1. Pediatric Considerations

2. Objectives for Module D
Differences in pharmacokinetic process in children
Terms associated with pediatrics
Converting from pounds to kilograms
Calculating pediatric dosages
Calculating safe drug ranges
Determining if medication is within safe range
Determining body surface area (BSA)

3. Pediatric Considerations
Those patients that are very young and very old respond differently than do the rest of the population
Patients in these age groups are also at increased risk of adverse reactions to medications
Pediatrics covers all patients under the age of 16
Until recently the FDA could not require drug
trials in children
Drug trials were not allowed in children. This was due to a couple of issues. No company wanted to take on the risk of putting children in drug trials that could cause harm. Secondly, it is very expensive because testing would have to be done at many different ages. (Example a 2 month is very different from a 14 month old, and so on….)

4. Pediatric Guidelines Age Group Classification < 37 weeks
Premature infant
37-40 weeks
Full term infant
Birth to 1 month
Neonate or Newborn
1 month to 1 year
Infant
1 year to 12 years
Children
12 years to 16 years
Adolescents

5. Neonates and Infants
Those less than one year (infants), especially those less than one month (neonates) are very different from adults!
Drug sensitivity in the very young is largely a result of organ immaturity
Infants and small children are not
little adults, special considerations must
be taken to insure that safety is
maintained!!!!!!

6. Special Considerations for this age group
Because of the immaturity of the organs that normally regulate drug levels, this age group may experience more intense and prolonged drug reactions.
This is due to an immature state of five pharmacokinetic processes:
Drug absorption
Protein binding
Blood-brain barrier
Hepatic drug metabolism
Renal drug excretion
These will be discussed individually a little later.

7. FYI facts about medications in newborns
Drugs administered IV decline more slowly than in adults, because of this the effect is prolonged
Drugs administered Sub-Q remain above the minimum effectiveness longer and rise higher resulting in prolonged and intense effects

8. Pharmacokinetics (Neonates and Infants)
Absorption
oral administration
IM administration
Topical administration
Distribution
protein binding
blood-brain barrier
Hepatic metabolism
Renal Excretion
Absorption: oral administration-GI emptying is unpredictable this can increase or decrease medication absorption.
IM administration- blood flow to muscles is usually decreased following delivery, this can decrease or slow absorption.
Topical administration- infants thin skin allows topical medication to be easily absorbed.
Distribution- (moving from the blood to the site of action)
protein binding- infants do not have a lot of protein at birth, drugs that are protein bound will reach higher levels due to the lack of protein to bind with, drug dosages of these drugs may need to be decreased
Blood-brain barrier- not completely formed at birth, allows drugs affecting the CNS to move easier, need to be very careful giving drugs that
affect the CNS.
Hepatic and Renal: both of these are immature at birth and during infancy leading to decreased excretion and altered metabolism. Because of this drug dosages may need to be altered.

9. Pharmacokinetics (1 year and older)
By the age of one MOST pharmacokinetic parameters are similar to those of adults
One important difference: The metabolize drugs faster that adults!!
Drug metabolism is markedly elevated until the age of 2 and then gradually declines
Between the ages of 1-2 kids metabolize drugs faster than adults. In order to get the same medication in you may have to either increase the dosage or increase the number of dosages.
Example: given two children with the same infection, one is 5 years old and the other is 18 months old. The 18 month old child may be on a larger dose than the 5 year old. This is because the 18month old is metabolizing the drug faster and needs a higher dose to get the drugs benefit.

10. Dosage Determination Can be based on weight Example: 5mg/kg/day
BSA (body surface area) may also be used to calculate medication dosages.
5mg/m2(of BSA)/day
BSA in m2= the square root of (ht in cm X wt in kg divided by 3600)
Take the square root at the end:
How to calculate: multiply the wt in kg X the ht in cm and equal it, then divide by 3600 equal it again, then take the square root

11. Pounds to kilograms There are 2.2 pounds per kg Example: 24 pounds
24 divided by 2.2= 10.90, repeating

12. Let’s work some of these problems
It is SUSCC policy to leave weight calculations in calculator. Rounding can be done at the end of the calculation. Specific instructions will be given within the math question.
77lbs
110lbs
77lbs= 35kg
110lbs= 50kg

13. More conversions 110 pounds 10 pounds 3 lbs 8 oz 110lbs= 50kg
10lbs= 4.54kg, repeating
3lbs 8 oz (must change 8oz to parts of a lb by dividing by 16 (16oz in a lb)= 3.5lbs= 1.590kg, repeating

14. Even more….. 21 lbs 63 lbs 52 lbs 21lbs= 9.54kg, repeating

15. How to solve calculation problems?
Kanamycin is ordered 10mg/kg/day in divided doses every 6 hours. The child’s weight is 28 lbs. How much will you administer per dose?
Do you need to change to kg? If so convert as needed.
Then multiply the mg ordered by the weight in kilograms that you left in your calculator
Look and see what they are asking you for
daily dose or single dose. If needed calculate
single dose

16. Math Problem #1 The recommended dosage of kanamycin
is 15mg/kg/day q 8 hours. The child weighs
25 kg. The amount for one dose is:
125mg/dose

17. Math Problem #2
The recommended initial dose of a drug is 1.5 mg/kg/day PO. The recommended daily dosage for a child weighing 44 lbs is:
30mg/day

18. Math Problem #3
The recommended dosage of IV vancomycin is 40mg/kg/day in divided doses q 6 hours. The child weighs 35kg. The amount for one dose is:
350mg/dose
Be sure to look at what the question is asking for!!

