PEDIATRIC HEALTH NURSING

UNIT-III
PHARMACOLOGICAL CARE ASPECTS
WHILE DEALING WITH PEDIATRIC
PATIENTS
Faculty
Sadia saeed
RN, Generic BSc.N
Unit objectives:
After this session the learner will be able to describe:
• Drug dosage calculation for the Pediatric drugs
• Common Pediatric drug dilutions
• Common Pediatric concerns/complications during drug therapy
• Caring for children receiving Chemotherapy, antimicrobial therapy
and long-term Insulin therapy
• Managing pain in children by using pharmacological and non-
pharmacological approaches
Pediatric drug dose calculation:
introduction
• The adult dosage of medication cannot be provided to infants and
children.
• Hence the pediatricians calculate the pediatric dose for kids.
• Proper dosing of the pediatric patient depends on a number of factors,
including the patient’s age and weight, overall health status, the
condition of such biologic functions as respiration and circulation, and
the stage of development of body systems for drug metabolism (e.g.,
liver enzymes) and drug elimination (e.g., renal system).
• In the neonate, these biologic functions and systems are
underdeveloped. Renal function, for example, develops over the first 2
years of life.
Cont…
• This fact is particularly important because the most commonly used drugs
in neonates, infants, and young children are antimicrobial agents, which
are eliminated primarily through the kidney.
• If the rate of drug elimination is not properly considered, drug can
accumulate in the body and lead to overdose and toxicity.
• Two methods are used for calculating safe pediatric doses. Based on body
weight, they are:
calculations of milligrams per kilogram or micrograms per kilogram or
according to body surface area (BSA) in square meters.
• The BSA method is the more accurate and therefore used widely for
chemotherapeutic agents.
• The milligrams per kilogram method are the most frequently used
elsewhere.
Cont…
• Birth to 1 year of age have greater percentage of body water
• Age 1 to 12 years metabolize drugs more readily than adults
• Children at risk for overdose, toxic reactions, and death – Due to immature
physiological processes E.g., absorption, distribution, metabolism,
excretion
• Before you make a start
• Familiarize yourself with your local medicines policy and procedures
• Be aware of PNC Code of Conducts, PMDC Standards for Medicines
Management
• Understand why your patient has been prescribed this medication, check
the care plans as well as dose, possible adverse effects, contraindications
and special precautions
Cont…
• Check prescription charts regularly. Omission is the second most
common reason for medication error
• Gather together the prescription chart, keys and second RN to act as
checker if required
• Wash your hands
• Check prescription chart
• Has the correct patient identification. Full name, hospital number if
required by local policy
• Has a completed and signed confirmation of allergy status on the front
of the chart
Cont…
• Provides a clear legible prescription of medication to be administered.
If this appears ambiguous it is safer to request that the prescription
chart is rewritten. Prescriptions should include date of prescription, the
generic drug name, route, dosage, date and time to be administered
and the prescriber’s printed name and signature
• Remember All checks should be completed independently
• With the second checker, select the correct medication and check that
it is within the expiry date. Consider formula/spoon/oral syringe
preference for children
• Check that the dose prescribed is correct for the age and weight of the
patient using a reference source
Cont…
• Independently calculate the volume of liquid or number of tablets
required. Compare answers. Recalculate if you disagree
• Measure the dose required. Both practitioners should witness all stages
of the process and confirm the amount prepared. Both nurses should
undertaken at bedside checks together
Administering the medicine
• Check that the patient’s name, date of birth and NHS (national health
service) number on the name band correlate with these details on the
