PEDIATRIC PHARMACOLOGY

& Math for Meds

Types of Pediatric Medication

Errors
37.5% Improper dose/quantity
19.9% Omission error
13.7% Unauthorized/Wrong drug
9.4% Prescribing error
Wrong administration technique
Wrong time
Medication prepared incorrectly
Wrong dosage form
Wrong route

Causes for Errors

43% Performance deficit
29.9% Knowledge deficit
20.7% Procedure/Protocol not followed
16.8% Miscommunication
Calculation error
Computer entry error
Inadequate or lack of monitoring
Improper use of pumps
Documentation errors
Lack in pediatric-formulated medications
Lack of pediatric-trained staf

Pediatric Pharmacokinetics

Absorption

Influencing factors
Childs age, health status, underlying disease,
hydration, route of administration
Route of administration
Gastric acidity, emptying, motility, surface area,
enzyme levels, intestinal flora
IM/SubQ
Peripheral perfusion
Efectiveness of circulation
Topical
Childrens skin is thin and porous

Pediatric Pharmacokinetics
(contd)
Distribution

Influencing factors
Body fluid composition
Neonates and infants are 70% water
Body tissue composition
Neonates and infants have less body fat
Protein-binding capability
Neonates and infants have less albumin
Efectiveness of barriers
Skin
Blood-brain barrier

Pediatric Pharmacokinetics
(contd)

Metabolism

Influencing factors
Maturational level of child
First-pass efect
Higher metabolic rate

Pediatric Pharmacokinetics
(contd)
Excretion

Areas of occurrence
Kidneys
Infants have decreased
Renal blood flow
Glomerular filtration rate
Renal tubular function
Intestines, salivary glands
Lungs
Sweat glands, mammary glands

Principles of
Medication Administration
Standardized dosage ranges have not been
established for children.
Children respond diferently to medications
than adults.
The nurse must incorporate principles of
growth and development when
administering medications.
The margin of safety is narrow.

Strategies for Medicating

Children
Infants: Cuddle and comfort.
Toddlers: Use play, minimize restraint, and
give praise and stickers as rewards.
Preschoolers: Ofer choices.
School-age children: Provide choices,
explanations, distraction, and support.
Adolescents: Explain, allow participation in
decisions, praise cooperation, and provide
outlet for frustrations.

Medication Administration
Procedures
Based upon child's developmental level
Oral medications
Injections
Alternative routes

Rectal
Ophthalmic
Optic
Topical
Nasal
Inhalation therapy

Question

The preferred site for intramuscular (IM)

injections in infants is __________.
A.
B.
C.
D.

deltoid
dorsogluteal
rectus femoris
vastus lateralis

Nursing Implications

Pediatric medication dosing and monitoring

Monitoring for therapeutic efects and adverse
reactions

Pediatric medication administration

Client identification
Considering developmental and cognitive
diferences
Diferentiating developmental from chronologic age

Maintaining safety with minimal restraint

Adolescent Considerations
Considerations

for adolescents

Individualized care specific to developmental

stage
Physical changes
Cognitive level and abilities
Emotional factors
Impact of chronic illness

Nursing Process: Pediatric

Pharmacology
Assessment

Developmental age
Age, weight, height
Health status
History of drug use
Nutritional/hydration status
Cognitive level
Family/child understanding

Nursing Diagnoses
Potential

nursing diagnoses

Delayed growth and development

Inefective tissue perfusion
Impaired urinary elimination
Deficient knowledge

Practice Question #1
Children have higher metabolic rates than adults.
The nurse realizes that this afects administration of
medication for pain in children in all of the following
ways except
A. higher requirement for medication
B. increased dosage
C. decreased frequency
D. increased frequency

Practice Question #2
Although adolescents have physical appearance
and organ structure and function similar to that of
adults, the nurse knows that their bodies continue
to grow and require increased vigilance in
monitoring
A. therapeutic and toxic drug levels.
B. side efects of medications.
C. route of medication administration.
D. frequency of medication administration.

Rules of Pediatric Med Admin

Body weight is the most important determiner of

dosages for infants and neonates whose ability to
metabolize drugs is not fully developed.
Health care provider will order the drug and
dosage.
Its the nurses responsibility to check each
dosage to be sure the order is correct.
The hospital pharmacist is a great resource for
information.
Dosages may be calculated in mcg per kg or mg
per kg or lb. per day.
The total daily dosage may be administered in
divided dosages.

Converting LB to
KG

There are 2.2 lbs in 1 kg.

