Pediatric Medication Administration Mary E. Amrine, BSEd, BSN, RN

Dosages for infants and children are a fraction of the amount given adults, and are reduced in proportion to the Weight Height Body surface area Age and condition of the child

Since children are smaller than adults by weight, body size and body surface area, they may require less medication than adults.

Factors related to growth and development significantly affect the child’s ability to metabolize and excrete drugs.

Immaturity in the processes related to absorption distribution metabolism and excretion can significantly alter the effects of a drug.

Liver function  Newborns and premature infants with immature enzyme systems in the liver, where most drugs are metabolized or broken down, have a lower plasma concentration of protein.  Protein is important for binding with drugs.  Without this binding, more drugs are in the infant’s system.

Kidney function  Newborns and premature infants can also have immature kidney function.  The kidneys are where most drugs are eliminated.  Thus, these infants are especially susceptive to the harmful effects of medications.

Beyond the newborn period….. Many drugs are metabolized more quickly by the liver, which in turn, may necessitate even larger doses or more frequent administration compared with adults.

As a result of increased metabolism in children, the effects of drugs may be achieved more quickly

Administration of an incorrect dosage to any patient is dangerous but with a child the risk is even greater

Calculating Dosages Once the child’s body weight is expressed in kg to correlate with the dosage specifications, the dosage itself can be calculated

One kg equals 2.2lb; to covert lb to kg….. divide by 2.2 Since you are dividing the answer in kg will be smaller than lb you are converting. Answers are expressed to the nearest tenth.

Calculation and Assessment of dosages based on weight  Pediatric dosages are frequently ordered on the basis of a child weight.  Dosages may be recommended based on mg/kg/day usually in divided doses  Body weight may need to be converted from lb to kg to correlate with dosage recommendations.

To convert lb to kg divide by 2.2  Calculating dosage is a two step procedure: a. calculate the total daily dosage for the child’s weight b. then divide this by the number of doses to be administered  To check the accuracy of a physician's order calculate the correct dosage for the child then compare it with the dosage ordered.

 Factors that make discrepancies dangerous are age, size, and overall medical condition of the child.  If the drug label does not contain all the necessary information for safe administration, additional information should be obtained from the PDR, or the hospital pharmacist.

Oral Medications  Most oral pediatric drugs are prepared as liquids to facilitate ease in swallowing.  If the child is old enough to cooperate, these dosages may be measured in a medication cup.  Solutions may also be measured using oral syringes. If oral syringes are not available hypodermic syringes without the needle can also be used for dosage measurement.

Suspensions  A suspension consists of an insoluble drug in a liquid base.  The drug in a suspension settles to the bottom between uses.  Thorough mixing immediately prior to pouring is mandatory

 When a child is administered a tablet or capsule, the nurse must check to be certain it has been actually swallowed.  If swallowing is a problem some tablets can be crushed and given in a small amount of applesauce or ice cream if there not contraindicated.  Remember, any enteric coated and time released tablets or capsules cannot be crushed since it would destroy the coating which allows them to function on a delayed action basis.

Parental Medications  The drugs given most frequently the subcutaneous rout are insulin and those immunizations which specifically require the sc route.  Any site with sufficient subcutaneous tissue may be used, with the upper arm being the preferred site for immunizations.

 The intramuscular route is used most frequently for immunizations such as DPT which must be given deep IM.  The IM site of choice for infants and small children is the vastus lateralis or rectus femoris of the thigh, because the gluteal muscle does not develop until a child has learned to walk.  Generally a pediatric dose is not more than 1mL per IM or Sq and the sites are rotated regularly.  Dosages are usually calculates to the nearest hundredth and measure in a tuberculin syringe.

Intravenous Medications  Pediatric IV medications involves a responsibility that is multi-faceted.  Infants and children, especially under the age of four, are incompletely developed physiologically and drug tolerance is a major concern.  Infants and acutely ill children can tolerate only a narrow range of hydration and fluid balance making IV drugs which are dilutes for administration a critical and exact skill.

For this reason, the Ohio State Board of Nursing allows only a Registered Nurse to administer IV solutions and medications. It cannot be delegated.

The fragility of infants’ and children's veins and the irritating nature of many drugs mandates careful site inspection for signs of infiltration and inflammation.

This should be done immediately, before, during and after completion of each medication administration.

Signs of inflammation would include redness, warmth, swelling and tenderness

Signs of infiltration would include swelling, coldness, pain and lack of blood return

Either complication necessitates the discontinuing of the IV and a restart at a new site.

IV medications are usually diluted for administration A flush is used following medication administration to make sure the medication has cleared the tubing and the total dosage has been administered.

Remember… Those who administer drugs to patients are legally responsible for recognizing incorrect dosage and alerting the physician. The one who administers an incorrect dose is just as responsible for the patient’s safety as the one who prescribes it.

The nurse should always know if the ordered dose is safe Safe practice dictates two nurses check calculations and amounts of drugs to be given before administering it to the pediatric patient.

Remember, this double checking requires each RN to do the calculation themselves and then compare results!

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