Special Populations

Question 1

Pediatric Dosing Rules

Answer 1

• Dose based on weight
• mg/kg/DOSE vs. mg/kg/DAY
• Do not exceed adult maximum dose (regardless of weight)

Question 2

3 Key Questions for Pediatric Patients

Answer 2

1. Alert
2. Drinking
3. Peeing

Question 3

Pediatric: Refer Immediately If…

Answer 3

• Refuses to nurse / accept fluids
• Has difficulty breathing or is bluish around the lips
• Is =< 3 mo with rectal temp => 100.4F
• Has blood in sputum, urine, feces

Question 4

Pediatric: Cough and Cold, Sx & Referral

Answer 4

• Self-limited viral infections occurring 6-8 times/year
• Symptoms: stuffy/runny nose, sneezing, sore throat, cough, post nasal drip

When to refer kids >3 months old

• “No” to any of the 3 key questions
• SOB or difficulty breathing
• Complaining of ear pain
• No improvement in cold symptoms after 1 week
• Children ≤ 3 months should be referred

Question 5

Pediatrics: Cough and Cold, Non-Pharm

Answer 5

First line therapy for children!

• Humidifiers or cool mist vapors
• Bulb syringe ± saline nasal drops
• Head elevation
• Increased fluid intake
• Pediatric specific fluids
• Rest

Question 6

Pediatrics: Cough and Cold, Drug Therapy

Answer 6

No sufficient data for common C&C drugs!

2008 FDA rec: do not administer OTC cough/cold preps to children <2 years

• Introduced child-resistant packaging
• New measuring devices
• Voluntary removal of infant combination products
• Warning against using antihistamines for sedation

Question 7

What if the pediatrician recommends cough/cold treatment?

Answer 7

• Only recommend medications labeled for children
• Single agents are preferred
• Check the active ingredients to avoid duplication
• Follow the directions as labeled in the Drug Facts
• Be extra careful if giving more than one medication
• Only use measuring devices that come with the medicine or those specifically made for measuring medications

Question 8

Pediatrics: Fever (Acet/Ibu Dosing)

Answer 8

• Common clinical symptom
• Determine whether treatment is indicated
• Refer to Fever lecture for treatment options: Non-drug therapy, Anti-pyretics: APAP, ibuprofen
• Acetaminophen: 160mg/5mL; 10-15 mg/kg/dose
• Ibuprofen: C-100mg/5mL; I-50mg/1.25mL; 5-10 mg/kg/dose

Question 9

Fever: When to Refer Kids

Answer 9

• Oral temp ≥ 103 F (or equivalent)
• Any infant ≤3 months with rectal temp ≥ 100.4 F
• Persistent fever >3 days ± treatment
• Refer children <2 years with fever for >24 hours

Children who are:

• Refusing or not taking in enough liquids (decreased UOP)
• Unusually sleepy, irritable or hard to wake up
• Repeated vomiting or diarrhea
• Seizures or history of febrile seizures
• Spots, rash or stiff neck

Question 10

Pediatrics: Pain

Answer 10

• Typically acute pain due to injury, illness, procedures

Barriers

• Myth that children do not experience pain the way adults do
• Lack of assessment and reassessment of pain
• Communication difficulty
• Adverse results of pain: increased anxiety, avoidance, suffering, parent distress

Question 11

Pediatrics: When to Refer for Pain

Answer 11

When to refer (Dr. Atayee)

• <2 years old with musculoskeletal pain
• <8 years old with headache
• Use with caution and shortest duration for kids <18 years

Treatment

• Analgesics: acetaminophen or ibuprofen
• Distraction
• Massage
• External application of heat or cold: cold (inflammation or swelling), heat (stiffness or chronic pain)

Question 12

Teething Pain

Answer 12

• Onset: Typically ~6 months (as early as 3 months)
• Symptoms: increase in drool, irritability, desire to chew on things, disrupted sleep, tender/swollen gums

Treatment options:

• Massage gums with finger
• Cool teething ring or washcloth
• Wipe drool to prevent rash

DO NOT RECOMMEND

• Benzocaine products for age <2 yrs
• Hylands Teething Tablets

Question 13

Pediatrics: Vomiting and Diarrhea, When To Refer

Answer 13

• Age <6 months
• Severe or worsening symptoms
• Unable to keep fluids down
• Severe abdominal pain
• Signs of dehydration

Question 14

Pediatrics: Vomiting/Diarrhea, Treatment

Answer 14

Infants

• Continue nursing if tolerated
• ORS: 1-2 tsp every 15 minutes, may increase if no vomiting.
• If no vomiting, resume nursing after 4 hours or formula after 8 hrs

Children >1 year

• ORS: 2-3 tsp every 15 minutes, may increase if no vomiting
• If no vomiting for 8 hours, resume regular fluids then add solids
• Resume regular diet after 24-48 hours

Question 15

Diaper Rash: Non-drug Therapy

Answer 15

• Frequent diaper changes
• Increase airflow
• Properly cleaning and drying of diaper area
• Change in diaper size, brands

Question 16

Diaper Rash, Treatment

Answer 16

Mild/Moderate

• Barrier Creams:
• Zinc oxide (10-40%) (desitin, triple paste)
• Petrolatum ointment (A&D ointment)

Severe

• Hydrocortisone 0.5-1% (apply sparingly twice a day)
• Antifungal cream BID-TID (clotrimazole, terbinafine)

Question 17

Older Adults

Answer 17

Defined as age ≥65 years

Challenges of OTC therapy in older adults

• Use more Rx and OTC meds than any other age group
• Account for ~30-40% of all OTC purchases
• Altered pharmacokinetics and sensitivity to meds
• More comorbid conditions
• Significantly more likely to experience ADEs
• Lower health literacy

Question 18

BEERS Criteria

Answer 18

Identifies ”potentially inappropriate” medications for older adults

• 1st generation antihistamines
• NSAIDs
• Proton pump inhibitors (PPIs)
• H2 blockers
• Mineral oil

Question 19

Strategies for Educating Older Adults (Cog.)

Answer 19

Provide short, concise health messages that detail the specific action to achieve desired health goal

Cognitive Challenges

• Focus on key points
• Communicate directions that need to be followed
• Use plain language
• Use reminders to aid memory (i.e. brochures, med lists)
• Repeat essential information

Question 20

Strategies for Educating Older Adults (V/H)

Answer 20

Visual Challenges

• Minimize the amount of text
• Make information easy to see and read
• Use black text on a non-glossy white background.
• Use 16 to 18 point font with space between lines
• Consider providing audio information

Hearing Challenges

• Talk face to face
• Limit background noise
• Speak clearly with more volume as needed
• Do not chew gum or eat while speaking

Question 21

Optimizing OTC use in Older Adults

Answer 21

• Conservatively assess eligibility for self-care
• Consider organ impairment and drug interactions
• Screen for duplicate therapy
• Identify preferred formulations and storage
• Design regimens that are convenient and easy to follow
• Provide clear education to patients and caregivers: (read labels for duplicate ingredients, consider written instructions, address health literacy)
• Update and encourage use of complete medication lists