Pharmacy in Pediatrics

Question 1

What is gestational age?

Answer 1

Time from conception until birth

Question 2

What is postnatal age?

Answer 2

Chronological age since birth

Question 3

What is post-conceptional age/corrected gestational age/postmenstrual age?

Answer 3

Age since conception

review slide 8

Question 4

Review slide 9 for important age definitions

Question 5

What is the age of a premature neonate?

Answer 5

< 37 weeks gestational age

Question 6

What is the age of a full term neonate?

Answer 6

neonate born 37 - 41+6/7 weeks gestational age

Question 7

What is the age of a neonate?

Answer 7

Full term neonate up to 28 days PNA

Premature neonate whose PCA is < 42-46 weeks

Question 8

What are some differences in absorption among pediatric patients?

Answer 8

Higher pH (less acidic earlier in life)
- Absorption of acid labile compounds is higher (ex. penicillin)
- Absorption of weak acids is reduced (ex. phenobarbital)

Question 9

How does gastric motility change with age in pediatrics?

Answer 9

Increases with age, normalizes at 4 months of age

Slower drug absorption and longer Tmax in neonates

Question 10

How is skin permeability different among pediatric patients?

Answer 10

Increased topical absorption in neonates/infants (due to thinner skin, therefore give lower potency)

Question 11

How is IM injections absorption different in pediatric patients?

Answer 11

Reduces skeletal muscle blood flow in neonates, but higher density of capillaries

Therefore more variable drug absorption

Question 12

What is unique about neonates and infants regarding their distribution.

Answer 12

Very large extracellular and total body fluid

Higher Vd of hydrophillic drugs

Decreased circulating albumin and AAG

Higher amounts of endogenous products (displace drugs from binding sites)

Question 13

What are some unique aspects of neonatal metabolism?

Answer 13

Delayed maturation of CYP enzymes (may result in more conservative drug dosing)

UGT increases with age

Question 14

What are some unique aspects of elimination among pediatric patients?

Answer 14

Tubular secretion is immature in neonates/infants, but rapidly increases

GFR increases with age (rapid increase in first 2 weeks of age and reaches adult values at 8-12 months)

Question 15

What is the Schwartz equation?

Answer 15

Estimates CrCl in pediatric patients (under 1 years old)

use k=0.413 as coefficient

Question 16

Review slide 24 for CrCl targets

Lower normal CrCl in younger children

Question 17

What are some ways suspension/solution drug formulation palatability can be improved?

Answer 17

Chocolate or strawberry syrup, peanut butter (coats tongue)

Applesauce (masks flavour, provides medium for mixing)

Ice cream (cold minimizes flavour, numbs taste buds)

Flavouring agent (risk of ruining flavour for patient, taste associated with drug)

Question 18

What are some oral administration tips for pediatric patients?

Answer 18

Do not adminster liquid straight back into the throat (gag-reflex)

Slowly introduce med to the rear cheek

Always use standardized measuring syringes, not household utensils

Question 19

What is the thirty minute rule with respect to oral drug administration?

Answer 19

If a child throws up in less than 30 min after drug admin, another dose can be given

If the child throws up again, then do not repeat dose

If the child initially throws up after 30 minutes, do not repeat the dose

Question 20

What are the three main types of parenteral access lines in pediatrics?

Answer 20

Peripheral IV (short-term use)

Central IV (longer-term use, PICC, broviac, umbilical catheter for neonates)

Intraosseous catheters (used in emergency situations)

Question 21

What are some characteristics of PICC lines?

Answer 21

Used when larger volumes and more concentrated drug solutions

Also placed if the patient will be in hospital for weeks

Question 22

What are some characteristics of broviac lines?

Answer 22

Port into veins near heart (ex. chemo patients)

Question 23

What are some characteristics of intraosseous lines?

Answer 23

They are drilled directly into bone marrow, can give lots of fluid this way (used in emergent situation)

Question 24

Review slide 46 and 47 for formula method for determining fluid requirements

Question 25

Review slide 48 and 49 for 4/2/1 method for calculating fluid requirements

Question 26

What fluid is appropriate in most children?

Answer 26

D5W/NS(normal saline) Excluding the following patients: - Renal or CV disease (risk of hypo/hypernatremia) - Diabetic ketoacidosis (limit dextrose sugar) - Severe burns (loose more fluid) - Underlying conditions that affect electrolyte regulation

Question 27

What factors need to be considered before assessing blood pressure readings in pediatric patients?

Answer 27

Age, sex, height HTN is generally defined as SBP or DBP greater than 95th percentile review slide 56 for BP chart

Question 28

Review slide 58 for typical BP readings among children

Question 29

Review slide 59 for typical HR readings for children

Question 30

Review slide 60 for typical respiratory rate readings for children

Question 31

What are some characteristics of rectal temperature readings in children?

Answer 31

Reference standard for core temps Gold standard of measurement, but invasive

Question 32

What are some characteristics of axillary temps in children?

Answer 32

Lower than rectal readings, but much less invasive and easier to obtain Preferred in neutropenic pts due to infection risk and children who can't coordinate oral temp

Question 33

What are some characteristics of oral temps in children?

Answer 33

0.6°C lower than rectal\ Generally preferred in children who can coordinate oral temp devices

Question 34

What is normal body temperature for children?

Answer 34

37.2*C +/-0.5*C within a day Colder in the morning, and late-afternoon/evening peak Neonates and infants have higher body temps (higher SA to weight ratio and metabolic rate)

Question 35

What is some new clinical advice about tetracyclines in children?

Answer 35

Tetracyclines have shown to chelate to developing bones and teeth, but short-term use (under 21 days) may be considered if clinical benefits outweigh harms Other reasonable options need to be exhausted before trying tetracyclines in children

Question 36

Why are fluoroquinoles not reccomended to use in children?

Answer 36

Arthropathy (cartilage and joint degradation) Can be used if it is a reasonable alternative to parenteral theraph Limited use when no other safe options are not safe or effective

Question 37

What is the caution with TMP/SMX in pediatric patients?

Answer 37

CI in infants under 2 months May cause hyperbilirubinemia or kernicterus (hyperbili in brain) due to competitive binding to proteins like albumin

Question 38

When can ASA be used in children despite reccomendation against use in this age group?

Answer 38

Cardiac conditions in pediatrics: - Kawasaki Disease - Post-operative Congenital Heart Repair Prophylaxis - Rheumatic Fever

Question 39

What is Kawasaki Disease?

Answer 39

Acute systemic vasculitis of childhood (inflammed vasculature) Self-limited in most cases cases, but if untreated with ASA, 1/4 of these cases eesult in coronary artery aneurysms

Question 40

What are some symptoms of Kawasaki Disease?

Answer 40

Fever that lasts over 5 days and 4+ of the following sx: - Strawberry tongue - Polymorphous rash - Changes in extremities (edema in hands/feet, erythema in soles/palms) - Cervical lymphadenopathy

Question 41

Review slide 80 to 99 for pediatric patient cases