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• Ellie Tabar, PharmD, provided this information
• The date of the information is Feb 11, 2025
• This information is PHAR 840/IPC focused on Immunologic conditions with special populations

Objectives

• Review pediatric medication complexities
• Explain differences in pediatric drug absorption
• Discuss pediatric dosing guidelines
• Practise calculating common pediatric doses
• Cover treatments for common pediatric conditions

Age Classification

• Premature neonates are born before 37 weeks
• Neonates are in the first 28 days of life
• Infants are 1-12 months old
• Toddlers are 1-2 years old
• Preschool children are 3-4 years old
• School-age children are 5-12 years old
• Adolescents are 13-18 years old

Pediatric Growth & Development

• Changes in weight or height over time relates to growth velocity
• Growth velocity is measured at each “well-child” care appointment using standardized growth charts.
• Reference for growth charts: https://www.cdc.gov/growthcharts/index.htm
• Term neonates commonly lose up to 10% of body weight during the first few days of life
• Infants should regain birth weight by 10-14 days of age.
• Infants should gain approximately 20–30 grams per day in the first three months
• Infants should double birth weight by 4 months
• Infants should triple birth weight by 1 year

Pediatric Nutrition

• Proper nutrition is needed for optimal growth
• Exclusive breastfeeding is recommended for the first 6 months
• Breastfeeding alongside complementary foods continues from 6 to 23 months
• Complementary feeding should initiate at 6 months of age
• Diversifying diet is key, including animal-source foods (meat, fish, poultry, dairy), fruits and vegetables, and legumes and nuts

Vitamin Supplementation

• All infants, including exclusively breastfed babies, need a daily vitamin D supplement of 400 IU (10 mcg), starting within the first few days after birth
• Infants continue supplementation until they consume at least 1 liter of vitamin D-fortified formula or milk daily
• Exclusively breastfed infants need an iron supplement of 1 mg/kg per day starting at 4 months of age until iron-rich complementary foods are introduced
• Formula-fed infants typically do not require additional iron supplementation
• Infants and children on strict vegan diets are at risk for vitamin B12 deficiency and supplementing is determined in consultation

Pediatric Pharmacokinetics

• Absorption: slower oral absorption, avoid IM (intramuscular) administration, increased topical absorption
• Distribution: higher percentage of water, lower protein binding, and lower fat.
• Metabolism: Neonates have slow metabolism and children have fast metabolism
• Elimination: kidney function of pediatric patients is slower, so adjust the dosing
• Drug dosing should be adjusted based on age & organ function

Obesity & Pharmacokinetics

• Overweight is defined as the 85th-94th percentile BMI
• Obese is defined as greater than or equal to the 95th percentile BMI
• Absorption is not majorly effected in obese children
• Hydrophilic drugs: ↓ Vd, use IBW
• Lipophilic drugs: ↑ Vd, may require adjustment (varies by drug) → TBW
• Liver enzyme activity may increase → some drugs metabolized faster
• Renal clearance may be increased → adjust dosing for renally excreted drugs
• Use IBW for hydrophilic drugs (e.g., aminoglycosides, vancomycin)
• Use IBW for benzodiazepines/opioids
• Use TBW for lipophilic drugs that distribute into fat (e.g., some anesthetics)
• Consider Adjusted Body Weight (ABW) for certain cases
• Adult doses should not be exceeded

Pediatric Dosing Guidelines

• Always calculate each dose individually
• Use reliable dosing handbooks
• Dosing units may vary (mg/kg/dose, mg/kg/day divided doses)
• Always use kg for weight-based dosing. Convert: Weight (lb) ÷ 2.2 = Weight (kg)
• Select the correct indication – Doses vary based on disease severity
• Choose the appropriate age group e.g. Neonatal Pediatric or Adolescent dosing
• Always verify calculations and avoid exceeding maximum doses

Pediatric Dosing

• By Weight (mg/kg) dosing is used for most drugs
• By BSA (Body Surface Area) is used for some medications
• BSA Formula: √[(Height (cm) × Weight (kg)] / 3600]
• Adjust to the tablet size to the nearest 10%
• Round the dose up to 10%
• The volume dose should be safely measurable
• Never exceed adult doses!

