Pediatric

Considerations
Presented by:
Tahreem Ikram
Sameera
Mushtaq
CONTENTS
 Medication Administration issues in children
 Medication error and prevention
 Drug administration
a. Oral medications
b. Ear, Nose, Eye drops
 Infents care (Teething, Diaper rash, Fever, Cough and cold,
Constipation, Vomiting and diarrhea, Gastroesophageal reflux, Sedation
and analgesia)
 Unique pediatric disorders (Hemolytic uremic syndrome, Idiopathic
thrombocytopenic purpura, Chronic idiopathic thrombocytopenic
purpura, Nephrotic syndrome)
Medication administration:(issues)
🠶 The safe and effective use of medication in children is challenging
because of:-
1. Lack of FDA approved indications and dosing guidelines for children
2. Limited evidence based medicines use
3. Pacuity of appropriate dosage formulations
 This focus on general principles guiding pediatric pharmacotherapy
of common pediatric disorders.

Medication error and prevention: ( causes)

The lack of appropriate information/guidelines for use of medication in
children, the miscalculation of doses, need of compound oral dosage forms
or to dilute commercially available formulation.
• Efforts have increased to improve medication ordering processes, to
standardize medication concentrations, to educate practitioners
about medication error prevention.
 Oral medications:
🠶 To a young child/infent require 2 adults, one to gently restrain the child while
other rapidly & accurately administer the medication. If only one adult is
available , one can restrain the arms & legs of child in a swaddling blanket/
large towel.
 The administration devices(CUP, SYRINGE, DROPPER)
accompainies liquid medicine of desired dose
• Oral syringe 1-2ml
• Household teaspoons not recommended
• Crushed tab/capsule mixed in
small amount of food(syrup)
• Medicine can be delivered in
small amount(10-15ml) of liquid
in a bottle
• Doses should not be diluted
into an entire scheduled
feeding or batches for future
adm.
(continue)
🠶 Otic medication should be instilled by putting the auricle down and out
in infents, but in adult auricle is up and
back to straighten the canal.

🠶 For installation of nose and

eyedrops, position the infent &
toddler with their head lower than
the rest of body because gravity
assists in dispersing the
medication.

🠶 To minimize the fear and improve

cooperation, explain the
procedures to children as simply as
possible.
🠶 Best to warm the medication
in your hand( few minutes
 TEETHING
🠶 Growth & development begin at 6th week of embryonic life, calcification
of enamel &dentin begins at 4th month of gestation, normal eruption
begins before 4-5 months of age and completed by 36 month of age.
🠶 Delayed and early eruption
🠶 Sign & symptoms: restlessness, increased salvation, thumb sucking,
gum rubbing and decreased appetite.
🠶 Treatment: gentle irrigation with water, a topical anesthetics gently rubbed
on mucous membrane with cotton applicator, no use of “local
anesthetic” for longer term, no “LIDOCAINE” use due to toxicity, firm/blunt
object chewing, wrapping cracked ice in soft cloth.
• Orabase baby analgesic teething gel
• Ibuprofen and Acetaminophen for younger children
 DIAPER RASH
🠶 Diaper Dermatitis: is not well defined, (chemical irritants, friction, bacteria,
skin wetness, pH) causes skin inflammation in diaper area, persistant
rashes can lead to localized fungal/bacterial infections.
🠶 Clinical presentation: mild scaling rash in perianal area, red
confluent erythemia, ulceration.
🠶 Treatment: change diaper as soon as possible at least every 2-4 hour
during the day, keep diaper area clean, use super absorbent disposable
diaper at night, expose diaper area to air oftenly, dry area completely
before applying new diaper,
🠶 Apply low potency “TOPICAL CORTICOSTEROIDS”, such as 0.5-1%
hydrocortisone twice daily upto 1 week in case of severe
inflammation.
 FEVER
🠶 Is defined as “an oral temperature >37.8 C(100 F), an axillary Temperature
>37.2 C(99 F), in children <5 years of age, a rectal temperature >38 C
(100.4 F).
🠶 Risk of Febrile Seizures: occur in children of 6 months- 5 years of age
who have increased temperature elevations as >38 C.
🠶 TYPES:1. Simple(last<15mins & do not have significant focal feature.
2. Complex(have longer duration with focal changes)
 TREATMENT: ( antipyretic therapy)
• Acetaminophen usual oral/rectal dose is 10-15mg/kg/dose every 4-6hr,
needed to a maximum of 65mg/kg/day(1st line drug in children)
• Ibuprofen is adm. as 5-10mg/kg/dose every 6-8hr to maximum of
40mg/kg/day(available as infant drop and child susoension)
• Aspirin not recommended.
 COUGH AND COLD

