Oleh :

Tri Yulianti
 MENGAPA KOK KHUSUS ???

Bayi/Anak ….. bukan orang dewasa dengan

ukuran kecil (mini).
Bayi/Anak ….. Fungsi & fisiologis organ
berkembang
Bayi/Anak yang menyusui ….. Hati-hati Obat didistribusikan ke
ASI
Bayi/Anak ……. Kepatuhan rendah (nggak mau, muntah dll).

Dosis Obat …. Penghitungan dosis & pertimbangan dosis

terapetik & toksik
 PENGGOLONGAN

Neonate ≤ 28 days (4 weeks) of life

Infant 29 days to ≤ 12 months

Child 1–12 years

Adolescent 13–18 years

Sumber : British Paediatrics

Association (BPA)
 PENGGOLONGAN

Neonatus , terjadi perubahan klimakterik

yang sangat penting

Bayi, masa awal pertumbuhan yang pesat

Anak-anak, masa pertumbuhan bertahap

Remaja, akhir tahap perkembangan secara

pesat hingga dewasa
 ABSORPSI

DISTRIBUSI

METABOLISME

EKSKRESI
 Absorbtion
✓ The absorption process of oral preparations may be influenced
by factors such as gastric and intestinal transit time, gastric
and intestinal pH and gastrointestinal contents
✓ Oral absorption may be different in premature infants and
neonates due to differences in gastric acid secretion and
pancreatic and biliary function.
✓ Neonates and infants have increased gastric pH (eg, pH 6–8)
due to lower gastric acid output by body weight, reaching adult
values by approximately 2 years of age.
✓ gastric emptying time only approaches adult values at
about 6 months of age.
 Low gastric acid secretion result in increased serum
concentrations of weak bases and acid-labile medications,
such as penicillin,
 and decreased serum concentrations of weak acid
medications, such as phenobarbital, due to increased
ionization
 gastric emptying time and intestinal transit time are delayed
in premature infants, increasing drug contact time with the
gastrointestinal mucosa and drug absorption.
 Deficiency in pancreatic secretions and bile salts in
newborns can decrease bioavailability of prodrug esters,
such as erythromycin, which requires solubilization or
intraluminal hydrolysis
 Intramuscular absorption.
 Absorption in infants and children faster than in
the neonatal period, since muscle blood flow is increased.
 On a practical note, intramuscular administration is very
painful so avoid.
 Im is usually reserved when other routes are not accessible,
 for example, initial IV doses of ampicillin and gentamicin for
neonatal sepsis.
✓ Topical or percutaneous absorption in neonates
and infants is increased due to a thinner
stratum corneum, increased cutaneous
perfusion, and greater body surface-to-weight
ratio.
✓ corticosteroids,should be limited to the
smallest amount possible.
 Rectal absorption can also be erratic due to uncontrollable
pulsatile contraction and risk of expulsion in younger patients
(ie, infants and young children). → NOT RECOMMENDED
 This route is useful in cases of severe nausea and vomiting
or seizure activity.
 For medications that undergo extensive first-pass
metabolism, bioavailability increases as the blood supply
bypasses the liver from the lower rectum directly to the
inferior vena cava.
 Inhalation absorption. Direct delivery of drug therapies
to the lungs has been the mainstay of treatment for
asthma
 systemic absorption of corticosteroids → produce
adrenal suppression.
 The administration of insulin by inhalation for the
treatment of both type 1 and type 2 diabetes mellitus in
adults was anticipated to be of benefit in children.
 The first licensed product (for adults) was launched in
2006 but was withdrawn in 2007 due to disappointing
worldwide sales.
RUTE OF ADMINISTRATION
SAFE

