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Health.1 > Neonates, Paediatrics and Adolescents > Flashcards

Neonates, Paediatrics and Adolescents Flashcards

1
Q

Describe the significant factors affecting the pharmacokinetics and pharmacodynamics of drugs in neonates, children and adolescents

Identify where to find information to inform your discussions regarding the safety of taking medicines in children

Recognise the importance of modifying your pharmaceutical care to the appropriate age of the patient at different stages of development and maturity

A
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2
Q

age categorisation and overlap in what?

A 
premature baby
newborn (neonate) 0-27days
infant 28days-2years
child 2-11 years
adolescent 12-16/18

overlap in development- cognitive, physical etc

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3
Q

where do highest % infant deaths occur (age cat)?

A

neonatal period: 70%

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4
Q

standard drugs prescribed to (homeogenous) adults regardless of what 5 aspects?

A 
height
weight
renal function
liver function
body composition

but children= NOT homogenous, each individual

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5
Q

BNFc general guidance for children

A

Meds only given when necessary and in all cases of potential benefit>risk

carefully discuss treatment options with child and carer, distinguish ADRs and effects of medical disorder

when benefits likely delayed, should be highlighted

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6
Q

why pharmacokinetics different in children? Therefore how to consider factors?

A

organs, body systems, enzymes that handle drugs develop at diff rates/

all PK factors interact and shouldnt be considered in isolation

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7
Q

PK: affects of absorption of diff formulations(3)

Oral, IM, percutaneous

A

oral
developmental changes in absorptive surfaces of gut,GI motility, intraluminal pH alter rate and extent
slow GI emptying
first pass metab increased for some drugs in kids

IM
erratic absorption due to reduced muscle mass and variable blood flow to/from injection site

Percutaneous
younger patient = increased as thinner stratum corneum, increased skin hydration

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8
Q

PK: affects of distribution of

a) water soluble drugs
b) protein bound drugs

A

a) ↑ Vd = ↓ conc of drug
=give ↑ dose per kg than adults e.g. gentamicin

b) ↓ albumin in neonates. ↓ PPB = more free drug.
e. g. morphine, phenytoin, diazepam: have greater unbound concs in plasma

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9
Q

Change in distribution of body water and fat in children

A

younger = greater total body water as % of weight

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10
Q

PK factors: metabolism

how may presence and activity of hepatic enz pathways vary in neonates and infants?

A

most phase 1 enz appear after birth but show rapid postnatal maturation

phase 2 enz (eg glucoronidation, sulfation) development less well understood

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11
Q

(metabolism, phase 1 enz)

caffeine used in preterm infant but why not after around 1 months age?

A

half life of caffeine = 20-36hrs in preterm infant.

1 month = rapid increase in metabolism so caffein no of little clinical use (for apnoea of prematurity)

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12
Q

why increased doses needed of morphine by 27-40 weeks to obtain pain relief?

A

morphine shows conjugation in neonates as young as 24wks. quadruples by 27-40wks = increased doses

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13
Q

PK factors: excretion.

when do GFR and renal function reach adult values?

A

GFR and renal func (inc tubular secretion) immature, take up to 6 months.

GFR in neonate = 30-40% of adult

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14
Q

GFR and renal func take longer to develop to adults. what does this mean for drugs excreted by kidneys?
example drug?

A

drugs excreted by kidneys accumulate
-gentamicin- careful dosing and changes to dosing interval

adjust dose regimens and closely monitor

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15
Q

formulae for dosing in children

and the limitations of it

A

dose = (childs body surface area/adult body surface area) x adult dose

  • only approximate
  • unreliable for preterm neonates and infants
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16
Q

3 less specific ways of expressing dosing in children?

A

age banding

  • for low therapeutic index drugs
  • e.g. paracetamol, amoxicillin

weight mg/kg
*more precise dosing

BSA mg/m^2

  • for narrow therapeutic index drugs
  • e.g. chemotherpay, immunosuppression
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17
Q

what to consider when prescribing for obese children

A

dont excees adult dose!!

mg/kg calculations.

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18
Q

how are doses calculated in emergency?

when?

A
  • tables in reference docs
  • Broselow tape: child length–> estimate weight

for Adrenaline, atrophine, glucagon

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19
Q

considerations for oral drug admin in children

A
  • how well tolerable
  • flavoured meds
  • sugar free- reduce cavities
  • remind parents: suspension have undissolved particles-shake before use
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20
Q

IV vs IM route in children.

which is not well tolerated and discouraged?

A

IM- lack of suitable muscle and unpredicatble absorption

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21
Q

in emergency, which route used if oral not tolerated

A

rectal e.g. diazepam

inhalational and buccal useful too

22
Q

how must oral drugs be admin to child? 3 considerations

A
  • dont add to feeds. interactions/ denature/ change
  • if dont finish bottle = underdose
  • some can be added to milk/juice. consult sites
23
Q

what are the 2 special routes for admin

A
  1. Intraosseous (IO): uses highly vascularised bone marrow for drug and fluid delivery. emergency. centre of bone
  2. buccal: non-invasive, for appropraitely permeable drugs. e.g. buccal midazolam
24
Q

what to counsel the parent about -meds for children (4)

A
  • what medicines for
  • when to take
  • how to take
  • common side effects and rare but important side effects to be aware of
25
Q

3 things to remember when prescribing for adolescents

A
  1. responsibility- may have own for own meds
  2. comsent- u16s can consent if imnformed
  3. compliance- peer pressure, keep prescribed drugs to minimum and avoid lunchtime doses if possible
26
Q

3 elements of physician-parent-child communication

A

informativeness: quantity and quality

interpersonal sensitivity: doctors behaviours and concerns

partnership building: invitation for input and concerns

27
Q

who are med errors more common in and why?

