Formulary of Approved Non-Prescription Medications
(**For Children Under 12 years **)
Child: _______________________
Home: _______________________
Allergies: ____________________________________________________________
All non-prescription medication will be administered per label instructions, unless otherwise
noted below. Please check with physician for age and weight dosing. (A generic equivalent of any of
the name-brand medications listed below may be substituted.)
Non-Prescription Medication
Administration Instructions Symptoms
Acetaminophen (Tylenol, Feverall,
Under 2 years of age: call MD Fever, headache, minor aches
Tempra, non-aspirin pain reliever etc.)
and pains
Adult Regular StrengthTablets: 325
24 to 35 lbs: 5 ml of infant
mg,
liquid or 5 ml (1 teaspoon) of
Junior strength Chews or Meltaways: children’s liquid or 2 children’s
160mg
chews or meltaways
Children’s Chews or
Meltaways: 80mg,
36 to 47 lbs: 7.5 ml (1 ½
Children’s Liquid: 160 mg/5 ml
teaspoons) of children’s liquid
New Infant Liquid: 160mg/5ml use
or 3 children’s chews or
included syringe
meltaways
****Only use the dropper or dosing
cup provided – do not use a
household teaspoon****
48 to 59 lbs: 10 ml (2
teaspoons) of children’s liquid
or 4 children’s chews or
meltaways or 2 junior strength
chews or meltaways
60 to 71 lbs: 12.5 ml (2 ½
teaspoons) of children’s liquid
or 5 children’s chews or
meltaways or 2 ½ junior
strength chews or meltaways
or 1 tablet of adult regular
strength
72 to 95 lbs: 15 ml (3
teaspoons) of children’s liquid
or 6 children’s chews or
meltaways or 3 junior strength
chews or meltaways or 1 to 1
½ tablets of adult regular
strength
Over 96 lbs: 20 ml (4
teaspoons) of children’s liquid
or 8 children’s chews or
meltaways or 4 junior strength
chews or meltaways or 2
tablets of adult regular strength
Ibuprofen (Advil, Motrin, Pedicare,
Fever etc.)
Rev 04/15
May give every 4 hours.
Do not give more than 5
doses in 24 hours
12 to 17 lbs: 1.25 ml of infant Fever, menstrual cramps,
drops or 2.5 ml (1/2 teaspoon) headaches, minor aches and
Formulary of Approved Non-Prescription Medications
(**For Children Under 12 years **)
Tabs: 200 mg
Junior strength swallow
tablets: 100mg
Chewable tablets: 50mg or 100mg
Children's liquid
suspension: 100mg/5ml
Pediatric/infant drops: 50mg/1.25ml
****Only use the dropper or dosing
cup provided – do not use a
household teaspoon****
of children’s liquid suspension pains
18 to 23 lbs: 1.875 ml of infant
drops or 3.75 ml (3/4
teaspoon) of children’s liquid
suspension
24 to 35 lbs: 2.5 ml of infant
drops or 5 ml (1 teaspoon) of
children’s liquid suspension or
100 mg of chewable tablets
36 to 47 lbs: 7.5 ml (1 ½
teaspoon) of children’s liquid
suspension or 150 mg of
chewable tablets
48 to 59 lbs: 10 ml (2
teaspoons) of children’s liquid
suspension or 200 mg of
chewable tablets or 200 mg of
junior strength swallow tablets
60 to 71 lbs: 12.5 ml (2 ½
teaspoons) of children’s liquid
suspension or 250 mg of
chewable tablets or 200 mg of
junior strength swallow tablets
72 to 95 lbs: 15 ml (3
teaspoons) of children’s liquid
suspension or 300 mg of
chewable tablets or 300 mg of
junior strength swallow tablets
Over 96 lbs: 20 ml (4
teaspoons) of children’s liquid
suspension or 400 mg of
chewable tablets or 400 mg of
junior strength swallow tablets
May give every 6 hours. Do
not give more than 4 doses in
24 hours
PediaCare Multi-symptom Cold plus Under 6 years of age: Do not Frequent cough, runny nose,
Acetaminophen
use. Call MD.
nasal congestion, chest sinus
(Acetaminophen 160 mg (fever reducer),
congestion
Chlorpheniramine maleate 1mg
6 years to under 12 years of
(antihistamine), Phenylephrine HCL 2.5 age: Take 10 ml every 4 hours
mg (decongestant), Dextromethorphan while symptoms last.
