Pediatric Principles 2 - 2024 - Presenter Slides - FINAL (1).pdf

PHM101: PHARMACOTHERAPY MODULE I PEDIATRIC PRINCIPLES: II PHARMACOTHERAPY: DOSING & DOSAGE FORMS Sabrina Boodhan Teskey, RPh, HonBSc, BScPhm, ACPR Clinical Pharmacist, Clinical Pharmacology/Toxicology, Pediatric Medicine & Surgical Services...

PHM101: PHARMACOTHERAPY MODULE I PEDIATRIC PRINCIPLES: II PHARMACOTHERAPY: DOSING & DOSAGE FORMS Sabrina Boodhan Teskey, RPh, HonBSc, BScPhm, ACPR Clinical Pharmacist, Clinical Pharmacology/Toxicology, Pediatric Medicine & Surgical Services The Hospital for Sick Children Adjunct Lecturer (Status), Leslie Dan Faculty of Pharmacy, University of Toronto Wednesday, February 7, 2024  Pediatric Principles: Series I-III Basics & Pediatric Talking to Development Pharmacotherapy Families Pharmacokinetic/ Dosing & Medication history, Pharmacodynamic Dosage Forms Vaccines, Counselling 2 Example Institute for Safe Medication Practices Canada. 2021. https://www.ismp-canada.org/download/safetyBulletins/2021/ISMPCSB2021-i10- 3 Pediatric-Formulations.pdf. Retrieved 5 Jan 2021.  Example Medication: Clonidine Patient: Child Prescribed off-label as 0.025 mg Chewed the first gummy and spit it (25 mcg) for a pediatric patient out Child had difficulty swallowing tablets Hypotension or liquids Bradycardia Pharmacy consulted prescriber and → Leading to hospitalization compounded the medication in a gummy formulation using clonidine Lack of commercially available products, pediatric- specific regulatory guidance powder Canadian federal regulations do not require 1000-fold error: each gummy pediatric data from manufacturers, low incentive contained 25 mg instead of 25 mcg Limited/delayed provincial/territorial reimbursement programs for pediatric formulations Institute for Safe Medication Practices Canada. 2021. https://www.ismp-canada.org/download/safetyBulletins/2021/ISMPCSB2021-i10- 4 Pediatric-Formulations.pdf. Retrieved 5 Jan 2021.  LEARNING OBJECTIVES By the end of this presentation, you should be able to: 1. Perform simple dosing calculations for assessing prescriptions and when recommending therapies 2. Select suitable dosage forms that consider effectiveness and safety 3. Identify potential adherence factors that may influence achievement of desired outcomes 5  ABBREVIATIONS BID Twice daily PK Pharmacokinetics BSA Body Surface Area PO By mouth Cap Capsule PRN As needed/When needed CR Controlled Release q_h Every __ hours DTaP diphtheria and tetanus QID Four times a day toxoids and acellular SR Sustained Release pertussis Tab Tablet DTP Drug Therapy Problem Tdap tetanus toxioid, reduced EC Enteric Coated diphtheria toxoid, and HCP Health Care Professional acelluar pertussis NKDA No Known Drug Allergies TDM Therapeutic Drug Monitoring ODB Ontario Drug Benefit TID Three times a day OHIP+ OHIP Plus UTI Urinary Tract Infection PD Pharmacodynamics 6 BACKGROUND Pharmacists’ Patient Care Process Joint Commission of Pharmacy Practitioners. Pharmacists’ Patient Care Process. Washington, DC: Joint Commission of Pharmacy Practitioners; 2014.  Medication Delivery to Patients ▪ If we think about the prescription as a step in the pharmacotherapy delivery process, there are many factors that may influence successful receipt from pediatric patients ASSESSMENT Pharmacotherapy Work Up ▪ In pediatrics, special attention is paid to the type of drug product and dosage regimen 1. Does the patient have an INDICATION for each of his/her drug therapies, and is each of the patients’ indications being treated with drug therapy? 2. Are these drug therapies EFFECTIVE for his/her medical condition? 3. Are these drug therapies as SAFE as possible? 4. Is the patient able and willing to ADHERE with drug therapies as instructed? 