Common Calculation for Dosing

• Patient’s weight (kg) x dose (mg/kg) = dose (mg)
• Acetaminophen example: 10 mg/kg/dose × 8 kg = 80 mg/dose
• Patient’s BSA (m²) x dose (mg/m²) = dose (mg)
• Acyclovir IV example: 1500 mg/m²/day × 0.79 m² = 1185 mg/day. Divided into three doses → ~395 mg per dose. Rounded to 400 mg IV Q8H
• Dose (mg) ÷ concentration (mg/mL) = volume (mL)

Volume Calculation Example

• A patient needs 250 mg of Medication X
• Medication X concentration: 400 mg/5 mL
• The parent should administer 3 mL

Dose Check Calculation Steps

• Divide the mg dosage by the patient's weight (kg) to get mg/kg
• Check if the mg/kg dose is within the dosing range for the drug
• Proceed to verify/fill the order if it is. If not, call the prescriber

Noah Case Study (5 kg)

• A 2-month-old 5 kg infant, named Noah, presented to the ED with:
  • Fever
  • Decreased PO intake
  • Bulging fontanelle
  • One episode of seizure
• Meningitis is suspected, start IV antibiotics
  • Ceftazidime
  • Vancomycin
  • Acyclovir (for HSV meningitis)
• Utilize infant dosing and not neonatal dosing because the patient is >1 month old
• Utilize the higher end of the dosing range to better penetrate the CNS

Fluid Maintenance Rate in Noah Case Study

• Noah is critically ill, needing to admit him and start IV fluids

Holliday-Segar Method

Acute Constipation in Children

Occurrences

• Dietary changes
• Toilet training periods
• School entry (change in routine, less water intake)

Diatery Recommendations

• High-fiber foods (recommended intake: age + 5g/day)
• Adequate hydration (water + age-appropriate fluids)

Healthy Toilet Habits

• Regular toilet sitting (5–10 minutes, 2–3 times daily, preferably after meals) is recommended
• Utilize a footstool to support proper posture

Fiber Supplements for Constipation

• Helps absorb water in stool, increasing bulk and movement
• Available as powders & gummies
• Best for mild constipation & long-term gut health
• Ensure proper hydration for effectiveness
• Gummies look like candy and can lead to overuse

Docusate (Colace) - Stool Softener

• Colace reduces the surface tension of the stool, allowing more water incorporation
• The drug is best used for children with hard, dry stools
• Comes in multiple products/concentrations—double-check dosing
• Do ​​not use with mineral oil; reduces absorption of fat-soluble vitamins
• Common side effect: Throat irritation (take with water)

Osmotic Laxatives for Constipation

• Osmotic laxatives work by drawing water into the intestines, softening stool, and making bowel movements easier
• Commonly used for both acute and chronic constipation
• Polyethylene Glycol 3350 (Miralax) is the most common
• Is the best treatment choice for chronic constipation and also first-line outpatient treatment for pediatics
• Magnesium Hydroxide (Milk of Magnesia) should be avoided if the patient has kidney disease
• Lactulose & Sorbitol are alternative options that may cause bloating
• Monitor electrolytes, especially with prolonged use

Lubricant Laxatives (Mineral Oil)

• It lubricates stool, decreasing water absorption from intestines
• Forms come in oral or enema routes
• The oral onset takes 6-8 hours
• The rectal onset takes 2-15 minutes
• Use should be avoided in young children, due to aspiration risk
• Can reduce absorption of fat-soluble vitamins (A, D, E, K)
• It can be a messy choice!
• Avoid homemade enemas (such as soap suds and herbal varieties)
• If needed stick to using normal saline enemas in healthcare settings

Stimulant Laxatives: Bisacodyl & Senna

• Used for bowel contractions for fast relief
• Typically used for “occasional constipation,” not first-line treatment for chronic use
• Use sparingly to “prevent dependency”

Bisacodyl (Dulcolax)

• Tablet, suppository or enema form
• Administration onset:
  • Oral onset is 6-12 hrs,
  • Suppository is 15-60 min
  • Enema is 5-20 min
• Do not crush/chew tablets and also avoid with antacids/dairy

Senna (Senokot)

