KMU Pharmacological Care Aspects While Dealing With Pediatric Patients

Pediatric
Medication
Administration
By
Hidayatullah Khan
MSN,MPH, BSN, CHPE, IP&C, RN &
DCH
hidayat.khan10@yahoo.com
Lecturer INS-KMU
1
General Guidelines
The responsibility of giving medications to
children is a serious one.
½ of all medications on the market today do
not have a documented safe use in children.
Children are smaller than adults and
medication dosage must be adjusted.
Children react more violently.
Drug reactions are not predictable.
2 hidayat.khan10@yahoo.com
General Guidelines
The impact on growth and development
must be considered when giving drugs to
children
Double checking is always best
Must double check these meds:
Lanoxin,
insulin,
heparin
Pediatric Drug Administration
Pediatric drug therapy should be guided by
the child’s age, weight and level of growth
and development
The nurse’s approach to the child should
convey the impression that he or she expects
the child to take the medication
Explanation regarding the medications
should be based on the child’s level of
understanding
The nurse must be honest with the child
regarding the procedure
1)It may be necessary to mix distasteful
medication or crushed tablets with a small
amount of honey, applesauce, or gelatin
Never threaten a child with an injection if he
refuses an oral medication
All medications should be kept out of the reach
of children and medications should never be
referred to as candy
Oral Medications
GI tract provides a vast absorption area for meds.
Problem: Infant / child may cry and refuse to take the

medication or spit it out.
Oral Medications
Do not use if child has vomiting, malabsorbtion or
refusal
Kids < 5 find it difficult to swallow tablets
Use suspension or chewable forms
Divide only scored tablets
Empty capsules in jelly
Do not call medication ‘candy’
Nursing Intervention
Infant:
Place in small amount of apple sauce or
cereal
Put in nipple without formula
Give by oral syringe or dropper
Have parent help
Never leave medication in room for parent to give
later.
Stay in room while parent gives the po medication
Nursing Interventions
Toddler:
Use simple terms to explain while
they are getting medication
Be firm, don’t offer to have choices
Use distraction
Band-Aid if injection / distraction
Stickers / rewards
Preschool:
Offer choices
Band-Aid after injection
Assistance for IM injection
Praise / reward / stickers
School-age
Concrete explanations, do not just say “it
won’t hurt”
Choices
Interact with child whenever possible
When the child is old enough to take
medicine in tablet or capsule form, direct him
or her to place the medicine near the back of
the tongue and to immediately swallow fluid
such as water or juice
Medical play
Nursing Interventions
Adolescent
Use more abstract rationale for
medication
Include in decision making
especially for long term medication
administration
Nursing Alert
For liquid medications, an oral
syringe or medication cup should be
used to ensure accurate dosage
measurement. Use of a household
teaspoon or tablespoon may result in
dosage error because they are
inaccurate.
Bowen & Greenberg
Household Measures Used to Give Medications
Oral Medication Administration
• Depress the chin with the thumb
to open infant’s mouth
• Using the dropper or syringe,
direct the medication toward the
inner aspect of the infant’s
cheek and release the flow of
medication slowly
• Note: child’s hands are held by
the nurse and child is held
securely against the nurses
body.
Oral Medications
Hold child / infant hands away from face
For infant: give in syringe or nipple
DO NOT ADD TO FORMULA
Small child: mix with small amount of juice or
fruit, give in syringe or allow the child to hold
the medicine cup and drink it at own pace if
he/she is big enough
Parent may give if you are standing in the room
Intramuscular Medications
Rarely used in the acute
setting.
Immunizations
 Antibiotics
Use emla
a local skin anaesthetic that is
applied to the skin prior to
procedures such as needles, to
help prevent pain.
IM Injection: interventions
Tell the child it is all right to make noise or
cry out during the injection. His or her job is
to try not to move the extremity.
IM Injection
Keep needle outside of child’s
visual field
Secure child before

giving IM injection.
Hold, cuddle, and comfort the

infant after the injection
Inspect injection site before

injection for tenderness or undue
firmness
Whaley & Wong
IM Injection Sites
Vastus Lateralis
Deltoid
Dorsogluteal
Vastus Lateralis:
Largest muscle in infant / small child.
0.5 ml in infant
1 ml in toddler
2 ml in pre-school
Use 5/8 to 1 inch (2.5 cm) needle
Compress muscle tissue at upper

aspect of thigh, pointing the nurse’s
fingers toward the infant’s feet
Needle is inserted at a 90-degree