10  CARE PLAN Selecting Interventions: Pediatrics Growth & Development Kearns GL et al. Developmental Pharmacology — Drug Disposition, Action, and Therapy in 11 Infants and Children. N Engl J Med 2003;349:1157-67 CARE PLAN Selecting Interventions: Pediatrics Growth & Development Medication Use Process Prescribing Transcription Dispensing Administration Monitoring Pharmaceutics Pharmacokinetics Therapeutics Safety Informatics Communication Skills 12 EVALUATION Follow-Up ▪ Determine actual outcomes of drug therapy and compare with the intended goals of therapy ▪ Determine the effectiveness and safety of drug therapy ▪ Evaluate patient adherence ▪ Establish the current status of patient/determine if new problems have developed Patient’s outcomes from drug therapies/interventions are documented Effectiveness of drug therapies is evaluated Safety of the drug is evaluated Care plan is revised, as needed (and documented) Evaluation is systematic and ongoing, until all goals of therapy are met Patient/family/caregivers and HCP are involved in the evaluation process, when appropriate 13  Reasons for Medication Errors: Examples: ▪ Polypharmacy ▪ Incorrect calculation ▪ Transcription error ▪ Sound-alike/look-alike ▪ Multiple care givers ▪ Incorrect dosage measurement 14  Community Pharmacy Hospital Informatics Pharmacy Industry & Family Research Health Team Pharmacists & Pediatric Care Specialty (IV, Compounding) Academia Drug Regulatory Information Manufacturing & Distribution 15  LEARNING OBJECTIVE 1 Perform simple dosing calculations when assessing prescriptions and when recommending therapies  Dosing Guidelines ▪ In ADULTS, there is often a UNIVERSAL DOSE: Drug ‘X’ 250-500 mg qid ▪ In PEDIATRICS, doses must be INDIVIDUALIZED and CALCULATED as mg/kg or mg/m2 based on: ▪ Weight** ▪ Age BSA (m2) = Height(cm) x Weight (kg) 3600 ▪ Disease State ▪ Body Surface Area 17  Dosing Guidelines CONSIDER ▪ Is the individual DOSE effective and safe? INDICATED If the dose is slightly LOW, is it SUBTHERAPEUTIC? EFFECTIVE If the dose is slightly HIGH, will TOXICITY result? SAFE ▪ DOSING INTERVAL ADHERENCE ▪ DURATION of therapy ▪ DOSAGE FORM WILL A DRUG THERAPY PROBLEM RESULT? 18  Dosing Guidelines: Pediatric Resources Reliable Sources of Information: ▪ Pediatric Dosage Handbooks ▪ Practice Guidelines ▪ Published Data ▪ Primary literature ▪ Pediatric Organizational Position Statements (e.g. American Academy of Pediatrics (AAP), Canadian Pediatric Society (CPS)) 19  Dosing Calculations Example (mg/kg) Pt: 2 year old (18 kg) girl, UTI Rx: Cephalexin 250 mg PO q8h x 7 days Assess the Dose: 42 mg/kg/day Pediatric Dosing Reference: Cephalexin Pt: 5 year old (20 kg) girl, cellulitis 25 – 50 mg/kg/day PO ÷ PLEASE every 6 or 8 hours Recommend the Dose: NOTE* Cephalexin 250 mg PO q6h (Acceptable range: 167-333 mg PO q8h or 125-250 mg PO q6h) 20  Dosing Calculations Example (mg/kg) Pt: 2 year old (18 kg) girl, UTI Rx: Cephalexin 250 mg po q8h x 7 days Assess the Dose: 42 mg/kg/day Pediatric Dosing Reference: HOW TO PERFORM CALCULATION TO “ASSESS Cephalexin THE DOSE”: 25 – 50 mg/kg/day PO ÷ 1. Calculate dose per day: every 6 or 8 hours 250 mg/dose x 3 doses/day = 750 mg/day 2. Calculate the dose per weight (kg) per day: 750 mg/day  18 kg = 42 mg/kg/day 21  Dosing Calculations Example (mg/kg) Pt: 5 year old (20 kg) girl, cellulitis Recommend the Dose: Cephalexin 250 mg PO q6h Pediatric Dosing Reference: HOW TO PERFORM CALCULATION TO “RECOMMEND THE DOSE”: Cephalexin 1. Calculate dose using guideline: 25 – 50 mg/kg/day PO ÷ Dosing guideline x weight ÷ frequency every 6 or 8 hours = 50 mg/kg/day x 20 kg = 1000 mg/day ÷ 4 = 250 mg/dose 4 times a day 22  Dosing Calculations Example (mg/m2) Pt: 2 year old (15 kg) boy, BSA: 0.92m2 Rx: Cyclosporine 29 mg IV q12h Assess the Dose: 31.5 mg/m2/DOSE 63 mg/m2/day Pediatric Dosing Reference: Cyclosporine 65 mg/m2/DOSE IV q12h 23  Dosing Calculations Example (mg/m2) Pt: 2 year old (15 kg) boy, BSA: 0.92m2 Rx: Cyclosporine 29 mg IV q12h Assess the Dose: 31.5 mg/m2/DOSE 63 mg/m2/day Pediatric Dosing Reference: ▪ Note the units of the dosing reference when assessing the dose. ▪ This dose is BELOW the dosing recommendation Cyclosporine in our reference and would need