1. Pediatric Meds Physiologic differences make children more sensitive to drugs and more at risk for adverse drug reactions Physiologic differences make children more sensitive to drugs and more at risk for adverse drug reactions Pharmacokinetics and pharmacodynamics are affected by changes in body fluid composition, differences in the cardiovasc, GI, renal, and neurological systems. Pharmacokinetics and pharmacodynamics are affected by changes in body fluid composition, differences in the cardiovasc, GI, renal, and neurological systems.

2. Physiologic Differences Physiologic differences between children and adults Physiologic differences between children and adults –Infants have immature kidneys and liver Delays metabolism and elimination of many drugs. Delays metabolism and elimination of many drugs. Slow gastric emptying time and decreased gastric acid secretion may delay absorption Slow gastric emptying time and decreased gastric acid secretion may delay absorption Infants have lower concentration of plasma proteins, therefore toxicity can occur with drugs that need to be bound to proteins. Infants have lower concentration of plasma proteins, therefore toxicity can occur with drugs that need to be bound to proteins.

3. Physiologic Differences (cont.) Infants have less total body fat and more total body water. Infants have less total body fat and more total body water. –Therefore, lipid soluble drugs require smaller doses with less fat present, and water soluble drugs require larger dosages. –As children grow, the changes in fat, muscle, body water, and organ maturity will alter the pharmaco-kinetics of drugs.

4. Variations in Medication Administration to Children See p. 540 Table 17-6 in B&B. See p. 540 Table 17-6 in B&B. Oral Oral Rectal Rectal Ophthalmic Ophthalmic Otic Otic Topcial Topcial Intramuscular Intramuscular Intravenous Intravenous

5. Oral Medications Dropper/oral syringe/teaspoon/cup/nipple Dropper/oral syringe/teaspoon/cup/nipple Do not ask child’s permission Do not ask child’s permission Give small amts down side of mouth in an infant Give small amts down side of mouth in an infant Encourage swallowing with a pacifier in an infant. Encourage swallowing with a pacifier in an infant. Crushed meds are put in a small amt of soft food: ice cream, applesauce, yogurt; must take it all. Crushed meds are put in a small amt of soft food: ice cream, applesauce, yogurt; must take it all. Do not mix meds with foods, or formula. Do not mix meds with foods, or formula. Do not try to trick child; be honest. Do not try to trick child; be honest.

6. Intramuscular Medications Vastus Lateralis is the preferred site in young children Vastus Lateralis is the preferred site in young children –Birth to 2yrs: vastus lateralis only –Except: MMR given SC in the arm at 15 mo and 5yrs. MMR given SC in the arm at 15 mo and 5yrs. DTaP given IM in deltoid at 5yrs. DTaP given IM in deltoid at 5yrs. Ventrogluteal site can be used if muscle is well developed and amount is 0.5-2ml. Ventrogluteal site can be used if muscle is well developed and amount is 0.5-2ml. Gluteus maximus (dorsal gluteal site) must not be used in the child less than 1 yr or before the child has been walking for one year; but vastus lateralis is the preferred site. Gluteus maximus (dorsal gluteal site) must not be used in the child less than 1 yr or before the child has been walking for one year; but vastus lateralis is the preferred site.

7. Intravenous Medications Infusion pumps are required Infusion pumps are required At least hourly fluid monitoring is required At least hourly fluid monitoring is required Medication volume should not fluid overload the child. Medication volume should not fluid overload the child. Agency specific policies for IV medication administration Agency specific policies for IV medication administration Given via peripheral or central line Given via peripheral or central line If a maintenance IV isn’t running, the medication needs to be flushed with saline, before and after. If a maintenance IV isn’t running, the medication needs to be flushed with saline, before and after. –Central lines require a terminal flush with Heparin when no longer in use (SASH).

8. Otic Medications Instilling ear drops Instilling ear drops –May need to clean the ear first –Position child with affected ear up –<3yrs pull pinna down and back –>3yrs pull pinna up and back

9. Ophthalamic Medications Instilling eye drops Instilling eye drops –Room temp –May need to wash eye –Supine and look up –Pull down lower lid –Allow child to blink –Dim lights allow child to open their eye more easily

10. Developmental Considerations Infants:developing trust. Involve parents in deliv. meds when possible. Infants:developing trust. Involve parents in deliv. meds when possible. Toddlers:developing autonomy. Follow routines, give choice betw 2 things, involve parents. Toddlers:developing autonomy. Follow routines, give choice betw 2 things, involve parents. Preschoolers: developing initiative. Play with safe equipment, be positive, keep choices limited and possible in reality, involve parents. Preschoolers: developing initiative. Play with safe equipment, be positive, keep choices limited and possible in reality, involve parents.