• Derived from natural plant sources
• 6-24 hours onset

Constipation in Infants

Dietary Modifications

• Prune juice
• Baby food
• Fiber-rich vegetable purees
• High-fiber cereal

Glycerin Suppositories

• A safe to use medicine
• Local Osmotic agent
• 15-60 Min Onset
• Dose: 1 suppository given PR QD or BID PRN

Stay away from

• Avoid mineral oil, it produces aspiration risk
• Saline agents are not recommended in children below 2 years of age due to electrolyte imbalances
• Avoid Enemas in children <2 years

Acute Gastroenteritis (AGE)

Diagnosis & Treatment Recommendations

• Nausea/Vomiting
• Diarrhea
• Anorexia
• Abdominal Cramps

What are the Major Viral Causes to Diagnose?

• Noroviruses
• Rotaviruses Enteroviruses

What can be a Major Consideration?

• Dehydration

AGE Treatments

• Oral Rehydration Therapy (ORT) is a great method to administer
• Use For Mild to Moderate Dehydration Conditions
• Supervise With Continuous Frequent, Small Sips of Electrolyte solutions
• Resume Age-Appropriate Diet
• Avoid High Sugar and High Fat Foods
• Encourage Protein and Nutrient Dense Meals and Snacks
• Probiotics Are Used to Support the Gut Microbiota
• Start Early for Potential Benefits

What are the Common Probiotic Treatments?

• Lactobacillus GG
• Saccharomyces boulardii
• Lactobacillus reuteri
• This can help to Reduce Diarrhea Duration

Treatment Options Continued - Severe Dehydration

• Intravenous Fluid Resuscitation for Severe Cases
• 20ml/kg Normal Saline IV, or Use if Unable to Resuscitate With ORT

AGE - Treatments Should Consist of Antiemetics & Antidiarrheals

• Use During Nausea & Vomiting
• Only If Oral Rehydration Therapy (ORT) is Prevented Due to these issues

Antiemetics

• Ondansetron 0.15mg/kg (Max: 8mg) x 1 dose

Antidiarrheals Should Not Be Utilized For Any of These!

• Loperamide (Imodium) Is Used on Slow Gut Movement. Risk of Side Effects Present
• Bismuth Subsalicylate (Pepto-Bismol) Side Effects Can Lead To, Reye’s Syndrome!
• Children’s Pepto - Not Effective for Most Children.

Medications - Oral Rehydration Therapy Solutions (ORS)

• Used for Mild to Moderate Dehydration Cases
• It Consists of The Utilization of Electrolytes
• It’s Easy to Administer!
• Commercial products + home remedies can be utilized for this.
• The method of care you can start ASAP
• For patients that are at least one year or older
  • Start With Smaller and Frequent Amounts Of 5mEq Q1 – 2min.
  • Syringe or Spoon Should Consist of Smaller Measurements

Guidelines for Oral Rehydration Therapy

Rehydration

• Administer Mild Dehydration Of 50mL/kg or over 4hrs.
• Administer Moderate Dehydration Of 100mL/kg or over 4hrs.
• Conduct Under healthcare supervision.

Maintain

• Replace Ongoing Losses with The Following, Based On Stool Movements
• Administer 10mL/kg on Constant Diarrhea
• Administer 2mL/kg On Constant Emesis.
• Resume normal feeds for age.

AGE Prevention

• Conduct Consistent Hand Hygiene.

Vaccinations.

• A Method to Include National Immunization Programs.
• Live Vaccine
  • contraindications - Severe Combined Immunodeficiency (SCID)
• Rota-Teq
  • Administer in 3 Series Doses, 2,4 & 6 Months.

Rota-Rix

• Administer at the ages of 2-4 Months.
• Give Prior to The Ages of 15 Weeks Old.
• Vaccine Doses are Complete in 8 Months.

What About Vaccine Interchangeability?

• Follow through with similar products that are convenient. Always Utilize This Method!

Interchangeability Cont.

• Administer The Vaccine If Missing Doses. The Doctor Will Determine The Next Step.
• If any dose was Rotateq® or the Vaccine Product is unknown for any Dose, a total of three Doses is needed.

