Pediatric Meds
• 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.
Physiologic Differences
• Physiologic differences between children
and adults
– Infants have immature kidneys and liver
• Delays metabolism and elimination of many drugs.
• 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.
Physiologic Differences (cont.)
• 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.
Variations in Medication
Administration to Children
•
•
•
•
•
•
•
•
See p. 540 Table 17-6 in B&B.
Oral
Rectal
Ophthalmic
Otic
Topcial
Intramuscular
Intravenous
Oral Medications
•
•
•
•
•
•
•
Dropper/oral syringe/teaspoon/cup/nipple
Do not ask child’s permission
Give small amts down side of mouth 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.
Do not mix meds with foods, or formula.
Do not try to trick child; be honest.
Intramuscular Medications
• 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.
• DTaP given IM in deltoid at 5yrs.
• 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.
Intravenous Medications
•
•
•
•
•
•
Infusion pumps are required
At least hourly fluid monitoring is required
Medication volume should not fluid overload the child.
Agency specific policies for IV medication administration
Given via peripheral or central line
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).
Otic Medications
• 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
Ophthalamic Medications
• 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
Developmental Considerations
• Infants:developing trust. Involve parents
in deliv. meds when possible.
• 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.
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.
• Adolescents: developing identity. Give
explanations at adult level (as applic).
General Considerations
• be truthful
• minimally threatening
• use the 5 rights: pt,drug, dose, route,
time.
• discrepancies must be determined
• lab results or levels may need to be
consulted before administration.
Dosage Determination
• preferred mechanism: unit of medic per
Kg of body weight.
• 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/dose with a defined interval.
• adult dose may be used for > 50 or 60 Kg
(per protocol).
Two Methods of Drug Calc
• D/H x V
• algebraic ratio equation A/B=C/D
Tylenol Suspension
• Give Tylenol 325mg po Q 4hrs to a 5yr old
who weighs 25Kg.
• Tylenol Susp. Comes 160mg/teaspoon;
1tsp=5ml
• How much will you give?
Tylenol Suspension Answer
• 160mg/5ml= 325mg/X
• Or D/H X V= 325/160 X 5ml
• Answer: 10 ml
Tylenol SDR
• 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 daily max dose if it is not to
exceed 5 doses/24hrs?
Tylenol SDR Answer
• 10 ( 25 Kg)- 15 (25Kg)= 250mg-375mg per
dose
• 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.
So, SDR ok for per dose as well as per day.
Amoxicillin Oral Suspension
• Give Amoxicillin 450mg po TID to a 2.5yr
old who weighs 15kg for an ear infection.
• Amoxicillin comes 250mg/5ml
• SDR is 90mg/kg/day for Otitis Media
• Is it within SDR?
• How much will you give per dose?
Amoxicillin Oral Suspension Answer
• SDR: 90mg(15Kg)=1350mg per day.
• 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:
– 250mg/5ml =450mg/X
– Or D/H X V: 450mg/250mg X 5ml
– Answer: 9 ml.
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?
Cefazolin 300mg IV Q 8hrs
• SDR for this child :
• 50(9.8)-100(9.8)= 490-980mg/24hrs
• child receives 900mg/day (300mg Q
8hr=300x3=900) OR
• 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.
Extraction of dose needed from
multi-dose container
• 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?
• 900mg/30ml=300mg/X
• 900X=30(300): X= 300(30)/900
• =10ml OR
• D/H X V : 300/900 X 30 = 10ml.
Ranitidine 50mg IV Q 8hr to a
3yr old weighing 18Kg
• Ranitidine comes in a multidose syringe of
150mg/30ml
• SDR for infants/children is 2-4mg/kg/24hr
divided Q 6-8hrs
• What is the SDR? Action needed?
Ranitidine Answer
• SDR: 2(18)-4(18)=36-72 mg/24hr
• 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.
IV Rate Calc.
• Use micro drippers in pedi
• Ml/hr = gtts/min
• A rate of 100ml/hr would be set at
100ml/hr (which is the same as
100gtts/min)
IV fluids administered as a bolus
over time.
• 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.
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
• 20 ml/hr
• 60 ml/hr
• 100 ml/hr
Answer to Maintenance IV Fluid
• The rate would be 60 ml/hr.
• 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.
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
• 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.