HBr 5mg (cough suppressant))
Ingredients per 5 ml
Do not exceed 5 doses (50 ml)
in 24 hours.
Rev 04/15
Formulary of Approved Non-Prescription Medications
(**For Children Under 12 years **)
Robitussin
a. DM Cough and Chest Congestion
a. Under 2 years of age: Call a. Cough and Chest Congestion
MD.
2 years to under 6 years of
age: Take ½ teaspoon every 4
hours.
6 years to under 12 years of
age: Take 1 teaspoon every 4
hours.
Do not exceed 6 doses in 24
hours
b. Cough
b. Cough Long-Acting
b. Under 4 years of age: Do
not use.
4 years to under 6 years of
age: Take 1 teaspoon every 6
to 8 hours.
6 years to under 12 years of
age: Take 2 teaspoons every 6
to 8 hours.
Do not exceed 4 doses in 24
hours
c. Cough and Cold CF
c. Cough, Chest
c. Under 4 years of age: Do
Congestion/Mucus, Nasal
not use.
Congestion
4 years to under 6 years of
age: Take 1 teaspoon every 4
hours.
6 years to under 12 years of
age: Take 2 teaspoons every 4
hours.
Do not exceed 6 doses in 24
hours
d. Cough and Cold Long Acting
d. Cough, Runny Nose,
d. Under 6 years of age: Do
Sneezing, Itchy watery eyes,
not use.
Itchy nose or throat
6 years to under 12 years of
age: Take 2 teaspoons every 6
hours.
Do not to exceed 4 doses in 24
hours
Mucinex Products
a. Multi-Symptom Cold for Children
a. Under 4 years of age: Do
a. Cough, stuffy nose, chest
(Guaifenesin 100 mg, Dextromethorphan not use.
congestion
HBr 5 mg, and Phenylephrine HCL 2.5
mg in 5 ml)
4 years to under 6 years of
age: Take 5 ml every 4 hours.
6 years to under 12 years of
age: Take 10 ml every 4 hours.
Rev 04/15
Formulary of Approved Non-Prescription Medications
(**For Children Under 12 years **)
Do not exceed 6 doses in 24
hours.
b. Under 4 years of age: Do
not use
b. Cough, chest congestion
b. Cough
(Guaifenesin 100 mg and
Dextromethorphan 5 mg in 5 ml or 1
teaspoon)
4 years to under 6 years of
age: Take ½ teaspoon to 1
teaspoon every 4 hours.
6 years to under 12 years of
age: Take 1 teaspoon to 2
teaspoons every 4 hours.
Do not exceed 6 doses in 24
hours.
c. Under 4 years of age: Do
not use.
c. Chest congestion
c. Chest Congestion
(Guaifenesin 100 mg in 5 ml or 1
teaspoon)
4 years to under 6 years of
age: Take ½ teaspoon to 1
teaspoon every 4 hours.
6 years to under 12 years of
age: Take 1 teaspoon to 2
teaspoons every 4 hours.
Do not exceed 6 doses in 24
hours.
d. Under 4 years of age: Do
not use.
d. Stuffy Nose and Cold
(Guaifenesin 100 mg and
Dextromethorphan 2.5 mg in 5 ml or 1
teaspoon)
d. Nasal congestion, chest
4 years to under 6 years of
congestion
age: Take 1 teaspoon every 4
hours.
6 years to under 12 years of
age: Take 2 teaspoons every 4
hours.
