Pediatrics Presentation

9 Pediatrics • E L L I E TA B A R , P H A R M D • FEB 11,2025 • PHAR 840/ IPC I M M U N O LO G I C CO NDI TI ON S AN D SPE CIA L P O P U L AT I O N S whichmed for contraindication neonate OtcAspin a tramadolcodon whyuseuit Acetaminophendose dose Ibuprofen ageso28dg neonate RightwrenthayBornsbonedefiency it is • Premature Neonate: Born < 37 weeks • Neonate: First 28 days of life • Infant: 1–12 months old Age Classification • Toddler: 1–2 years old • Preschooler: 3–4 years old • School-age: 5–12 years old • Adolescent: 13–18 years old Pediatric Growth & Development Growth Velocity • Change in weight or height over time • Multiple points compared over time (more than one measurement) • Measured at each “well-child” care appointment using standardized growth charts https://www.cdc.gov/growthcharts/index.htm Weight • Term neonates commonly lose up to 10% of body weight during the first few days of life • Should regain birth weight by 10–14 days of age • Infants should gain approximately 20–30 grams per day in the first three months • Infants should double birth weight by 4 months • Infants should triple birth weight by 1 year ofgettinginfati Pediatric Nutrition  bathientsand antibody lessrisk y Proper Nutrition is Necessary for Optimal Growth • During the first 6 months, exclusive breastfeeding is recommended. on food solid • From 6 to 23 months, continue breastfeeding alongside the introduction of complementary foods.  Complementary Feeding • Initiate at 6 months of age. • Ensure the diet is diverse, including: • Animal-source foods (meat, fish, poultry, dairy) • Fruits and vegetables oka• Legumes and nuts fiber andhealthyfat protein Vitamin Supplementation TTRidgtdiseaseCDeformformottheiriegs Vitamin D • Recommendation: All infants, including those who are exclusively breastfed, should receive a daily supplement of 400 IU (10 mcg) of vitamin D, starting within the first few days after birth. • Duration: Continue supplementation until the infant consumes at least 1 liter (approximately 34 ounces) of vitamin D-fortified formula or milk daily. tBlod Iron nutrigenioxygentiBlaindevelopment • Breastfed Infants: Starting at 4 months of age, exclusively breastfed infants should receive an iron supplement of 1 mg/kg per day until iron-rich complementary foods are introduced. • Formula-Fed Infants: Typically do not require additional iron supplementation, as formula is iron-fortified. arenregy Vitamin B12 • At-Risk Populations: Infants and children on strict vegan diets are at risk for vitamin B12 deficiency. Supplementation should be considered, with dosages determined in consultation with a pediatrician. amountofbraastmilk thatbabiestakedoesat harenoughuitainfinitt forbabiesvolumeof distribution smalltheir Pediatric Pharmacokinetics eats obey polessstongfacid Absorption: Slower oral, avoid IM, increased topical absorption mgspregMA Distribution: Higher water %, lower protein binding, lower fat Metabolism: Neonates = slow, children = fast bodiesaresmall lessspreading ofthedrug Babresheremoreyator fordistribution it depend ftp.tskontveduytobehydngphd lipophilicforvolugeof Elimination: Slower kidney function → Adjust dosing SDngrengefrombody Final Tip: Always adjust drug dosing based on age & organ function! xxphenytoin psitighproteinbinting GIfgiventokids morefreedngimoretoxicity or distribution uselbytDonttwonttogerstimulate thedies locerdges By Miso 12460 FUSS12.360 hr dininch Obesity & Pharmacokinetics • Overweight: 85th–94th percentile • Obese: ≥95th percentile Dosing Considerations • Absorption: No major e ect Exon 81811Lipophilic