prescription chart
• If possible, ask the patient/parent to tell you his/her name and date of birth
• Check the allergy section on the prescription chart for contraindications to
administration
• Explain purpose of the medication to the patient/ family and gain consent
for administration
• The patient/family/non-registered nurse/play specialist may wish to be
involved in the administration procedure. Remember This must always be
performed under the supervision of an RN who remains accountable for
any delegation of this task
Cont…
Closing the intervention
• After administering the medication both nurses should sign the prescription
chart to evidence that the medication has been given
• Offer the patient a drink, particularly if the medicine has an unpleasant taste
• Record reasons for non-administration of the drug on the prescription chart
and in the nursing documentation
• Make the patient comfortable. Offer bravery rewards if appropriate. Ask
whether there are any further interventions required. Inform the patient
and/or family when you will be returning
• Dispose of equipment safely with clean spacers as required. Wash your
hands
• Observe patient for adverse effects
Administering Medications to Children
• Body weight is an important factor used to calculate doses for
pediatric patients as well as adults. Medications dosed in small
amounts may be dosed as micrograms per kilogram.
• In the past, formula methods of pediatric doses were used;
• some based on age (Young’s, Cowling’s, and Fried’s rules)
• and one on weight (Clark’s rule).
• Safe pediatric dosages calculated by:
– Body weight
• Measured in mg per kg, mcg per kg, etc.
– Body surface area (BSA)
• Measured in m2
BSA calculation formula:
Cont…
Calculation formula
• Dose = What you want × Amount it is in What you have
For example:
• you need to administer 60mg Paracetamol which comes as a 120-mg
in 5- mL preparation:
• Dose = 60/120 × 5 = ½ × 5 = 5/2 = 2.5mL
Calculating IV fluid rates Rate = volume/time
• Example 500mL over 4 hours Rate = 500/4 = 125mL/hour
Principles of drug calculations
• The metric system To undertake drug calculations it is imperative to
understand the units of measurement used in the prescription and
administration of drugs.
• The units are expressed using the System International within the
standard metric system of weights and measures (Blair 2011).
Units Abbreviations Conversions
• Kilogram (kg)-1kg = 1000 g
• Gram (g)-1g = 1000 mg
• Milligram (mg)-1 mg = 1000 microgram (μg)
• 1 microgram (μg) = 1000 nanogram (ng)
• Litre (L)-1 L = 1000 mL
Cont…
• Fractions A useful resource when undertaking drug calculations is to learn
common fractions expressed as a decimal.
• This is helpful when calculating dosages from ampoules.
• 1/2 = 0.5 (1ml divided 2= 0.5)
• 1/4 = 0.25 (1ml/4 = 0.25)
• 1/5 = 0.2 (1ml/5 = 0.2 )
• 2/4 = 0.5 ( 2ml/4 = 0.5)
• 2/5 = 0.4 (2ml/5 = 0.4 )
• 3⁄4 = 0.75 (3ml/4 = 0.75)
• 3⁄5 = 0.6 (3ml/5 = 0.6 )
• 4⁄5 = 0.8 (4ml/5 = 0.8)
• Worked example If you require half of a 1-mL ampule you will require 0.5 mL
Formula method
• This method requires relevant numerical figures to be inserted into an
equation, which once solved provides the necessary volume of liquid
or number of tablets that need to be administered
• What you want (prescription) ÷ What you have (stock strength) × What its in
(volume) = Volume to be administered
• What you want (prescription) ÷ What you have (stock strength) = Number of
tablets to be administered
• Worked examples
• You need to administer 120 mg paracetamol The dose strength available is 120
mg paracetamol in 5 mL = 120 ÷ 120 × 5 = 5 mL
• You need to administer 25 mg prednisolone This is available in 5 mg tablets =
25 ÷ 5 = 5 tablets
Common Pediatric Drug Dosages:
• Syp:Amoxicillin 250mg/5ml:
60mg/kg/dose
= 60mg/10kg/TDS
= 60mg x10kg x 3time in a day
= 600mg x3 time in a day
Total Dose =600mg x 3
= 1800mg in a whole day.
Syp: Available dose 250mg/5ml
so 1ml =50mg
50mg x 12 =600mg
Ans : so 12ml 3 time in a day.
Common Pediatric Drug Dosages:
Injection: Ciprofloxacin 200mg/100ml:

