Paediatric RAG list
THE PAEDIATRIC RAG LIST INCLUDES THOSE DRUGS AND INDICATIONS SPECIFIC TO USE IN CHILDREN ONLY.
For those drugs/indications which may be used in both children and adults, check the adult RAG/DNP/grey list. This includes all “off label” use of licensed medicines.
RAG list entries may be subject to a lag period to allow for implementation by Trusts/localities. Please check with your individual Trust or locality.
If an indication is not stated then the designated status relates to licensed indications only.
Some indications in paediatrics may be “off-label”, for example licensed medicines used for an unlicensed indication or at an unlicensed dose. Medicines may be used off-label if there is a recognised evidence base and/or it is standard treatment, in terms of paediatric medicines. Inclusion of guidance in the BNF for Children provides a suitable evidence base.
Exceptions may arise and it is to be remembered that the RAG list is advisory and cannot be expected to include every possible use of every drug. Primary care prescribers and specialist teams are encouraged to discuss individual patient circumstances and consider where prescribing is best managed taking into account monitoring requirements, drug interactions, frequency of routine patient visits to the specialist and the specialist nature of the condition being treated. Clinical judgement should be used to arrive at the most reasonable outcome. However, if it is not possible to reach a consensus or a specific issue has arisen, please submit an application to the Clinical Reference Group to assess or re-assess the RAG status.
Please read the Guidelines on Defining Red, Amber, Green, DNP, and Grey Status for further detail on assigning a RAG status prior to submitting any queries or applications to GMMMG.
In line with NHS England guidance, GM do not routinely support prescribing for conditions which are self-limiting or amenable to self-care. For further details see GM commissioning statement.
Red Amber Green Classifications
| Classification | Guidance |
|---|---|
| Red | Drugs considered to be specialist medicines and prescribing responsibility for these medicines should normally remain with the consultant or specialist clinician. These drugs should not be initiated or prescribed in primary care. It is recommended that the supply of these specialist medicines should be organised via the hospital pharmacy or specialist service. This may include arranging for supply via a home care company. |
| Amber | Drugs suitable for shared care arrangements under a shared care protocol. |
| Green | Drugs that are suitable for initiation and ongoing prescribing within primary care. |
| Green (specialist initiation) | Drugs that are suitable for ongoing prescribing within primary care following initiation by a specialist service. Little or no monitoring is required. |
| Green (specialist advice) | Drugs that are suitable for initiation by primary care following written or verbal advice from a specialist service. Little or no monitoring is required. |
| DNP | Products which are not recommended for prescribing in any setting. “Do Not Prescribe” status may relate to a specific medicine, or to prescribing for a particular indication. This is in addition to all medicines with a “not NHS” or “Drugs of Low Clinical Value” classification in the BNF, and those medicines with a NICE “Do not do” recommendation. |
| Grey | Products which are not suitable for routine prescribing but suitable for exceptional use in a defined patient population. Prescribers should ensure that more suitable alternatives have been considered and ruled out as not being appropriate before recommending or prescribing a medicine with a GREY list status. In these cases a RAG of RED, AMBER or GREEN will also be assigned to clarify in which care setting prescribing responsibility lies. |
| Other |
Criteria for inclusion on DNP/grey lists:
- Criterion 1: Products of low clinical effectiveness, where there is a lack of robust evidence of clinical effectiveness or there are significant safety concerns.
- Criterion 2: Products which are clinically effective but where more cost-effective products are available, including products that have been subject to excessive price inflation.
- Criterion 3: Products which are clinically effective but, due to the nature of the product or condition being treated, are deemed a low priority for NHS funding.