🠶 SIGN AND SYMPTOMS: sore throat, nasal congestion, rhinorrhea, sneezing,

cough and irritability.
🠶 TREATMENT: use of:
• Topical nasal decongestants(phenylephrine)
• Antihistamines are not effective for rhinorrhea and are not
recommended
• Antitussives should not be used if cough is productive
• Expectorants (guaifenesin) are also not effective
• CDC recommends: not to use OTC cough medicines for <2years of age
unless advised by doctor & if need, prescribe nonprescription
medication containing single agent.
 CONSTIPATION

🠶 Defined as stool frequency of less then 3 per week/ occurance of pain

on defecation(signifying hard stools), due to diet low in fiber, lack of
time/routine for toileting, passage of painful stool resulting in fear of
defecation.
🠶 Stool retention over time may result in soiling/encorpresis.
🠶 The recommended medication for treatment of constipation are:
1. OSMOTIC AGENT (lactulose, sorbitol, barley malt extract,
magnesium hydroxide, phosphate anema)
2. LUBRICANT (mineral oil)
3. STIMULANTS (senna, biscodyl, glycerin suppositories).
 VOMITING AND DIARRHEA
 Vomiting or emesis is defined as forceful expulsion of gastrointestinal (GI) contents
through the mouth or nose; nonforceful expulsion of GI contents is considered
regurgitation.
• In newborns, regurgitation of small amounts of breast milk or formula after feeding,
especially when burping, is common. In most cases, regurgitation usually resolves by 1
year of age and rarely causes a problem
• Other causes of vomiting during the newborn period include pyloric stenosis,
gastroesophageal reflux, overfeeding, food intolerance, and GI obstruction. Beyond the
neonatal period, the most common cause of vomiting is infection.
 Diarrhea refers to an increase in frequency, volume, or liquidity of stool when
compared with normal bowel movements.
• Acute diarrhea in infants and children generally is abrupt in onset, lasts a few days,
and usually is caused by viruses.
• Diarrhea is considered chronic if it is longer than 2 weeks in duration and can be
caused by malabsorption, inflammatory disease, alteration of intestinal flora, milk or
protein intolerance, and drugs.
Dehydration can occur easily as acute net intestinal fluid losses are relatively much
greater in young children than in adults. This may result from inefficient transport
systems in the developing intestine. In addition, the percent of total body water in
children is higher than in adults; thus, they are more susceptible to body fluid shifts. Total
body water changes from 80% of total body weight in premature infants to 70% in term
infants and 60% in adults. Finally, the renal capacity to compensate for fluid and
electrolyte imbalances in the infant is limited compared with an adult's.