A

paediatric practises as higher chance of error - wight-based dosing, off label use
13% presc error rate

small mistakes = big effect in child

28
Q

how can harm form meds be avoided in children

A

dosing

  • check age/ weight/ BSA against doses. calcs
  • sensibly round doses for measurable amount
  • liquids presc: prescribe weight not volume

child resistant packaging

29
Q

3 drugs to avoid in children and why?

A

IV Chloramphenicol: Grey baby syndrome. low BP, CVA

Aspirin: Reye’s syndrome. mitochon damage –> rash,liver damage

Tetracycline: growing teeth and bone

30
Q

why is codeine avoided in children

A

codeine is metabolised to morphine by CYP2D6 = variable metabolism, rapid metab, airway issues.

pharmacogenetic variation–> serious toxicity

31
Q

what else regarding medicines should be checked and avoided in children? (3 examples)

A

some excipients. in BNFc

Benzyl alcohol: fatal tox syndrome
Polyoxyl castor oils: anaphyl.
Propylene glycol

32
Q

how and what to report regarding ADRs?

A

yellow card scheme

all serious suspected ADRs to established drugs inc OTC.
All ADRs to black triangle drugs

33
Q

what is growth chart based on?

A

childs growth chart.
based on optimal range of weight and heights.
centiles = % expected to be below line

half children: 25-75th centile

34
Q

how may systemic, nasal, inhaled CORTICOSTEROIDS affect children growth

A

low-medium doses decrease growth by average 1cm in first year of treatment

temporary effect. expected to attain expected adult height (majority)

35
Q

how may weight be estimated in emergency situations?

A

formulae:
0-12months: wt(kg) = [age(m) / 2 ] + 4
1-5 years: wt(kg) = [age(y) x 2 ] + 8
6-12 years: wt(kg) = [age(y) x3 ] + 7

based on average. not precise

36
Q

what does herd immunity refer to?

A

when 95% population immune, exposure risk of unvaccinated individuals = very low

37
Q

where to check for info on immunisations?

A

Green book

immunisations against infectious disease

38
Q

when does immunisation for children begin and what vaccines given?

A

at 2 months

  • 13 valent pneumococcal vaccine
  • HPV (girls only)
  • MenB: Meningococcal group B
39
Q

5 considerations/action when tretaing pain

A
  • assess type and intensity
  • start at appropraite level on pain ladder
  • connsider adjuvant analgesics at all stages
  • consider DDIs, ADRs, contraindications
  • titrate up/down as req

SOCRATES

40
Q

when may meds be administered in schools?

Conditions and how to supply

A

conditions: asthma, epilepsy, eczema, diabetes

separate labelled container
schools need parental permission to admin meds
try avoid school time dosing where possible (BD or MR forms)

41
Q

government advice regarding aspirin and children

A

u16s never given meds containing aspirin unless prescribed by doctor

42
Q

sources of info

A

BNFc
SPC- may not assist in dosing if unlicensed in children
medicinesforchildren.org.uk -advice for HCPs and parents

43
Q

why are paediatric medicines trials not often conducted? (5)

A
  • small market
  • ethical- obtaining informed consent
  • need for microassays e.g. blood samples
  • hard to predict long term effects during maturation
  • high regulatory req
44
Q

when can an unlicensed drug be used for children? what requirements must be met

A

=drug doesnt have marketing authorisation

  • cant meet clinical need by licensed meds
  • use supported by evidence and experience
  • only obliged gain consent if unusual drug/uncommon indication

doctors responsibility increased.
is a common practise in paeds

45
Q

what is ‘off label’ use in context of children?

A

when meds are lciensed for use in adults but given to children

46
Q

reasons for:

a) off label use
b) unlicensed use

A

a) use in diff age/indication/dose/route

b) special formulations of licensed drug/important drug/ chemical used as drug/ change to licensed drug

47
Q

what influences drug disposition and effect in children?

A

they are developing physically.

NOT just small adults, they are individual

48
Q

what types of drugs must be carefully considered in growing children?

A

drugs affecting:

  • growth tissues
  • intellectual development
  • sexual maturation/ reproductive potential
49
Q

why are some drugs (benzylpenicillin) given less times in neonates daily but at a higher dose (gentamicin) than adults?

A

Neonates have a higher water content than adults: higher Vd: decreases clearance, stays in body longer. Give less times a day to get levels to inhibit bacteria.

Gentamicin: same issues but given less freq. every 36 hours

50
Q

what to monitor with gentamicin?

A

serum level monitoring due to inherent toxicities (BNF- renal and ear) dose adjusted according to outcomes of monitoring

measure does: after 1st and just before next. maintain in narrow thera. range

51
Q

Why would sodium valproate and phenytoin be potentially the wrong treatment choices in an adolescent?

A

Increased appetite, hirchutism: hair growth excessive (side effect)

Health.1 (12 decks)

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