| Drug (proprietary examples) | BNF chapter | Indications and rationale | Formulary drug | RAG status | Information | Responsible commissioner | Date added |
|---|---|---|---|---|---|---|---|
| Alpha-1 antitrypsin | 9 | Alpha-1 anti-trypsin deficiency: Type 1 diabetes mellitus in children. | Red | NHSE | |||
| Amiodarone | 2 | Red | ICS | ||||
| Amisulpride | 4 | Atypical antipsychotics (Oral) use in children. Licensed Indications & unlicensed indications supported by NICE. | Amber | ICS | |||
| Amisulpride | 4 | Atypical antipsychotics (Oral). All other unlicensed indications incl short-term use. | Red | ICS | |||
| Anti reflux milks (infant formula) | 9 | Criterion 3 | DNP | DNP | See GMMMG guidance: Cow’s milk protein allergy: prescribing infant formula in primary care. |
Sep 2022 | |
| Antipsychotics | 4 | When used by the eating disorder service | Red | ICS | |||
| Aripiprazole | 4 | Atypical antipsychotics (Oral) use in children. Licensed Indications & unlicensed indications supported by NICE. | Amber | Shared care protocols available for: |
ICS | ||
| Aripiprazole | 4 | Atypical antipsychotics (Oral). All other unlicensed indications incl short-term use. | Red | ICS | |||
| Aripiprazole | 4 | Tourette's Syndrome and other tic disorders in children and adolescents | Red | For new patients only |
ICS | ||
| Asfotase alfa | 9 | Paediatric-onset hypophosphatasia | No | Red | NICE HST23: Asfotase alfa for treating paediatric-onset hypophosphatasia |
NHSE | Jul 2023 |
| Atomoxetine | 4 | ADHD amber once patient stabilised | Amber | Shared care protocol: Atomoxetine for ADHD in children and adolescents |
ICS | ||
| Azathioprine | 1 | Inflammatory bowel disease | Amber | ICS | |||
| Aztreonam lysine nebules | 5 | Cystic fibrosis April 13: commissioned by NHS England | Red | NHSE | |||
| Betaine | 9 | Homocystinuria | Red | NHSE highly specialised criteria only |
NHSE | ||
| Chloral hydrate | 4 | All indications | No | Red | MHRA DSU: Chloral hydrate, cloral betaine (Welldorm): restriction of paediatric indication, Oct 2021 |
ICS | Jul 2023 |
| Ciclosporin | 8 | Childhood nephrotic syndrome | Red | NHSE | |||
| Ciclosporin 0.1% eye drops (Verkazia®) | 11 | For treatment of vernal keratoconjunctivitis in patients aged 4 to 18 years old and who are subject to active follow-up (e.g. reviewed every 6 months) | Green (specialist initiation) | ICS | |||
| Citalopram | 4 | For use in paediatric indications where a shared care protocol is available. | Amber | Shared care protocols available for:
|
ICS | ||
| Clobazam | 4 | Antiepileptic. As per NICE guidance | Green (specialist advice) | ICS | |||
| Clonazepam | 4 | Antiepileptic. As per NICE guidance | Green (specialist advice) | ICS | |||
| Clonidine | 4 | Tourette's Syndrome and other tic disorders in children and adolescents | Red | For new patients only |
ICS | ||
| Cloral betaine | 4 | All indications | No | Red | MHRA DSU: Chloral hydrate, cloral betaine (Welldorm): restriction of paediatric indication, Oct 2021 |
ICS | Jul 2023 |
| Clozapine | 4 | Atypical antipsychotics (Oral) use in children | Red | ICS | |||
| Colistimethate – nebulised | 5 | Colomycin®, Promixin® for cystic fibrosis | Red | For new patients |
NHSE | ||
| Dexamfetamine | 4 | ADHD amber once patient stabilised | Amber | Shared care protocol: Dexamfetamine for ADHD in children and adolescents |
ICS | ||
| Domperidone | 1 | Gastro indications | Amber | Shared care protocol: Domperidone for Paediatric Gastro-oesophageal Reflux Disease (GORD) |
ICS | ||
| Dornase alfa (Pulmozyme®) | 3 | Cystic fibrosis | Amber | NHSE | |||
| Emollient bath additives | 13 | Criterion 1 When used for the management of eczema in children. This recommendation does not apply to the use of standard emollients when used in the bath as a soap substitute |
DNP | DNP | |||
| Emollient bath additives containing antimicrobials | 13 | Criterion 1 Only for short term use in patients with infected eczema |
Grey | Green | ICS | ||
| Ethinylestradiol (tablets) | 6 | Pubertal induction for use only when estradiol matrix patches are unsuitable or not tolerated | Grey | Amber | Shared care protocol: Ethinylestradiol for the induction of delayed puberty |
ICS | |
| Flecainide | 2 | For use in paediatric patients, although unlicensed in children - well established therapy and in the children's BNF. | Red | RED until patient stabilised, then GREEN |
ICS | ||
| Fluoxetine | 4 | For use in paediatric indications where a shared care protocol is available. | Amber | Shared care protocols available for:
|
ICS | ||
| Fluvoxamine | 4 | For use in paediatric indications where a shared care protocol is available. | Amber | Shared care protocols available for:
|
ICS | ||
| Goserelin | 6 | Precocious puberty | Red | ICS | |||
| Growth hormone (Somatropin) | 6 | For children. | Amber | ICS | |||
| Guanfacine | 4 | ADHD | Amber | Shared care protocol: Guanfacine for childhood and adolescent ADHD |
ICS | ||
| Haloperidol | 4 | Tourette's Syndrome and other tic disorders in children and adolescents | Red | For new patients only |
ICS | ||