6mg/kg/dose
= 6mg/5kg/BD
= 6mg x5kg x 2time in a day
= 30mg x 2time in a day
Total Dose =30mg x 2
= 60mg in a whole day.
Injection: Available dose 200mg/100ml
so 1ml =2mg
15ml =30mg
Ans: 15ml 2 time in a day.
Common Pediatric Drug Dosages:
Amoxicillin 250mg/5ml:
50mg /kg/dose, 250mg in 5ml -50mgx10kg= 200,TDS (3 time in a
day,50x 3=150 so 250- 150=100mg remain ,1ml/5ml TSF
Ciprofloxacin 250mg/5ml:
150mg/kg/dose ,250mg-150mg=150mg, 2.5ml/5ml ,BD x (2
time in a day),1/2 Tsf.
Azithromycin:
(IV/PO) 10 mg/kg (Max: 125 mg) OD x 1time in a day.
then 20mg/kg/dose(Max: 250 mg) BIDx 2 time in a day .
Penicillin:
25 - 50 mg/kg/dose (TDS)x 3 time in a day ,8 hourly.
Erythromycine : 50 mg/kg/dose QDS x 4 time in a day, 6 hourly.
Cont…
Cefepime
• 50 mg/kg/dose (max: 2 g) Q12 Fever and neutropenia Q8
Cefotaxime
• 25 - 50 mg/kg/dose (Max: 2 g/dose) Q6-8
Ceftriaxone
• 50 - 75 mg/kg/day (Max: 1 g/day) Q24
• Meningitis 100 mg/kg/day (Max: 2 g/dose) Q12-24
Ciprofloxacin(IV/PO)
• 10 - 15 mg/kg/dose BID
Cont…
Levofloxacin (IV/PO)
• Birth - 4 yo: 10 mg/kg/dose (Max: 750 mg) Q12
• ≥ 5 yo: 10 mg/kg/dose (Max: 750 mg) Q24
Linezolid (IV/PO)
• Birth - 11 yo: 10 mg/kg/dose (Max: 600 mg) Q8
• ≥ 12 yo: 10 mg/kg/dose (Max: 600 mg) Q12
Meropenem
• 20 mg/kg/dose (Max: 1 g/dose) Q8
Metronidazole (IV/PO)
• 10 mg/kg/dose (Max: 500 mg) Q8
Cont…
Penicillin G
• 100,000 - 250,000 units/kg/day Q4-6 (Premixed: 1 million, 2 million, 3
million units)
Penicillin V Pneumococcal prophylaxis:
• < 3 years: 125 mg BID > 3 years - 5 years: 250 mg BID
Vancomycin (IV)
• 15-20 mg/kg/dose Q6-8 (Consult: Pharmacy to dose)
• Meningitis: 20 mg/kg/dose Q6-8
Cont…
Acetaminophen
• Forms: liquid, tablet, capsule, rectal suppository
• Usual oral dosage: children < 12 years: 10-15 mg/kg/dose every
4-6 hours as needed.
• Do not exceed 5 doses (2.6 g) in 24 hours
• Children > 12 years & adults: 325-650 mg every 4-6 hours as
needed, not to exceed 4g/day
Cont…
Ibuprofen
• Forms: liquid, tablet Usual oral dosage:
• Children < 12 years: 4-10 mg/kg/dose every 6-8 hours
• Children > 12 years: 200 mg every 4-6 hours as needed
(maximum 1200 mg/24 hrs)
• * Pediatric dosage should not exceed adult dosage.*
Composition of Fluids
• Isotonic: electrolyte content approximately 310 meq/L
• Examples: D5W, D10W, NS, LR
• Hypotonic: electrolyte content less than 250meq/L (never used in
children)
• Examples: No examples in pediatrics
• Hypertonic: electrolyte content exceeds 375 meq/L
• Examples: 3% saline, D5.45NaCl, D5.9NaCl
Maintenance Fluid Requirements
• Fluid calculations are based on weight in kilograms

