedman AB: Improved growth in young children with severe chronic renal insufficiency who use specified nutritional therapy. J Am Soc Nephrol 12: 2418–2426, 2001[Abstract/Free Full Text]
2. Kaushal R, Barker KN, Bates DW: How can information technology improve patient safety and reduce medication errors in children’s health care? Arch Pediatr Adolesc Med 155: 1002–1007, 2001[Abstract/Free Full Text]
3. McMahon SR, Rimsza ME, Bay RC: Parent can dose liquid medication accurately. Pediatrics 100: 330–333, 1997[Abstract/Free Full Text]
4. Meyers A, Sampson A, Saladino R, Dixit S, Adams W, Mondolfi A: Safety and effectiveness of homemade and reconstituted packet cereal-based oral rehydration solutions: a randomized clinical trial. Pediatrics 100: 1997

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