to be 65 mg/m2/DOSE IV q12h investigated closer…is there a reason for the low dose or was it a calculation error? ▪ Based on our reference, the dose should be: = 60 mg IV q12h 24  Dosing Calculations Example (mg/m2) Pt: 2 year old (15 kg) boy, BSA: 0.92m2 Rx: Cyclosporine 29 mg IV q12h ▪ This dose is BELOW the dosing recommendation in our reference and would need to be investigated closer…is there a reason for the low dose or was it a calculation error? ▪ Based on our reference, the dose should be: = 60 mg IV q12h Pediatric Dosing Reference: Pt: 7 year old (30 kg) girl, BSA: 1.08m2 Cyclosporine 65 mg/m2/DOSE IV q12h Recommend the Dose: Cyclosporine 70 mg IV q12h 25  Dosing Calculations: Cautions ▪ Careful with Division (mg/kg/day vs mg/kg/DOSE) ▪ Decimals ISMP Canada. ISMP Canada Safety Bulletin. Nov. 2016. Available from URL: https://www.ismp- canada.org/download/safetyBulletins/2016/ISMPCSB2016-08-OpioidPrescribing.pdf#page=5 ▪ Units of Measure ▪ Consider pros and cons of which units of measure are used: (e.g. clonidine 0.1 mg vs 100 mcg) 26  ISMP Canada “Do Not Use” list ISMP. Do not use. Dangerous abbreviations, symbols and dose designations. 2006. Available from URL: https://www.ismp- 27 canada.org/download/ISMPCanadaListOfDangerousAbbreviations.pdf  LEARNING OBJECTIVE 2 Select suitable dosage forms that consider effectiveness and safety Dosage Form Selection Therapeutics Drug Coverage* PK/PD Pharmaceutics Safety Patient Feasibility acceptance 29  Nutritional Development 0 – 6 months 6 – 9 months 9 – 12 months ▪ Exclusively ▪ Breastmilk/formula ▪ Breastmilk breastmilk or ▪ Iron-containing foods ▪ Finger foods formula ▪ Pureed foods ▪ Bite-sized foods Adapted from: SickKids staff. Nutrition as your baby gets older. AboutKidsHealth. Trusted answers from The Hospital for Sick Children. 2018 30 The Hospital for Sick Children. Introducing food to your baby. 2021. Available from URL: https://assets.aboutkidshealt h.ca/AKHAssets/Introducing_ food_to_baby_and_Allergy_f 31 oods.pdf Development & Enteral Dosage Forms Neonates 1 m – 2 yrs 2 – 5 yrs 6 – 11 yrs ▪ Liquids, ▪ Liquids, ▪ Liquids, ▪ Liquids small small dispersable ▪ Solids, chewable 12 – 18 yrs tablets, ▪ Solids volumes volumes tablets/ disintegrating/ (tablets, (drops, (solutions, powders/ dispersable capsules) liquids suspensions) sprinkles suspensions) tablets/ sprinkles 32  Dosage Form Selection Patient ▪ Ensure dosage forms are acceptable for patient’s acceptance abilities (i.e. diet, development) ▪ Dosecan be measured with Feasibility an available dosage form ▪ Provide appropriately sized Safety measuring aids ▪ Teach caregivers how to administer 33  DOSAGE FORM RESOURCES Where to look? ▪ Pharmacy suppliers ▪ Hospital formulary What are some resources? ▪ Compendium of Pharmaceuticals and Specialties* ▪ Health Canada Drug Product Directorate Database* Also need to consider differences in dosage forms: ! Nonmedicinal ingredients, drug properties/pharmacokinetics, “interchangeability”, etc. 34  Alterations of Dosage Forms Often required when drugs are not available in dosage forms suitable for children Examples include: ▪ Splitting tablets ▪ Crushing tablets ▪ Opening capsules ▪ Mixing with food ▪ Compounding, if necessary When selecting a drug product, consideration must be taken to ensure that drug properties (e.g. SR, CR, EC) are not compromised that may affect stability and effectiveness 35  Dosage Form Example Pt: 3 year old (12.5 kg) boy Rx: Metronidazole 125 mg po q8h Let’s consider that this patient is only able to receive tablets. Pediatric Dosing Reference: Metronidazole How could this medication be Oral: 15-30 mg/kg/day  TID dispensed and administered? Dose Limit: 2 grams/day Split 250 mg in half using a pill splitter Each half tablet would be crushed and Dosage Forms: mixed in small amount of suitable 250 mg tablets, 500 mg capsules, liquid/food (if reference checked) 15 mg/mL compounded suspension 36  Dosage Form Example Pt: 3 year old (12.5 kg) boy