Term
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Definition
What the body
does to the drug
• ADME
• Absorption, distribution, metabolism, excretion |
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Term
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Definition
What the drug
does to the body |
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Term
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Definition
• Oral Route: Gastric pH is increased in neonates
- Acid-labile drugs (i.e. penicillin): greater
bioavailability in neonates than in older
infants/children
• Rectal Route: More frequent and higher
amplitude pulsatile contractions in lower intestine
- Dosage form may be expelled before
contents absorbed
• Intramuscular: Lower muscle mass, decreased
total volume that may be administered |
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Term
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Definition
• Total body water to lipid ratio: Neonates have higher water
to lipid ratio than older children/adults
- Volume of distribution is increased for hydrophilic
drugs (i.e., B-lactam antibiotics and
aminoglycosides) = larger weight-based doses
• Neonates have higher levels of circulating bilirubin; may
result in displacement of highly-protein bound drugs
leading to kernicterus |
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Term
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Definition
Age related maturation of
various cytochrome P450
hepatic enzymes involved in
the Phase I oxidative
metabolism of a significant
amount of medications
• CYP3A4
• CYP2C9
• CYP2C19
• CYP2D6
• CYP2E1
• CYP1A2 |
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Term
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Definition
Maturation of kidney corresponds with age. Preterm
infants and neonates with impaired renal blood flow
demonstrate lower rates of drug clearance than other
newborns.
• May require lower doses and prolonged intervals
• Therapeutic drug monitoring |
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Term
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Definition
• Pediatric dosing can be based on both the
age and weight of the patient
• Perinatal age terminology
[image] |
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Term
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Definition
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Term
| calculating postmenstrual age |
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Definition
| Calculate the neonate’s postmenstrual age by adding the gestational age and the chronological age. The gestational age is 26 weeks + (chronological age of 16 days * 1 week / 7 days) = 28 weeks corrected age as this is a preterm neonate. This neonate has a chronological age of > 14 days. The correct vancomycin dosing interval is 12 hours |
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Term
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Definition
• Premature neonate:
• Neonate born at <37 weeks gestation
• Full-term neonate
• Neonate born at 37–42 weeks gestation
• Neonate: term infant at birth to 28 days
• Infant: 1 month to 1 year
• Toddler: 1 to 3 years
• Pre-school: 3 to 6 years
• School age: 6–12 years of age
• Adolescent: 12–18 years of age
• Adult: greater than 21 years of age |
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Term
| Maximum Medication Dosage |
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Definition
• In general, doses of medications for pediatric patients
should not exceed doses for adults
• Always cross-check the maximum dose for pediatric
patients and adult patients – they may be different
• Clindamycin
25 kg patient: 20 mg/kg/day = 500 mg/day = 166 mg/dose < maximum
single dose of 400 mg
65 kg patient: 20 mg/kg/day = 1300 mg/day = 433 mg/dose > maximum
single dose of 400 mg. Round down to 400 mg po TID. |
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Term
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Definition
Supplied as concentrations (mg/mL)
May be supplied as many different concentrations
Example – amoxicillin (125mg/5 mL, 200 mg/5 mL, 250
mg/5 mL, 400 mg/5 mL)
Consider ease of administration
• Choose most concentrated product if possible to
provide least amount of volume for pediatric patients
• Round to appropriate mL (if clinically appropriate)
- Practicality of drawing up the dose in the oral
syringe
- Least measurable amount = 0.1 mL in a 1 mL oral
syringe |
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Term
| Palatability and Formulations |
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Definition
- Children about 6–8 years can swallow a
tablet or capsule
• Never assume; ask child and caregiver
• Pill trials
- Consider taste of oral liquid medications
• Worst offenders: Clindamycin, metronidazole,
ferrous sulfate • Clindamycin: may open capsule in soft food
(e.g., applesauce) |
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Term
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Definition
- Write the patient’s weight on prescription in
kilograms (kg).
• Pharmacist will be able to double-check the dose,
only if provided with the patient’s weight.
- Always prescribe the dose in milligrams (mg)
and milliliters (mL) for liquid medications.
• Select and write the concentration for
liquid medications.
• Do not write teaspoon or tablespoon. |
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Term
| LM is a 5-year-old child who weighs 40 lb and who requires amoxicillin for treatment of community-acquired bacterial pneumonia. You look up the dose in the Pediatric Dosing Handbook (Lexicomp) and determine her dose should be 90 mg/kg/day divided twice daily. What volume and concentration of amoxicillin should you prescribe for LM? |
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Definition
800 mg/ 10 ml twice daily
Convert lb to kg using conversion factor of 2.2.
Calculate the following: 40 lb / 2.2 = 18.2 kg.
Total daily dose = 90 mg * 18.2 kg = 1,638 mg/day.