drugs: ↑ Vd → May require adjustments (varies by drug)->TBW MEE Benzodiazepines opiods Pharmacokinetics in Obese Children Hydrophilic drugs: ↓ Vd → Use IBW, Aminoglycosides Agdrophifiesvancomycin BMI Classification • Distribution: highetininchl • Metabolism: Liver enzyme activity may increase → Some drugs metabolized faster • Elimination: Renal clearance may be increased → Adjust dosing for renally excreted drugs • Use IBW for hydrophilic drugs (e.g., aminoglycosides, vancomycin) • Use IBW for benzodiazepines / opioids • Use TBW for lipophilic drugs that distribute into fat Eton (e.g., some anesthetics) • Consider Adjusted Body Weight (ABW) for certain cases • Do not exceed adult doses Pediatric Dosing Guidelines Essential Considerations: Always calculate each dose individually Use reliable dosing handbooks Key Points to Remember: Dosing units vary: Can be reported as mg/kg/dose or mg/kg/day (divided doses) Always use kg for weight-based dosing -Convert: Weight (lb) ÷ 2.2 = Weight (kg) Dosing Adjustments: Select the correct indication – Doses vary based on disease severity Choose the appropriate age group: Neonatal vs. Pediatric vs. Adolescent dosing Safety Warning: Always verify calculations and avoid exceeding maximum doses DOSING By Weight (mg/kg) • Used for most drugs By BSA (Body Surface Area) • Formula: √[(Height (cm) × Weight (kg)] / 3600] • Used for chemotherapy and some other medications Round Dose (Up to 10%) • Adjust to the appropriate tablet size • Ensure a safely measurable volume dose Important Note: • Do not exceed adult doses! COMMON CALCULATION Mg/kg Dosing • Patient’s weight (kg) × dose (mg/kg) = dose (mg) • Example: Acetaminophen 10 mg/kg/dose × 8 kg = 80 mg/dose BSA Dosing • Patient’s BSA (m²) × dose (mg/m²) = dose (mg) • Example: Acyclovir IV 1500 mg/m²/day × 0.79 m² = 1185 mg/day • Divided into three doses → ~395 mg per dose • Rounded to 400 mg IV Q8H Volume Calculation • Dose (mg) ÷ concentration (mg/mL) = volume (mL) Volume Calculation • Patient needs 250 mg of Medication X • Medication X concentration: 400 mg/5 mL • What volume should the parent administer? A. 0.63 mL B. 3.125 mL C. 3 mL D. 5 mL Sfmx2501mg 3 125mL 3rd cephtrixone contraindicatedwitreageofthbery Case: Noah (5 kg) A 2-month-old 5 kg infant, Noah, presents to the ED with: • Fever • Decreased PO intake • Bulging fontanelle • One episode of seizure The team suspects meningitis and wants to start IV antibiotics. They ask for advice on dosing for the following medications: toffee • Ceftazidime • Vancomycin • Acyclovir (for HSV meningitis) Pointers for Dosing: • Since the patient is >1 month old, use infant dosing, not neonatal dosing. • Since this is meningitis, use the higher end of the dosing range for better penetration into the CNS. • Fluid Maintenance Rate: • Since Noah is critically ill, the team wants to admit him and start IV fluids. What maintenance rate would you recommend? 9m45 2omylogthr poweneedtolmaiths Acute Constipation in Children of Common Occurrences of Acute Constipation • Dietary Changes (e.g., switching from breast milk/formula to solid foods) • Toilet Training Periods • School Entry (change in routine, less water intake) Prevention Strategies 1.Dietary Recommendations • High-fiber foods (recommended intake: age + 5g/day) • Adequate hydration (water + age-appropriate fluids) 2.Toilet Habits • Encourage regular toilet sitting (5–10 minutes, 2–3 times daily, preferably after meals) • Use a footstool to support proper posture fiberatwater together goes fpthorebowlmovement but can'tpoof softener Fiber Supplements for Constipation • Helps absorb water in stool, increasing bulk and movement • Available as powders & gummies • Best for mild constipation & long-term gut health • Ensure proper hydration for e ectiveness • Gummies look like candy—risk of overuse! 