Pedriatric Flashcards
Gestational age
Estimated maturity at birth
Pre-term
<37 weeks of age
Full-term
37-40 weeks of age
Neonate
0-1 month of age
Infant
1-12 months of age
Young child
2-5 years
Older child
6-12 years
Adolescent
13-17 years
Medication Errors
Failure of a planned action to be completed as intended
The 5 rights
the right patient, the right drug, the right dose, the right route, and the right time.
Prescribing
Dispensing
Administration
Documentation
Reasons why these errors occur
Dosing medications usually require conversions and calculations
Dosage forms and strengths are not always available
Dosage recommendations are not always available
Medication adherence is difficult
Clinical studies in the pediatric population are scarce
___% of meds have pediatric indication
25
1997 FDA Modernization Act
The purpose of this was to enable the FDA to reduce the average time required for a drug review from 30 months to 15 months.
Growth
increase in size, ->weight, height
Development—changes in function or form is Maturity, intellect
Development
Changes in function or form
–> maturity, intellect
Drugs that can affect both growth and development
Thalidomide
Fluoroquinolones
Thalidomide Case
Used for nausea and morning sickness in pregnant women
Caused phocomelia -shortened or absent long bones of the limbs and many internal malformations
Growth charts for birth to 36 months
weight-for-stature for boys and girls
Length/weight-for-age for boys and girls
Growth charts for 2 to 20 years
Stature/weight-for-age for boys and girls
BMI-for-age for boys and girls
Overweight: 85th to <95th percentile
Obese: ≥95th percentile
Underweight: <5th percentile
Interpreting a BMI chart: 25th percentile meaning
BMI the same or more than 25 percent of reference population
BMI less than 75 percent of the reference population
Weight changes of Neonates
Weight may decrease to 10% below birth weight in the first week of life (due to amniotic fluid from womb)
Weight gain of 30 grams/day for the first month of life
Growth Changes of Infants
Double birth weight by 4 months of life
Weight should triple and length should double by 1 year of life
Growth changes of Children and Adolescents
Weight gain of 2-3 kg/year
Height increases of 5-8 cm/year
Site of temperature measurement
Rectal (most accurate way to access)
Oral
Axillary
Tympanic
Normal BP also expressed in percentiles
SBP and DBP <90% based on age, sex and height
Pre-Hypertension
SBP and DBP are between 90%-95% based on age, sex, and height
Hypertension
SBP and DBP >95% based on age, sex and height
Stage 1: >95-99% plus 5 mmHg
Stage 2: >99% plus 5 mmHg
Newborns have higher ___than children or adolescents
Heart Rate
the normal upper limit is 190 compared to a 10 YOA which is 110
Respiratory rate from neonates and children
infants have high RR as their lungs have low capacity whereas they get older their lungs have higher capacity.
Pharmacokinetics
what the body does to the medication
- Absorption
- Distribution
- Metabolism
- Elimination
Pharmacodynamics
What the medications do to the body
- Therapeutic
- Toxic
In full-term infants, gastric pH remains elevated ___at birth but declines to ____ within 24 hours
6-8, 1-3
Acid-labile drugs have
increased absorption
ex. penicillins, erythromycin
Weak acids have
decreased absorption
ex. Phenobarbital, Ganciclovir
immature bile acid production
decreases absorption such as Fat soluble vitamins
Gastric emptying is ___ in pre term infants but ____ during 1st week of life
slower in pre-term infants
increased during 1st week of life
Absorption IM
Infants have___
decreased muscle mass
poor perfusion
decreased muscle contractions
Percutaneous absorption can be greatly increased in newborns due to:
Underdeveloped epidermal barrier
Increased skin hydration
Absorption of topical medications in pediatrics
Increased skin irritation from topical medications
Systemic absorption from topical medications
Distribution is determined by physicochemical and physiological factors such as
Extracellular fluid, total body water, and protein binding can all influence the distribution
Infants and children have a higher __ to ___ ratio
body water to lipid
Decreased drug binding in newborns due to