Causes of Vomiting in Infants and Children

1)Drug induced- Narcotics,cancer chemotherapy,theophylline,antibiotics,alcohol,anesthetics
2)Metabolic or Endochrine disorders
3)Infectious Diseases - otitis media,meningitis,appendicitis,Uti,viral or bacterial gastroentitis
4)Mechanical Obstruction - bowel obstruction,pyloric stenosis
5)Inflammatory - pancratitis,inflammatory bowel disease,peptic ulcer disease
6)Psycologic - chemotherapy,bulimia
7)Miscellaneous - gastroesophageal reflux,intracranial pressure,head injury or trauma,food intolerance
 Oral Replacement Therapy
• Treatment should be focused on the prevention of dehydration and the restoration and
maintenance of adequate fluid and electrolyte balance. Mild to moderate diarrhea without
dehydration generally is managed at home by continued age-appropriate feeding. Fluid
losses in stools can be replaced with a glucose-containing ORS.
• Oral glucose–electrolyte formulations (e.g., Pedialyte), designed to enhance glucose and
sodium absorption, are commercially available and should be used in infants and young
children. Gatorade is an alternative for older children, but carbonated beverages and fruit
juices do not contain sufficient sodium to replace diarrheal losses. Rehydration and
maintenance solutions can be made more palatable with sugar-free flavorings (e.g., Kool-
Aid, Crystal Lite).
• The World Health Organization (WHO) formerly promoted use of an oral replacement
solution (WHO formula) containing sodium (90 mEq/L), potassium (20 mEq/L), bicarbonate
(30 mEq/L), chloride (80 mEq/L), and 2% glucose for the widespread management of acute
diarrhea in third-world countries. The WHO formula, which had a 90% successful
rehydration rate for the management of diarrhea, contained a high concentration of
sodium because secretory diarrhea (e.g., cholera) is associated with substantial loss of
sodium. Malabsorptive diarrheas, such as those associated with rotavirus infections, are
associated with much lower loss of sodium (<40 mEq/L). Although commercially available
ORS contain less sodium than the WHO formulation, these preparations were equally
effective as the WHO formula
 Drug Therapy
What medications can be recommended for the treatment of diarrhea in children?

• Antibiotics should be used only when systemic bacteremia is suspected; when

immune defenses are compromised; or when a persistent enteric infection is sensitive
to antibiotics.
• In general, antidiarrheal preparations are not recommended for infants or children
because they have little effect on acute diarrhea, are associated with side effects, and
direct attention away from the use of oral hydration therapy.
• Drugs that alter GI motility should be avoided, especially in children with high fever,
toxemia, or bloody mucoid stools, because they may worsen the clinical course of the
bacterial infection. Adsorbents, such as Kaopectate, adsorb bacterial toxins and water
and lessen the symptoms of diarrhea by producing more formed stools, but they do
not decrease the duration of diarrhea or fluid and electrolyte losses. Kaopectate also
can adsorb nutrients, enzymes, and antibiotics
• Probiotics are most useful in infectious viral gastroenteritis (but not in bacterial
infections) when used early in the course of disease. Lactobacillus GG, in doses of at
least 106 to 109 colony-forming units per day, has been the most consistently
beneficial in clinical trials
 Gastroesophageal Reflux
Most reflux in infants is believed to be caused by transient relaxations of the lower
esophageal sphincter (LES). Infants also might be predisposed to reflux because of their body
positioning (e.g., slumped over in a car seat or lying supine); their consumption of a liquid
feeding that exceeds the volume capacity of the stomach; and in premature infants, a
decrease in peristaltic activity. Infants and young children also might have undiagnosed
underlying conditions that predisposes them to reflux (e.g., neurologic disorders, hiatal hernia,
hypertrophic pyloric stenosis, cow's milk protein allergy).Of cases of reflux in infants, 80% are
benign and resolve by 18 months of age,39 and reflux in older children resolves in a
timeframe similar to that of adults. If untreated, GER can result in esophageal strictures
Clinical Presentation
• symptoms often are nonspecific (e.g., failure to thrive [FTT], recurrent pneumonia, apnea,
dysphagia, reactive airway disease, apparent life-threatening events [ALTE], hematemesis
• additional symptoms (e.g., FTT, irritability, ALTE, respiratory difficulties)
Treatment
Therapy should focus on providing symptom relief and maintaining normal growth. The goals
of therapy are to heal esophagitis and prevent complications in infants and children with
pathologic GER so that surgery can be avoided. Infants and young children with underlying
neurologic problems (e.g., cerebral palsy) are unlikely to have spontaneous resolutions of GER
and frequently require aggressive antireflux therapies and surgical intervention.
 Drug Therapy
Oral Drugs Used to Treat GER in Infants
1)Acid Suppressing Agents
2)Antacids (aluminum or magnesium hydroxide)
3)Proton Pump Inhibitors(Omeprazole,Esomperazole,Lansoprazole,Pantoprazole)
4)H2 Receptor Antagonists(Cimetidine,Famotidine,Nizatidine)
5)Prokinetic Agents(Bethanechol,Cisapride,Metoclopramide,Erythromicin)
6)Surface Active Agents(Sucralfate)