2/9/2 02 5 18 Docusate (Colace) - Stool Softener • Reduces surface tension of stool, allowing more water incorporation • Best for children with hard, dry stools • Comes in multiple products/concentrations—double-check dosing Avoid with mineral oil (reduces absorption of fat-soluble vitamins) • Common side e ect: Throat irritation (take with water) Ed emonth Acute 0 3 subacute Osmotic Laxatives for Constipationagonth gal chronic MOA: Osmotic laxatives work by drawing water into the intestines, softening stool, and making bowel movements easier. They are commonly used for both acute and chronic constipation. Maggieconstipation • Polyethylene Glycol 3350 (Miralax) - Most common • Best for chronic constipation & first-line treatment in pediatrics • Magnesium Hydroxide (Milk of Magnesia) - Avoid in kidney disease sugaralcohol • Lactulose & Sorbitol a- Alternative options, may cause bloating nephalopaty Monitor electrolytes, especially with prolonged use 2/9/2 02 5 20 Lubricant Laxatives (Mineral Oil) • MOA: Lubricates stool, decreasing water absorption from intestines • Forms: Oral or enema • Oral Onset: 6-8 hours • Rectal Onset: 2-15 minutes jyBobiesconinholleititat causetherespiratoryrisk • Avoid in: Young children (aspiration risk) • Reduces absorption of: Fat-soluble vitamins (A, D, E, K) • Messy option! tharsh Avoid homemade enemas (soap suds, herbal) Use **normal saline enemas** in healthcare settings if needed fastest't relive cotipation Better than Stimulant Laxatives: BisacodylMe & Senna • MOA: Directly stimulate bowel contractions for fast relief • Used for **occasional constipation**, not first-line for chronic use • as Ifkeepusinggoingtolosethe Use sparingly to **prevent dependency** • Bisacodyl (Dulcolax): Tablet, suppository, enema naturalfunction Onset: Oral (6-12 hrs), Suppository (15-60 min), Enema (5-20 min) Do not crush/chew tablets, avoid with antacids/dairy • Senna (Senokot): Derived from natural plant sources. 2/9/2 02 5 6-24 hours 22 Case: Noah • You receive a question from the parent of Noah, a 3-year-old toddler. The parent is concerned because Noah has not had a bowel movement in 4 days and seems to be straining when trying to go. • Upon further questioning, theAcute parent tells you that Noah has recently been potty training and often refuses to sit on the toilet. They also mention that Noah’s diet consists mostly of chicken nuggets, white bread, and milk, with very few fruits or vegetables. • What recommendations can we make for Noah and his family? Non pharm Morefiber water limitcheckernuggets recommend 2/9/2 02 5 Midd 23 Constipation in Infants hayforInfants Dietary Modifications: mmBest - Prune juice, baby food , Fiber-rich vegetable purees, High-fiber cereal Glycerin Suppositories (Safe to use ): -MOA: Local osmotic agent - Onset: 15-60 minutes - Dose: 1 suppository PR QD or BID PRN Avoid: - Mineral oil (Aspiration risk ) - Saline agents in children <2 years (Electrolyte imbalances ) - Enemas in children <2 years • Key Takeaway: First-line treatment is diet changes, glycerin suppositories only if needed! 