This document discusses several key points regarding pediatric pharmacy practice: - Children represent a significant portion of the global population but have poorly developed organ functions and are at higher risk for toxicity and adverse drug reactions. Historical events like the sulfanilamide elixir death and thalidomide tragedy demonstrate this risk. - Pediatric patients require specialized pharmacist care due to age-related variability in drug absorption, distribution, metabolism, and excretion, as well as higher risk of dosing errors due to non-standard doses, need for compounding and dilutions, and less tolerance for mistakes. - The roles of pediatric pharmacists include dosing calculations and consultations, medication history reviews, discharge counseling, drug

1. Paediatric Pharmacy
Practice
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2. 20 to 25% of total world population
Poorly developed organ functions and highest
risk of toxicity and poor clinical response.
Sulphanilamide elixir- death: Thalidomide
tragedy.
Taste of
Raspberries, Taste
of Death
The 1937 Elixir
Sulfanilamide
Incident 2

3. Why Do We Need Paediatric
Pharmacists?
Children are at increased risk of adverse
drug events (ADE’s)
Pharmacologic factors
•Age-based variability in absorption,
distribution, metabolism, and excretion of
drugs
Physiologic factors
•Weight and/or body surface area (BSA)
need
to be considered for each drug for each
patient
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4. Process factors
•Individualized dilution of stock
medications
and fluids
•Multiple concentrations of same drug
• Dilution errors
Environmental factors
•ICU settingWeight-based dosing
Error dosing rate
Error rates inversely related to size or
weight of patient
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5. Paediatric medication orders are more
prone
to errors than adult orders
 Doses are not standard
 Math errors can occur when calculating
the dose
 Suspensions often have to be compounded
 Tablets may have to be cut
 Dilutions need to be made to make
amounts that are measurable
 However, children have less tolerance for
errors
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6. Preemie <37 weeks gestation (gestational
age is the time from conception
until
Birth)
Full Term 37-42 weeks gestation
Neonate First 30 days of life
Infant First year of life
Toddler From 1 to 2 years of life
Child Age 3-11
Adolescent Age Age 12 on
Definition of a child is based on age
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7. Special Challenges of Practicing in
Pediatrics
 Lack of published information on
therapeutic uses and monitoring of drugs
 Lack of FDA approval for many drugs used
in pediatrics
Lack of appropriate commercially available
dosage forms and concentrations of commonly
used medicationsInability of patients to communicate with
caregivers
Interacting with parents
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8. Skills Necessary
Dosage calculations
Dosage-form selection
Specialized drug preparation and
administration techniques
Understanding of PK/PD changes occurring
with age
Understanding of disease-specific
conditions
affecting drug choice or dose
Understanding nature of medication errors
in
pediatric patients 8

9. Role of the Paediatric Pharmacist
Ensure the patient receives the necessary
drug in a manner that allows the intended
therapeutic effect to be realized.
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10. Patient interviews
Medication history
•Inquiring about OTC and herbal
medications
Allergy history
•True allergic reaction?
Immunization history
•Can make recommendations to MD if
patient is not up-to-date on immunizations 10

11. Discharge counselling
Administration & use of appropriate
measuring device dosage
Preparation of form at home, if
necessary
Attention to taste of liquid medications
Prevention of accidental ingestions
School / day-care issues directed at
patient and/or caregiver
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12. Drug Information
Influence selection of drug therapy in initial
phase of patient care
•Consult with physician and patient
Provide current, unbiased and relevant drug
information
Assist with finding literature supporting use of
drugs for unlabeled indications
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13. Therapeutic Drug Monitoring
Understanding timing / indication of
monitoring to prevent unnecessary blood draws
on children
Account for age-related differences in
dosage
Documentation in patient chart
Monitor steps of the medication use
process
Reduce drug costs
Avoidance of medication errors resulting
from over- or underdosing
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14. Reduce Medication Errors
Report medication errors
Encourage others to report medication
errors or suspected ADE’s
Participation in quality-improvement
committees
Develop and enforce policies and procedures
for safe medication practices 14

