Chapter: Special Pop. Peds/ CF/ Transplant/ WeightLoss Flashcards
Age Classification
AGE CLASSIFICATIONS
Neonate: 0-28days
Infant: 1 month - 12 months
Toddler: 1-3?
Child 3 - 12 years
Adolescent 13-18 years
Infants can become seriously ill very quickly. Children must be referred to urgent care in certain situations…
SAFE MEDICATION ADMINISTRATION:
Household spoons should not be used for measuring
medication!!! What should be used instead? and When dispensing high-risk liquid medications, follow these safety guidelines:
All liquid medications should be dispensed with
an oral dosing syringe or dosing cup (oral syringes preferred;can decrease measuring errors).
.
When dispensing high-risk liquid medications, follow these safety guidelines:
- Stock only one strength if multiple strengths are available, storing them in a designated high-risk area with clear instructions.
- Doses should be expressed in total mg and mg/kg per dose.
- Pharmacists should verify that the dose is suitable for the child’s weight, obtaining weight information from the parent if necessary.
- Container labels should display both the dose (mg) and volume (mL), and medications should be dispensed with a measuring device.
NEWBORN BABY HEALTH
APGAR SCORING
The Apgar score evaluates a newborn’s condition one minute and five minutes after birth across five categories: heart rate, respiratory effort, color, muscle tone, and reflex irritability. Each category receives a score from 0 (worst) to 2 (best), with a total score of 10. A score of 7-10 indicates a healthy infant, while a lower score signals the need for additional medical attention.
NEWBORN BABY HEALTH
SCREENING AND MEDICATIONS
Newborns undergo screening for congenital illnesses like phenylketonuria and cystic fibrosis soon after birth. Standard medications administered include intramuscular vitamin K to prevent bleeding, ophthalmic erythromycin or silver nitrate to prevent conjunctivitis, and the initial dose of the hepatitis B vaccine. Additional treatments may include analgesia for circumcision and light therapy for jaundice.
NEWBORN BABY HEALTH
PRE-TERM BABY CONDITIONS
Low Apgar scores in pre-term infants often stem from underdeveloped lungs and hearts. Treatment for respiratory issues may involve oxygen via face mask, continuous positive airways pressure, or full ventilator support with intubation. Patients on ventilators may need sedatives and analgesics. Common cardiovascular conditions include hypotension, intraventricular hemorrhage (IVH), patent ductus arteriosus (PDA), and persistent pulmonary hypertension of the newborn (PPHN). Hypotension is primarily treated with IV fluids, and IVH may necessitate blood transfusions if severe.
NEWBORN BABY HEALTH
PATENT DUCTUS ARTERIOSUS
The ductus arteriosus, a fetal blood vessel between the aorta and pulmonary artery, typically closes after birth. When it remains open (patent), known as a PDA, medical intervention is necessary. NSAIDs like IV indomethacin or ibuprofen can aid closure by blocking prostaglandins. NSAIDs must be given within 14 days of birth for effectiveness. However, they shouldn’t be used in the third trimester of pregnancy as they might prematurely close the PDA.
NEWBORN BABY HEALTH
PERSISTENT PULMONARY HYPERTENSION OF
THE NEWBORN
When newborns fail to relax lung blood vessels, it can result in PPHN. Treatment typically involves supportive care and inhaled nitric oxide to dilate pulmonary arterioles. Some drugs used for pulmonary arterial hypertension, like prostacyclin analogues and PDE-5 inhibitors, can also be used. PPHN may be associated with in utero exposure to SSRIs. Pre-term infants are at higher risk for pulmonary conditions such as respiratory distress syndrome (RDS) and respiratory syncytial virus (RSV).
NEWBORN BABY HEALTH
RESPIRATORY DISTRESS SYNDROME
Respiratory Distress Syndrome (RDS) stems from insufficient surfactant production in underdeveloped lungs. Surfactant, crucial for maintaining alveoli stability, is typically produced adequately by week 35 of gestation. Pre-term infants often lack surfactant, leading to alveolar collapse, RDS, and potentially respiratory failure. Most infants born before 35 weeks receive surfactant post-birth. Surfactant products,( recognized by either “surf” or “actant” in the name,) like poractant alfa (Curosurf) and calfactant (lnfasurf), aid in treatment.
OTC PRODUCTS FOR CHILDREN< 12 MONTHS OLD
MILD PAIN AND FEVER
Avoid aspirin and salicylate-containing products in children under 16 due to the risk of Reye’s syndrome, especially during viral infections like influenza and chickenpox. It might not be evident if a child is recovering from a viral illness, so recommending aspirin or salicylates for those under 16 should be avoided. Acetaminophen infant drops and children’s suspension have the same concentration to minimize dosing errors in older children.