Maintenance Fluid Intake

0 – 10 kg weight needs 4 cc/kg/hr

11 – 20 kg weight needs 2 cc/kg/hr additional

21 kg plus weights needs 1 cc/kg/hr additional

Principles of IV Access
• The largest visible vein is not necessarily the preferred one
• Consider the comfort of the patient
• Consider the position and extent restraint
• Consider the vessel’s ability to maintain a needle
• Consider the solution to be infused
Purpose of IV Therapy
• Correct fluid and electrolyte imbalances
• Administer medications
• Administer blood products
• Administer nutrients
 Developmental Considerations
INFANT
• Handle infant gently, speak softly
• Avoid arm used for thumb sucking
• Cuddle immediately after insertion
• Don’t feed immediately prior to insertion
• Avoid presence of extra personnel to minimize stranger anxiety
Developmental Considerations
TODDLER/PRESCHOOLER:
• Prepare child immediately prior to procedure
• Give simple explanations in concrete terms
• Explain that you will help child hold still
• Emphasize that the IV is not punishment
Developmental Considerations
SCHOOL-AGER
• Prepare child ahead of time, but on the day of insertion only
• Give the child choices as appropriate
• Give positive reinforcement after completion
Developmental Considerations
ADOLESCENT
• Prepare teenager several hours to a day before procedure
• Approach discussions on a more adult level
• Discuss fears related to procedure
• Include teen in decisions
Pediatric Optimal Locations
• Hands
• Forearm
• Feet
• Scalp

**Note if the child is a thumb sucker, etc.

Pediatric Catheter Gauges
• Use the largest catheter you can successfully insert
• Catheter Sizes:
Newborn: 24, 22 gauge
Infant < 1 year: 24, 22 gauge
1 – 8 years: 22, 20, 18 gauge
8 years and older: 20, 18, 16 gauge
IV house used to protect the IV site.
Complications of PIVs
• Mechanical factors predispose IV infusion to shorter dwelling time
• Mechanical factors include:
Insertion site
Length of catheter
Size of vessel
Vessel fragility
Activity level of the patient
Forceful administration of boluses of fluid
Infusion of vesicants or irritants through small
vessels
Complications of IV Therapy
• Infiltration (extravasation)
• Fluid leaks into subcutaneous tissue
Complications of IV Therapy
Catheter Occlusion
• Blockage usually by clotted blood or precipitate
Air Embolism
• Air enters circulation & travels to right side of heart
Phlebitis
• Injury to vein without clot
• Inflammation of the blood vessel
Complications of IV Therapy
Thrombophlebitis
• Inflammation of a blood vessel with thrombus formation
Infection
• Introduction of pathologic organisms locally or systemic
Metabolic derangement
• Imbalance in electrolytes, minerals, glucose & proteins
Venous Access Devices (PICC)
Characteristics of Pediatric
Administration Sets
• Calibrated volume & control chamber with a limited capacity & an
automatic shutoff mechanism
• Ie. Buretrol, Metriset
• Standard of Practice
• All IV meds should be placed on a syringe pump if child is < 6 months
Buretrol Administration Set
 Characteristics of Pediatric
Administration Sets
• Drip chamber with microdropper delivering 60 gtts/min or
60cc/hr
• Tubing compatible with pump, catheter adapter for needleless
systems
• Standard of practice: All IV sites should be checked and
reprogrammed every hour
• Arm boards are utilized to maintain integrity of IV site (may
also require restraints)
COMMONPEDIATIONCONCERNS/
COMPLICATIONS DURING DRUG THERAPY
• The pediatric market has focused mostly on only a limited
number of therapeutic areas.This lack of of pediatric formulations
often leaves for health care professionals no alternative but to use
adult medicines in an off-lable or unlicensed manner. In the
united states,two-thirds of medicines used in pediatrics are off-
label. The drugs exposes the child to a high risk of severe adverse
reactions.The risk of medication errors is 3 time higher than those
observed among adult.Misunderstanding of Instructions and
apparent ineffectiveness or side effects of treatment.
• SPECIFIC PEDIATRIC ADRS:
1: Aspirin = Reye’s syndrome.
Conti...
2:Cefaclor = serum sickness.
3: Lamotrigine = Cutaneous eruptions.
4:Valproate = Hypatotoxicity.
5:Phenobarbiton = Paradoxical hyperactivity
6: Corticosteroids = Growth suppression.
7: Delayed HRS = Fever , Rash , Lymphadenopathy.
8:Thalidomide = Polyneuritis, Nerve damage and mental retardation.
9: Sulfonamide therapy = Bilirubin, Hyperbilirubinemia,
Encephalopathy.
Pediatric Pain Management
Introduction, Pain Assessment and Pain Management
(Non-pharmacological &Pharmacological)
Introduction:
Definition of pain:
An unpleasant sensory and emotional
experience associated with actual or potential tissue damage
International Association of Pain (1979)
• Always subjective and is learned through experiences R/T
injury in early life
• Can be assessed by verbal, behavioral and physiological
indicators
Need to differentiate
“PAIN” from “DISTRESS”