So kg body weights are smaller than lb weight
Conversions from lb to kg are made by dividing

body weight by 2.2

Fractional lb. may be
converted to the nearest
quarter and written as
decimal fractions instead of
oz.
lb (4 oz) as 0.25
lb (8 oz) as 0.5
lb (12 oz) as 0.75

Example 1

Convert the weight of a 27 lb child to

kg.
27 = 27.25
27.25 / 2.2
=
Round to the nearest tenth.
=

Example
2

Convert the weight of a 58 lb child to

kg.
58 = 58.75
58.75 / 2.2
=
Round to the nearest tenth.
=

Practice problems

Convert the weight of a 7 lb newborn to

kg.
Convert the weight of a 15 lb infant to
kg.

Convert the weight of a 34 lb child to

kg.

Converting KG to LB

There are 2.2 lb in 1 kg.

To convert from kg to lb, multiply by 2.2
The answer in lb will be larger than the kg.

Express weight to the nearest tenth.

Example 1

A child weighs 23.3 kg. Convert to lb.

23.3 x 2.2 =
Round to the nearest tenth.

Example 2

Convert the weight of a 14.2 kg child to lb.

14.2 x 2.2 =
Round to the nearest tenth.
=

Practice problems

Convert the weight of a 21.3 kg child to lb.

Convert the weight of a 2.2 kg infant to lb.

Convert the weight of a 43.7 kg child to lb.

Calculating Dosages from

Drug Label Information

Two-step process.

First, calculate total daily dosage

Then, divide it by the number of doses per
day to
find how much should be administered at
one time.

Example 1

The label reads Cefaclor oral suspension.

The available dosage is 125 mg/5 mL.
The usual children dosage is 20-40 mg/kg/day.
This dosage is to be
given in divided doses
every 8 hours.
24 hr / 8 hr = 3 doses
The child is 18.2 kg.

13

 Calculate the
recommended daily
dosage range first.
Lower daily dosage = 20 mg/kg
20 mg x 18.2 kg = 364 mg/day

Upper daily dosage= 40 mg/kg

40 mg x 18.2 kg = 728 mg/day

So the recommended range

for this 18.2 kg child is 364728 mg/day.

 The drug is to be given in three divided doses.

Lower dosage:
364 mg / 3 = 121 mg per dose

Upper dosage:
728 mg / 3 = 243 mg per dose

The per dose dosage

range is 121 mg to 243 mg
per
dose every 8 hrs.

Putting Dosage Range into Play

1.

If the order is to give 125 mg every 8 hours, is

this within the recommended dosage range?

2. If the order is to give 375

mg every 8 hours, is this within
the recommended dosage
range?

3. If the order is for 75 mg

every 8 hours, is this an accurate
dosage?

4. If the order is for 250 mg

every 8 hours, is this accurate?

5. If the dosage ordered is 125

mg every 4 hours, is this an
accurate dosage?

Pediatric Oral and Parenteral

Medications

Differences Between Adult and Pediatric Dosages

Most oral drugs are liquids for
ease of administration.
Dosages are dramatically smaller.
Medicine cups, oral syringes, or droppers.

37

 Oral suspensions will have to be

reconstituted.
Oral suspensions must be thoroughly
shaken.
Check to make sure pills are swallowed.
Pills can be crushed
and
given with carrier as
long
as theyre not
enteric-

Intramuscular and
Subcutaneous
Medications
Insulin and immunizations
Dosage calculations are
done
the same way as with
adults,
but dosages are
sometimes
calculated to the
nearest
hundredth and
measured using
a tuberculin syringe.

Pediatric IV Medications

Methods of IV Medication
Administration

May be given over several hours or

intermittent with several dosages in a
day.
Burettes are used for small volumes
because theyre calibrated in 1 mL
increments and exact measurement of
small volumes is possible.
When IV medications are diluted for
administration, it is necessary to look at
hospital policy on inclusion of the
medication volume as part of the
volume specified for dilution.

Administration of
Intravenous Medications
Site selection
Infusion pumps

Rate and quantity of intravenous (IV) fluids

Close monitoring
Immediate onset of action

Prevention of bloodstream infection

Hand hygiene
Scrubbing of the port's hub

Example 1
A dosage of 125 mg in 1 mL of D5 NS is to be diluted in 20
mL of D5 NS and infused in 30 minutes. It is to be
followed with a 5 mL D5 NS flush. A pump will be used
and the tubing is a micro drip burette.

125 mg has a volume of 1 mL.

Add 19 mL of D5 NS to the

burette, and the 1 mL of

medication, and mix thoroughly.

