Medicosnext
Sanjaya Mani Dixit
Mr. Sanjaya Mani Dixit is a pharmacist, pharmacologist, and medical journalist, currently serving as an Assistant Professor of Pharmacology at Kathmandu Medical College. He has extensive teaching experience across MBBS, BDS, Pharmacy, Nursing, and Physiotherapy programs, reflecting his strong command of pharmacology and drug-related sciences. Having completed his bachelor’s and master’s studies in Pakistan and China, he brings both national and international perspective to the pharmaceutical and medical fields. As the editor of MedicosNext magazine, he is committed to curating meaningful, locally relevant medical content that addresses Nepal’s unique healthcare landscape. He is also an active advocate for medication and patient safety, working to enhance awareness and standards across the country.
During the recent revision of Nepal’s National List of Essential Medicines (NLEM), 7th edition, a critical gap in pediatric pharmaceutical care became starkly evident. While conducting consultations with various professional societies, the Pediatric Society of Nepal put forward what appeared to be a straightforward, rational request: include specific strengths and dosage forms suitable for children for medicines already listed in the NLEM. This request was certainly rational in that nearly 40% of Nepal’s population is under 18 years of age, of which many are under 5 years old, ensuring access to age-appropriate medications should be a healthcare priority.
“In Nepal, medicines for children often exist; but in forms they simply cannot use.”
However, this seemingly simple recommendation exposed a profound challenge in Nepal’s pharmaceutical landscape. Even if pediatric-specific strengths and dosage forms were included in the NLEM, the nation lacks the regulatory infrastructure, supply chain mechanisms, and market incentives to ensure such specialized formulations would be consistently available across healthcare facilities. Many of these medicines already exist in higher strengths or adult dosage forms, yet children cannot access them in appropriate doses. This leads to a paradox, medicines exist but in forms unsuitable for pediatric use. This led to a crucial realization: if pharmaceutical compounding were a common standardized practice in Nepal, this accessibility crisis could be significantly mitigated. This exposes the uneven development of healthcare professions here in Nepal. While the field of medicine practice has started seeing DMs and MCh’s in clinical practice. The field of pharmacy despite having started a PhD program here in Nepal is still in its nascent phase with Hospital Pharmacies acting like mere medicine distribution channels and Clinical Pharmacy settings almost non-existent in hospitals. Some paediatric dosage forms that could be made in-house in small settings, necessitates patient parties to go hunting in different places, only to return empty handed and exasperated.
“Listing pediatric formulations in the NLEM is meaningless unless systems exist to make them available at the bedside.”
The 7th revision of Nepal’s NLEM brought into sharp focus the systematic barriers preventing pediatric patients from accessing age appropriate pharmaceutical care. Let us consider a common scenario: a medicine like captopril, essential for managing hypertension in children with chronic kidney disease, appears on the NLEM but only in 25 mg or 50 mg tablets suitable for adults. A young child requiring 0.3 mg/kg body weight three times daily has no commercially available formulation meeting this need. Healthcare providers face untenable choices, crushing adult tablets and estimating portions (risking inaccurate dosing), prescribing alternative medications, or forgoing treatment. This is where geometric mixing of powder or extemporaneous suspension preparation could be helpful, if only hospitals had the human resource and the settings to prepare such medicines.
Research examining medicines access in Nepal reveals the mean availability of essential medicines for children stands at only 61.3% in public hospitals and 60.6% in private pharmacies, both falling significantly short of WHO’s 80% availability target. Even medicines treating diseases causing the highest child mortality, including zinc sulphate for diarrhea and cotrimoxazole for infections show suboptimal availability. This is in part because of minimal prescription generation for medicines which are of immense value yet the pharma industries neglect their marketing and production, in that the profit margin is less.
Nepal’s pharmaceutical market is driven primarily by adult medicine demand, with limited commercial incentive to manufacture or import low-volume pediatric formulations. This reality prompted the central question: What if, instead of waiting for market forces to deliver pediatric formulations, Nepal worked in revitalizing pharmaceutical compounding? If pharmacists possessed the training, resources, and regulatory support to safely compound pediatric formulations from available materials, the gap between policy and practice could be bridged.
Why Pediatric Patients Need Compounding
As famously quoted by Jean-Jacques Rousseau, “Children are not simply small adults”, they represent a heterogeneous population requiring specialized pharmaceutical considerations. Research indicates that approximately 10% of children aged 6-11 cannot swallow pills due to fear, anxiety, or developmental stage. The most compounded medicines globally are omeprazole, captopril, spironolactone, propranolol, digoxin and furosemide; they often lack pediatric formulations.