Acetaminophen is the preferred option for pain and fever relief but can lead to liver failure when exceeding the safe dosage. Accidental acetaminophen overdose is often due to its presence in multiple products, so it’s crucial to counsel parents about this risk and the various packaging of acetaminophen. Ibuprofen should not be used in infants younger than 6 months for pain or fever due to the risk of kidney damage. Pharmacists and parents should be aware that ibuprofen products come in different dosage strengths for infants and children.
For children 6 months and older, acetaminophen or ibuprofen is appropriate for pain and fever relief. These medications are often given alternately every three hours (e.g., acetaminophen followed by ibuprofen three hours later), with each drug administered every six hours. Ibuprofen’s longer action may provide benefits if given before sleep.
.
APAP: 10-15 mg/kg/dose every 4-6 hours (max 75mg/kg/day)
Ibu: 5-10 mg/kg/dose every 6-8 hours (max 40mg/kg/day)
OTC PRODUCTS FOR CHILDREN< 12 MONTHS OLD
NASAL CONGESTION
Nasal congestion in babies is common and typically not serious. Children under 2 mainly breathe through their noses. Avoid smoke exposure near children. Sitting them upright in a car seat indoors can help. Using a cool mist humidifier at night, especially in winter, can ease congestion. Steam from a running shower can also help, but prevent burns by keeping the child away from hot water. Gentle suction with saline drops can loosen mucus. The FDA advises against over-the-counter cough and cold medications for children under 2, and most manufacturers suggest avoiding them under 4, with some products not recommended for those under 6.
OTC PRODUCTS FOR CHILDREN< 12 MONTHS OLD
CONSTIPATION
For intermittent constipation in infants, oral polyethylene glycol 3350 (MiraLax) is recommended at a dose of 0.2 - 0.8 g/kg/day. Prunes or pears, in fruit or juice form, can also help. Glycerin suppositories are commonly used for quick relief, although FDA approval is for children aged 2 years and older. Consult a pediatrician for ongoing constipation issues.
OTC PRODUCTS FOR CHILDREN< 12 MONTHS OLD
DIARRHEA
Dehydration from severe diarrhea can be dangerous in infants. Oral rehydration solutions like Pedialyte and Enfamil Enfalyte are recommended to replace fluids and electrolytes. Avoid antidiarrheal medications such as bismuth subsalicylate due to the risk of Reye’s syndrome. Loperamide is not recommended for over-the-counter use in children under 6 years old.
COMMON CONDITIONS IN YOUNG CHILDREN
BACTERIAL MENINGITIS: symp, how is it diagnose, the predominant pathogen, empiric treatment in neonates?, what agent is NOT use/ why?
The classic signs of meningitis are uncommon in neonates (age 0 - 28 days). Bulging fontanelles (swelling between the bones of the skull) and nuchal rigidity (inability to bend the neck) will be present in< 25% of cases; otherwise , the symptoms are nonspecific.
.
A definitive diagnosis in a suspected case can be made with a lumbar puncture . The likely pathogens causing bacterial meningitis in a neonate differ from other age groups due to the vertical transmission
of organisms from the mother to the baby in the birth canal. The predominant pathogens are Group B Streptococcus (GBS), Escherichia coli, Listeria and Klebsiella. Empiric treatment in neonates consists of ampicillin plus either cefotaxime or gentamicin.
.
Ceftriaxone, which is used in adults, is generally avoided in neonates . Ceftriaxone displaces bilirubin from albumin, which can cause bilirubin-induced brain damage (kernicterus). Ceftriaxone and calcium-containing solutions can precipitate, causing an embolus and death
COMMON CONDITIONS IN YOUNG CHILDREN
RESPIRATORY SYNCYTIAL VIRUS (RSV): What are the characteristics and treatment options for Respiratory Syncytial Virus (RSV) infection in children?
RSV infection is common, typically affecting children by age two. While older, healthy children may experience cold-like symptoms, RSV can be life-threatening/ deadly in premature babies and neonates, often leading to bronchiolitis. Symptoms include fever, cough, dyspnea, and cyanosis. Treatment is primarily supportive care, involving oxygen therapy, IV fluids, and suctioning of secretions. In severe cases with underlying conditions like prematurity or cardiopulmonary disease,inhaled ribavirin (Virazole) may be considered, but it’s not recommended for routine cases.