2/9/2 02 5 24 fly stomach of inflammation stomach Mt Acute Gastroenteritis (AGE) Clinical Manifestations: • N/V • Diarrhea GbAntibioticdogthworktowardsthis • Anorexia Major Causes (Viruses): • Abdominal Cramps orgettingfromfoodwater • Noroviruses • Rotaviruses • Enteroviruses Major Concern: **Dehydration** 2/9/2 02 5 25 sugar armolkete dehydrationorconstipation AGE Treatment: Hydration & Diet Wgst goodbagonaro Oral Rehydration Therapy (ORT) dehydration • Appropriate for mild to moderate dehydration • Can be managed at home with frequent small sips of ORT solutions 2 Resume Age-Appropriate Diet • Avoid high-sugar and high-fat foods (Encourage nutrient-dense meals to aid recovery ,BRAT diet is no longer recommended) 3 Probiotics (Support Gut Microbiota) • Lactobacillus GG & Saccharomyces boulardii are the most studied strains • May reduce diarrhea duration by ~1 day • Start early for potential benefits Intravenous Fluid Resuscitation (For Severe Dehydration) • 20 mL/kg Normal Saline (NS) IV 2/9/2 02 5 GW • Used in cases where ORT is not feasible or dehydration is severe Goralrehydration 26 profitorredyeNY mpg AGE Treatment - Antiemetics & Antidiarrheals or severeNy Antiemetics • Use only when nausea and vomiting prevent oral rehydration therapy (ORT) • Ondansetron 0.15 mg/kg (MAX: 8 mg) x 1 dose Antidiarrheal Agents - Not Recommended • Loperamide (Imodium®) - Slows down gut movement, risk of serious side e ects • Bismuth Subsalicylate (Pepto-Bismol®) - May cause Reye’s Syndrome • Children’s Pepto® - Not e ective for diarrhea 2/9/2 02 5 27 Startassoonasdiareah Me stars Oral Rehydration Therapy -Oral Rehydration Solutions (ORS) - Mild to moderate dehydration - Carbohydrates + electrolytes included - Cost e ective - Easy to administer (at home) - Commercial products + home remedies -Start ASAP -For ≥ 1 Year Old -Small and frequent aliquots: 5 mL Q1-2 min - Spoon or syringe for smaller children 2/9/2 02 5 28 Oral Rehydration Therapy 1. Rehydrate - Mild dehydration: 50 mL/kg given over 4 hours - Moderate dehydration: 100 mL/kg given over 4 hours - Under HCP observation 2. Maintain - Replace ongoing losses: 10 mL/kg per loose stool 2 mL/kg per episode of emesis Eyal -While diarrhea persists - Resume normal feeds for age (as tolerated) 2/9/2 02 5 29 Case: Noah (11 kg) Noah’s mom comes into the pharmacy and says that her 14-month-old son has been experiencing vomiting and diarrhea since this morning. She reports that he has had two episodes of diarrhea and one episode of vomiting today. When asked about his behavior and hydration status, she mentions that he is still alert and interactive but appears a bit more tired than usual. She also notes that his mouth looks dry and that he hasn’t had a wet diaper in the last five hours. You classify him as having mild dehydration. • What would you recommend for Noah? offrehydration 2/9/2 02 5 30 moderate too mylaggivenover Case: Noah (11 kg) • 4hr Oral Rehydration Therapy! • If Noah is 11 kg, how much ORS should he get to replace his fluid deficit? A. 110 mL B. 400 mL C. 550 mL D. 1100 mL • How much ORS should you recommend Noah’s mom to give him with each loose stool? 2/9/2 02 5 31 AGE Prevention • Hand hygiene • Rotavirus vaccination - Recommended by WHO: Rotavirus vaccines are recommended for inclusion in all national immunization programs. Exam - Live vaccine: Contraindications - Severe Combined Immunodeficiency (SCID) - RotaTeq® (RV5): Administered in a 3-dose series at ages 2, 4, and 6 months. - Rotarix® (RV1): Administered in a 2-dose series at ages 2 and 4 months. • The first dose should be given before 15 weeks of age. • All doses should be completed by 8 months of age. 2/9/2 02 5 32 AGE Prevention • Interchangeability: • It is recommended to complete the series with the same product whenever possible. • If the previous product is unknown or unavailable, continue with the available product. • If any dose in the series was RotaTeq®, or the vaccine product is unknown for any dose, a total of 3 doses should be administered. 