Decreased plasma protein concentration
Lower binding capacity
Decreased affinity
Competition
Decreased drug binding in newborns results in
Increased free drug
Increased volume of distribution
Body fat is ___ in neonates and infants than in adults
much lower
highly lipid-soluble drugs are ___widely distributed in neonates and infants
less
Kernicterus is
Irreversible damage to the brain
Development secondary to the displacement of bilirubin by sulfisoxazole in neonates
Metabolism produces a water-soluble product that then is either ___ eliminated or excreted in ___
renally, bile
Metabolism is responsible for
Pro-drug conversion (fosphenytoin, chloramphenicol)
Active drug elimination
Metabolism is ___ in infants than in older children and adults
slower
CYP450 System
Approximately half of the adult values for full-term infants
Different isoenzymes mature at different times
Exceeds adult values at 1 year until about 9 years of age
The increased metabolization of drugs
That’s why we see double the dose in children or more frequent dosing because they metabolize faster
There are __ groups of enzymes that all mature at different times
3
Group 1 enzymes
peak during 2nd and 3rd trimester
Group 2 enzymes
Relatively constant through life
E.g. 2C19, 3A5
Group 3 enzymes
Little function in early life
Expression increases over first several years of life
E.g. 2C9, 2D6, 3A4
Metabolism—Pediatric Considerations in Neonates and young infants
Decreased enzyme capacity in Neonates, young infants result in Increased t1/2; decreased clearance means dose less frequently
Example
Phenobarbital
Metabolism—Pediatric Considerations in children are
Increased enzyme capacity leads to Decreased t½; increased clearance (dose more or dose frequently)
Example
Theophylline
Voriconazole
Infants have a well developed __ pathway but an underdeveloped __ pathway
sulfation, glucuronidation
Examples are
Chloramphenicol
Morphine
Acetaminophen
Grey Baby Syndrome
Cardiovascular instability
Rapid progression to death
Related to chloramphenicol administration for sepsis
Immature glucoronidation –> decreased metabolism of chloramphenicol –> increased concentration
Gasping baby syndrome
Benzyl Alcohol
Preservative in many multiple dose IV and PO formulations (pentobarbital, heparin flush, etc.)
Related to immaturity of glycine conjugation system resulting in accumulation of benzoic acid metabolite
Anion gap metabolic acidosis, seizures, gasping, intraventricular hemorrhage, death
Try to avoid if possible; if not keep at <= 25mg/kg/day
Elimination usually occurs via the
kidneys
GFR is much __ in infants than older children and adults
lower
pre-term: as low as 0.6-0.7ml/min per 1.73 m^2
full-term: 2-4ml/min per 1.73 m^2
Elimination in new-nates through kidney
Decreased GFR in neonates and infants leads to increased t1/2; reduced clearance (dose lower )
Example
aminoglycosides
Elimination—Treatment Considerations
Decreased tubular secretion in neonates and infants increased t1/2; reduced clearance (dose lower)
Example
beta-lactam antibiotics
Calculating creatinine clearance in pediatrics
Schwartz Equation
1-18 years of age
ml/min/1.73m^2
Normal serum creatinine levels
It is high from birth till first five days then it declines. After that is reach to normal creatinine levels as child age
Schwartz Equation
CLcr = k x height /Scr
CLcr = mL/min/ 1.73m^2
k= age specific proportionality constant
height = height in cm
Scr = serum creatinine in mg/dl
Age specific proportionality constants
age K
0.33
full term --> 0.45
2-12 yrs --> 0.55
13-18 yrs --> 0.55 (female)
--> 0.7 (male)Bedside Schwartz
GFR (ml/min/1.73 m2) = (0.41 x height in cm)/ creatinine in mg/dl
Weight based dosing
Most common dosing method
Maximum dose not established for pediatric patients—make sure to not surpass adult dosing
Age based dosing
Easy to use
Assumes ADME is the same for all patients
Body-surface-area dosing
Precise
Used for drugs that require exact dosage calculations (i.e. chemo)
Pediatric Resources
Lexicomp Pediatric Dosage
Micromedex
Respective Guidelines are AAP Report of the Committee on Infectious Disease
Medication administration concerns
Adherence is difficult
Not always available in proper dosage forms/strengths
