Introduction:

Galenic medicine, involving the extemporaneous preparation of customized medications, is vital in neonatology and pediatrics. Approximately 40% of drugs used in children are magistral formulations or used off-label, often due to the lack of suitable commercial products [1]. The choice of pharmaceutical form is pivotal; children under 6-8 years often have difficulty swallowing tablets or capsules, making solutions and suspensions the preferred forms to avoid airway obstruction [2].

Excipients are not inert. They serve critical functions: as vehicles to improve drug delivery, ensure stability, facilitate manufacturing, and enhance palatability. However, for neonates and children, certain excipients can pose serious risks due to their underdeveloped metabolic and excretory systems [3, 4]. The skin of a newborn, particularly preterm infants, is thinner and more permeable, offering a poor barrier and increasing the risk of systemic toxicity from topical applications [5, 6].

This manuscript reviews the current state of knowledge regarding excipient safety in pediatric populations, identifies harmful substances to avoid, proposes safer alternatives, and discusses practical considerations for the galenic formulation of safe and effective medicines for children.

2. Materials And Methods

This review was conducted from an observational perspective. A comprehensive analysis of relevant scientific literature was performed using major online databases (e.g., PubMed, Scopus, Web of Science) with keywords including "excipients," "neonatology," "pediatrics," "galenic," "safety," and "toxicity." Only peer-reviewed articles, official guidelines from regulatory bodies (EMA, FDA), and authoritative pharmacological texts were considered.

In addition, a five-year observational analysis (2019-2023 external production; 2024 internal production) was conducted in a hospital galenic laboratory. The study monitored official reports concerning excipient or vehicle toxicity in magistral preparations (capsules, oral suspensions, syrups, solutions, gels, powders) for neonatal and pediatric patients.

3. Results

3.1. Literature Review Findings

The pediatric population exhibits vast pharmacokinetic and pharmacodynamic variability, making them exceptionally vulnerable to excipient toxicity [1, 3]. Key findings from the literature include:

· High-Risk Excipients: A consensus identifies the most concerning excipients for neonates as: benzyl alcohol, ethanol, propylene glycol, polysorbate 80, parabens, benzoic acid, sodium benzoate, benzalkonium chloride, sorbitol, and aspartame [3, 7, 8].

 According to Annex 5 WHO TECHNICAL REPORT SERIES  2012

Development of paediatric medicines: points to considerin formulation

“Solubility enhancers;The aqueous solubility of the API may limit the concentration achievable in formulated solutions and, hence, the desirable dose volume. In many cases an acceptable solution requires solubility enhancing methods, like use of non-ionic surfactants and of co-solvents such as glycerol, liquid macrogols and ethanol. If solubility enhancers are to be used, consideration should be given to the safety of both the agent and the formulation, the risk of irritation and damage of intestinal tissues in neonates caused by hyperosmolality or other local toxicity”

· Mechanisms of Toxicity (some) :

  · Benzyl Alcohol: Associated with fatal "gasping syndrome" in preterm neonates due to metabolic acidosis and CNS depression [9].

  · Propylene Glycol: Can cause CNS depression, seizures, and hyperosmolality; its half-life is significantly prolonged in neonates (~17 hrs vs. ~5 hrs in adults) [10].

  · Ethanol: Causes neurotoxicity and cardiovascular problems; exposure is linked to developmental delays [3].

  · Sodium Benzoate: Can displace bilirubin from albumin, increasing the risk of kernicterus in jaundiced neonates [7].

  · Parabens: Potential endocrine-disrupting effects, with heightened sensitivity in newborns [11]. hyperbilirubinaemia, hypersensitivity reactions, and delayed-contact dermatitis Neonates

  · Aspartame: Contraindicated in patients with phenylketonuria (PKU) as it metabolizes to phenylalanine [3].

  Glicerol :cases of neurological toxicity have been reported in the paediatric population .

 Sulfites :  that can cause slight flushing, dermatitis, hypotension, diarrhea urticaria and abdominal pain to life-threatening asthma and anaphylactic reactions.

Water : is the most commonly used agent in paediatric formulations, as liquid preparations are easier to administrate and allow a more accurate dose adjustment . Water is an ideal medium for the proliferation of microorganisms (bacteria and fungi) despite their purification.”

· Topical Formulations: The immature skin barrier in infants, coupled with a high surface-area-to-weight ratio, increases systemic absorption. Excipients like propylene glycol, sodium lauryl sulfate, and certain preservatives can cause irritation, in some situation since  burns, or systemic toxicity [5, 6]. Parabens can cause contacts dermatitis, to be  be avoided for small children in cosmetic: silicons products, petrolate, agressive  tensioattive and substantie that can alter the skin functions

Povidone-iodine is an effective antiseptic, but its topical use has been associated with a number of adverse reactions in burn patients and in neonates as a result of transcutaneous absorption.