• Pain related to fear and anxiety

• Often exhibited by children
• Highly correlated with the degree of pain in
children
• May reflect other emotional reactions
Neonatal Pain Perception
• By 24 weeks gestation the pain pathways are able to
provide sensory input regarding pain
• First encounter with pain is the vitamin K injection
• Newborn infants have well-developed H-P axis
• Pain impulses in newborns conducted by unmyelinated C-
type fibers
• Newborns lack descending inhibitory neuro-transmitters
• RESULT: Infants cannot modulate their pain well.
Developmental Reactions to Pain
• Infants
• Rely on caregivers to notice pain
• Give behavioral signs that they are hurting
• Change in activity—restlessness, clinging or whining,
 appetite
• Physiologic indicators—tachycardia, tachypnea,  BP
Developmental Reactions to Pain
• Toddlers
• Have poor body boundaries
• Intrusive experiences, even if not painful, are anxiety
producing
• Often react intensely and physically resist
• Biting, kicking, hitting, running away
• Help parents understand reactions and avoid punishment
• Use play activities & distraction
• Use bandages but be aware of anxiety when they are
removed
Developmental Reactions to Pain
• Preschoolers (3-6 yrs)
• Need reassurance that pain is not a punishment
• Magical thinking & egocentric
• Exaggerated ideas about illness that are worse than reality
• Can lead to feelings of shame guilt, fear
• May view illness as punishment for something
• Resist during painful procedures: fear of mutilation and
bodily injury
• Concrete thinkers; may misinterpret words
• Allow to express feelings – provide play opportunities
• Give simple explanations: short, simple, clear
Developmental Reactions to Pain

• Preschoolers (3-6 yrs.) cont’d

• Praise for good behavior Cannot always indicate source or location

of pain
• Believe in the magical nature of pain—allows for effectiveness of
some therapies e.g. kiss, Band-Aid. It works because they believe
in it.
Developmental Reactions to Pain
• School Age (6-12 years)
• Able to locate pain in terms of body parts
• Main concern: body integrity; < concern for pain than
disability or death
• Feel that injury is r/t guilt (so they deserve pain)
• Want factual info & reasons for things
• Adolescent (13-19 years)
• Afraid of looking like a baby
• Often hesitant to express feelings of pain
• Main concern: body image
• Fear death as well
Pain Assessment
Tools
Premature Infant Pain Profile (PIPP)
• Developed at the Universities of Toronto and McGill in Canada.
• Used for infants less than 36 weeks gestation
• Scores <6= minimum Pain, 6-12 = mild-moderate Pain, >12 =
moderate to severe pain
• Scoring instructions:
• Score gestational age before examining infant.
• Score the behavioral state before the potentially painful event by observing the
infant for 15 seconds .
• Record the baseline heart rate and oxygen saturation.
• Observe the infant for 30 seconds immediately following the painful event.
• Score physiologic and facial changes seen during this time and record
immediately.
Neonatal Infant Pain Scale (NIPS)
• The Neonatal Infant Pain Scale (NIPS) is a behavioral scale
and can be utilized with both full-term and pre-term infants.
• From birth to one year of age
• The tool was adapted from the CHEOPS scale and uses the
behaviors that nurses have described as being indicative of
infant pain or distress.
Neonatal Infant Pain Scale (NIPS)
Neonatal Infant Pain Scale (NIPS)
• Total pain scores range from 0-7. The suggested interventions based upon the
infant's level of pain are listed below.
• The difficulty with any tool that is not self report is the ability to differentiate
between pain and agitation, however, the non-pharmacological intervention may
help differentiate between these two (i.e. changing the wet diaper, feeding the
infant, repositioning, etc).
N-PASS: Neonatal Pain, Agitation and Sedation Scale
FLACC Pain Scale
Faces Pain Scale
Numeric and Oucher pain scale
Poker chip tool:
Non-Pharmacological Pain Management
• Infants Kangaroo Care