Gastroesophageal Reflux (GER) & GERD in Infants

• Reflux is Common.
• Usually Improves with Age
• Must Rule out Serious Conditions that May Trigger

Uncomplicated GER

• Infant must have Good Weight Gain
• Feeds Well
• Not Irritable
• There is No Medical Treatment Needed; implement Non-Pharmacological Measurements

Gastroesophageal Reflux Disease

• Poor Weight Gain
• Feeding Refusal
• Marked Irritability

Lifestyle/Non-Pharmacological Modifications

• Elevate the baby's head as they sleep
• Avoid meals close to bedtime
• Implement dietary changes as needed
• Eliminate exposure to secondhand smoke

How to Utilize Nutritional Adjustments

• If Infants have difficulty, provide a small amount
• Use thickened feedings or anti-regurgitations
• In Breast Feeded Infants, Mothers Can Eliminate Dairy.

Pharmacological Interventions

• Utilize Acid Suppressants
• Proton Pump Inhibitors (PPIs)
• Omeprazole, Lansoprazole
• Administer For 4-8 weeks to reduce stomach acid
• Histamine-H2 Receptor Antagonists (H2RAs)
• Famotidine

What Can Cause Intestinal Gas in Infants?

Simethicone

• A 40mg Oral Suspension
• Decreases Tension With Gas Allowing To be More Expelled Easily!

Absorption

• Not Absorbed from the Gastrointestinal Tract
• It is generally safe for infants to use
• Some are typically filled with herbal ingredients such as fennel, ginger, chamomile, etc.

What is Gripe Water?

• A Product With A History of Not Regulated By The US Food and Drug Administration!
• Safety and Effectiveness Have Not Been Confirmed!

What can you do for a child facing pediatric pain?

• Pediatric Context: Used in The 1990’s. As a Result, Neonates & Young Children Won’t Experience As Much Pain As Other Aging Demographics.
• Neonates and Young Children: Research Is Constantly Developing in Infants to show Increased Intensity with this specific Demographic.
• Difficulty Assessing The Pain
• There are potential fears for adverse effects
• Concerns may exist with the Parents or Healthcare Givers.

What Pain Medications Options Exist For Treatment?

• It should consist of Mild Levels. So Start With Acetaminophen Use or NSAIDS.
• Utilize Non-Pharmacological Approaches
  • Implement Distractions to Mitigate Irritability.
  • Therapeutic Touch to Assist with Calmness
  • Swaddling or Sucking So They Don’t Have Trouble Breathing.
  • Art and Play Therapy

How do you treat Acetaminophen (Tylenol®)?

• For mild pain and fever
  • Use a relatively safe recommended dosage
  • Easy to administer

What Are The Formulations Can You Offer For The Treatment?

• Oral (Solution,Tablets and Capsules)
• PR Suppositories
• Intravenous

Guideline Dosing

• Always Treat As If They Are Below 12-Years Old to Assist With Safety!
• 10 – 15mg Per kg Every 4-6 Hours As Needed.
• Max should consist of 75mg Per Kg Per Day.
• What Should Children above the ages of 12 do?
  • If the Patient Is Over 12YO they Can Administer Above with 325-650 mg Every 4-6 Hours, As Needed
  • You Shouldn’t Surpass 3g Within Adults.

How Do We Manage Teething For Patients?

• Starts Generally At The Range Of 6-10 Months.

If the patient is experiencing symptoms please check for the following:

• Irritability
• Excessive Drooling
• Always Having the need to chew on a substance
• Mild Gum Discomfort If Any. What Are Some Uncommon Symptoms That Do Not Need Teething Treatment?
• In the case of Fever >100.4˚ F (38˚C) or High.
• Diarrhea Or Vomiting
• Severe cases of rashes breaking out. What Is The Right Way to Administer the Product with Comfort For the Patient?
• Always Provide and Ask For Chilled Teething Rings! Offer Wet and Cold Wash Cloths. Always Seek and Confirm Products Safety, Effectiveness, and Precautions For The Patient! Otherwise Avoid Them! What Should Consist of These?
• OTC teething gels and topical analgesics
• Homeopathic products in the form of tablets
• Teething necklaces in the form of Amber

NSAIDs-Ibuprofen (Motrin®, Advil®):

• Inhibit COX-1 & COX-2
• Reduces pain, fever, and inflammation

What is helpful per dose utilized:

• For reducing fever ≥6 Months

Mild to Moderate Pain Needs with a good dose of:

Inflammatory Conditions (e.g., juvenile idiopathic arthritis) Use weight based dosing: 5-10 mg per kg per dose Q 6-8 hours PRN Maximum dose-Consists of 40 ml per kg in any case.