COMMON CONDITIONS IN YOUNG CHILDREN
RSV PPX: When is RSV prophylaxis recommended, and who are the candidates for this treatment according to the American Academy of Pediatrics?, what drug is used?
There is no vaccine for RVS. Palivizumab (Synagis) is a humanized monoclonal antibody indicated for the prevention of serious lower respiratory tract disease caused by RSV in children at high risk of the disease.
RSV prophylaxis is recommended by the American Academy of Pediatrics (AAP) during RSV season (late fall, winter, early spring). In addition to premature, palivizumab is used for certain infants and children < 24 months with select medical conditions that affect respiration.
Palivizumab is dosed monthly at 15 mg/kg per dose by intramuscular (IM) injection. In neonates and infants, the IM injection site is the anterolateral thigh muscle. The deltoid can be used in children once the muscle mass is adequate, which usually does not occur until at least 3 years of age. Infants should not receive more than five monthly doses during the RSV season. If the baby becomes infected with RSV, no further doses of palivizumab should be given.
COMMON CONDITIONS IN YOUNG CHILDREN
What is Croup?
Croup (Laryngotracheobronchitis), typically caused by a viral infection, leads to inflammation of the upper airway, resulting in symptoms like inspiratory stridor, barking cough, and hoarseness. While bacterial infections are less common, they may cause more severe symptoms. Croup is most prevalent in children under six years old and often worsens at night. Treatment depends on the severity of symptoms.
COMMON CONDITIONS IN YOUNG CHILDREN
Croup: Drug Treatment for Mild, Moderate or Severe Illness
Systemic steroids, typically dexamethasone (0.6 mg/kg x 1 PO/ IM/ IV;), are crucial in treating croup across all severity levels. In moderate to severe cases, patients experiencing breathing difficulty receive systemic steroids followed by nebulized racemic epinephrine if necessary. Nebulized racemic epinephrine is a 1:1 mixture of dextro (D) isomers and levo (L) isomers (the L-isomer is the active component). If racemic epinephrine is not available, L-epinephrine is used.
Epinephrine is an adrenergic agonist that relaxes the bronchial smooth muscle and causes bronchodilation. When administered using a nebulizer, the onset of action is fast but the duration of action is short; it lasts up to two hours at most. A child receiving epinephrine should be monitored for up to four hours for the recurrence of symptoms. The child should not be discharged until breathing is easy with no stridor at rest and after receiving steroids to reduce inflammation.
Drugs not Generally Recommended in Peds
■ Codeine should not be used in children under 12 years old, and in those under 18 years old after tonsilectomy or adenoidectomy. The FDA has restricted codeine use in patients under 18 due to safety concerns. Codeine is metabolized to morphine by CYP2D6.
■ Promethazine is C/I for children under 2 years old due to the risk of severe respiratory depression.
■ Quinolones are generally not recommended for pediatric patients due to potential adverse effects on cartilage, bone, and muscle, except for specific cases like anthrax treatment.
■ Tetracyclines are avoided in children under 8 years old because they can stain teeth and weaken growing bone and cartilage. However, they are used in tick-borne diseases like Rocky Mountain spotted fever (doxy) when the benefits outweigh the risks.
■ Benzocaine-containing topical teething products are not recommended for children under 2 years old due to the risk of methemoglobinemia, and the FDA is working to remove them from the market.
PRIMARY TOXICITIES FROM
ACCIDENTAL OVERDOSE IN CHILDREN
Iron and acetaminophen are frequent causes of accidental overdose in children, who may mistake them for candy. Even a single tablet of certain medications, like sulfonylureas, can be fatal to an infant. It’s crucial to educate older patients about storing medications safely to prevent accidental ingestion by children. If a child ingests anything potentially toxic, contact the poison control center immediately for guidance.
Cystic Fibrosis
What are the key characteristics and diagnostic methods for cystic fibrosis?
Cystic fibrosis (CF) is an incurable, hereditary disease caused by a mutation in the gene for the protein cystic fibrosis transmembrane conductance regulator (CFTR). The mutation causes abnormal transport of chloride, bicarbonate, and sodium ions across the epithelium, leading to thick, viscous secretions. The thick mucus affects the lungs, pancreas, liver, and intestines, causing difficulty breathing, lung infections, and digestive complications. The name cystic fibrosis refers to the characteristic scarring (fibrosis) and cyst formation that occurs within the pancreas. The average life expectancy of a person with CF is 35-40 years, with more than 75% of patients being diagnosed by 2 years of age. The disease is progressive, with some eventually qualifying for lung transplantation.