Do not exceed 6 doses in 24
hours.
Delsym Children’s Cough Relief
Under 4 years of age: Do not
use.
4 years to under 6 years of
age: Take 2.5 ml every 12
hours. Do not exceed 5 ml in
24 hours.
6 years of age to under 12
years of age: Take 5 ml every
12 hours. Do not exceed 10
ml in 24 hours.
Rev 04/15
Cough
Formulary of Approved Non-Prescription Medications
(**For Children Under 12 years **)
Pseudoephedrine Hcl (Pseudoval,
Sudafed, etc.) Tabs 30 mg;
Elixir/Liquid: Children's Sudafed
15mg/5ml
Emetrol Liquid
Dramamine (Dimenhydrinate)
Under 6 years of age: Do not
use.
Congestion of ears and sinuses
6 up to 12 years of age: 30 mg
every 4 to 6 hours not to
exceed 120 mg (4 doses) in 24
hours.
Under 2 years of age: Do not Nausea
use.
2 to 12 years of age: Take 5 ml
to 10 ml every 15 minutes. Do
not exceed 5 doses in one
hour.
Under 2 years of age: Do not Nausea
use.
2 to 6 years of age: 12.5 mg
to 25 mg every 6 to 8 hours.
Do not exceed 75 mg per day.
Diphenhydramine Hcl (Benadryl,
Banophen, etc) Capsule: 25 mg;
Elixir: 12.5 mg/5 ml
Children's Liquid: 6.25 mg/5 ml
6 to 12 years of age: 12.5 mg
to 25 mg every 6 to 8 hours.
Do not exceed 150 mg per
day.
Under 6 years of age, call MD. Runny nose, sneezing
6 to 11 years of age: Take
12.5 mg to 25 mg every 4 – 6
hours not to exceed 150 mg in
24 hours.
Dyclonine 0.1% Sore Throat Spray
Spray the throat with up to 3 Sore Throat Pain/Discomfort
(Cepacol, etc)
sprays not to exceed up to 3
Ingredients per 10ml: Dextromethorphan times daily.
hydrobromide 30mg, Doxylamine
succinate 6mg, Sodium Citrate 500mg,
Cetylpyridinium Chloride 2.5mg, Alcohol
10%by volume
Calcium Carbonate: Children’s Pepto 2 to 5 years of age: Chew one Heartburn, indigestion
400 mg of calcium carbonate
tablet (400 mg). Do not exceed
3 tablets (1200 mg) in 24
hours.
OR
Tums for Kids: 750 mg calcium
carbonate per tablet
Rev 04/15
6 to 11 years of age: Chew two
tablets (800 mg). Do not
exceed 6 tablets (2400 mg) in
24 hours.
2 to 4 years of age: Chew ½
tablet (375 mg). Do not
exceed 2 tablets (1500 mg) in
24 hours.
Formulary of Approved Non-Prescription Medications
(**For Children Under 12 years **)
5 to 11 years of age: Chew
one tablet (750 mg). Do not
exceed 4 tablets (3000 mg) in
24 hours.
Mylicon Phazyme; Flatulex; Mylicon;
Gas-X; Mylanta Gas
Liquid drops: 40 mg per 0.6 ml or 20
mg per 0.3 ml
Chewable tablets: 40mg,
Chew 1 tab up to 4 times a
day. *DO NOT give with other
medications. Must be
administered 2 hours before or
2 hours after giving other
meds.
2 to 12 years of age: 40 mg
Gas
either chewable tablet or liquid
drops every 6 hours after
meals and at bedtime. Do not
exceed 240 mg in 24 hours.
Under 2 years of age: 20 mg in
liquid drop form every 6 hours
after meals and at bedtime.
Do not exceed 120 mg in 24
hours.
The drops can be mixed with
water, infant formula or other
liquids for use in small
children.