11. Developmental Considerations (cont.) Schoolagers: developing industry. Give explanations, involve them in their care, reward system as needed to instill cooperation (usually cooperative), use therapeutic play to help with coping, involve parents as appropriate to their relationship. Schoolagers: developing industry. Give explanations, involve them in their care, reward system as needed to instill cooperation (usually cooperative), use therapeutic play to help with coping, involve parents as appropriate to their relationship. Adolescents: developing identity. Give explanations at adult level (as applic). Adolescents: developing identity. Give explanations at adult level (as applic).

12. General Considerations be truthful be truthful minimally threatening minimally threatening use the 5 rights: pt,drug, dose, route, time. use the 5 rights: pt,drug, dose, route, time. discrepancies must be determined discrepancies must be determined lab results or levels may need to be consulted before administration. lab results or levels may need to be consulted before administration.

13. Dosage Determination preferred mechanism: unit of medic per Kg of body weight. preferred mechanism: unit of medic per Kg of body weight. BSA primarily used for calc. Chemotherapy (ht and wt accd to West nomogram) BSA primarily used for calc. Chemotherapy (ht and wt accd to West nomogram) mg/kg/day (24 hrs) divided by a certain amt of hrs or mg/kg/day (24 hrs) divided by a certain amt of hrs or mg/kg/dose with a defined interval. mg/kg/dose with a defined interval. adult dose may be used for > 50 or 60 Kg (per protocol). adult dose may be used for > 50 or 60 Kg (per protocol).

14. Two Methods of Drug Calc D/H x V D/H x V algebraic ratio equation A/B=C/D algebraic ratio equation A/B=C/D

15. Tylenol Suspension Give Tylenol 325mg po Q 4hrs to a 5yr old who weighs 25Kg. Give Tylenol 325mg po Q 4hrs to a 5yr old who weighs 25Kg. Tylenol Susp. Comes 160mg/teaspoon; 1tsp=5ml Tylenol Susp. Comes 160mg/teaspoon; 1tsp=5ml How much will you give? How much will you give?

16. Tylenol Suspension Answer 160mg/5ml= 325mg/X 160mg/5ml= 325mg/X Or D/H X V= 325/160 X 5ml Or D/H X V= 325/160 X 5ml Answer: 10 ml Answer: 10 ml

17. Tylenol SDR Tylenol SDR is 10-15mg/kg/dose not to exceed the daily max dose. Tylenol SDR is 10-15mg/kg/dose not to exceed the daily max dose. What is the SDR for this child of 25 Kg? What is the SDR for this child of 25 Kg? What is the daily max dose if it is not to exceed 5 doses/24hrs? What is the daily max dose if it is not to exceed 5 doses/24hrs?

18. Tylenol SDR Answer 10 ( 25 Kg)- 15 (25Kg)= 250mg-375mg per dose 10 ( 25 Kg)- 15 (25Kg)= 250mg-375mg per dose SDR per day would be 5(250)-5(375)=1250- 1875mg per day SDR per day would be 5(250)-5(375)=1250- 1875mg per day Daily max. dose not to exceed 5 doses of 325mg would be 5(325mg)=1625mg in 24hrs. Daily max. dose not to exceed 5 doses of 325mg would be 5(325mg)=1625mg in 24hrs. So, SDR ok for per dose as well as per day. So, SDR ok for per dose as well as per day.

19. Amoxicillin Oral Suspension Give Amoxicillin 450mg po TID to a 2.5yr old who weighs 15kg for an ear infection. Give Amoxicillin 450mg po TID to a 2.5yr old who weighs 15kg for an ear infection. Amoxicillin comes 250mg/5ml Amoxicillin comes 250mg/5ml SDR is 90mg/kg/day for Otitis Media SDR is 90mg/kg/day for Otitis Media Is it within SDR? Is it within SDR? How much will you give per dose? How much will you give per dose?

20. Amoxicillin Oral Suspension Answer SDR: 90mg(15Kg)=1350mg per day. SDR: 90mg(15Kg)=1350mg per day. Given TID so would give 1350 /3= 450mg per dose (as ordered) so dose is a safe dose. Given TID so would give 1350 /3= 450mg per dose (as ordered) so dose is a safe dose. How many ml’s to deliver this dose: How many ml’s to deliver this dose: –250mg/5ml =450mg/X –Or D/H X V: 450mg/250mg X 5ml –Answer: 9 ml.