21 hidayat.khan10@yahoo.com angle.
Bowden & Greenberg
Deltoid
Use ½ to 1 (2.5 cm) inch needle
0.5 to 1 ml injection volumes
More rapid absorption than
gluteal regions.
Bowden & Greenberg
Dorsogluteal
Gluteal muscle does not
develop until a child begins
to walk; should be used for
injections only after the child
has been walking for a year
or more
Should not be used in
children under 5 years.
½ to 1 ½ inch needle
1.5 to 2 ml of injected
volume.
Bowden & Greenberg
Eye Drops
Eye:
Pull the lower lid down
Rest hand holding the dropper with the medication on
the child’s forehead to reduce risk of trauma to the eye.
Eye Drops
Pull the lower lid down
Rest hand holding the

dropper with the medication
on the child’s forehead to
reduce risk of trauma to
the eye.
Whaley & Wong
Ear Drops
26 hidayat.khan10@yahoo.com Whaley & Wong

Ear Drops
In children younger than age 3 years the pinna is
pulled down and back to straighten the ear canal
In the child older than 3 years, the pinna is pulled up

and back.
Nose Drops
Position child with

the head hyper extended
to prevent strangling
sensation caused by
medication trickling into
the throat.
28 Whaley & Wong

Nose drops
Act as vasoconstrictors excessive use may be
harmful
Discontinued after 72 hours
Congested nose will impair infants ability to
suck
Give 20 minutes before feeding
Have kleenex
Keep child’s head below the level of shoulders
for 1 to 2 minutes after instillation
Rectal
Usually sedatives and antiemetics
Use little finger
Insert beyond anal sphincter
Apply pressure to anus by gently
holding buttocks together until desire to
expel subsides
Intravenous Medications
IV route provides direct access into the
vascular system.
Adverse effects of IV medication
administration:
Extravasation of drug into surrounding
tissue
Immediate reaction to drug
IV Medication Administration
Check your institution's policy on which drugs
must be administered by the physician and
which must be verified for accuracy by another
nurse.
All IV medications administered during your
pediatric rotation must be administered under
direct supervision of your clinical instructor.
IV Medication Administration
Check for compatibilities with IV
solution and other IV medications.
Flush well between administration of
incompatible drugs.
IV medications are usually diluted.
Nursing Alert
The extra fluid given to administer IV
medications and flush the tubing must
be included in the calculation of the
child’s total fluid intake, particularly in
the young children or those with
unstable fluid balance.
Bowden & Greenberg
Nursing Alert
Hourly assessment
Documentation
Patency, infiltration, inflammation, rate,
pain
Use mini/micro drip chamber for control
IV Medications
IV push = directly into the tubing
Syringe pump = continuous

administration
Buretrol = used to further dilute drug
IV Push
•Morphine
•Solu-medrol
•Lasix
Drug that can

safely be
administered
over 3 to 5
minutes.
37
Bowden & Greenberg
IV push
Medication given in a portal down the
tubing – meds that can be given over a 1-3
minute period of time.
Lasix: diuretic
Morphine sulfate: pain
Demerol: pain
Solu-medrol: asthmatic
IV Pump
Bowden & Greenberg
Syringe pump
Accurate delivery system for administering
very small volumes
ICU
NICU
IV Buretrol
41 hidayat.khan10@yahoo.com Bowden & Greenberg