2/9/2 02 5 33 Gastroesophageal Reflux (GER) & GERD in Infants no esophagusisgot • Reflux is common in infants • Usually improves with age • Must rule out serious underlying conditions yet developed • Uncomplicated GER (“Happy Spitter”)Infant has good weight gain, Feeds well, not irritable, No medical treatment needed Non-pharmacological measures recommended • Gastroesophageal Reflux Disease (GERD)- Poor weight gain, Feeding refusal, Marked irritability 2/9/2 02 5 34 Non-Pharmacological Interventions • Lifestyle Modifications: so • Elevate head during sleep thestomach gravitykeeps contentdown • Avoid meals close to bedtime • Implement dietary changes as needed • Eliminate exposure to secondhand smoke a causeweakeningof esophagus Nutritional Adjustments: • For infants, consider smaller, more frequent feedings • Use thickened feedings or anti-regurgitation formulas tolerated toit a IFBabiesare • In breastfed infants, mothers may eliminate cow's milk and eggs from their diet 2/9/2 02 5 35 Pharmacological Interventions Acid Suppressants: theadds Block a • Proton Pump Inhibitors (PPIs) - Omeprazole, Lansoprazole - Used for 4–8 weeks to reduce stomach acid a Pepsi • Histamine H₂ Receptor Antagonists (H2RAs) - Famotidine 2/9/2 02 5 36 Case: Noah (8.1 lb.) 13 • Noah is a 6-week-old, 8.1 lb. infant admitted to the hospital for Failure to Thrive and weight loss. His parents report persistent feeding di iculties, including frequent vomiting, back arching during feeds, and irritability. Despite trying non-pharmacological measures, Noah continues to struggle with weight gain. • How should we manage Noah’s reflux? • A. Continue non-pharmacological measures until 2 months • B. Start famotidine • C. Start omeprazole • D. Start calcium carbonate • What prescription would you recommend? • Specify formulation, dose, and frequencY • (Handwritten note option: “If can take PO, use ___; if not, use ___ IV”) 2/9/2 02 5 37 Intestinal gas in infants Simethicone 40 mg/0.6 mL Oral Suspension Eton • Mechanism of Action: Simethicone decreases the surface tension of gas bubbles, allowing them to coalesce and be expelled more easily. theblood a Notgoingto • Absorption: Not absorbed from the gastrointestinal tract, making it generally safe for infants. Gripe Water streamworklocally • Composition: Typically contains herbal ingredients such as fennel, ginger, chamomile, and sometimes sodium bicarbonate. • E icacy and Safety: • The U.S. Food and Drug Administration (FDA) does not regulate gripe water, and its safety and e ectiveness have not been confirmed. 2/9/2 02 5 38 Pediatric Pain Treatment Pharmacological Treatment Options Ibuprofen gadoids • Mild Pain: Acetaminophen (APAP) and/or NSAIDs post sway •a Moderate Pain: Weak opioids Tramadol sophentenol • Severe Pain: Strong opioids cat Non-Pharmacological Approaches morphine • Distraction Techniques • Therapeutic Touch • Swaddling & Sucking for Infants • Art & Play Therapy 2/9/2 02 5 41 SELiverinjury Acetaminophen (Tylenol®) Drug of choice for mild pain and fever • Relatively safe when used within the recommended dosage • Easy to use with multiple formulation Mechanism of Action (MOA): Central inhibition of prostaglandin synthesis, Peripheral blockade of pain impulse generation In Formulations: Oral(Solution, tablets, capsules), Rectal (PR):( Suppositorie), Intravenous (IV) Dosing Guidelines Infants & Children <12 years • Oral/Rectal: 10-15 mg/kg/dose every 4-6 hours as needed • Maximum: 75 mg/kg/day (not to exceed 4 g/day) Children ≥12 