Divide daily dose by 2 for twice daily dose = 819 mg every 12 hours.
Amoxicillin concentration: 200 mg/5 mL = 20.5 mL (volume). This is a large volume; therefore, recommend more concentrated formulation of 400 mg/5 mL.
Dose stays the same = 819 mg every 12 hours.
Volume to be administered is half = 10.2 mL.
Can you round dose to 10 mL? Yes, will provide 800 mg every 12 hours = 87 mg/kg/day, which is within dosing range for pneumonia |
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Term
| Compared to adults, the water-to-lipid ratio is |
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Definition
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Term
| Determining Renal Function |
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Definition
- Measuring creatinine clearance
• 24-hour urine collection
- Estimating creatinine clearance
• Cockcroft-Gault
• Schwartz Equation
- Creatinine
• Product of normal muscle breakdown
• Freely filtered
• Not reabsorbed
• Somewhat secreted |
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Term
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Definition
• Used to assess renal function in pediatrics
- Gold standard
Schwartz: CLcr = (K x L)/SCr
• CLcr measured in mL/min/1.73m2
• L = body length in cm
• K = proportionality constant
- Function of urinary creatinine excretion per unit of
body size
- Directly proportional to muscle component of body
weight during steady state conditions |
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Term
Schwartz Equation
Proportionality Constants |
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Definition
0.33 Low birth weight ≤1 year
0.45 Full-term ≤1 year
0.55 2–12 years
0.55 13–21 years female
0.70 13–21 years male |
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Term
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Definition
- Equation:
• Male: (140 - age) x (IBW)
72 x Scr
• Female: multiply male estimated clearance
by 0.85
• IBW (M) = 50 kg +2.3 kg/inch >5 feet
• IBW (F) = 45 kg + 2.3 kg/inch >5 feet
- Measured in mL/min
- Used for adult population |
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Term
Dosing Medications in Renal Insufficiency
• Renal dosing |
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Definition
• Use the calculated CrCl
• The total daily dose in renal dysfunction
should decrease
• Pediatric Lexicomp has renal dose
adjustments |
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Term
| Medications to Avoid in Children |
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Definition
Codeine, Topical Pain Relievers for Teething Pain, Tetracyclines, Highly protein-bound medications: Ceftriaxone
and Sulfamethoxazole/Trimethoprim, Salicylates |
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Term
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Definition
Different amounts of active
ingredients in each product
• Write out strength on
prescription
• That is, Tylenol #3:
Acetaminophen 120 mg and
codeine phosphate 12 mg
per 5 mL
-Can lead to “dumping” of
morphine |
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Term
| • Codeine is converted to |
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Definition
morphine by the liver
enzyme CYP2D6
• Poor metabolizers: may
experience no significant
analgesic effect
• Ultra rapid metabolizers:
may result in respiratory
depression and death
- Routine use of codeine,
especially in pediatric
patients, is being eliminated |
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Term
Codeine was often prescribed for
pain control after |
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Definition
surgery to remove
children’s tonsils and/or adenoids
• FDA’s Adverse Event Reporting
System (AERS) database was
reviewed from 1969 to 2012
- 10 deaths and three overdoses
associated with codeine
• Boxed warning (FDA’s strongest
warning)
- Risk of codeine to manage pain in
children after a tonsillectomy and/or
adenoidectomy |
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Term
| Topical Pain Relievers for Teething Pain |
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Definition
- FDA recommends avoiding topical pain relievers in
teething
• Lidocaine 2% oral viscous solution
• Topical benzocaine
- Lidocaine: new black box warning
• Serious harm: seizures, severe brain injury, and cardiac
abnormalities
• 22 case reports of severe adverse reactions including fatalities
- Benzocaine (“Orajel”): methemoglobinemia
- AAP recommendations: refrigerated teething ring, gentle
massage of child’s gums |
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Term
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Definition
Tissue hyperpigmentation in pediatric patients
• Nail, skin, bone specifically tooth enamel
• Permanent tooth discoloration
- More common with long-term use, but observed with
repeated, short courses when used during tooth
development Avoid during last half of pregnancy,
infancy, and childhood ≤ 8 years of age
• Manufacturer states to use only when the potential benefits
outweigh the risks in severe or life threatening conditions |
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Term
Highly protein-bound medications: Ceftriaxone
and Sulfamethoxazole/Trimethoprim |
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Definition
Use extreme caution in neonates due to risk of
hyperbilirubinemia, particularly in premature infants
Fatal precipitation reactions in neonates due to coadministration
of calcium-containing solutions have been
reported; concurrent use in neonates is contraindicated
Sulfamethoxazole/Trimethoprim: May be used in
infants ≥ 2 months |
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Term
Contraindicated in hyperbilirubinemic
neonates and neonates <44 weeks postmenstrual age |
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Definition
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Term
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Definition
• Salicylates such as aspirin for children with viral infections has been
associated with Reye syndrome
• OTC-labeling: Children and teenagers who have or are recovering
from chickenpox or flu-like symtpoms should not use this product.