What Type If Infant Needs Ibuprofen?

• Infant Drops (50mg/1.25mL) for the ages of 6-23 months (Must use the accurate syringe)

Suspension

• Children's
• 100mg per age for at least 2yold
• Chewable/Regulate
• The baby must be six years or older.

What Products Consist of A Great Meal With GI Assistance When Administering?

• Yogurt or Milk Consist of A Great Form of Administration
• For Children And Infants. Otherwise The Pain Will Be Extremely High.

What is useful in Ibuprofen

• Contraindications such as if babies are below six months (kidney injury) and with dehydration is always helpful.
• Viral infections such as the following.
  • Varicella
  • Influenza

If the Patient Undergoes With Gl Protection

• Use Consistently
• Consider PPI or H2-blocker for prolonged therapy.

NSAIDs - Aspirin

• NOT Recommended for Children
• Always Avoid For Great Caution

Risk of Reyes Syndrome

• Triggered With Viral Infections.
• Symptoms: Vomiting and Confusion. Also Followed With Seizures.
• Leads with vomiting confusion and further cases.
• Leads swelling, further hepatic damage

Prevention Methods To Always Review

• Stay Far and Clear away from Salicylates

Treatments For Symptoms Are Usually Performed With, Supportive Care!

• Can Be Utilized With NSAIDs such as
• Naproxen
• (Naprosyn® Aleve®)*
• Rx With 125mg/5 mL With Various Tablet
• Max dose is with 1250 mg Every Day

Analgesic.

• 5-7 Everyday.
• Ketorolac (Toradol)*
• Limit doses up to 5 days Max
• Oral Doses of 20mg or more every 8 hours
• Utilized Via IV With Children
• Box Warning with the Following Below
• GI AND RENAL

Indomethacin

• Usually Closes The Heart

  What Can be used as pain reliever, and what products/medication needs to be avoided for treatment?

  Avoid!!
  

  -Codeine

  • Metabolized with high dependence with CYP2D6 -Poor patients = No pain relief Ultra patients = Respiratory Depression
  • FDA: Always Avoid On Every Situation!
    Trimepridine Utililized by CYP2D6 & 3A4 to activate Linked to Respiratory Depression issues FDA: Also Avoid Them! For Most Cases Above Children Are Always On Risk.

What are the factors to evaluate while looking at fever?

• Fever: 4 weeks
• Fever:101f
• It may be due to medication.

Guidelines

• Normal:36-38 degrees celsius
• Abnormal: 100.4f

Most cases with Fever is not dangerous with the following method recommendations

• Always Administer It By Parents!
• Fever - The Phobia Is very Common However The Phobia Itself As Not A Disease!
• A Lot has to be performed for management!

Infants & Neonate Guidelines

• 0-28 Days Needs Treatment, Followed by a 38+ Degree Celsius in the Body. As a Result, It’ll be Needed to Be Sent Over To Emergency Department.
  • Do not treat with OTC Medications. Unless Given In The Hospital, It Is Important to Never Provide Any Medications.
• Common Guidelines Over Fever Control*

What should be expected as the usual rate of fever?

-Self Limit What should be expected for evaluation for medical purposes? -Fever lasts for 4+ days If patient is not consuming enough fluids what should you do? -The patient, requires a great number of hydration for better flow.

How should It be utilized/Managed During Cases?

• It Has Always Been a Requirement to manage everything at home with fluides. Also, What can be a common goal for administering comfort for Fever? A. It must be utilized for any case to increase the child's comfort! You can also provide the following care, by doing everything with heart. A. provide The following care, by doing everything with heart. - Provide The Following Care, By Doing Everything With Heart. Utilize to keep The child hydrated. Check often, if that is the case or not. If not, then always consult a doctor.

What Can We Do For a General Cold?

• Provide Great Pain and Relief to Mitigate Pain Ibuprofen should always be utilized for the most accurate methods