15. Drug Use Evaluation
Low therapeutic index drugs
Those responsible for serious
medication errors
High frequency of preventable adverse
drug reactions
Expensive medications
Education
Patients
 Nursing unit staff
 Physicians
 Pharmacy students and residents
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16. Research
 Pediatric patients are “therapeutic
orphans”
Insufficient research in pediatric
patients
Expansion of adult diseases into the
pediatric population (i.e. AIDS)
Use of therapeutic agents in children
without FDA approval
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17. Pharmacokinetic
considerations
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18. Absorption
– Gastrointestinal
pH- gastric acid output maturity is related to
postnatal age and
approaches adult values by 3 months of age
GI motility- neonates have a delay in gastric
emptying time, adult values are reached at 6-8
months of age
GI contents- develops rapidly within the first
year of life,
underdeveloped flora can increase absorption of
drugs (digoxin)
–
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19. 19
Percutaneous
Absorption is increased in the newborn
due to immature
epidermal barrier and increased skin
hydration during the first 2
weeks of life
Increased surface area to weight ratio
increases percutaneous
absorption

20. Distribution
–Body Water
• Neonates are 80% body water compared to 55%
in adults
• Vd is increased for drugs that distribute to
aqueous parts of the body (aminoglycosides)
• Total body fat is 1% in a 29 wk neonate
• Total body fat is 15% in a full term baby
• Total body fat is 20-25% in 2yo toddler
• Fat content tends to increase between 5-10 years
followed by a decrease through age 17
• Vd is increased for drugs that are highly lipid
soluble
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21. – Plasma Protein Binding
• Neonates have decreased plasma protein which
increases unbound concentrations (ex: Phenytoin
may only be 70% bound in a neonate compared to
90% in an adult)
– Blood Brain Barrier
• An immature BBB due to incomplete CNS
myelination results in increased CNS drug
penetration
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22. Metabolism
– Neonates have decreased activity of many enzyme
pathways, that is why drug dosages are decreased
for neonates
P450 activity is 50% of adult levels
Decreased hydroxylation activity leads to
decreased metabolism of phenobarbital, phenytoin,
lidocaine
Children have increased hepatic enzyme activity
between 2-4 years of age. This may be due to large
liver size compared to total body weight. Doses are
increased during this time for theophylline,
phenytoin, and phenobarbital.
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23. At birth, kidney function is decreased, GFR
matures first, then tubular secretion, and lastly
tubular reabsorption
GFR at birth is 2-4 ml/min, which is 0.5% of an
adult level
After the first week of life, a significant
increase in GFR is seen, this explains why
recommended doses change after 7 days of life
At 1 year, GFR reaches 70 ml/min/m2
Around 12-24 month of age, GFR and tubular
secretion are more mature than tubular
reabsorption and cause an increased renal
clearance of drugs (digoxin)
Excretion
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24. Administering
Medications to
Children
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25. • Safe pediatric dosages calculated by:
– Body weight
• Measured in mg per kg, mcg per kg, etc.
– Body surface area (BSA)
• Measured in m2
Remember
 1 kg = 2.2 lb
– When converting pounds to kilograms, round kilogram
weight to one decimal place
• Tenths
 1 lb = 16 oz
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26. Dosage is optimally calculated by using the
child’s body weight or mass and the appropriate
dose in milligrams per kilogram (mg/kg).
A. Fried’s rule for infants
age (in months) X adult dose
............................
= dose for infant
150
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27. age (in years)
............................. X adult dose =
age (in years) + 12
dose for child
Young’s rule for children 2 years old or older
weight (lb) X adult dose
........................................ = dose for child
150 lb (avg wt of adult)
Clark’s rule
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28. BSA of child (m)2 X adult dose
............................................... =
1.73 m2 (avg adult BSA)
approximate dose for
child
Child’s dosage based on body surface area
(BSA)
In the case of some drugs, such as chemotherapy, doses are
based on body surface area (BSA). This value can be determined
from the patient’s height and
weight, using either a nomogram or the following equation:
height (cm) X weight (kg)
BSA (m)2 = .......................................
3600
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29. Although the total body water content of
an adult
accounts for approximately 60% of body
weight, the total body water content of a
healthy newborn is
(A) 40%.
(B) 50%.
(C) 70%.
(D) 80%.
(E) 90%.
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30. THANK YOU
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