Prescribing for

Children

Dr U Mahamithawa
Senior lecturer Paediatrics

I used to think I was the only one

kids hated... I don't know what I'd do
if it weren't for you guys.

Objectives
What is Paediatrics?
What are the challenges of prescribing for
children?
Do children have the same pharmacokinetic
and pharmacodynamic responses to drugs as
adults?
Are there special features in relation to
paediatric prescriptions?
Are drugs given to lactating women secreted
into their milk?
Is poisoning from accidental ingestion of
drugs common among children?

Paediatrics
Paediatrics is concerned with
the health of infants, children and
adolescents
their growth and development
their opportunity to achieve full potential as
adults
In Sri Lanka
children <12yrs of age come under the care
of paediatricians

Challenges of prescribing for

children
Paediatrics includes a range of ages preterm
and term neonate, infant, child and adolescent
Dramatic differences in pharmacokinetics,
pharmacodynamics and psychosocial changes in
the different age groups
Variation in bioavailability depending on age,
route of administration and illness
Children detest medicines that have an
unpleasant taste or cause discomfort
Dosage errors are common due to need for
calculation based on size of child, dilutions for iv
drugs

Definitions
Pharmacogenetics
genetically determined variations in drug
response
Pharmacokinetics
a drugs disposition within the body
absorption, distribution, metabolism and
elimination
Pharmacodynamics
relationship between drug dose/concentration
and response effectiveness or toxicity

Pharmacokinetics
Factors affecting oral absorption of
medications
Paramete
r

Neonate

Infant

Child

Gastric
acid
secretion

Reduced

Normal

Normal

Gastric
emptying
time

Decreased

Increased

Increased

Intestinal
motility

Reduced

Normal

Normal

Billiary
function

Reduced

Normal

Normal

Microbial
flora

Acquiring

Adult
pattern

Adult
pattern

Distribution
Increased total body water as a % of total
body weight
total body water and ECF volume decreases
with age
Neonates require higher doses of water
soluble drugs on a mg/kg basis
Plasma protein binding reduced in neonates
low levels of albumin and globulin
altered binding capacity
high bilirubin levels can displace drugs from
albumin

Metabolism
Enzyme systems mature at different times
may be absent or present in reduced
amounts at birth
Altered metabolic pathways for some drugs
Metabolic rate increased in children
may need more frequent dosing or
increased doses (mg/kg)

Excretion
Complete maturation of renal function not
reached until 6-12 months of age
Before 34 wks of gestation GFR is markedly
reduced

Other factors affecting

bioavailability
Dosage form
spitting of foul-tasting medicine
inaccurate measurement of small volumes
of liquid medicines
Drug interactions with food especially milk
Drug being mixed with large quantity of
food or milk full dose might not be taken
Drugs should not be mixed or administered
in a babys feeding bottle

Dosage form

Compliance in children influenced by

formulation, taste, appearance and ease of
administration

Whenever possible painful IM injections

should be avoided

Children should be involved in decisions

about taking medicine and encouraged to
take responsibility for using them correctly

Dosage form contd

Rate of absorption faster with a liquid compared with

solid formulations
Liquid>suspension>capsuletablet>sustained
release tablet
Children >5yrs ( and some older children!) find a
liquid formulation more acceptable than tablets and
capsules
For long term treatment it is possible to train a child to
take tablets
An oral syringe should be used for accurate
measurement and controlled administration of
liquid medicine especially if the dose is <5ml

Dosage form contd..

Liquid preparations containing sugar

encourage dental caries
Sugar free medicines are preferred for long
term use
Try to use products which avoid the need for
administration during school hours eg.
modified release prep or drugs with long half
lives
Intravenous route is assumed to be the most
dependable and accurate route for drug
delivery but there are potential sources of error

Dosages

Children are not mini-adults

paediatric doses should be obtained from a
paediatric dosage reference text
NOT extrapolated from adult doses

Dose calculation
Most drugs calculated for body weight
In over weight children body weight
calculation could result in over dosing
Dose should be calculated for an ideal
weight based on height and age
Body surface area calculation more
accurate than body weight

Prescription writing

Full name and address

Age and date of birth

Legal requirement in the case of prescription only medicines to

state age for children <12yrs

Whenever possible state the current weight to enable dose

prescribed to be checked

Unnecessary use of decimal points should be avoided eg 3mg

not 3.0mg 500mg not 0.5mg
If decimals are unavoidable a zero should be written in front of
the decimal point 0.5ml not .5ml

Prescription writing

Communicate, communicate, communicate

with patient and family

Adverse drug reactions

Important to report adverse reactions
because..
Action of the drug and its pharmacokinetics
may be different in children
Drugs are not extensively tested in children
Many drugs are not specifically licenced for
use in children and are used off-label

Drugs in human milk

Almost all drugs given to lactating women

are secreted to some extent into their milk

Drug use should be as minimal as possible

during (pregnancy) and lactation

Very few drugs are contraindicated during

lactation

Safety in the home

>50% of human poisoning exposures occur

in children <5ys

Almost all these exposures are unintentional

>90% of these occur in the home

Ingestion is the most common route of

poisoning