2.  <37 weeks gestation: preterm  < 1month: neonate/newborn  1 month-1 year: infant  1-3 years: toddler  3-6 years: preschooler  6-12: school-aged  12-20: adolescent

3.  Challenge to safety, effectiveness  Children change/grow  Physiological characteristics influence pharmacokinetics  Ethics: pediatric drug studies?  75% of drugs not fully approved for pediatric use

4.  gastric pH, gastric emptying time, GI tract motility  At birth, gastric pH neutral or slightly acidic  Immaturity of hydrochloric acid-producing cells in the stomach  Diet high in alkaline foods (milk)  At 3 years, gastric pH is at adult level  Gastric emptying slower in premature infants

5.  IM injections dependent and muscle mass and blood flow to area  responses depend on development  Topical administration: similar  Infants: thinner epidermis= rapid drug absorption

6.  many factors influence drug absorption variability  IV drugs often cause the least variable response ◦ bypasses absorption step in GI tract

7.  The passage of drug from absorption site to peripheral tissues  Dependent on amount of water and/or fat, affinity of drug for protein- binding sites in plasma and tissue  Age-related changes affect how fast drug acts and how much reaches receptor sites

8.  Water and fat content varies greatly in pediatric patients  Adult 55% water  Full-term infant 70-75% water  Premature infant 85% water

9.  Proteins like albumin, “bind” part of drug in an inactive state  unbound portion: active  “Bound” drug molecules may be released back into the system over time  Kids: drugs bind to protein to lesser extent ◦ May produce a greater response - more active drug circulating  Blood-brain barrier not mature- more drugs enter central nervous system

10.  Involve liver enzymes  Inactivates drugs and promotes elimination  Kids: variable d/t developmental and genetic differences in growth  Liver enzymes decreased (immaturity)  Maternal drug use: intrauterine exposure can alter neonate’s metabolizing enzymes and drugs transmitted through breast milk affect liver enzyme action  Children have higher metabolic rates

11.  Renal excretion primary pathway  Dependent on level of maturity of the kidneys  Immature kidneys also receive relatively low fraction of cardiac output  Medications circulate longer- more risk of toxicity  Drugs and dosages in neonates and infants must be assessed carefully

12.  More sensitive (immaturity)  Drugs affecting CNS (morphine, barbiturates) have exaggerated effect  Central nervous system immature until ~8 months of age  Body temperature control more easily disrupted in pediatric patients: acetaminophen and salicylate overdose can raise temperature

13.  Usually calculated based on body weight- not very accurate but commonly used  May be determined by body surface area calculations and compared with charts called nomograms  Nomograms: use height and weight ◦ Accurate only after liver and kidneys are mature

14.  Weight-based only: milligrams of drug per kilogram of child per day = mg/kg/day ◦ Remember the daily dose probably is further divided into smaller doses to be given a number of hours apart  Body surface area: ◦ Calculation review in Pickar ◦ May be checked against a nomogram

15.  child’s history and allergies  Establish trust  Understand developmental level of the child  Use kind, firm approach  Explain procedures clearly  When possible, give choices  Never deceive children  Do not mix medications with essential foods  Obtain parental assistance as appropriate  Use praise

16.  Otic meds: pull the pinna back and down for children < 3 years old  IV meds: gtt factor on Buretrol IV set is 60-100 gtts/mL  IV sites: secure in manner that doesn’t prevent child from playing or moving  IV/IM prep: use EMLA anesthetic cream 1-2 hours prior to injection

17.  About half of calls to Poison Control Centers in 2010 were for children <6yrs  Preach prevention!  Do not recommend syrup of ipecac in home  Parents to call poison control before administering anything

18.  Use with caution with kids  More susceptible to adverse effects (immaturity)  Poison centers: herbal remedies and supplements  Not always safe  Need to educate that herbals are not FDA-regulated – consult herbal expert

19.  Need to know: let providers know about supplements  Parents: tell provider about all herbals, meds, supplements used by children

20.  Gear teaching to the child’s development  What does child know?  Correct misconceptions  Short attention span  role playing and visual aids  Praise, give rewards

22.  Elderly: ~ 13% of the population  Consume ~ 34% of prescription drugs  Polypharmacy: the practice of taking multiple medications  2007: Up to 25% of hospitalizations of elders (>65yrs) are due to adverse drug rxns

23.  ‘red flag’ drugs: pp 145-146  Drug activity may differ  Research: legal, medical and ethical issues  Sensory impairment, social isolation, inadequate nutrition, poverty

24.  Reduced gastric acidity, emptying  Decreased muscle tone, motor activity  Reduction in blood flow to major organs  Thinner skin surface  IM absorption difficult to anticipate

25.  Body water content decreased  Body fat increased  Altered muscle tone  Decrease in protein-binding capability but may be absorbed into fatty tissue and released back into bloodstream over time -> cumulative effects

26.  Enzyme levels are decreased  Reduced liver function, circulation  Decline in the body’s ability to transform active drugs into inactive metabolites ◦ Drugs more likely to sedate and linger in the system

27.  Blood flow to kidney is reduced  GFR reduced by 40-50%  Tubular secretion and reabsorption decreased  Decreased number of intact nephrons  More likely to have drug toxicity  Creatinine clearance, BUN

28.  Number and nature of drug receptors  May be a greater or diminished drug response: toxicity  Impaired homeostasis  Increased likelihood of adverse reactions  Communication problems

29.  Sensory, memory losses  multiple pharmacies and providers  More drugs, more errors: polypharmacy  Interactions with nonprescription drug use, communication problems, sharing drugs, hoarding drugs, and dietary factors

30.  medication history  vital signs, height and weight  Assess sensory function, environment, support system, financial concerns, and physical or mental impairments  Ensure patient can access prescriptions

31.  Try to use liquid PO drug forms, when possible, because absorption not much affected by gastric emptying rate  IM: use ventrogluteal site  Elders receiving IV infusions: fluid overload risk

32.  hearing aids and glasses  Speak clearly and slowly  Keep sessions brief  visual aids; reading material (large print)  Help them figure out how to add new meds into their lives

33.  Include family members  Caution: no more or less than prescribed, no outdated meds  diet, exercise (check with provider), adequate fluid intake  flu vaccine and pneumonia vaccines