Changes in behavior (along with nausea and vomiting) may be an
early sign of Reye syndrome. Contact your healthcare provider if these
occur.
• Caution: OTC-products may have different ingredients
- Pepto-Bismol: Bismuth salicylate – avoid in children
- Children’s Pepto-Bismol – Calcium carbonate – okay for use in children |
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Term
| Amoxicillin in pediatrics |
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Definition
Indications: First line therapy in many pediatric infections such as acute
otitis media and community acquired pneumonia
Class: Beta-lactam antibiotic
Cost: Inexpensive
Precautions/Considerations: Patients with concomitant mononucleosis
may develop erythematous rash; avoid use in patients. Chewable tablets
may have phenylalanine – consult manufacturer’s label. |
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Term
| Amoxicillin/Clavulanate in pediatrics |
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Definition
Indications: Second-line therapy for acute otitis media,
community-acquired pneumonia, bacterial sinusitis, urinary tract
infections
Class: Beta-lactam antibiotic with beta-lactamase inhibitor
Cost: Inexpensive |
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Term
| Various ratios of amoxicillin to clavulanate potassium in oral suspension |
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Definition
200 Amoxicillin 200 mg and clavulanate potassium 28.5 mg 7:1
250 Amoxicillin 250 mg and clavulanate potassium 62.5 mg 4:1
400 Amoxicillin 400 mg and clavulanate potassium 57 mg 7:1
600 Amoxicillin 600 mg and clavulanate potassium 42.9 mg 14:1 |
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Term
| Clavulanate potassium causes |
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Definition
| gastrointestinal upset, diarrhea |
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Term
| Trimethoprim-Sulfamethoxazole in pediatrics |
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Definition
Indications: Skin soft tissue infection (due to MRSA), urinary tract infection
Class: Sulfonamide antibiotic
Cost: Inexpensive
Precautions/Considerations: Dosed based on the trimethoprim component. May
increase risk for hyperkalemia in dose-dependent fashion. Dose adjustments in
renal impairment. Highly protein bound; only dosing for patients ≥2 months and
older |
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Term
Medication Errors –
How to Prevent Them |
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Definition
- Pediatric patients are 3 times more
likely to have a medication error
- >40% of caregivers make errors in
dosing liquid medications
- Counseling strategies
• Advanced communication
techniques
• Teach-back method
• Always ensure the caregiver
knows how to read the
increments on an oral syringe
and how to use it |
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Term
AAP Recommendations for Prescribers to Prevent
Dosing Errors - Prescriber Actions |
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Definition
• Confirm the patient’s weight is correct.
• Ensure the weight-based dose does not exceed the adult dose
• Double check calculations
• Write weight on each order
• Include dose and volume when appropriate
• Identify patient drug allergies and inquire at each encounter
• Write out all instructions rather than using abbreviations
• Avoid vague instructions such as “take as directed”
• Avoid use of terminal zero to the right of decimal (eg use 5 rather than
5.0)
• Use generic medication names rather than trade names
• Avoid abbreviations of drug names
• Ensure prescriptions and signatures are legible and include contact
information |
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Term
AAP Recommendations for Prescribers to Prevent
Dosing Errors - Education and Communication |
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Definition
• Stay current and knowledgeable concerning changes in medications
and treatment of pediatric conditions (AAP, FDA)
• Use pharmacist consultation if available
• Review patient’s existing drug therapy, including OTC medications or
herbal or dietary supplements, and inquire about old and new
allergies before prescribing medications
• Remain familiar with individual hospital medication ordering system
• Ensure that drug orders are complete, clear, unambiguous, and
legible. Discuss medication changes with nursing, other staff, and
families.
• Speak with patient or caregiver about medication that is prescribing
and any special precautions.
• Report errors and encourage blame-free error reporting
• Become involved in medication system development and review such
as the pharmacy & therapeutics (P&T) committee |
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Term
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Definition
• Children are not small adults.
• Utilize appropriate pediatric dosing references.
• Write the patient’s age and weight in kilograms and pounds on
prescriptions.
• Write medication doses in milligrams and milliliters, along with
concentrations on prescriptions.
• Consider volume of medications and round doses to
measurable volumes as clinically able.
• Provide medication counseling using the teach back method to
ensure caregiver knows how to properly administer
medications. |
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Term
| Which medication below should be avoided in children due to its association with fatal events and the availability of safer alternatives? |
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Definition
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