Calculate the mL/hr flow rate.
VTBI x 60
time in min
20 mL x 60
30 min
= 40 mL/hr

 An antibiotic dosage of 50 mg has been

ordered diluted in 20 mL of D5W to infuse over
20 min. A 15 mL flush of D5W is to follow. A
micro drip will be used, but an infusion control
device will not be used.
Read the medication label to determine what
volume contains 50 mg. You determine that 50
mg is contained in 2 mL.
Run 18 mL of D5W into the burette and add
the 2 mL containing the drug. Mix thoroughly.
Calculate the flow rate in gtt/min necessary
to deliver the medication.
VTBI x 60
20 min

= 60 gtt/min

Practice problem

Determine the volume of solution that must

be added to a burette to mix the following IV
drugs. Then, calculate the flow rate in gtt/min
using a micro drip and mL/hr using a pump.
A dosage of 100 mg in 2 mL is diluted to 30 mL
of D5W to infuse in 20 min.
Dilution volume
Gtt/min_
mL/hr

 Determine the volume of solution that must be

added to a burette to mix the following IV drugs.

Then, calculate the flow rate in gtt/min using a

micro drip and mL/hr using a pump.

The volume of a 10 mg
dosage of medication is 1
mL. Dilute to 40 mL and
administer over 50 min.
Dilution volume
Gtt/min_
mL/hr

Practice problem

Determine the volume of solution that must

be added to a burette to mix the following IV
drugs. Then, calculate the flow rate in gtt/min
using a microdrip and mL/hr using a pump.
A medication of 1 g in 4 mL is to be diluted to
60 mL and infused over 90 min.
Dilution volume
gtt/min ___
mL/hr

Comparing IV Dosages Ordered with

Average Dosages
A child weighs 22.6 kg and has an order for 500 mg of
medication in 100 mL of D5W every 12 hours. The
normal dosage range is 40-50 mg/kg/day. Determine if

the dosage ordered is within normal range.

Calculate the normal daily dosage range for this child.
40 mg/day x 22.6 kg = 904 mg
50 mg/day x 22.6 kg = 1130 mg
Calculate the dosage infusing in 24 hr.
500 mg in 12 hr = 1000 mg in 24 hr

Assess the accuracy of the dosage ordered.

The 500 mg in 12 hr is
within 904-1130 mg/day
dosage range.

Example 2
A child with a body weight of 18.4 kg is to receive a medication
with a dosage range of 100-150 mg/kg/day. The order is for 600 mg
in 75 mL of D5W every 6 hours. Determine if the dosage is within
normal range.
Calculate the normal daily dosage range.

100 mg/day x 18.4 kg = 1840 mg/day

150 mg/day x 18.4 kg = 2760 mg/day

Calculate the daily dosage ordered.

The dosage ordered is 600 mg every 6 hours (4 doses/24 hours)

600 mg x 4 = 2400 mg/day
Assess the accuracy of the dosage ordered.
The dosage ordered, 2400 mg/day, is within the normal range of
1840-2760 mg/day.

Example 3

A child weighing 32.7 kg has an IV of 250 mL of D5W

containing 400 mcg of medication to infuse in 5 hours. The
normal range for this drug is 1-3 mcg/kg/hr. Determine if this
dosage is within normal dosage range.
Calculate the hourly dosage range.
1 mcg/kg/hr x 32.7 kg = 32.7 mcg/hr
3 mcg/kg/hr x 32.7 kg = 98.1 mcg/hr
Calculate the dosage infusing per hour.
400 mcg / 5 hr = 80 mcg/hr
Assess the accuracy of the dosage ordered.
The dosage of 80 mcg/hr infusing is within the normal range of
32.7-98.1 mcg/hr.

Practice problem

Calculate the normal dosage range to the nearest

tenth and the dosage being administered for the

following medications. Assess the dosages
ordered.
A solution of D5W containing 25 mg of a drug is

Practice problem

An IV solution containing 125

mg of medication is infusing.
The dosage range is 510 mg/kg/dose, and the child weighs
14.2 kg.
Dosage range per dose
Is dosage accurate?

Practice problem

A child weighing 14.3 kg is to

receive an IV drug with a dosage
range of 50-100 mcg/kg/day in
two divided doses. An infusion of
50 mL of D5W containing 400 mcg
to run in
30 min has been ordered.
Daily dosage range_
Daily dosage ordered
Is dosage accurate?

Emergency Medications
Use the Broselow tape to determine color of
drawer to open
Look for Code cart on Pediatric unit.

Many drugs are not recommended for use in

Pediatric patients always look up the drug
and contact the pharmacy