High Oral > SC > IM > IV Low

CONVENIENCE

High Oral > SC > IM > IV Low

COST
High IV > IM > SC > ORAL Low
Distribution
 In pediatric patients, apparent volume of
distribution (Vd) is normalized based on body
weight and expressed as L/kg.
 Extracellular fluid and total body water per
kilogram of body weight are increased in neonates
and infants, resulting in higher Vd for water-
soluble drugs, such as aminoglycosides, →
neonates and infants often require higher doses
by weight (mg/kg) than older children and
adolescents to achieve the same therapeutic
serum concentrations
Presentase volume cairan
ekstraseluler dan kadar air total
dlm tubuh terhadap berat badan
Usia Kadar air dlm tubuh Cairan ekstraseluler
% %
Preterm neonatus 85 50
Term neonatus 75 45
3 bulan 75 30
1 tahun 60 25
Dewasa 60 20
 Neonates and infants have a lower
normal range for serum albumin (2–4
g/dL, 20–40 g/L), reaching adult
levels after 1 year of age.
 Highly protein bound drugs, such as
sulfamethoxazole-trimethoprim, are
not typically used in neonates due to
theoretical concern for bilirubin
displacement. This displacement may
result in a complication known as
kernicterus, from bilirubin
encephalopathy.
 Neonates have lower body adipose composition
compared with older children and adults, their overall
Vd for many lipid-soluble drugs (eg, lorazepam) is
similar to infants and adults.
 Some medications (eg, vancomycin, phenobarbital)
may also reach higher concentrations in the central
nervous system of neonates due to an immature
blood-brain barrier
Metabolism
 Hepatic drug metabolism is slower at birth in full-term infants
compared with adolescents and adults, with further delay in
premature neonates.
 Phase 1 reactions and enzymes, such as oxidation and
alcohol dehydrogenase, are impaired in premature neonates
and infants and do not fully develop until later childhood or
adolescence.
 Use of products containing ethanol or propylene glycol can
result in increased toxicities, including respiratory
depression, hyperosmolarity, metabolic acidosis, and
seizures, → avoided in neonates and infants.
 due to an increased liver mass to body mass ratio
→ Increased dose requirements by body weight
(eg, mg/kg) for some hepatically metabolized
medications (eg, theophylline, phenytoin, valproic
acid, carbamazepine) in young children (ie, ages
2–4 years) is theorized
 Phase 2 reactions, sulfate conjugation by
sulfotransferases is well developed at birth in term
infants.
 In neonates, this deficiency results gray baby
syndrome with use of chloramphenicol
Renal Excretion
 Nephrogenesis completes at approximately 36-week
gestation → premature neonates and infants have
compromised glomerular and tubular function that may
correlate with a glomerular filtration rate (GFR).
 GFR increases with age and exceeds adult values in early
childhood, after which there is a gradual decline to
approximate adult value during adolescence.
 Below 3–6 months of age the glomerular filtration rate is
lower than that of adults.
 Tubular function matures later than the filtration process.
 Generally, the complete maturation of glomerular and tubular
function is reached only towards 6–8 months of age.
 KETENTUAN UMUM

Perhitungan dilakukan secara individual

Lihat buku standar pediatrik dan buku terapi
pada anak lainnya
Lihat petunjuk kemasan (package insert)
Dihitung sendiri berdasar : umur, berat
badan atau luas permukaan tubuh
 BERDASARKAN UMUR

Formula Young

Umur (tahun)
Dosis anak = x dosis dewasa
Umur + 12 (tahun)
 BERDASARKAN BERAT BADAN

Formula Clark

Berat badan (kg)

Dosis anak = x dosis dewasa
70 (kg)
BERDASARKAN LUAS PERMUKAAN TUBUH

Luas permukaan tubuh (m2)

Dosis anak = x dosis dewasa
1.73 (kg)

Luas permukaan = tinggi (cm)x berat (kg)

tubuh 3600
 Apakah obat benar-benar diperlukan ?
Jika terapi obat diperlukan,
obat yang mana yang sesuai ?
Jenis sediaan apa yang diperlukan ?
Bagaimana memperkirakan dosis obat ?
Berapa lama pemberiannya ?
Bagaimana Kepatuhan minum obat & Edukasi?
Apakah obat benar-benar diperlukan ?

