It has been estimated that 1.3 million deaths occur annually across all patient populations due to medication errors. Furthermore, medication errors are potentially more harmful and have a higher incidence rate in the pediatric population than in the adult population.
It should be clear that in terms of drugs, children are not mini adults. Children have different rate of metabolism and drug absorption. Thus prescribing an adult dose to your pediatric patient may end up as a toxic dose to them.
DMD center will be providing a guideline for prescribing medication for pediatric patients and a recap of how to determine the correct dosage for our pediatric patients.
Here are some guidelines in avoiding any complications:
- When considering prescribing for children, the first step is identifying the age group it be use for: Neonate (birth to 1 month), infant (1 MONTH to 2 years) and adolescent (12-18years)
- Check the weight and whether the weight of the patient is appropriate with the age. Always re-checked at each treatment before prescribing.
- If there is any difference in the weight relative to the age, find out underlying disease (e.g.: cerebral palsy-under weight of the baby). Check if there is a need for calculating the dosage based on surface area.
- When prescribing for a child, it is particularly important to give the parents all relevant information such as:
- the name of the drug
- the reason for the prescription
- how to store and administer the drug safely (if appropriate)
- common side-effects
- how to recognize adverse reactions.
- When prescribing most medication in children are dosed according to body weight (mg/kg) or body surface area (BSA) (mg/m2). Care must be taken to properly convert body weight from pounds to kilograms (1 kg= 2.2 lb) before calculating doses based on body weight. Doses are often expressed as mg/kg/day or mg/kg/dose
- Dosing also varies by indication, therefore diagnostic information is helpful when calculating doses.
The following examples are typically encountered when dosing medication in children.
Patient is a 1-yr-old child weighing 22 lb . You will be prescribing Amoxicillin (40 mg/kg/day) to be given thrice a day for 7 days. Preparation available is 400 mg/5 mL.
Step 1. Convert pounds to kg
22 lb × 1 kg/2.2 lb = 10 kg
Step 2. Calculate the dose in mg:
10 kg × 40 mg/kg/day = 400 mg/day
Step 3. Divide the dose by the frequency:
400 mg/day ÷ 3 (TID) = 133 mg/dose TID
Step 4. Convert mg dose to mL
133mg/dose ÷ 400 mg/5 mL = 1.66 mL TID
Patient is a 5-yr-old weighing 18 kg. You will be prescribing ceftriaxone 100 mg/kg/day given IV once daily. Preparation available is of 40 mg/mL.
Step 1. Calculate the dose in mg:
18 kg × 100 mg/kg/day = 1800 mg/day
Step 2. Divide the dose by the frequency:
1800 mg/day ÷ 1 (daily) = 1800 mg/dose
Step 3. Convert the mg dose to mL:
1800 mg/dose ÷ 40 mg/mL = 45 mL once daily
- Another thing to consider, is when a child is over 50 kg or if the drug, when calculated per kg, reaches the adult dose, the adult dose should be prescribed. Never exceed the maximum adult dose (e.g. a 60 kg child receiving a stat dose of paracetamol should receive the adult dose of 1000mg, not 20 mg/kg x 60 = 1.2g).
- Drugs that are fat soluble must be dosed at ideal body weight (IBW), not total body weight (TBW).
- It is important to take note not to calculate the medication of obese patients based on their TBW as it may pose them a risk of overdose.
The following drugs on this list poses a risk when prescribed to children:
- Aspirin - not recommended in any children < 12 years unless under pediatrician supervision
- increased risk of Reye syndrome (acute hepatic encephalopathy)
- Cefaclor - not recommended in children, suitable alternative should be used high risk of serum sickness reaction 7-10 days later.
- Ceftriaxone - not recommended in neonates (use cefotaxime instead) can displace bilirubin and lead to increased hyperbilirubinemia
- Codeine not recommended in children < 12 years, or post adenotonsillectomy < 18 years risk of respiratory failure
- Mefenamic Acid not recommended for children < 12 years old
- Co-trimoxazole - not recommended in neonates (use trimethoprim alone instead) can displace bilirubin and lead to increased hyperbilirubinemia
- Ibuprofen - contraindicated in infants < 3 months old.
- Metoclopromide - not recommended in any children < 12 years, suitable alternative should be used (e.g. ondansetron)risk of oculogyric crisis - reversal agent is benztropine
- Prochlorperazine (Stemetil) - not recommended in any children < 12 years, suitable alternative should be used (e.g. ondansetron) risk of oculogyric crisis - reversal agent is benztropine
- Tetracyclines (doxycycline, minocycline) - not recommended in children < 8 years can cause tooth discolouration & enamel dysplasia as well as possible bone problems.
- Tramadol - not advised in children < 12 years, or post adenotonsillectomy < 18 years risk of respiratory failure
In conclusion, we should be aware of 3 things. First, when prescribing pediatric patients. Awareness and vigilance in terms of assessing, understanding and the prevention of any adverse effect with the medication given to our patients. Second, is understanding that in prescribing any disease, it’s better to based it on the weight of the patient. Basing it to the weight makes things easier to manage how much the drug can saturate the body.
Lastly monitoring the use of medication in children is of paramount importance. Some medication may do more harm than good to them. We as health care professionals should be aware of what type of medication they are and what can they do to our patient’s body.
Dr. Bryan Anduiza - Writer
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