· Databases and Resources: The STEP (Safety and Toxicity of Excipients for Paediatrics) database was developed to compile safety data on excipients for children, addressing a critical knowledge gap [12].

3.2. Observational Analysis Results

Over the five-year observation period in the galenic lab, no official written reports of toxicity directly attributed to excipients were filed. However, several proactive interventions were documented:

1. A request to avoid titanium dioxide in capsules for an oncology patient with a diagnosed allergy.

2. A request for a citrus-free glucose solution for a pregnant woman with a citrus allergy.

3. A specific request for wool wax (cera lanetta) in a cream for a patient with ichthyosis.

This suggests that while adverse events are rare, vigilance and individualized assessment are standard practice.

3.3. Examples of Formulations and Vehicles

Several common pediatric galenic preparations and their bases were identified (See Figures 1-11 in Appendix for examples):

· Ready-to-Use Vehicles: Commercial vehicles like SyrSpend® SF PH4 (preservative-free or preserved with potassium sorbate), Ora-Blend®, Ora-Plus®, and Ora-Sweet® are commonly used for compounding stable oral suspensions [13, 14].

· Common Preparations: Examples include extemporaneous suspensions of flecainide, propranolol, captopril, ibuprofen (with Wagner bases) , and niaprazine [14, 15] and fig. n  3.

· Innovation: Excipient bases for automated compounding and 3D printing (e.g., CuraBlend®) are emerging technologies for producing personalized doses in pediatrics [16].

4. Discussion

The case of phenytoin intoxication in Australia (1968-69) due to a change from calcium sulfate to lactose excipient starkly illustrates that excipients are pharmaceutically active and can critically influence drug bioavailability and safety [17]. This historical lesson underscores the necessity of meticulous excipient selection for vulnerable populations.

Our review confirms that neonates and preterm infants are at the highest risk due to physiological immaturity. The principle that "the use of excipients in pediatric formulations should be justified through a risk-based assessment" is paramount [18]. This involves:

1. Patient Factors: Assessing age, weight, organ function, and comorbidities, allergies and intolerance (e.g., PKU, lactose intolerance, avoid saccarose in diabetic, global sodium charge provided by the APIs and excipients  in CV pathology).

2. Excipient Factors: Evaluating the excipient's function, daily intake, duration of therapy, and potential for additive toxicity in polypharmacy.

3. Formulation Factors: Ensuring chemical and physical compatibility between API and excipients and establishing a valid beyond-use date based on stability studies.

4) the duration of the therapy (short of prolonged esposition to a topical therapy).

5) avoid flavoring oral suspension for very small children ( to prevent allergies)

6) To be considered for every substantia is also the thereshold for toxicity: some excipients or at some concentration can be harmful for newborn and not for higher children.

7) Useful to consult the technical sheet of the bases used for every single APIs, not give too much rapid responce inaccurate to physicians according the compatilibility: verify literature, pharmaceutical technique texbook, pharmacopeia, internationla public healthcare website and database and other useful official resource.

Verify the quantitative limits admitted (BNF for children) and the route of administration.

For pharmacists, the process is multifactorial:

· Verification: Scrutinizing prescriptions for dosage, excipient choice, and potential allergies.

· Selection: Choosing the appropriate pharmaceutical form and vehicle (e.g., buffered vehicles for acid-labile APIs).

· Quality Control: Using calibrated equipment, purified water, and following aseptic techniques when necessary.

· Labeling: Providing clear instructions (e.g., "Shake Well," storage conditions) and a complete list of excipients.

· Communication: Educating caregivers on correct administration and collaborating closely with prescribers to select the safest formulation.

The observational study's lack of adverse event reports is positive but likely reflects under-reporting and the effectiveness of preventive risk assessment rather than an absence of risk.

5. Conclusion

The preparation of galenic formulations for neonates and children is a complex process that demands a deep understanding of pharmaceutical technology, pharmacology, and toxicology. Excipients must be considered active ingredients whose safety profiles are age-dependent.

A proactive, collaborative approach between pediatricians, neonatologists, and pharmacists is essential. This involves:

· Consulting toxicity databases (e.g., STEP).

· Prioritizing licensed products, then off-label use of licensed products, before resorting to unlicensed magistral preparations.

· Selecting excipients with the highest safety margin for the specific age group.

· Avoiding known high-risk excipients like ethanol, propylene glycol, benzyl alcohol, and parabens in neonates whenever possible.

· Utilizing modern, well-characterized ready-to-use vehicles that minimize harmful additives.

· Embracing new technologies like 3D printing for dose personalization, provided excipient safety is ensured.

Ultimately, the goal is to ensure that every magistral formula is not only therapeutically effective but also unequivocally safe, adhering to the highest standards of pharmaceutical practice.

Conflict Of Interest: The authors declare no conflict of interest.