21. Cefazolin 300mg IV Q 8hrs Cefazolin 300mg IV Q 8hrs –Age 3yrs: Wt 9.8 Kg –SDR Cefazolin = 50-100mg/kg/24hrs Q 8 hr. –Calc recomm dose for this child, compare it to ordered dose, action needed?

22. Cefazolin 300mg IV Q 8hrs SDR for this child : SDR for this child : 50(9.8)-100(9.8)= 490-980mg/24hrs 50(9.8)-100(9.8)= 490-980mg/24hrs child receives 900mg/day (300mg Q 8hr=300x3=900) OR child receives 900mg/day (300mg Q 8hr=300x3=900) OR 490/3= 163mg/dose up to 980/3=326mg/dose (300mg/dose) 490/3= 163mg/dose up to 980/3=326mg/dose (300mg/dose) child’s dose is within SDR (either per dose or per day); safe to give. child’s dose is within SDR (either per dose or per day); safe to give.

23. Extraction of dose needed from multi-dose container Cefazolin 300mg comes in a multi-dose syringe labeled 900mg/30ml. Cefazolin 300mg comes in a multi-dose syringe labeled 900mg/30ml. How many ml’s will you deliver to give the correct dose of 300mg? How many ml’s will you deliver to give the correct dose of 300mg? 900mg/30ml=300mg/X 900mg/30ml=300mg/X 900X=30(300): X= 300(30)/900 900X=30(300): X= 300(30)/900 =10ml OR =10ml OR D/H X V : 300/900 X 30 = 10ml. D/H X V : 300/900 X 30 = 10ml.

24. Ranitidine 50mg IV Q 8hr to a 3yr old weighing 18Kg Ranitidine comes in a multidose syringe of 150mg/30ml Ranitidine comes in a multidose syringe of 150mg/30ml SDR for infants/children is 2-4mg/kg/24hr divided Q 6-8hrs SDR for infants/children is 2-4mg/kg/24hr divided Q 6-8hrs What is the SDR? Action needed? What is the SDR? Action needed?

25. Ranitidine Answer SDR: 2(18)-4(18)=36-72 mg/24hr SDR: 2(18)-4(18)=36-72 mg/24hr SDR per dose: 36/3=12 mg up to SDR per dose: 36/3=12 mg up to 72/3=24mg per dose. Dose ordered is 50mg Q 8hr which exceeds the SDR so would notify the physician.

26. IV Rate Calc. Use micro drippers in pedi Use micro drippers in pedi Ml/hr = gtts/min Ml/hr = gtts/min A rate of 100ml/hr would be set at 100ml/hr (which is the same as 100gtts/min) A rate of 100ml/hr would be set at 100ml/hr (which is the same as 100gtts/min)

27. IV fluids administered as a bolus over time. If 250ml NS is administered via microdrip over 3 hrs: If 250ml NS is administered via microdrip over 3 hrs: –volume X gtts/min = 250 X 60 = 15000= 83.3 – time 180 –Or 250 / 3 = 83.3ml/hr –The IV rate would be set to 83.3 for three hours and checked hourly.

28. Maintenance IV Fluid The maintenance IV fluid of D5 ½ 20 KCL/L is supposed to run at a rate of 60ml/hr. What would be the IV pump rate? 80 ml/hr 80 ml/hr 20 ml/hr 20 ml/hr 60 ml/hr 60 ml/hr 100 ml/hr 100 ml/hr

29. Answer to Maintenance IV Fluid The rate would be 60 ml/hr. The rate would be 60 ml/hr. 80 and 100 ml/hr are incorrect. 80 and 100 ml/hr are incorrect. You only divide the total amount to be delivered by time when it is a bolus, or a times amount of fluid delivery. You only divide the total amount to be delivered by time when it is a bolus, or a times amount of fluid delivery.

30. Agency Policy re: size of bag to hang for maintenance fluids The size of the bag for maintenance fluid should be consistent with agency policy The size of the bag for maintenance fluid should be consistent with agency policy For example, for all children 6yrs and younger no more than 500ml bags should be used for maintenance fluid. For example, for all children 6yrs and younger no more than 500ml bags should be used for maintenance fluid. Therefore, a 1L bag of IV maintenance fluid would be against agency policy for the child 6 yr and younger. Therefore, a 1L bag of IV maintenance fluid would be against agency policy for the child 6 yr and younger.