• Tactile: touching, stroking, patting, swaddling

• Motion: rocking, bouncing
• Comfort: sucking/ pacifier, sucrose—
24% sucrose solution just before procedure
• Environment: quiet, soft music, low lights
• Kangaroo Care: Kangaroo care also called skin-to-skin
contact, is a technique of newborn care where babies are
kept chest-to-chest and skin-to-skin with a parent, typically
their mother.
Non-Pharmacological Pain Management
• Toddlers & Preschoolers
• Preparation: simple, sensory, developmentally appropriate
• Caregiver presence
• Distraction: bubbles, glitter wands, books, rain stick
• Praise: offered freely, for trying (not for succeeding)
• Simple choices
• “One voice”—allows distraction without over stimulating
Non-Pharmacological Pain Management
• School Age
• Preparation/ rehearsal—have “practice kits” with
real equipment to feel and get familiar with
procedure ahead of time.
• Distraction
• Relaxation techniques
Non-Pharmacological Pain Management
• Adolescents
• Preparation—allow adequate time
• Distraction
• Relaxation techniques
• Often need lots of reassurance and clarification of the procedure.
Pharmacological Pain
Management
 Caring for children receiving
Chemotherapy, Antimicrobial
therapy and long-term Insulin
therapy
Cancer chemotherapy
• It is the use of antineoplastic agents to attempt to kill tumor cell by
interfering with cellular functions and reproduction
Introduction
• The use of chemicals to treat cancer began in the early 1940s
• The era of modern chemotherapy begun in 1948 with the introduction
of nitrogen mustard
• It is only in the last 10 to 15 yrs., however , that chemotherapy has
become a major treatment modality.
Cont…
Objectives of chemotherapy
• To maximize the death of malignant tumor cells
• To cure the client with cancer
• Control the tumor growth when cure is not possible
• To extend the life span and improve the quality of life of client with
cancer
Side effects of chemotherapy
• Myelosuppression Nail Discoloration, Dermatitis
• Fatigue Fingertip Ulceration and
Photosensitivity
• Nausea and vomiting
• Stomatitis and mucositis
• Pulmonary toxicity
• Renal toxicity
• Neurotoxicity Gonadal suppression
• Cardio toxicity
• Alopecia
• Taste changes
• Skin changes : Hyper Pigmentation,
01/28/2022
Hypersensitivity reactions
HSR are rare ,can be serious and – Be with the client
life threatening – Emergency equipments and
The antineoplastics agents: drugs
– L-asperginase – Baseline vital signs
– Carboplatin
– Bleomycin
– Cisplatin and
– Teniposide
Precautions to ensure client
safety..
– Obtain allergy history
– Test dose
Hypersensitivity reactions
1:Dyspnea 13:Stop drug administration Maintain iv
2:Tachycardia access with 0.9% NS
3:Chest tightness or pain 14:Notify physician Maintain airway
4:Dizziness ( supine position with feet elevated)
5:Pruritus 15:Administer Epinephrine,
6:Anxiety Aminophylline, Diphenhydramine
7:Inability to speak 8:
Nausea
9:Abdominal pain 10:
Hypotension
11:Cloudy sensorium
12:Fused appearance and cyanosis
Extravasation Treatment:
– Stop administration
– Aspirate any residual drug and blood in IV tubing , needle, and
infiltration site.
– Instill IV antidote
– Apply cold or warm pack for 24 hrs.
• Alkylating agent - sodium thiosulfate
• Antitumor antibiotics - hydrocortisone
• Plant alkaloids - hyalouronidase
Nursing management of patient
undergoing chemotherapy
• Patient should be protected from infections
– Wash hands regularly with antibacterial agent
– Avoid crowd with cold, flu or infections
– Avoid raw fruits and vegetables
• Help the patient to identify period of more fatigue and activeness
– Patient should take rest prior to an activity
– Maintain good nutritional status and hydration status by taking balanced diet
• Antiemetic's should be administered one hr. prior to chemotherapy
– Patient should take light meal of non irritating food before treatment
– Ensure adequate fluid intake being consumed & retained
Cont…
• Low fiber and residue diet (E.g. fresh fruits, vegetables , seeds and nuts)
should be recommended to patient as these food can cause diarrhea
• Fried food should be avoided as they produce gas
• Patient should be taught to maintain a record of episodes of diarrhea & foods
that cause diarrhea
• Rectal area of patient should be kept clean &dry to maintain skin integrity.
For oral mucositis:
• patient should be taught to do oral assessment and characteristics of saliva &
ability to swallow
• Patient should be taught to do tooth brushing & flossing before and after
each meal and bed time
• Patient should feed with soft non irritating high protein and high calorie
foods
Cont…
• Tobacco and alcohol should be avoided
• Body weight should be measured at least twice a week. If patient is
malnourished, give parenteral nutrition
• For alopecia: patient should be addressed to use turban, cap or wig as
hair loss is very stressful to patient.
• Advice the patient that hair will grow after the chemotherapy treatment