Rx: Metronidazole 125 mg po q8h Let’s consider that this patient is only able to receive tablets. Pediatric Dosing Reference: Metronidazole How could this medication be Oral: 15-30 mg/kg/day  TID dispensed and administered? Dose Limit: 2 grams/day  Need to ensure tablets can be split,  crushed and mixed with food Dosage Forms: 250 mg tablets, 500 mg capsules, Family comfortable with this strategy  15 mg/mL compounded suspension 37 DISSOLVE & DOSE **For selected medications only** Utilized as a quick and efficient alternative when: ▪ Drug is not commercially available in a liquid form ▪ No documented extemporaneous liquid formulation exists/not suitable ▪ Dose cannot be obtained from tablet form ▪ Certain pharmaceutical considerations are satisfied 38 DISSOLVE & DOSE PHARMACEUTICAL CONSIDERATIONS SOLUBILITY ▪ DRUG must be soluble in water ▪ Other ingredients in tablet may: ▪ be insoluble and sink to bottom or, ▪ make solution cloudy STABILITY ▪ Solution must be administered immediately since stability cannot be guaranteed for longer than 20 minutes 39 DISSOLVE & DOSE Example: Captopril 5 mg po q8h Instruct caregiver(s): ▪ Dissolve 12.5 mg captopril tablet in 12.5 mL water to make 1 mg/mL solution ▪ Withdraw and administer 5 mL of solution (= 5 mg dose) ▪ Discard remaining solution ©The Hospital for Sick Children. All Rights Reserved. This document is specific to SickKids internal activities at the time of printing. SickKids does not accept responsibility for use of this material by any person or organization not associated with SickKids. No part of the document should be used for publication without appropriate acknowledgement. 40  COMMON QUESTIONS Can I mix the medicine with my child’s food? Can I add the medicine to my baby’s bottle? ▪ What types of foods is the child eating? ▪ Consider drug-food interactions ▪ Receive full dose? Feeding aversions? Compounding? 41  COMPOUNDING The combining or mixing together of two or more ingredients (of which at least one is a drug or pharmacologically active component) to create a final product in an appropriate form for dosing Practiced primarily by pharmacists; other HCP may also practice compounding activities when licensed Regulatory authorities in each province/territory Non-sterile products to specialized products for IV solutions or ophthalmic preparations Health Canada. Policy on Manufacturing and Compounding Drug Products in Canada (POL-0051). 2009. Retrieved at: https://www.canada.ca/en/health-canada/services/drugs- health-products/compliance-enforcement/good-manufacturing-practices/guidance-documents/policy-manufacturing-compounding-drug-products.html#a7 42  COMPOUNDING Key Points from Health Canada Policy on Compounding: Patient-healthcare professional relationship Actively regulated and facility is inspected by regulatory authorities Risk management processes in place Only done if there is a therapeutic need or lack of product availability; not solely for economic reasons Customized therapeutic solution to improve patient care without duplicating an approved drug product Health Canada. Policy on Manufacturing and Compounding Drug Products in Canada (POL-0051). 2009. Retrieved at: https://www.canada.ca/en/health-canada/services/drugs- health-products/compliance-enforcement/good-manufacturing-practices/guidance-documents/policy-manufacturing-compounding-drug-products.html#a7 43  COMPOUNDING: Example Worksheet The Hospital for Sick Children. Compounding Pharmacy Service. 