years, Adolescents & Adults • Oral/Rectal: 325-650 mg every 4-6 hours as needed • Maximum: 3 g/day for adolescents and adults 2/9/2 02 5 42 Case: Noah (7.2 kg, 6 MO) • Noah is a 6-month-old, 7.2 kg infant whose father visits the pharmacy seeking advice on Noah’s recent fussiness and disrupted sleep patterns. Over the past few days, Noah has been more irritable, drooling excessively, and frequently putting his hands in his mouth. His father is also worried because Noah has been rejecting his bottle more than usual. • After consulting their pediatrician, they were told that teething may be the cause. Noah ’s father wants to know what can be done to help soothe Noah’s discomfort so he can sleep better at night. • What recommendations would you provide for Noah’s teething discomfort? Acetaminophen 2/9/2 02 5 to singingDose 46hrp any 43 Teething Onset & Symptoms- Starts: Around 6-10 months of age slain • Common Symptoms: Crankiness/Irritability, Excessive drooling, Chewing on objects, Mild gum discomfort, Slight increase in body temperature (not true fever) Infection or • Uncommon Symptoms (Not Typically Due to Teething):Fever >100.4°F (38°C), Diarrhea or vomiting, Severe rash Management: Use chilled teething rings , O er a cold, wet washcloth for chewing Avoid Unsafe & Ine ective Remedies: • Over-the-counter (OTC) teething gels and topical analgesics (e.g., benzocaine-containing products) → Risk of methemoglobinemia poisonousplight seizure highly me cause • Homeopathic teething tablets (e.g., belladonna-containing products) → Potential toxicity • Amber teething necklaces, bracelets, or anklets → Strangulation and choking hazard 2/9/2 02 5 44 Maxi79mgKsldayINGMoreton Igiday Case: Noah (7.2 kg, 6 MO) • Acetaminophen before bedtime • Which product? How much should she measure? • What about teething gels? 2/9/2 02 5 45 NSAIDs-Ibuprofen (Motrin®, Advil®) thatsignal messenger pod no Mechanism of Action: Reversibly inhibits COX-1 & COX-2 → reduces prostaglandin synthesis • E ects: Reduces pain, fever, and inflammation Indications: • Fever reduction in children ≥6 months • Mild to moderate pain management • Inflammatory conditions (e.g., juvenile idiopathic arthritis) -Infant Drops (50 mg/1.25 mL): For 6–23 months (use dosing syringe for accuracy) -Children’s Suspension (100 mg/5 mL): For ages 2+ years -Chewable/Regular Tablets: For ages 6+ years (ensure child can safely swallow) Dosing • Weight-based dosing: 5-10 mg/kg per dose Q 6-8 hours PRN Give with food or milk to reduce GI upset • Maximum dose: 40 mg/kg/day (do not exceed 4 doses/day) 2/9/2 02 5 46 Ibuprofen (Motrin®, Advil®) Cautions & Contraindications: • Do NOT use in infants <6 months (risk of kidney injury) Avoid in: • Dehydration or renal impairment (risk of acute kidney injury) • Suspected viral infections (e.g., varicella, influenza) (potential link to Reye’s syndrome) • Chronic use without GI protection (consider PPI or H2-blocker for prolonged therapy) 2/9/2 02 5 47 NSAIDs- Aspirin Aspirin: Not Recommended for Children & Adolescents in't Risk of Reye Syndrome sprin • Triggered by viral infections (especially influenza or varicella). • Symptoms: Vomiting, confusion, seizures, coma. • Lab Findings: Increased prothrombin time, Hyperammonemia, Hypoglycemia, Metabolic acidosis • Leads to: Brain swelling, hepatic damage. • Complications: Brain damage, coma, death. • Treatment: Supportive care. • Prevention: Avoid salicylates in children! 