• Patient should be carefully assessed for pulmonary side effects
(pulmonary edema ) & cardiovascular effects (ventricular dysfunction &
heart failure)
• Patient should be taught about management of adverse effects and
interventions are planned so patient can self manage the illness and
facilitate coping strategies with help with help of support gumps.ss
Diabetes Mellitus:
Introduction
• Diabetes mellitus is the most common endocrine disease and one
of the most common chronic conditions in children
• Type 2 diabetes and other types of diabetes, including genetic
defects of beta cell function, such as maturity-onset diabetes of the
young, are being increasingly recognized in children and should
be considered when clinical presentation is atypical for type 1
diabetes
 Cont…
• Children with new-onset type 1 diabetes and their families
require intensive diabetes education by an inter-professional
pediatric diabetes health-care (DHC) team. Education topics
should include:
• Prevention, detection and treatment of hypoglycemia
• Insulin action and administration
• Dosage adjustment
• Blood glucose and ketone testing
• Sick-day management
• Prevention of DKA
• Nutrition and exercise
DKA, diabetic ketoacidosis
Insulin Therapy:
• It is reasonable to start with a basic insulin regimen (e.g. minimum 3
injections per day) but a more intensive approach is indicated if success not
achieved despite good effort
• Insulin is the mainstay of medical management
• The choice of insulin regimen depends on many factors:
• Child’s age
• Duration of diabetes
• Family lifestyle
• Socioeconomic factors
• Family, patient, and physician preferences
Insulin Therapy
• Starting regimen should comprise:
• ≥2 daily bolus injections
• ≥1 basal insulin injection
• If initial regimen fails to meet glycemic targets, more intensive
management may be required:
• Three methods of intensive diabetes management can be used at any
age:
• Similar regimen with more frequent injections
• basal bolus regimens using long and rapid acting insulin analogues
• continuous subcutaneous insulin infusion (CSII, insulin pump therapy)
Cont…
Insulin Therapy
• Children with new-onset diabetes should be started on boluses of
rapid-acting insulin analogues combined with basal insulin (e.g.
intermediate-acting insulin or long-acting basal insulin analogue)
using an individualized regimen that best addresses the practical
issues of daily life [Grade D, Consensus]
• Insulin therapy should be assessed at each clinical encounter to
ensure it still enables the child to meet A1C targets, minimizes the
risk of hypoglycemia and allows flexibility in carbohydrate intake,
daily schedule and activities [Grade D, Consensus].
 Cont…
• If these goals are not being met, an intensified diabetes management
approach (including increased education, monitoring and contact with
diabetes team) should be used [Grade A, Level 1 for adolescents; Grade
D, Consensus for younger children], and treatment options may include
the following:
• Increased frequency of injections [Grade D, Consensus]
• Change in the type of basal and/or bolus insulin [Grade B, Level
2, for adolescents; Grade D, Consensus, for younger children]
• Change to CSII therapy [Grade C, Level 3]
Glucose Monitoring
• Self-monitoring of blood glucose is an essential part of management of
type 1 diabetes
• Subcutaneous continuous glucose sensors allow detection of
asymptomatic hypoglycemia and hyperglycemia
• Subcutaneous continuous glucose sensors may have a beneficial role in
children and adolescents but evidence is not as strong as in adults
Nutrition
• All children with type 1 diabetes should receive counselling from a
registered dietitian experienced in pediatric diabetes
• Children with diabetes should follow a healthy diet as recommended
for children without diabetes in Eating Well with Canada’s Food
Guide
• There is no evidence that one form of nutrition therapy is superior to
another in attaining age-appropriate glycemic targets
• Use of insulin to carbohydrate ratios may be beneficial but is not
required
 Cont…
• The effect of protein and fat on glucose absorption must also be
considered
• Nutrition therapy should be individualized (based on the child’s
nutritional needs, eating habits, lifestyle, ability, and interest) and must
ensure normal growth and development without compromising glycemic
control
• All families should understand the importance of hypoglycemia (severity
and frequency) along with treatment and follow up strategies
 Hypoglycemia
• Hypoglycemia is a major obstacle for children with type 1 diabetes and
can affect their ability to achieve glycemic targets
• Significant risk of hypoglycemia often necessitates less stringent
glycemic goals, particularly for younger children
• There is no evidence in children that one insulin regimen or mode of
administration is superior to another for reducing non-severe
hypoglycemia
Examples of Carbohydrate for Treatment of Mild to
Moderate Hypoglycemia
Patient Weight <15 kg 15 to 30 kg >30 kg