2021. Available from URL: https://www.sickkids.ca/siteassets/care--services/for-health-care-providers/compounding- recipes/metronidazole-15mgml-pharmacy-compounding-recipe.pdf  DOSAGE FORMS: CAUTIONS Situations when specific dosage forms may cause further complications Examples: Enteral tube administration www. aboutkidshealth.ca Ketogenic diet Short bowel 45  DOSAGE FORMS: CAUTIONS When assessing dosage forms, consider sound-alike, look-alike drugs SOUND-ALIKE LOOK-ALIKE clobazam vs clonazepam sulfadiazine vs sulfasalazine DTaP vs Tdap 46 *Relevant for both drug selection and dosage form comparisons Alterations of Dosage Forms Therapeutics Drug Coverage* PK/PD Pharmaceutics Safety Patient Feasibility acceptance 47  Dosage Forms Example Pt: 2 year old (18 kg) girl, UTI Rx: Cephalexin 250 mg PO q8h What would be an appropriate Dosage Form? Suspension Pediatric Dosing Reference: Cephalexin Pt: 5 year old (20 kg) girl, cellulitis 25 – 50 mg/kg/day PO ÷ Rx: Cephalexin 250 mg PO q6h every 6 or 8 hours What would be an appropriate 50 mg/mL suspension Dosage Form? Suspension 250 mg, 500 mg tablets 48  LEARNING OBJECTIVE 3 Identify potential adherence factors that may influence achievement of desired outcomes Adherence Factor: Taste Taste/flavour – common reason for refusing medicationsǂ Age-related changes in response to sweet and bitter taste Genetic predisposition TAS2R38 is the most commonly studied gene (bitter taste) ǂ Mennella JA et al. Children’s perceptions about medicines: individual differences and taste. BMC Pediatr. 2015;15:130. ADHERENCE FACTOR: Poor Taste COMMON “OFFENDERS”: ▪ Clindamycin palmitate ▪ Metronidazole ▪ Prednisone EXAMPLE: PREDNISONE* PREDNISOLONE Taste Not good, bitter Better Availability Compounded Commercial Strength 5 mg/mL 1 mg/mL Volume per dose Smaller Larger *Compounded suspension 51 ADHERENCE FACTOR: Poor Taste Suggestions: ▪ Dispense higher concentration of suspension ▪ Placing tablet(s) in an empty CAPSULE ▪ Numb taste buds with an ice cube/popsicle before dose ▪ Drink cold water after liquid medication ▪ Hold nose as medicine is swallowed ▪ Use a dropper/oral syringe to give medicine to children 52 ADHERENCE FACTOR: Complexity of Regimen ▪ Too many dose times ▪ Challenging to prepare/administer medication Explanation ▪ Separating from feeds/other medications Provide Medication ▪ Mitigating side effects relative to dose times Calendar 7 AM 11 AM 3 PM 7 PM     Provide clearly Domperidone Suspension     labelled measuring Propranolol Suspension   devices Lansoprazole Disintegrating tablet  Follow up Vitamin D Drops  53 ADHERENCE FACTOR: Drug Coverage ▪ Provincial Drug Coverage “OHIP Plus” ▪ Eligible children and youth under 25 years of age http://www.health.gov.on.ca/en/pro/programs/drugs/ohipplus/ 54  OHIP+: Key Points Provincial Drug Coverage for children and youth: – First announced January 1, 2018 – Amendment: April 1, 2019: drug coverage for individuals 24 years of age and under who do not have a private plan. for those who are covered under a private plan, they are ineligible for coverage under OHIP+ so long as the private plan remains in place. No coordination of benefits.* – Covered by OHIP – Aged 24 and younger – Present valid Ontario Health Card and prescription – Medications available through the ODB program (4,400 drug products) and additional drugs via the Exceptional Access Program (EAP) – Nutrition Products listed in the ODB program where a doctor has prescribed as the patient’s sole source of nutrition 55 Revisit Example 56  Example: Revisted Medication: Clonidine Patient: Child Prescribed off-label as 0.025 mg Chewed the first gummy and spit it (25 mcg) for a pediatric patient out Child had difficulty swallowing tablets Hypotension or liquids Bradycardia Pharmacy consulted prescriber and → Leading to hospitalization compounded the medication in a Lack of commercially available products, pediatric- gummy formulation using clonidine specific regulatory guidance powder Canadian federal regulations do not require 1000-fold error: each gummy pediatric data from manufacturers, low incentive Limited/delayed provincial/territorial contained 25 mg instead of 25 mcg reimbursement programs for pediatric formulations Institute for Safe Medication Practices Canada. 2021. https://www.ismp-canada.org/download/safetyBulletins/2021/ISMPCSB2021-i10- 57 Pediatric-Formulations.pdf. Retrieved 5 Jan 2021.  