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Paediatric Prescribing and Common Medications

Paediatric Prescribing and Common Medications. Diana Mowbray Paediatric Clinical Pharmacist Rotherham NHS Foundation Trust. Things to Consider When Prescribing. Child’s age and weight (Kg) / surface area Allergy status Obesity / underweight Immune status How to get the drug into the body.

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Paediatric Prescribing and Common Medications

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  1. Paediatric Prescribing and Common Medications Diana Mowbray Paediatric Clinical Pharmacist Rotherham NHS Foundation Trust

  2. Things to Consider When Prescribing • Child’s age and weight (Kg) / surface area • Allergy status • Obesity / underweight • Immune status • How to get the drug into the body

  3. Common Drugs • Antipyretics • Pain killers • Antibiotics • Inhalers • Anti-epileptics • Anti-reflux medications • Fluids

  4. Antipyretics • Paracetamol • 15mg/Kg 4hrly • Ibuprofen • 1-3/12 5mg/Kg TDS/QDS • 3/12 – 1yr 50mg TDS/QDS • 1-4yrs 100mg TDS • 4-7yrs 150mg TDS • 7-10yrs 200mg TDS • 10-12yrs 300mg TDS • >12yrs up to 400mg TDS/QDS

  5. Oral Pain Killers • Paracetamol • Can go up to 20mg/Kg in > 1/12 • Max 90mg/Kg/day • Can use a loading dose • Ibuprofen • As for antipyretics (max 30mg/Kg/day) • Diclofenac • Up to 1mg/Kg (max 50mg) TDS

  6. Oral Pain Killers contd • Codeine • 0-12yrs 0.5-1mg/Kg every 4-6hrs • > 12yrs 30-60mg every 4-6hrs • Max 240mg daily • Morphine • 1-12/12 80-200micrograms/Kg 4hrly • 1-2yrs 200-400micrograms Kg 4hrly • 2-12yrs 200-500micrograms/Kg 4hrly max 20mg • >12yrs 5-20mg 4hrly

  7. Antibiotics . Penicillins eg amoxicillin • Cephalosporins eg cefotaxime • Macrolides eg erythromycin • Aminoglycosides eg gentamicin • Trimethoprim • Metronidazole

  8. Inhalers • Ipratropium bromide • Can be useful in young babies for wheeze • Salbutamol • Useful in all ages for wheeze – variable response in young babies • Beclometasone • Useful at step 2 upwards of the asthma management guidelines

  9. Anti-epileptics • Carbamazepine • Sodium valproate • Phenytoin • Phenobarbitone • Midazolam • Clobazam • Diazepam

  10. Anti-reflux medications • Gaviscon infant sachets • Ranitidine • Domperidone • Omeprazole / Lansoprazole

  11. Fluids • Sodium chloride 0.45% with Dextrose 5% - basic children’s fluid • Dextrose 10% - basic neonatal fluid • May be with or without potassium chloride dependent on clinical situation

  12. Calculations • Always best calculated against weight / surface area where possible • NSF for children recommends all calculations should be documented in patient’s notes

  13. Anti-reflux medications • A 5 week old term baby (4.13Kg) presents with GORD. They have been treated with Gaviscon infant sachets at home. The child is still vomiting and not gaining weight. • You are asked to prescribe oral Ranitidine and Domperidone • What doses would you prescribe?

  14. Anti-reflux medications • Ranitidine – 1mg/Kg TDS • Prescribe as 4.1mg or 4mg TDS • Domperidone – 200-400microgram/Kg 3-4 times a day • Prescribe as 830-1650micrograms 3-4 times a day (0.83-1.65mg)

  15. Anti-reflux medications • Ranitidine comes as 75mg/5ml solution • Calculate the volume required • 0.27ml • Domperidone comes as 1mg/ml suspension • Calculate the volume required • 0.83-1.65ml

  16. Anti-epileptics • A 7 yr old (21.7Kg) is admitted with generalised seizures and needs to be started on sodium valproate 200mg/5ml • What dose would you prescribe initially and what dose would you anticipate the patient being maintained on? • What volumes of medication will this mean needs drawing up?