Amount of carbohydrate 5g 10 g 15 g

Carbohydrate Source

Glucose tablet (4 g) 1 2 or  3 4

Dextrose tablet (3 g) 2 3 5

Apple or orange juice; regular 40 ml 85 ml 125 ml

soft drink; sweet beverage
(cocktails)
Cont…
• Frequent use of continuous glucose monitoring in a clinical care
setting may reduce episodes of hypoglycemia
• In children, the use of mini-doses of glucagon has been shown to be
useful in the home management of mild or impending hypoglycemia
associated with inability or refusal to take oral carbohydrate
• Dose = 10 mcg x (years of age)
• Dose range 20 – 150 mcg
 Severe Hypoglycemia
Age ≤5 yrs  0.5 mg glucagon SC or IM

Age >5 yrs  1 mg glucagon SC or IM

• Consider reducing insulin doses in short term to avoid repeat event
• Dextrose 0.5 to 1 g/kg should be given intravenously over 1-3
minutes to treat severe hypoglycemia with unconsciousness when
intravenous access is available
• In children, the use of mini-doses of glucagon (10 mcg per year of
age with minimum dose 20 mcg and maximum dose 150 mcg)
should be considered in the home management of mild or
impending hypoglycemia associated with inability or refusal to
take oral carbohydrate