Pediatric Medications Administrations

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Pharmacokinetics
Administration
Physiologic attributes
Pharmacokinetics in infants 
Pharmacokinetics in children
Pediatric Medication Calculations
Developmental Considerations
Reaction to Pain

 

Pharmacokinetic principles

Administering medications to the pediatric population includes knowledge of:
bulletPharmacokinetics
bulletSerum drug levels
bulletDrug dosing in infants and children
bulletCognitive and psychosocial developmental considerations
bulletRoute of administration of medication
 

Pharmacokinetics:  Is the study of the concentration of a drug within the body during the process of absorption, distribution, metabolism and excretion.

  

Absorption is the process that involves drug movement from the site of entry in the body to the blood stream.

Distribution is the transport of the the drug in body fluids from the bloodstream to the tissues of the body. Distribution is effected by body water content, body fat content, and plasma protein levels.

Metabolism is the process by which drugs are chemically inactivated so that they can be excreted.

Excretion is the process whereby metabolized drugs are removed from their sites of action and eliminated by the body.

 
Serum drug levels: Monitoring serum levels help to determine appropriate dosage, scheduling, and route of administration. Determine if drug levels are reaching toxicity levels.

Determine if drug level is to low for therapeutic response.

Peak and trough levels help to determine if drug is in the desired range for therapeusis and safety.

Peak level is the highest concentration a drug reaches after a number of doses have been administered.

Trough level is the lowest concentration a drug reaches between doses.

Therapeutic Index (TI) is the concentration of a drug necessary to produce the desired therapeutic effect without causing toxicity.

Steady state: Steady state concentration of a drug refers to the state in which the drugs distribution is in equilibrium with the body. The amount of the drug taken in is equal to the amount of the drug excreted.

Loading dose is a relatively high dose used with some drugs to start therapy to shorten the length of time it takes to read a steady state concentration. Once a loading dose has been given, the drug dose is decreased to the maintenance dose and given on a regular schedule.
Drug dosing in infants and children. Recommended doses for FDA approved drugs must be computed based on the individual child's weight.

Accurate drug dose is critical since infants / children doe not have the mature physiological responses to compensate for drug errors.

  

Two methods of calculating pediatric dosage are:

bulletBSA of body surface area
bulletmg/kg calculation

The mg/kg formula will be used during the pediatric rotation for calculating accurate drug dosages for the pediatric patient.

 
Cognitive and psychosocial developmental considerations Developmental age is the functioning level of the child.

Strategies consistent with the child's developmental are needed to ensure safe and effective medication administration.

Assessing the child's temperament can led to determining best method of administering a medication.

General guidelines for administration of medications to pediatric patient include:

bulletHonesty is always a priority, children must always be told the truth.
bulletCareful attention to vocabulary used is essential in giving explanations so as not to frighten the child.
bulletForceful retrain should never be used.
bulletPraising the child after successful administration of medication, regardless of behavior during the process.
bulletNever threaten or shame a child into taking a medication; thoughtful limit-setting is only accepted.
bulletCommunicate to the child using developmental appropriate language when behavior will and will not be tolerated.

 

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Rate of Drug Absorption by Route of Administration

Route of Administration Absorption Characteristics
Enteral

 

 

Parenteral

 

 

 

 

 

 

 

 

 

Inhalation

 

 

Rectal

 

Sublingual, Buccal

 

Topical

 
bulletabsorption of drug varies
bulletgastric pH
bulletempty of full stomach
bulletinteraction with other drugs that increase or decrease absorption

 

Subcutaneous

Absorption is rapid in aqueous solutions.

Absorption is slower in oily preparations.

Intramuscular

Absorption rapid due to increased blood flow.

Intravenous

Absorption is immediate due t direct injection into the blood stream.

Intrathecal

Absorption is rapid in the CNS due to bypass of blood brain barrier.

 

Absorption is rapid due to large surface area of lungs.

Vascularity of lungs promotes ready entry into the blood stream.

 

Absorption is generally erratic.

 

Absorption is rapid and complete as long as tablet is retained at administration site.

 

Absorption is erratic but more complete in children due to smaller body surface area

 

 

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Physiologic Attributes of Infants and Implications for Drug Therapy.

Attribute Implication
Increased total body water.

Increased membrane permeability, skin and blood-brain barrier.

Decreased body fat.

Immature kidney, liver function.

Immature temperature regulation

 Increased distribution of drug, decreased blood levels of water-soluble drugs.

Increased CNS distribution and likelihood of neurotoxicity, enhanced topical absorption.

Increased absorption of fat-soluble drugs.

Prolonged excretion or metabolism of certain drugs.

May dehydrate readily, increasing concentration of drugs.

 

 Adapted from Shlafer: The nurse, pharmacology, and drug therapy, Menlo Park, California, 1993, The Benjamin/Cummings Publishing Company.

 

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Pharmacokinetics in Infants 

Absorption

Rates of drug absorption in the infant are lower than absorption rates in children and adults.

Prolonged gastric transit time and variable gastric pH lead to diminished absorption.

Frequent feeding may impede drug absorption.

Low levels of intestinal flora and reduced enzyme function can led to decreased absorption.

Low peripheral perfusion and immature heat regulation can decrease absorption of IV, IM, or SC medications.
Distribution

 Low concentration of plasma proteins and diminished protein-binding capacity allow drugs to be more available in the circulation.

Greater permeability of the blood-brain barrier, allows for rapid access of drugs to the CNS.

Total Body water is 80% compared to the adult 50%.

Higher doses of water soluble drugs may be needed to achieve therapeutic effects.

 Metabolism

Drug-metabolizing enzymes in the the liver of infants are immature.

More drugs in circulatory system may increase potential for drug toxicity.