Example : Key Points Lack of Alteration of Harmful Suitable Dosage Form Outcome Formulation Recommendations to Pharmacy Managers/Pharmacists/Technicians: ▪ Communicate need for compounding with prescriber, discuss alternatives ▪ Compound only when benefits outweigh potential risks ▪ Use standardized master formulas, supported by references, rationale for ingredients, units of measure that are consistent within systems ▪ Use commercially available tablets/capsules ▪ Utilize software to build in additional checks, input patient weight ▪ Document on worksheet, independent double-check, refer to NAPRA guidelines ▪ Unique identifiers for ingredients 58 ▪ Pharmacist follow up with family  Example : Key Points Lack of Alteration of Harmful Suitable Dosage Form Outcome Formulation Clonidine: Tablets Compounded Suspension Dissolve and Dose *supporting documentation for clonidine is available 59  LEARNING OBJECTIVES By the end of this presentation, you should be able to: 1. Perform simple dosing calculations for assessing prescriptions and when recommending therapies 2. Select suitable dosage forms that consider effectiveness and safety 3. Identify potential adherence factors that may influence achievement of desired outcomes 60 Take Home Messages ▪ Careful individualized attention is required when children require drug therapy ▪ Children are at risk for medication errors due to dosing calculations errors and alterations of dosage forms ▪ Pharmacists play a key role in ensuring children achieve desirable health outcomes by virtue of our expertise in drug therapy 61  References 1. Institute for Safe Medication Practices Canada. 2021. https://www.ismp-canada.org/download/safetyBulletins/2021/ISMPCSB2021-i10-Pediatric-Formulations.pdf. Retrieved 5 Jan 2021. 2. Joint Commission of Pharmacy Practitioners. Pharmacists’ Patient Care Process. Washington, DC: Joint Commission of Pharmacy Practitioners; 2014. 3. SickKids Staff. AboutKidsHealth: Nutrition as your baby gets older. Retrieved 31 Jan 2020 from URL: https://www.aboutkidshealth.ca/Article?contentid=498&language=English 4. Lexicomp Inc. Pediatric & Neonatal Lexi-Drugs Online 2021. Available from: http://online.lexi.com.myaccess.library.utoronto.ca/lco/action/doc/retrieve/docid/pdh_f/129883#war 5. Lau E. Ed. The Hospital for Sick Children: Drug Handbook and Formulary, 2020 6. ISMP Canada. ISMP Canada Safety Bulletin. Nov. 2016. Available from URL: https://www.ismp-canada.org/download/safetyBulletins/2016/ISMPCSB2016-08- OpioidPrescribing.pdf#page=5 7. ISMP. Do not use. Dangerous abbreviations, symbols and dose designations. 2006. Available from URL: https://www.ismp- canada.org/download/ISMPCanadaListOfDangerousAbbreviations.pdf 8. The Hospital for Sick Children. AboutKidsHealth. Introducing food to baby and allergy foods. 2021. Available from URL: https://assets.aboutkidshealth.ca/AKHAssets/Introducing_food_to_baby_and_Allergy_foods.pdf 9. Health Canada Drug Products Database [online]. Retrieved 31 Jan 2020 from URL: https://health-products.canada.ca/dpd-bdpp/index-eng.jsp 10. SickKids Staff. AboutKidsHealth: G/GJ tubes: Caring for your child and their G tube. Retrieved 31 Jan 2020 from URL: https://www.aboutkidshealth.ca/Article?contentid=2905&language=English 11. Mennella JA et al. Children’s perceptions about medicines: individual differences and taste. BMC Pediatr. 2015;15:130. 12. Ministry of Health and Long-Term Care. 2021. OHIP Plus. http://www.health.gov.on.ca/en/pro/programs/drugs/ohipplus/ 13. The Noun Project Inc. Icons. 2021. Available from URL: https://thenounproject.com/ 14. Health Canada. Policy on Manufacturing and Compounding Drug Products in Canada (POL-0051). Retrieved at: https://www.canada.ca/en/health- canada/services/drugs-health-products/compliance-enforcement/good-manufacturing-practices/guidance-documents/policy-manufacturing-compounding-drug- products.html#a7 15. The Hospital for Sick Children. Compounding Pharmacy Service. 2020. Available from URL: https://www.sickkids.ca/en/care-services/for-health-care- 62 providers/compounding-service/ THANK YOU