Sedation and Analgesia

Sedation
Conscious Sedation
Sedation often is needed for children who must undergo diagnostic or therapeutic
procedures or when placed in an intensive care setting. In general, the IV
administration of drugs provides the most rapid onset of action. The absorption of
intramuscularly (IM), rectally, or orally administered sedatives can be variable,
especially in infants and young children.
 Drugs Commonly Used for Conscious Sedation

1)Chloral hydrate Pentobarbital induces sedation in children more

2)Diazepam (Valium) rapidly than chloral hydrate and has shorter
duration of action. A lower milligram per kilogram
3)Fentanyl (Sublimaze)
dose of pentobarbital is needed in older patients
4)Lorazepam (Ativan) than younger infants and children. Intravenous
5)Meperidine (Demerol) pentobarbital should be given in 1 mg/kg
6)Midazolam (Versed) increments to minimize risk of respiratory
7)Morphine depression. Paradoxical reactions (e.g.,
8)Pentobarbital (Nembutal) excitation and hyperactivity) can occur with
9)Propofol (Diprivan) barbiturates; however, the administration of a
10)Combination drugs narcotic (e.g., morphine) to the excited child can
convert the reaction to a peaceful sedation.
11)Thorazine
12)Ketamine Morphine and fentanyl can provide both sedation
13)Etomidate and analgesia in patients undergoing painful
14)Dexmedetomidine procedures (e.g., bone marrow biopsy).
Propofol, an anesthetic agent, appears safe as a sedative for
Benzodiazepines (i.e., lorazepam, diazepam, and
elective pediatric procedures. It is as effective as other sedatives,
midazolam) can induce sedation, hypnosis, muscle
and is associated with shorter recovery times and hospital stays.
relaxation, and amnesia, and can decrease anxiety in
Transient hypotension and severe respiratory depression can occur,
patients undergoing procedures
however, and the patient should be closely monitored.
 Intensive Care Unit Sedation

Children who require mechanical • Propofol, with its a rapid onset of action and quick
ventilation commonly receive medication recovery from sedation on discontinuation, is
to induce sedation to obviate resistance commonly utilized in the ICU.
from the patient during ventilator • This drug does not provide analgesia and should
manipulations. Children who receive drugs be combined with a narcotic when used after a
to induce paralysis also generally need painful procedure. Adequate sedation is usually
adequate sedation to minimize the fear achieved with a bolus dose followed by a
continuous infusion titrated to effect.
associated with being aware but unable to • Adverse effects of propofol include hypotension,
move. Critically ill children often require dose-dependent respiratory depression,
constant sedation; therefore, medication myoclonus, and seizure activity.
should be administered on a set schedule • Prolonged propofol infusions have been
or as a continuous IV infusion rather than associated with a “propofol-related infusion
on an as needed (PRN) basis. syndrome” characterized by persistent and
worsening metabolic acidosis, cardiovascular
instability, arrhythmias often resistant to
aggressive management, and fatalities
 Analgesia
Inadequate pain control in children usually is the result of inaccurate pain assessment or
misconceptions about pain. The pain experienced by infants and children often has been treated
less aggressively than pain in adults
Narcotic analgesics
• Morphine is one of the most commonly used agents to treat moderate and severe pain in
children and the pharmacokinetic parameters of this drug are well established. The elimination
and clearance of morphine in children >5 months of age is similar to that in adults. Neonates
demonstrate decreased clearance of morphine and a longer elimination half-life when
compared with older infants and children
• Fentanyl, a popular analgesic because of its rapid onset and short duration of action, is most
often administered as a continuous or epidural infusion for the management of postoperative
pain. It also is administered as an intermittent bolus for short procedures. Fentanyl is highly
lipophilic and rapidly penetrates the blood–brain barrier. Because it has a larger volume of
distribution in neonates, infants, and toddlers, higher dosages may be needed to achieve a
desired effect
• Codeine often is administered orally in combination with acetaminophen to treat mild to
moderate pain. It should not, however, be administered parenterally because parenteral
administration offers no advantage over the IM administration of morphine or meperidine and
is potentially dangerous. Serious adverse events after IV or IM administration of codeine have
occurred in both children and adults
 Non-Narcotic Analgesics