| Hydrocortisone granules (Alkindi) | 6 | For management of adrenal insufficiency, only in patients requiring doses <5mg. Alkindi should not be used in combination with hydrocortisone tablets to make up dose increments ≥5mg. | Grey | Green (specialist initiation) | ICS | ||
| IV Formulations | 0 | Unless part of an agreed local pathway. | Red | Commissioner depends on drug and indication |
ICS or NHSE |
||
| Leuprorelin | 6 | Precocious puberty | Red | ICS | |||
| Liraglutide | 6 | Obesity in people aged 12-17 years | DNP | DNP | May 2022 | ||
| Lisdexamfetamine | 4 | ADHD amber once patient stabilised (> 3 months) | Amber | Shared care protocol: Lisdexamfetamine for ADHD in children and adolescents |
ICS | ||
| Lithium | 4 | Paediatric use | Red | ICS | |||
| Melatonin | 4 | Sleep disorders, ADHD. Unlicensed specials only to be used in exceptional circumstances. Doses greater than 6mg are RED | Amber | Shared care protocol: Melatonin for children and adolescents |
ICS | ||
| Melatonin 1 mg/mL oral solution (Colonis brand licensed product) | 4 | Not suitable for use in children and adolescents aged 0-18 due to safety & efficacy concerns. | DNP | DNP | |||
| Metformin | 6 | Type 2 diabetes | Green (specialist initiation) | ICS | |||
| Methylphenidate | 4 | ADHD amber once patient stabilised | Amber | Shared care protocol: Methylphenidate for ADHD in children and adolescents |
ICS | ||
| Midazolam (buccal) | 4 | Epilepsy | Green (specialist initiation) | ICS | |||
| Modafinil | 4 | Sleepiness associate with narcolepsy | Red | ICS | |||
| Nadolol | 2 | Prolonged QT syndrome | Red | ICS | |||
| Nutritional Supplement Drinks | 9 | When used by the eating disorder service | Green | ICS | |||
| Olanzapine | 4 | Atypical antipsychotics (oral). Licensed Indications & unlicensed indications supported by NICE. | Amber | Shared care protocols available for:
|
ICS | ||
| Olanzapine | 4 | Atypical antipsychotics (oral). All unlicensed indications not supported by NICE, including eating disorders. | Red | ICS | |||
| Omalizumab | 3 | Allergic asthma prophylaxis. | Red | NHSE | |||
| Omalizumab | 3 | Severe chronic spontaneous urticaria | Yes | Red | ICS | ||
| Omeprazole MUPS tablets | 1 | GORD | Green | ICS | |||
| Paliperidone | 4 | Atypical antipsychotics (oral) use in children. Licensed Indications & unlicensed indications supported by NICE. | Red | Pending production of a shared care protocol |
ICS | ||
| Paliperidone | 4 | Atypical antipsychotics (oral). Unlicensed indications not supported by NICE | Red | ICS | |||
| Palivizumab | 5 | RSV | Red | NHSE | |||
| Paraldehyde | 4 | Status epilepticus | Red | ICS | |||
| Peanut protein powder (Palforzia) | 3 | Criterion 1 Peanut allergy Only for use in people aged 18 and over if treatment started between the ages of 4 to 17, as per NICE guidance. |
Grey | Red | NICE TA769: Palforzia for treating peanut allergy in children and young people |
ICS | Jun 2022 |
| Phenazone / lidocaine eardrops (Otigo) | 12 | Acute otitis media. Use only if an immediate oral antibiotic prescription is not given, and there is no eardrum perforation or otorrhoea |
Green | ICS | Sep 2022 | ||
| Poractant alfa (Curosurf®) | 3 | Pulmonary surfactant | Red | NHSE | |||
| Potassium Phosphate | 9 | When used by the eating disorder service | Red | ICS | |||
| Quetiapine | 4 | Atypical antipsychotics (oral) use in children. Licensed Indications & unlicensed indications supported by NICE. | Amber | Shared care protocols available for:
|
ICS | ||
| Quetiapine | 4 | Atypical antipsychotics (oral). All other unlicensed indications incl short-term use. | Red | ICS | |||
| Risperidone | 4 | Atypical antipsychotics (oral) use in children. Licensed Indications & unlicensed indications supported by NICE. | Amber | Shared care protocols available for:
|
ICS | ||
| Risperidone | 4 | Atypical antipsychotics (oral). All other unlicensed indications incl short-term use. | Red | ICS | |||
| Risperidone | 4 | Tourette's Syndrome and other tic disorders in children and adolescents | Red | For new patients only |
ICS | ||
| Secukinumab | 13 | Biologics/cytokine modulators | Red | NHSE | Jul 2022 | ||
| Sertraline | 4 | For use in paediatric indications where a shared care protocol is available. | Amber | Shared care protocols available for:
|
ICS | ||
| Somatrogon | 6 | Growth disturbance Red pending availability of a shared care protocol |
Red | ICS | Jun 2023 | ||
| SSRIs | 4 | When used by the eating disorder service | Amber | ICS | |||
| Stiripentol | 4 | Paediatric patients | Red | ICS | |||
| Sulpiride | 4 | Tourette's Syndrome and other tic disorders in children and adolescents | Red | For new patients only |
ICS | ||
| Testosterone injection | 6 | Delayed puberty | Green (specialist initiation) | ICS | |||
| Tobramycin – nebulised | 5 | Tobi®, Bramitob® for cystic fibrosis | Red | For new patients |
NHSE | ||
| Tofacitinib | 10 | Biologics/cytokine modulators | Red | NICE TA735: Tofacitinib for treating juvenile idiopathic arthritis |
NHSE | Jul 2022 | |
| Triptorelin | 6 | Precocious puberty | Red | ICS |