19. Math Problem #4
The recommended children’s dosage of Vibramycin is 2mg/lb of body weight daily in two divided doses on the first day. The child weighs 40 lbs. Vibramycin syrup is available in 50mg/5mL. The amount(mL) for one dose is:
You need to administer 40mg/dose. Set up your ratio and proportion and solve for X.
You will administer 4mL of medication.

20. Math Problem #5
The recommended dosage of amoxicillin is 20mg/kg/day in divided doses every 8 hours. The child weighs 11 lbs. The total daily dose is:
100mg/day

21. Math Problem #6
The recommended dosage of rifampin for children under 1 month of age is 5mg/kg/dose given every 12 hours for 2 days. Rifampin syrup is available in 10mg/mL. The number of mL of the rafampin syrup for 2 days’ dosage for a three week old. 9.9 pound infant is:
See next slide

22. Take a breath!!!!!! Lets go step by step:
Convert 9.9 pounds to kg (leave in calculator)
Multiply weight in kg(in calculator) x 5= per dose amount
Multiply per dose amount x2= daily dose
Multiply daily dose x2= two day dose
Plug into formula and solve for mL
9mL should be administered.

23. Math Problem #7
Doctor’s order: Tylenol Elixir 240 mg po for a child who weighs 21kg
Recommended dosage:
1 tsp for weight for 24 to 35 lbs
1 ½ tsp for weight of lbs
Available: Tylenol Elixir 80mg/1/2 tsp. What is the number of mL to give in one dose?
7.5mL should be given, looking at the recommended dose does this fall within the range?
7.5mL= 1.5tsp, the child weighed 46.2 lbs, so yes it does fall within the recommended range

24. Math Problem #8
The recommended daily dosage of Thorazine is 0.55mg/kg/day in divided doses every 6-8 hours. The child weighs 66 lbs. Thorazine is available in 25mg/mL. The number of mLs given for each individual dose given every 8 hours would be:
5.5mg should be given for each dose. Set up ratio and solve for X.
0.22mL should be given

25. Math Problem #9
The pediatric dosage of Pyopen is 100mg/kg/day in divided doses QID. The child weighs 25kg. Pyopen is available in 1g/2.5mL. The number of milliliters will you give for each individual dose. How many mg would you give in each individual dose?
625mg/dose
1.56mL

26. Math Problem #10
The pediatric dosage of Velosef is 50mg/kg/day. The total daily dose for a child weighing 33lbs is:
750mg/day

27. Safe Dosage Range
Pediatric dosages have a safe dosage range. Nurses need to be sure that the medicine ordered falls in this range.
Example: The recommended dose of Keflex is 25-50mg/kg/day in divided doses

28. Safe Dose Ranges Convert weight to kg if needed
Multiply the weight (in calculator) by minimum dose= low recommended dosage range
Multiply the weight (in calculator) by maximum dose= high recommended dosage range
SUSCC policy is to keep the weight in the calculator, don’t round or drop it at the hundredths place.

29. Safe Dose Problem #1
The recommended children’s dosage of Keflex is mg/kg/day in divided doses. The safe daily dosage range for a child weighing 42 lbs is:
mg/day

30. Safe Dosage Problem #2
The recommended children’s dose is 3-5 mg/kg/day every 12 hours. The range of doses that are safe for a child weighing 9 lbs is: (single dose range)
mg/day divide each by 2= mg/dose

31. Safe Dosage Problem #3
The recommended dosage of morphine sulfate is 0.1 to 0.2mg/kg/dose. The safe dose range for a child weighing 74 pounds is:
mg/dose

32. Safe Dosage Problem #4
The recommended pediatric dosage for a drug is 0.02 to 0.05mg/kg/day. The safe daily dosage range for a child weighing 14 lbs is:
mg/day

33. Safe Dose Problem #5
The recommended pediatric dosage of a drug is 0.1 to 0.3 mg/kg/day in two divided doses. The safe daily dosage range for a child weighing 19 lbs 6 oz is:
19.375lbs= …..
mg/day

34. Safe Dosage Problem #6
The recommended daily dosage for an infant is to 0.06 mg/kg/day in divided doses every 8 hours. The safe dosage range per dose for an infant weighing 6.5 pounds is:
mg/day divided by 3= mg/dose

35. Safe Dose Problem #7
The recommended pediatric daily dosage of Penicillin G is 25,000 to 90,000 units/kg/day in three to six divided doses. The maximum safe dosage that could be given every 4 hours for a child weighing 18 lbs 12 oz is:
18 lbs 12oz= 18.75lbs/ 2.2=8.5227……
127,840.9 units/dose