 A buretrol or volutrol is an intravenous
delivery device attached between the IV fluid
bag and the intravenous catheter. It is used to
deliver IV fluids in a safe manner to children
and medications* in some nursing units.
 Usual volume capacity is 100 ml. Some units
have a policy that a buretrol will be used on all
children under 10 kg while others may state 20
kg. Individual units vary on policy.
 In practice: Make note of hospital/unit policy
for use of buretrols. Current theory is that
buretrols should be used for children weighing
<10-15 kg.
IV Buretrol
Buretrol acts as a second chamber
Useful when controlling amounts of fluid
to be infused
Useful for administering IV antibiotics /
medications that need to be diluted in
order to administer safely
Intravenous Therapy
Central Venous Line
Whaley &
Central Venous Line
A large bore catheter that are inserted either
percutaneously or by cut down and advanced
into the superior or inferior vena cava
Umbilical line may be used in the neonate
Used for long term administration of meds
Used for chemotherapy
Total parental nutrition
Child With Central Venous Line
Whaley & Wong
Type of fluid
Glucose and electrolytes
Maintenance
Potassium added
Crystalloid: Normal Saline or lactated ringers
Fluid resuscitation
Acute volume expander
Colloid: albumin / plasma / frozen plasma
Complications
Infiltration
Catheter occlusion
Air embolism
Phlebitis
Infection
Infiltration
Infiltration: fluid leaks into the subcutaneous tissue
Signs and symptoms:
Fluid leaking around catheter site
Site cool to touch
Solution rate slows are pump alarm registers down-
stream-occlusion
Tenderness or pain: infant is restless or crying
Catheter Occlusion
Fluid will not infuse or unable to flush
Frequent pump alarm
Flush line
Check line for kinks
Air embolism
The IV pump will alarm when there is air in the tubing
Look to see that there is fluid in the IV bag or buretrol
Slow IV rate
Remove air from tubing with syringe
Phlebitis
Often due to chemical irritation
When medications are given by direct intravenous
injection, or by bolus (directly into the line) it is
important to give them at the prescribed rate.
Always check the site for infiltrate before giving an IV
medication
Signs and symptoms: phlebitis
Erythema at site
Pain or burning at the site
Warmth over the site
Slowed infusion rate / pump alarm goes off
Reason for pump alarm
Needs to have volume re-set
Needs more IV solution in bag or buretrol
Kinked tubing at infusion site
Child lying on tubing
Air in tubing
Infiltrated at site of infusion
Clinical Pearls
If alarm states upward occlusion
Look at IV bag
Look at fluid level in buretrol
Look to see if ball in drip chamber is floating
If alarm states downward occlusion
Look to see that all clamps are open
Look to see if line is kinked
Irrigate with normal saline or heparin
Calculation of Doses
Dose Definitions
Dose of a drug: the quantitative amount administered or
taken by a patient for the intended medicinal effect
 Single dose: the amount taken at one time
 Total dose (Daily dose) : the amount taken during the course of
therapy (may be subdivided in divided doses)

 Dosage regimen: the schedule of dosing (4 times per day for 10
days)

number of doses  total quantity
Size of dose
58
Dose Definitions
 Usual pediatric dose: : the amount that ordinarily produces the medicinal effect
intended in the infant or child patient
 Usual dosage range : the quantitative range or amounts of the drug that may be
prescribed within the guidelines of usual medical practice

 Median effective dose: the amount that produces the desired intensity or effect in
50% of the individuals tested.
 Minimum effective concentration:

the minimum concentration determined
that can be expected to produce the drug’s
desired effects in a patient.
 Minimum toxic concentration:

 The base level of blood serum concentration that produces dose-related toxic effects.
59
Dose Measurement
 Doses are measured and administered by professional and paraprofessional
personnel in case of institutional setting.
 adults or child’s parents are generally measures and administers medication in

the home setting.
 Household measures
Household measure ounce Metric system

(Abbreviation)
1 teaspoonful (tsp) 1/6 fluidounce 5 ml f
1 tablespoonful (tbsp) 1/2 fluidounce 15 ml f ss
60
Dose Measurement
Household measures
Signa Label dose
f i One teaspoonful 5 ml
f ii One dessertspoonful 10 ml
f ss One tablespoonful 15 ml
f One coffee cupful 30
m One drop
 Calibrated droppers
 US Pharmacopeia, official medicinal dropper held vertically
delivers approximately 20 drops water per millilitre.
 A drop (abbreviated gtt) doesn’t represent a definite quantity
(few liquids have the same surface and flow characteristics as
water).
61
Dose Measurement
Case 1
 A physician asks a Nurse to calculate the dose of a cough syrup so that it may be safely
administered dropwise to a child. The cough syrup contains the active ingredient
dextromethorphan , 30 mg/15 ml, in a 120- ml bottle. Based on the child’s weight and
literature references, the Nurse determines the dose of dextromethorphan to be 1.5 mg
for the child.
The medicine dropper to be dispensed with the medication is calibrated by the Nurse and
shown to deliver 20 drops of the cough syrup per 1 ml.
Calculate the dose in drops, for the child.
 Answer
 30 mg dextromethorphan 15 ml
 1.5 mg dextromethorphan X ml
 X = 15 * 1.5/30 = 0.75 ml
 Number of drops of cough syrup in 0.75 ml dose
 1 ml 20 drops of cough syrup
 0.75 ml X drops of cough syrup
 X = 0.75 * 20/1 = 15 drops of cough syrup
62
Calculation of doses
 According to age: for Child and infant doses
 Young’s rule
Dose for Child   Age of child  years   X adult dose

 age  years   12
 Cowling’s rule
Dose for Child   Age at next birthday  years  X adult dose

 24
 Fried’s rule for infants
Dose for Infant   Age months   X adult dose

 150
63
 According to body weight
 Clark’s rule
Child dose   weight lb   X adult dose

 150
 According to body surface area (BSA)
Child dose    
 BSA of the child m 2 
2  X adult dose
 1.73 m 
Child dose  BSA of the child m 2  X dose per m 2

 To determine patient’s BSA, use standard Nomogram or this equation
Patient ' s height cm  Patient ' s weight kg 

 2
Patient ' s BSA m 
3600
64
 If the adult dose of phenobarbital is 15 mg, what will be the dose
for an 8 year-old child?
 Young’s rule
Dose for Child   Age of child  years   X adult dose

 age  years   12
 = (8/8+12)X 15 = 6 mg
 Cowling’s rule
Dose for Child   Age at next birthday  years  X adult dose

 24
 = (9/24)X 15 = 5.625
65

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Pediatric

Problem: Infant / child may cry and refuse to take the

Secure child before

Hold, cuddle, and comfort the

Inspect injection site before

Use 5/8 to 1 inch (2.5 cm) needle

Compress muscle tissue at upper

Needle is inserted at a 90-degree

0.5 to 1 ml injection volumes

More rapid absorption than

Pull the lower lid down

Rest hand holding the

26 hidayat.khan10@yahoo.com Whaley & Wong

In the child older than 3 years, the pinna is pulled up

Position child with

28 Whaley & Wong

Bowden & Greenberg

IV push = directly into the tubing

Syringe pump = continuous

Buretrol = used to further dilute drug

Drug that can

41 hidayat.khan10@yahoo.com Bowden & Greenberg

 Single dose: the amount taken at one time

 Minimum effective concentration:

 Minimum toxic concentration:

 adults or child’s parents are generally measures and administers medication in

Household measure ounce Metric system

Dose for Child   Age of child  years   X adult dose

Dose for Child   Age at next birthday  years  X adult dose

 Fried’s rule for infants

Dose for Infant   Age months   X adult dose

Child dose   weight lb   X adult dose

 According to body surface area (BSA)

Child dose  BSA of the child m 2  X dose per m 2

Patient ' s height cm  Patient ' s weight kg 

Dose for Child   Age of child  years   X adult dose

Dose for Child   Age at next birthday  years  X adult dose

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