DIAGNOSIS
Newborn screening (NBS) is performed in the U.S. in the first 2-3 days after a baby is born. NBS includes testing for CF and other conditions. If the initial screening identifies a risk of CF, then a sweat chloride test (or “sweat test”) is performed to confirm the diagnosis. The sweat test measures the amount of salt (chloride) in the sweat, which is high in patients with CF.
CF: S/Sx
CF presents with hallmark symptoms including salty skin, poor growth and weight gain, thick mucus production, recurrent lung infections, coughing, and breathlessness. Additionally, pancreatic duct obstruction leads to steatorrhea (fatty stool) and malabsorption of nutrients, often accompanied by clubbing of the fingers. Untreated CF can lead to malnutrition and failure to thrive.
CF: lung complications; What is the foundational approach to managing thick mucus and reducing the risk of lung infections in cystic fibrosis (CF), and why is the correct administration order of inhaled medications crucial in this treatment?
A variety of medications are employed to manage thick mucus and lower the likelihood of lung infections in CF. Administering the inhaled medications in the correct order is critical to maximize absorption and effect. Airway clearance therapies, such as bronchodilators, hypertonic saline, and dornase alfa, precede/given before inhaled antibiotics. In CF treatment, inhaled therapies are fundamental, delivering drugs directly to the lungs with minimal systemic absorption, thereby reducing toxicity risks.
CF: Intermittent Infection - What are the common bacterial organisms found in cystic fibrosis patients, and how does the treatment approach differ for infections caused by Pseudomonas aeruginosa?
Impaired mucus clearance in cystic fibrosis leads to bacterial colonization and lung infections. Common early organisms include Staphylococcus aureus and Haemophilus influenzae, followed by to Pseudomonas aeruginosa in older patients. Exacerbations feature increased cough, sputum production, breathlessness, and decreased FEV1. Treatment involves prolonged antibiotics and methods to enhance airway clearance.
.
For Pseudomonas aeruginosa infections, 2 IV abx therapy is recommended to prevent resistance. These include animoglycosides, beta lactams, and quinolones. Higher doses are often needed to counter altered drug metabolism, ensure effective lung tissue levels, and address bacterial resistance.
Chronic lung infections with Pseudomonas aeruginosa in cystic fibrosis (CF) patients are linked to a faster decline in pulmonary function. To combat this, inhaled antibiotics are recommended. Treatment is cyclical, lasting 28 days on and then 28 days off, leading to improved lung function and fewer acute exacerbations. The frequency of these exacerbations correlates strongly with lung function deterioration and reduced life expectancy in CF.
.
Ensuring proper adherence to the prescribed inhalation regimen is essential to mitigate the development of antibiotic resistance. For instance, aztreonam (Cayston) and tobramycin (TOBI, TOBI Podhaler) are administered with dosing intervals tailored to maintain consistent bacterial eradication while minimizing the risk of resistance emergence. Additionally, a six-month trial of oral azithromycin (no direct activity agaisnt pseudomonas) may be considered for patients not responding to standard treatments, as it can disrupt bacterial biofilm formation, potentially enhancing lung function and decreasing exacerbations.
CF Agents
Step 1: Bronchodilator
Eg. Albuterol (2-4 x QD) - inhaled
CF
Pancreatic enzyme products (PEPs): name, warnings, SEs, Common issues?
- Pancrelipase (Creon, Viokace, Zenpep)
- Warnings: Fibrosing colonopathy advancing to colonic strictures (rare: higher risk with doses> 10,000 lipase units/kg/day), mucosal irritation
- **SEs: **Abdominal pain, flatulence, nausea
- Common issues? Pic
CF
CYSTIC FIBROSIS TRANSMEMBRANE CONDUCTANCE REGULATOR (CFTR) MODULATORS: what are they? MOA? name the drugs and what they are approved for?
Ivacaftor enhances chloride transport by prolonging CFTR channel opening, while lumacaftor, tezacaftor, and elexacaftor correct CFTR folding defects, thereby increasing the amount of CFTR delivered to the cell surface. Genotype testing is required before initiating treatment if the patient’s CF genotype is unknown, as each drug is approved for specific mutations. The most common mutation in the CFTR gene is a homozygous F508del mutation (2 copies of same allele). Combination products like Orkambi, Symdeko, and Trikafta are approved for the most common CF mutation.
WL
SELECT DRUGS/CONDITIONS
THAT CAN CAUSE WEIGHT GAIN
SELECT DRUGS/ CONDITIONS
THAT CAN CAUSE WEIGHT LOSS
RX weight loss drugs… and the different caveats of when to avoid then/ extra notes for the different types of conditions