The need for compounding extends beyond dose adjustment. Children are highly sensitive to taste and smell, and poor palatability directly undermines medication adherence. Sometimes compounding medicines for children can be helpful in cases even when the commercially available formulations exist in that:
● some medicines may contain excipients inappropriate for pediatric use,
● lack necessary dose flexibility, or
● prove unaffordable for Nepal’s low-income families.
In Nepal’s context, where commercial pediatric formulations are scarce, compounding becomes not merely an option but a necessity for appropriate pediatric care.
Expanded Role of Pharmacists in Pediatric Centers
While pharmacists’ compounding activities have diminished in developed countries as manufacturers expanded pediatric product lines, pharmacists in Nepal must assume a more comprehensive role. This encompasses several critical functions. First, pharmacists must collaborate closely with pediatricians to design age-appropriate formulations when commercial products are unavailable, requiring expertise in pharmaceutical calculations, pediatric pharmacokinetics, and excipient safety. Second, they must ensure preparation quality and stability, as problems with extemporaneous preparations have been linked to adverse events or therapeutic ineffectiveness.
“In a country where commercial pediatric formulations are scarce, pharmaceutical compounding is not a luxury; it is a necessity.”
Pharmacists also serve as essential advisors on medication safety. Research demonstrates that pharmacist-led interventions in low- and middle-income countries can reduce medication errors by 57%, with studies in pediatric settings showing a decline in prescribing mistakes by up to 35%, particularly with antibiotics, antiepileptics, and cardiovascular drugs.
In resource-constrained Nepal, pharmacists must navigate significant limitations. Nearly 60% of pharmacy professionals globally utilize commercial compounding vehicles, though usage drops to 50% in regions like Africa and South America, where locally developed vehicles remain prevalent. Pharmacists must develop cost-effective formulation strategies using locally available materials while maintaining quality standards.
While compounding addresses critical access gaps, it introduces quality assurance challenges. Nepal’s pharmaceutical quality assurance systems remain underdeveloped, with studies identifying substandard medicines and health facilities lacking infrastructure to maintain recommended storage conditions.
Incompatibilities between active pharmaceutical ingredients or excipients may affect safety, efficacy, and stability. While physical incompatibilities may be visually detected, chemical incompatibilities require sophisticated monitoring, a capacity often limited in resource-constrained settings.
Capacity Building for Safe Compounding Practice
Addressing these challenges requires systematic capacity building. All staff involved in extemporaneous preparations must receive training appropriate for their role, including good preparation practices, formulations, quality assurance, and medication error prevention. Nepal needs standardized compounding protocols adapted to local contexts, prioritizing commonly needed pediatric medications while considering local disease burdens, available raw materials, and economic constraints.
Professional development programs must equip pharmacists with specialized pediatric compounding competencies, including pharmaceutical calculations, formulation design, stability testing, and patient counseling. Infrastructure development is equally critical, compounding facilities need dedicated clean areas, quality raw materials, calibrated equipment, and robust documentation systems.
As Nepal strengthens its pharmaceutical regulatory capacity through initiatives like revising its National Medicines Policy and Drug Act, incorporating comprehensive guidelines for compounding practice should be a priority. Rather than viewing compounding as outdated, policymakers should recognize it as a necessary component of pediatric healthcare in resource-limited settings.
The future of pediatric pharmaceutical care in Nepal depends on balancing multiple objectives:
● expanding access to commercial pediatric formulations where feasible,
● strengthening compounding capacity where necessary,
● ensuring quality across all medication sources, and
● building a skilled pharmacy workforce.
While commercial pediatric formulations remain the ideal solution, professional compounding will continue serving as an essential bridge until comprehensive pediatric pharmaceutical access becomes reality.
“Strengthening pediatric care in Nepal requires more than policy reform; it demands empowered pharmacists, safe compounding practices, and investment in quality systems, until paediatric dosage forms are widely available in the Nation.”
Pharmaceutical compounding for pediatric patients in Nepal exemplifies how global trends must adapt to local realities. The NLEM revision process revealed that simply listing pediatric formulations in policy documents is insufficient without mechanisms ensuring their availability. Nepal’s limited access to appropriate medicines creates an enduring need for compounding services, with pharmacists assuming expanded roles requiring advanced competencies and unwavering commitment to quality. By investing in pharmacy education, infrastructure, and regulatory frameworks supporting safe compounding practices, Nepal can better serve its pediatric population. The practice of compounding represents a vital pharmaceutical service ensuring that Nepal’s children receive appropriate, safe, and effective medications tailored to their unique needs.