Children have difficulty with administration Tablets, diskus inhalers
Palatability Issues
Compounding is often necessary
Risk-to-benefit ratioDeciding when it is appropriate to treat
Steps to take as the Pharmacist
Obtain weight, age, sex Ask about allergies Calculate dose Compare dose with reference Make sure dose is appropriate Dispense with required materials Measuring cup/oral syringe Medication guides
Counseling Pediatric Patients
Show how to use Explain -How it works If patient is an adolescent, include them in your counseling -Dosage -Frequency -Expectations -What to do if there is no improvement Be available for future questions
Common Cold in Pediatric populations
6-8 episodes per year
AOM
Middle ear infection
Concerns about over-treating
Pharyngitis
Inflammation of the throat
Type 1 DM
autoimmune disorder affecting insulin secretion
Eczema
Chronic, itchy skin condition
Conditions seen most commonly in pediatric populations
Common Cold AOM Pharyngitis Type 1 DM Eczema Asthma Hand, Foot, and Mouth Disease
Why is immunization important
Vaccines have reduced or eliminated many devastating infectious diseases
Herd immunity
Passive Immunity
Person is given antibodies to a disease
Immediate protection
Only lasts few weeks or months
Via mother-to-baby, IVIG
Active Immunity
Disease organism triggers immune system to produce antibodies to that disease
Takes several weeks to develop
Long-lasting, sometimes life-long immunity
Via infection, vaccines
Vaccines are made using the same components (antigens) of bacteria or viruses that cause disease
- Live but weakened (attenuated)
- Part of the bacteria or virus (conjugated, subunit)
- Inactivated toxin (toxoid)
How do Vaccines Work
Vaccines containing antigens are injected into the body
The immune system produces antibodies to fight off these antigens
Memory cells will remember how to produce those antibodies again
When actual bacteria or viruses enter the body, memory cells can produce the same antibodies quicker to fight off disease
Comfort measures for vaccine concerns
Display a positive attitude Use soft and calm tone Make eye contact Explain why vaccines are needed Be honest Antipyretics (not routinely recommended by ACIP) Distraction techniques – music, books, “blowing away the pain” Sucrose solutions or breastfeeding Tactile stimulation Administration technique
Common Adverse Reactions
Mild Injection site reactions such as Soreness Redness Swelling Fussiness Low grade fever
Valid contraindications for vaccines
Severe allergy to prior vaccine
moderate to severe acute illness (defer until illness resolves)
Anaphylactic reaction to vaccine componenets
Egg Products --> influenza, yellow fever Neomycin --> IPV, MMR, Var Streptomycin --> IPV Polymixin B --> IPV Baker's yeast --> HepB Gelatin--> Var, MMR
Screening Questions for Vaccinations
Is the child sick today? How sick?
Allergies? How bad (anaphylaxis)?
Previous adverse reactions to vaccines?
Immune status of child or other medical conditions?
Recent history of asthma or wheezing?
Recent transfusions of blood, blood products, IVIG?
Patient pregnant?
Special Populations
Immunocompromised patients
–> live vaccines contraindicated
Pregnancy
- ->inactivated flu shot
- -> live vaccines contraindicated
Vaccine Information Statements (VIS)
Sheets produced by CDC
Document in medical record
–> VIS edition and date provided
–> name, address and title of provider, vaccine manufacturer, and lot #, date of administration
–> record combo vaccines as individual vaccines
VIS information covered
Why vaccinate Who should receive the vaccine Risks/Adverse Reactions What to look for/do NCVIA and VAERS
Vaccine Adverse Event Reporting System (VAERS)
National reporting system jointly administered by CDC and FDA
Children are not usually able to swallow tablets until at least ______ age
6 years of
Medication adherence is difficult because of
Palatability of medications
Parents are responsible for the administration
Growth charts are used to monitor progress
Height, weight, and BMI are expressed as percentiles
16 charts available
Sorted by age and gender
Increased enzyme capacity leads to Decreased t½; increased clearance (dose more or dose frequently)
Example
Theophylline
Voriconazole