Drug dosages for infants must be calculated carefully and drug levels and clinical responses closely monitored.

Excretion

Infant kidneys have higher resistance to blood flow, lower GFR with a decreased ability to concentrate urine.

Infants may secrete drugs more slowly, increasing risk of drug accumulation.

 

 

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Pharmacokinetics in Children

Absorption

Gastric pH equal to adult by 2 to 3 years of age. 

Gastric emptying rates are faster than infants.

Skin and blood-brain barrier become more effective.

Distribution

Plasma proteins reach adult levels by age 1.

Children up to age 2 years of age may require higher dosages of water-soluble drugs.
Metabolism

Liver enzymes are more effective at metabolizing drugs.

Due to elevated BMR some drugs are metabolized more rapidly.

Drug dosages relative to body weight may need to be higher.

Drugs may need to be more closely monitored.

 

 Excretion

Children over 12 months of age are able to excrete drugs effectively.

 

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Reaction to Pain

The developmental stage of a child affects how the child perceives and reacts to pain. The nurse needs to consider the child's developmental stage when assessing and managing pain in children.

Neonate Because motor pathways are poorly developed, neonates respond with generalized body movements and do not withdraw affected limb.
About 3 months Infant begins to localize pain.
About 6 months The infant can remember painful events in the past and associated past and current events. They may anticipate pain. 
13 to 14 months Anticipatory distress continues. Goal directed movements to reduce pain appear, such as rubbing a painful site. Other indications of pain include irritability, restlessness, rigidity, lethargy, poor feeding, disturbed sleep, crying, tachycardia and respiratory distress.
Toddler React to pain with intense emotion and resistance. They cannot comprehend the meaning of pain and often react with aggression such as biting, hitting, and temper tantrums. Reaction to pain is influenced by past memories, attachment to parents and physical restraint.
Preschool They have egocentric fantasy, magical thinking and intense concern about body injury. Pain may be perceived as punishment. Nurses need to explain that pain is not related to the goodness of the child.
School age They are able to describe pain. As the child gets older they are able to use more abstract terms to describe pain. The child attempts to master the pain and may use coping mechanisms similar to adults. 
Adolescent They often display self-control when in pain and may try to conceal the pain. However, they may not be able to deal with the underlying anxiety and the repressed emotional energy may lead to acting out. Showing concern, providing pain relief and providing control may help the adolescent cope with painful situations.

Adapted from Morrison, H.M. (1991). Pain in the critically ill child. In: Puntillo, K.A. Pain in the critically ill: Assessment and Management. Gaithersburg, MD: Aspen Publishers, Inc.

 

 

 

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Developmental Considerations

 

 

Developmental Age (1 month to 1 year)

 

bulletPoor head control requires support to minimize choking
bulletHands should be monitored to prevent interference.
bulletDrug agents require precise measurement
bulletPhysical comfort during administration.
bulletInitial response to medication is to spit or drool.
bulletAllow parent to give medication with nurse watching.

 

 

 

 
 

 

 

 
 

Developmental Age (1 to 2 years)

 

bulletAllow child to choose a position to take the medication
bulletFollow routine of home
bulletTaste of medication may be disguised
bulletUse single commands
bulletAllow child to familiarize self with dosing device
bulletGiving medications at this age may be a real challenge
bulletGive simple choices: a cup or a spoon, but you need to do it now.
bulletDo not over negotiate.

 
 

 

 

 
Pre-School (3 to 6 years)

 

bulletTablets and capsules should be crushed - most children this age are unable to to swallow pills.
bulletAllow child to make decisions about how to take the medication and place of administration.
bulletMore cooperative since understands the relationship between illness and treatment. ie This will make you feel better. The medication is helping you to get better.
bulletExplanation about medications can be a little more detailed.
bulletIn a very reluctant child the parent may be the best person to administer the medication.
bulletTherapeutic play with animals or dolls may be helpful
 

 

 

 
 

School Age (6 to 12 years)

bulletCan usually swallow capsules or tablets
bulletPraise child after drug administration
bulletAllow the child to have a sense of control
bulletUnderstands that drug taking may have long term benefits
bulletReview any side effects of medications

 
 

 

 

 
 

Adolescent (12 to 18 years)

 

bulletInclude in therapeutic decision-making to foster respect.
bulletNeed more explicit explanation about medications.
bulletIncorporate group or peer activities as appropriate
bulletAble to appreciate causal relationships
bulletMinimize dependent drug regiments where possible

 
 

 

 

 

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Pediatric Medication Calculation

Web links for administration of medication to children. Liquid Medication Administration: Children's Hospital Medical Center

http://www.fda.gov/fdac/features/196_kid.html

 
Prevention of Medication Errors in the Pediatric Inpatient Setting http://www.aap.org/policy/re9751.html

 
Pediatric Medication Calculation with post-test.

 

 http://www.accd.edu/sac/nursing/math/pedsmath.html

 

 

 

JCAHO Pain Standards

Health providers are expected to be knowledgeable about pain assessment and management, and facilities are expected to develop policies and procedures supporting the appropriate assessment of pain and the use of analgesics and other pain control interventions. Some key concepts are:

 

bulletrecognize the rights of patients to appropriate assessment and management of pain
bulletassess the existence and , if so, the nature and intensity of pain in all patients
bulletrecord the results of the assessment in a way that facilitates regular reassessment and follow-up
bulletdetermine and assure staff competency in pain assessment and management, and address pain assessment and management in the orientation of all new staff
bulletestablish policies and procedures which support the appropriate prescription or ordering of effective pain medications
bulleteducate patients and their families about effective pain management, and address patient needs for symptom management in the discharge planning process.

 

 

 

                                                                 ( JBCRN, 2006)