Sebagian besar penyakit anak bisa sembuh

sendiri

Alternatif non-farmakoterapi lebih

diutamakan (diet,istirahat,dll)

Contoh: Antibiotik pada ISPA ringan

Jika terapi obat diperlukan, obat yang
mana yang sesuai ?

TEPAT INDIKASI
TEPAT PENDERITA
TEPAT OBAT
TEPAT DOSIS, RUTE, SAAT
PEMBERIAN & LAMANYA
WASPADA TERHADAP E.S.O
Jika terapi obat diperlukan, obat yang
mana yang sesuai ?

Tetrasiklin …. Merusak gigi & menghambat

pertumbuhan tulang

Kortikosteroid topikal secara rutin … iritasi

kulit & gangguan pertumbuhan

Kloramfenikol … resiko grey syndrome

Jika terapi obat diperlukan, obat yang
mana yang sesuai ?

Aspirin … iritasi lambung & sindrom Reye

Sulfonamida, Kotrimoksazol … resiko kern-

ikterus

Obat antibiotik pada diare akut, obat anti

muntah … dianjurkan untuk dihindari
Jenis Sediaan Apa yang Diperlukan ?

Rute pemberian yang sesuai

Usia anak
Ketersediaan bentuk sediaan
Pengobatan lain yang sedang dijalani
Kondisi Penyakit
Jenis Sediaan Apa yang Diperlukan ?

Pemberian obat secara oral yang paling

sesuai dan dianjurkan

Bentuknya : cair, tablet, puyer, atau yang

lain, tergantung kondisi anak, tingkat
penerimaan, apakah sudah dapat menelan dll
Jenis Sediaan Apa yang Diperlukan ?

Obat yang diberikan melalui rektal sangat

sedikit, mengingat sulitnya memperkirakan
tingkat absorpsinya

Diazepam per rektal bermanfaat dalam

mengatasi kejang demam
Jenis Sediaan Apa yang Diperlukan ?

Pemakaian obat secara inhalasi mungkin

kurang cocok untuk anak, karena memerlukan
cara penyedotan yang konsisten & dalam.
Nebuliser lebih dapat diterima

Pemberian obat secara intramuskuler

sebaiknya dihindari … menyakitkan anak

IV dapat digunakan tetapi perlu beberapa

pertimbangan
 Bagaimana Menentukan Dosis ?

Perhitungan dilakukan secara individual

Lihat buku standar pediatrik dan buku terapi

pada anak lainnya

Lihat petunjuk kemasan (package insert)

Dihitung sendiri berdasar : umur, berat

badan atau luas permukaan tubuh
 Berapa Lama Pemberian Obat ?

Tidak ada standar yang pasti

Untuk self limiting disease , dapat diberikan

obat simptomatis sampai gejala hilang

Untuk penyakit kronis, misal TBC dapat

sampai 6,9 ,bahkan 12 bulan)
Bagaimana Kepatuhan & Edukasi ?

Faktor obat

Frekuensi pemberian dan

keragaman jenis obat

Pola penyakit

Hubungan dengan pasien

Cara pemberian obat yang efektif

Menghindarkan obat dari jangkauan anak

Pengobatan untuk infeksi berulang

Penggunaan obat untuk penyakit kronik

Masalah ketidak-taatan

Penyalahgunaan obat
Contoh :
 Bayi berusia 11 bulan dirawat di rs dgn
infeksi saluran kemih dan suhu tubuh
37,8. beratnya 9,6 kg dan sebelumnya
menderita ISK dua kali. Bayi tersebut
mendapatkan resep parasetamol 120
mg tiap 3 jam bila perlu dan
kotrimoksasol/trimetropim untuk 7 hari,
dn dosis trimetoprim 50 mg/5ml
diresepkan 2 kali sehari @ 2 ml.
 Dari literatur diketahui :
 Dosis Trimetoprim : 4 mg/kg dalam
dosis terbagi setiap 12 jam
 Parasetamol diberikan maksimal 4 kali
sehari.
Terima kasih