  17. Sodium Valproate • Initiate on 5-7.5mg/Kg BD • 108.5-162.75mg BD • Ideally prescribe 110-165mg BD • 2.7-4.1ml BD • Maintenance is 12.5-15mg/Kg BD • 272-324mg BD • 6.6-8.1ml BD

  18. Lamotrigine • A 3yr old (14.5Kg) known epileptic on sodium valproate 3.8ml BD for 8 months is admitted with uncontrolled seizures. • You are asked to prescribe Lamotrigine in addition • What dose will you prescribe?

  19. Lamotrigine • Lamotrigine interacts with sodium valproate (inhibits hepatic catabolism) and so a lower dose is required than would be if it was used with any other anti-epileptic • Initial dose: 150microgram/Kg OD for 14 days, increasing gradually to a usual maintenance of 1-5mg/Kg in 1-2 divided doses (max 100mg) • Calculate the doses required

  20. Lamotrigine • Initial dose is 2.2mg (2.175mg) • This can be achieved by dissolving a 5mg tablet in 5ml water and giving 2.2ml • Maintenance is 14.5-72.5mg/day

  21. Other problem • This child is also on a low dose of sodium valproate for it’s weight. • 3.8ml = 152mg = 10.5mg/Kg/dose • Usual maintenance is 12.5-15mg/Kg/dose • This is probably due to weight increase in the last 8 months and should be adjusted accordingly (perhaps before considering an additional drug!)

  22. Prescribing problems • A patient arrives with the following list of medication from mum (who has left the drugs at home). Which ones would you be confident to prescribe? • Baclofen 20ml TDS • Glycopyrollate 4ml QDS • Clonazepam 3.5ml BD • Sodium Valproate 10ml BD • Levetiracetam 3ml BD • Alimemazine 7.5ml ON

  23. Prescribing Problems • Baclofen only comes as 5mg/5ml • Glycopyrollate is only available as a “special” • Clonazepam is only available as a “special” • Sodium valproate only comes as 200mg/5ml • Levetiracetam only comes as 100mg/ml • Alimemazine is available in 2 strengths

  24. Neonatal infusions • A 760g neonate requires a dopamine infusion to run at 7.5microgram/Kg/minute • The infusion is prepared as 30mg dopamine in 50ml of 10% dextrose • What rate should the prescription state for the pump to run at?

  25. Neonatal infusions • 0.76Kg x 7.5micrograms/Kg/min = 5.7micrograms/min • 5.7micrograms/min x 60mins = 342micrograms/hour • 30mg dopamine in 50ml contains 30 x 1000 / 50ml = 600micrograms/ml • The infusion needs to run at 342 / 600 = 0.57ml/hour

  26. Common problems • Decimal points may not be clear • Trailing zeros eg 2.0 may be mistaken for 20 • Missing zeros eg .5 may be mistaken for 5 • Use of abbreviations to be avoided • Concentration errors when only a volume is prescribed • Frequencies / times of administration not prescribed on kardex = drugs not given

  27. Common problems • Not reading all the information in BNFC to find an appropriate dose • Mixing up of routes and doses • Mixing up of reason for giving and doses • Using correct age range (especially in neonatal period) for doses and frequencies

  28. Quick Quiz • How many mg of adrenaline in 1ml of • 1 in 1000? • 1 in 10,000? • How many mmol of sodium in 500ml of 0.45% sodium chloride with 5% glucose? • A 10Kg child requires 0.2mmol/Kg (50mg/Kg) magnesium sulphate. How much of a 50% solution do you need?

  29. Answers • 1g in 1000ml = 1mg/ml 1g in 10,000ml = 0.1mg (100microgram) /ml • 0.9% sodium chloride contains 150mmol Na/L = 75mmol in 500ml = 37.5mmol in 500ml of 0.45% • 10Kg x 50mg/Kg = 500mg. A 50% solution contains 50g/100ml = 50,000mg/100ml = 500mg/ml

  30. Questions ?

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