Acetaminophen, salicylates, or nonsteroidal anti-inflammatory drugs (NSAID) commonly are

used for treatment of mild to moderate pain Salicylates and NSAID can have an opioid-
sparing effect and are useful in the management of bone pain and pain associated with
inflammation. Aspirin is not used routinely in children because of its association with Reye's
syndrome. Ketorolac (Toradol) is the only NSAID available parenterally.Side effects associated
with salicylates and NSAID are minimal, although gastritis may occur, especially after
prolonged use. NSAID also have been associated with renal toxicity.

Unique Pediatric Disorders

Hemolytic Uremic Syndrome

It is characterized by microangiopathic hemolytic anemia, thrombocytopenia, and acute

renal failure. HUS typically occurs several days to 2 weeks after an episode of
gastroenteritis, upper respiratory tract infection, or acute flulike illness. HUS is classified into
diarrhea-associated (D+) and non–diarrhea-associated (atypical or D-) illness.
Diarrhea-associated HUS is more frequent, has seasonal variation, and occurs
primarily between 6 months and 4 years of age.
It most often is associated with E. coli (usually subtype O157:H7) that produces a
vero-cytotoxin similar to the shiga-toxin produced by Shigella species.
Pathologically, WBC activation and endothelial cell injury in the kidney lead to fibrin
deposition and platelet adherence to vessel walls. Glomerular lumens are swollen
and occluded resulting in renal insufficiency. Red blood cells (RBC) and platelets are
damaged by the fibrin strands as they pass through the narrowed vessels.
Abnormalities in coagulation involving prostacyclin-thromboxane axis and von
Willebrand factor have been implicated in the pathogenesis of thrombocytopenia.
How can STEC infection be prevented?
The risk of STEC infection can be minimized by using the following guidelines.
Wash all fresh food thoroughly.
Remove the outer leaves of lettuce and greens.
Cook chicken and ground meats until all pink is gone and juices run clear.
Cook fish until it is opaque and flakes easily.
Do not drink unpasteurized milk, milk products, or juices.
Do not eat raw eggs.
Wash hands with soap and water after using the bathroom, changing diapers,
before eating, and after handling raw meat, poultry, or seafood.
 Treatment
Therapy should be directed at managing the complications (e.g., fluid and electrolyte imbalance,
anemia, thrombocytopenia, renal failure, hypertension, seizures) that are associated with HUS.
Antimotility agents should be avoided because, in addition to having little if any clinical benefit,
they may increase morbidity.
What other modes of therapy have been used to treat HUS in children?
Many treatments (e.g., aspirin, dipyridamole, heparin, streptokinase, urokinase, corticosteroids)
have been evaluated in cases of HUS, but few have improved outcomes.98,99 Plasmapheresis and
plasma infusion, exchange transfusions, and fresh frozen plasma administration also have been
ineffective. Although a vaccine for E. coli O157:H7 has been studied, it is not yet approved for
clinical use: a toxin binding agent has been clinically evaluated and found ineffective.
Idiopathic Thrombocytopenic Purpura
Idiopathic thrombocytopenic purpura (ITP) in children generally is an acute, self-limited, benign
disease with spontaneous remission occurring in approximately 80% of cases within 6 months of
diagnosis whether treated or not. Chronic ITP evolves from the acute form in approximately 25% of
cases, although <10% of these are clinically significant. Mortality rates are low, and most deaths
can be attributed to intracranial hemorrhage, which occurs in <1% of children with platelet counts
<10,000/mm3.The social and psychological effects that occur secondarily to restriction of normal
childhood physical activity is the primary morbidity.
 Treatment
Observation, splenectomy, glucocorticoids, IVIG, and anti-D immune globulin have been
used to treat acute ITP. Platelet transfusions are ineffective because infused platelets are
removed rapidly by the reticuloendothelial system.
Goals of Therapy
The ultimate goal of therapy for ITP is induction of remission. If remission does not occur,
therapy is aimed at maintenance of hemostatic platelet levels and prevention of
catastrophic hemorrhage. Severe internal bleeding has occurred in patients, however,
despite treatment with steroids or IVIG. Another goal of therapy is to avoid performing a
splenectomy, which would put the child at an increased risk for infections.