Prune Juice, Karo Syrup
Infant: use 1 to 2 TBSP per
Constipation
day mixed in formula. If no
bowel movement occurs within
five days, call for a physician
appointment.
Diaper Rash Cream
Wipe the diaper area
Diaper rash
(perineum) clean. Dry the
area. Allow the area to
breathe. Apply generous
amount of the cream and
spread in a thick layer to the
affected area.
First Aid Antiseptic
Clean the affected area first. Minor cuts, scrapes, burns
Spray (Benzalkonium Chloride: Bactine, Spay a small amount on the
etc)
area 1 to 3 times daily. May
Ingredients depended upon brand to be be covered with a sterile
used
bandage after the area has
dried.
If under 2 years of age, call
MD.
Burn Spray External Analgesic
Apply topically to affected area Minor burns
(Lidocaine HCl 2%)
1 to 3 times daily.
If under 2 years of age, call
MD.
Medicaine Swabs
Per label instructions
Insect Stings, Bites
CalaGel Medicated Anti-Itch Gel
Wash areas well to remove the Pain and Itching associated with
(Diphenhydramine HCL and
poisonous plant oil from the
Poison Oak/Ivy, Sumac, insect
ZincAcetate)
skin. Apply thin layer to
bites, rashes, minor skin
affected area.
irritations
Rev 04/15
Formulary of Approved Non-Prescription Medications
(**For Children Under 12 years **)
If under 6 months of age, call
MD.
Calamine Lotion
Wash area with cold soapy
Poison Oak, Poison Ivy, Sumac
Ingredients: Zinc Oxide, 0.5% Iron Oxide water. Apply 3 to 4 times daily
liberally to affected area and
allow to dry.
If under 6 months of age, call
MD.
Hydrocortisone Cream 1%
Clean area with soap and
Itches, Rashes, Minor Skin
10mg of Hydrocortisone in 1 Gram
water. Apply a thin layer 2 to 4 Irritations, Dermatitis
times daily to affected area.
Gently rub into affected area.
If under 2 years of age, call
MD.
Triple Antibiotic Ointment
Clean affected area with soap Minor abrasions, cuts,
Ingredients in 1 Gram: Bacitracin Zinc
and water. Apply a small
400 units, Neomycin Sulfate 3.5mg,
amount 1 to 3 times daily to
Polymyxin B Sulfate 5,000 units
affected area. May cover with
a sterile bandage.
If under 2 months of age, call
MD.
Antifungal Cream
Clean and dry the affected
Jock Itch, Athlete’s Foot, Minor
Ingredients depended upon brand to be area. Apply the cream 1 to 2 Fungal Rashes
used
times daily to affected area
being sure to cover the area
completely. Do not apply a
bandage to the area.
If under 2 years of age, call
MD.
Pain Relieving Gel/Cryotherapy
Rub a thin film over the
Minor aches and pains of sore
(menthol and camphor: Ben Gay,
affected area up to 4 times
muscles, joints, associated with
BioFreeze, etc)
daily.
strains, sprains, backaches
Ingredients: Methyl Scalicylate 30%,
If under 2 years of age, call
Menthol 10%, Camphor 4%
MD.
Sunscreen
Apply to exposed skin 20 to 30 Prevention of sunburn
Ingredients depended upon brand to be minutes prior to going outdoors
used
in the sun. Reapply after 2 to 4
hours if still outdoors. Use
lightweight clothing and hats to
reduce surface area.
Exceptions:
_____________________________________________________________________
______________________________________________________________________
______________________________________________________________________
I have reviewed both pages of this formulary, and with the exceptions noted
above, agree to the use of these Non-Prescription Medications.
Rev 04/15
Formulary of Approved Non-Prescription Medications
(**For Children Under 12 years **)
_______________________________________________
Signature of Physician
___________
Date
_______________________________________________
Printed Name of Physician
____________
Telephone
Revised 4-6-15 F Edwards, RN Nursing Director
Rev 04/15