36. Safe Dosage #8
The recommended children’s dosage of Keflex is 50-75mg/kg/day in divided doses. The daily safe dosage range for a child weighing 52 pounds is:
mg/day

37. Safe Dosage #9
The recommended dosage of morphine sulfate is 0.1 to 0.2mg/kg/dose. What is the range for each dose for a child weighing 40lbs is:
mg/dose

38. Safe Dosage #10
The recommended pediatric dosage for Dilantin for a child is 5-7 mg/kg/day in divided doses every 12 hours. The safe daily dosage range for an infant weighing 6 pounds 6 ounces is:
mg/day

39. Safe Dosage #11
The recommended pediatric dosage of phenobarbital is 6-8 mg/kg/24 hours. A safe daily dosage for a child weighing 9.8kg is:
Therapeutic or Nontherapeutic?
58.6mg/day
65mg/day
75mg/day
78.5mg/day
mg/day
Nontherapeutic
Therapeutic

40. 1.What is the child's weight in kg?
A child is to receive vancomycin 750mg IVPB every 6 hours. The child weighs 68 pounds. The recommended dosage of vancomycin is 40 to 60 mg/kg/24 hours. Vancomycin is available in 250mg per 5 mL.
1.What is the child's weight in kg?
2.What is the safe daily dosage range?
3.Is the ordered dose within the safe range?
4. If yes, how many tsps are you going to give per dose?
30.909……
mg/day
3. 750mg x4= 3000mg/day, NO
What would you have to do? Call the doctor?
Let’s say we call the doctor and he changed the frequency to every 12 hours. If it now safe to give the medication?
750mg x2=1500mg/day, so yes it is now safe to give the medication
4. 3tsp (15mL=3tsp), be sure to read the question carefully!!

41. 1.What is the child’s weight in kg?
The MD orders Tegretol 150mg PO TID for a child weighing 58 lbs. The recommended oral dosage for a child is mg/kg/day. Tegretol is available in 100mg per 5 mL.
1.What is the child’s weight in kg?
2. What is the safe daily dosage range?
3. Is the ordered dose safe?
4.How many mL will you administer?
26.36…..
mg/day
150mg x3=450mg/day, yes it is safe
7.5mL

42. You must mix a medication before it can be administered
You must mix a medication before it can be administered. The vial contains 1 gm of medication. The directions state: Add 3mL sterile water to the vial to make 0.2 gm per mL. How many mL would you give to administer 375mg
1.87mL, don’t use the 3mL (go back to the concentration that is given once mixed)

43. The patient takes 2 tablets QID. Each tablet contains 325mg
The patient takes 2 tablets QID. Each tablet contains 325mg. What is the total weight of medication the patient takes per day?
2600mg, mg is a unit of weight

44. What is the child’s weight in kg? What is the safe dosage range?
The recommended pediatric dosage of Demerol is 1-2 mg/kg/dose. The child weighs 46 pounds. The MD orders 30mg of Demerol. Demerol is available in 25mg/mL vials.
What is the child’s weight in kg?
What is the safe dosage range?
Is the order within the safe dosage range?
How many mL will you administer?
20.909……
mg/dose
30mg, yes
1.2mL

45. Is the dosage in the therapeutic range?
The recommended pediatric daily dosage of phenobarbital is 4-6mg/kg/24 hours. The child weighs 31kg. The MD orders 45mg PO TID. Phenobarbital is available in 15mg/mL vials.
Is the dosage in the therapeutic range?
If yes, how many mL will you give?
mg/day
2. 45 x 3=135mg/day, yes
ss=1/2 gr= 30mg
Administer 1.5mL

46. The most accurate method for calculating pediatric dosages is Body Surface Area (BSA)
The pharmacy or physician usually provides BSA calculations, but nurses can also calculate or check medications based on BSA

47. What is the BSA of the following child?
Child weighs 24 pounds and 36cm in height
0.27m2

48. What is the BSA of the following child?
Child weighs 44 pounds and 60cm in height
0.57m2

49. What is the BSA of the following child?
Child weighs 25 pounds and 40cm tall
0.35m2

50. What is the BSA of the following child?
Child Weighs 10 pounds and 35cm tall
0.21m2

51. What is the BSA of the following child?
Child weighs 15 lbs 2 oz is and 39cm tall
0.27m2

52. Using BSA to determine dosage
The recommended dosage of medication is 100mg/m2/day in divided doses every 8 hours. The child weighs lbs and is 43cm tall. How many mg of medication should be administered per dose?
0.79m2 x 100mg= 79mg/day divided 3=26.33mg/dose

53. Using BSA to determine dosage
The recommended dosage of medication is 150mg/m2/day in divided doses every 8 hours. The child weighs 75 lbs and is 100 cm tall. The medication is available in 50mg/2mL.
How many mg of medication should be administered per dose?
How many mL should be administered per dose?
BSA= 0.97m2
145.5mg/day divided by 3= 48.5mg/dose
1.94mL

54. Any Questions????????