Chronic Idiopathic Thrombocytopenic Purpura

Chronic ITP is defined as thrombocytopenia lasting >6 months. Different approaches exist
for the treatment of chronic ITP, but all agree that splenectomy should be delayed to allow
for spontaneous remission as long as hemostatic platelet counts are maintained and the
child remains asymptomatic
To maintain adequate platelet counts or to control symptoms before splenectomy is
needed, IVIG, anti-D, or glucocorticoids have been prescribed.IVIG sometimes is cited
as the treatment of choice for chronic ITP because it has relatively few side effects.
Doses of IVIG (0.8–1 g/kg) or anti-D (50–75 mcg/kg) might need to be repeated to
maintain hemostatic platelet counts.108 Long-term steroid use is discouraged because
steroids have not been consistently effective, and because of adverse events (e.g.,
exacerbation of thrombocytopenia, delayed bone growth).

Nephrotic Syndrome

Nephrotic syndrome in children typically is characterized by proteinuria,

hypoalbuminemia, edema, and hypercholesterolemia. Overall, it is a relatively rare
pediatric disorder with an incidence of 2 to 7 cases per 100,000 children under 18 years
of age. This idiopathic nephrotic state can present as minimal change nephrotic
syndrome or focal segmental glomerular sclerosis. Minimal change disease is in part
characterized by normal glomeruli on microscopic analysis. It is by far the more
common manifestation in children, with >75% of those <12 years of age having this
type of nephritic syndrome.
 Treatment
• Patients with nephrotic syndrome have an increased total body sodium owing to increased
retention, even in the presence of low serum levels and decreased intravascular volume.
Therefore, sodium restriction is important. Although it is not practical to set a sodium limit
in children, a “no-added salt” diet is usually recommended in which family support and
participation is crucial. Many institutions will provide patients with examples of foods that
are low in sodium (e.g., fresh beef or chicken, fresh vegetables). Patients may eat the
normal recommended daily allowance of protein, because protein restriction does not
consistently decrease proteinuria or have an impact on the progression of renal disease.

• A regimen of prednisone 2 mg/kg/day or 60 mg/m2/day (80 mg/day maximum) for 4

weeks, followed by 2 mg/kg/day or 40 mg/m2/day every other day, and subsequently
tapered over another 4 weeks generally constitutes the first line of therapy. Single daily
dosing is as effective as daily divided dosing. Some data support a longer regimen of 6
weeks of every day therapy followed by 6 weeks of every other day therapy. Longer
treatment courses (i.e., 5–7 months, including daily therapy for 4 to 8 weeks followed by
every other day therapy) might prove to be more effective in preventing relapse. Adverse
effects are not significantly different with the longer regimens.
What other complications are possible in children with nephrotic syndrome?

• Nephrotic syndrome can lead to a hypercoagulable state, which has been attributable
to increased factor V and VIII, increased fibrinogen, decreased coagulation inhibitors
(e.g., antithrombin III), and increased platelet activity.

• Children with nephrotic syndrome have an increased risk of infection secondary to

alterations in circulating immune globulins, cellular immunity, and chemotaxis.

• Hyperlipidemia is a common complication of nephrotic syndrome, but it usually

resolves spontaneously in steroid-responsive patients. Lipid levels may remain
elevated in steroid-resistant patients and, if diet intervention is insufficient, bile acid
sequestrants are FDA approved for use in pediatric patients.