2/9/2 02 5 48 NSAIDs we lesstrettenay Longerhalflifthan Naproxen (Naprosyn®, Aleve®) nappy • Rx: 125 mg/5 mL suspension, various tablet forms • Inflammatory dose: Max 1250 mg/day (10-20 mg/kg/day) • Analgesic dose: 5-7 mg/kg/dose q8-12h • OTC: 220 mg tablets • Children ≥12 years: Max 600 mg/day 2/9/2 02 5 serious lotsof Moe Ketorolac (Toradol®) • Limit use to 5 days max • Oral dose (≥17 years): 200 mg initial, then 200 mg q8-12h • IV use (children ≥2 years): 0.1-0.2 mg/kg q6-8h • Boxed Warnings: GI, renal, so thrombotic risks cardiouasaderaat Indomethacin (Indocin®) • IV use: Closes PDA in neonates 49 se causeseizure unpredictable Pain Medications to Avoid drag intlebody moiPro activate Codeine • Metabolized to morphine by CYP2D6 activity Inert gg a • Poor metabolizers → No pain relief • Ultra-rapid metabolizers → High morphine levels → Respiratory depression, death • FDA: Avoid in children 2/9/2 02 5 É Tramadol • Metabolized by CYP2D6 & 3A4 to active forms • Linked to respiratory depression and death in children • FDA: Avoid in children produg clopidogrel 50 27.2719 Case: Noah (60 lb.) Noah, an 8-year-old child, sprained his wrist. What can we give for his pain? 1. Aspirin 81 mg Acetaminophen to IsmylagHog Max 7Srgits1dg 15 27.27404 2. Acetaminophen 975 mg 3. Acetaminophen 360 mg 4. Ibuprofen 600 mg 2/9/2 02 5 51 FaeroeSymptoms Normal Temperature Ranges by Method most Effectalsoaccurate goldstandard forinfants Preferred Methods: than3mont less • Rectal: 100.4°F (38°C) • Oral: 99.5°F (37.5°C) Other Methods (May Be Less Reliable): • Axillary (Underarm): 99°F (37.2°C) • Temporal (Forehead): 100.4°F (38°C) • Tympanic (Ear): 100.4°F (38°C) 2/9/2 02 5 Parental “fever phobia” is common, but fever itself is not dangerous. if its above107its it dangerous an seizure means 53 Neonates & Infants: Fever Management Bcitcanbe Neonates (0–28 days): mom • Fever (≥100.4°F or 38°C) is an emergency → Refer to ER immediately info • Risk of serious bacterial infection (SBI): ~10-15% of febrile neonates • Workup includes: CBC, blood culture, Urinalysis (UA) & urine culture, Lumbar puncture (CSF analysis), Chest X-ray if respiratory symptoms • Empiric IV antibiotics until infection is ruled out Infants (1–3 months): • Ill-appearing: Refer to ER • Well-appearing: Work up fever in clinic • Do not treat fever with OTC medications in neonates (<3 months) GoDon'twantto maskthesymptoms 2/9/2 02 5 54 Older Children: Fever Management Fever is Usually: • Self-limiting (often viral in origin) When to Seek Medical Evaluation: • Fever lasts >4 days, Especially if accompanied by rash, red mouth/tongue → Rule out Kawasaki Disease infection • Not drinking enough fluids (risk of dehydration) • Ill-appearing (lethargic, di iculty breathing, severe pain) • Parents’ concern – Trust parental judgment Otherwise: • Can be managed at home with fluids, rest, and fever control (acetaminophen/ibuprofen as needed) 2/9/2 02 5 55 Fever Management Goals: • Identify the cause • Increase child’s comfort Supportive Care: • Fluids → Keep child hydrated • Cool measures (Not necessary) ex Medications: • Acetaminophen: 10-15 mg/kg per dose every 4-6 hours as needed • Ibuprofen: 5-10 mg/kg per dose every 6 hours as needed • Caution: Not recommended for infants <6 months or causestring BodyTempretoret • Sponge with tepid (not cold) water • No alcohol baths 2/9/2 02 5 56 Case: Noah (8 lb.) Noah is a 4-week-old, 8 lb. baby boy who presents with symptoms of nasal congestion and fever (101°F/38.3°C). His mother has come to the pharmacy to pick up cold medicine for him. She mentions that the rest of the family has a similar cold, and she is concerned about his symptoms. What should you suggest for him? A. Advise mom to call the pediatrician B. Give Acetaminophen 65 mg PO every 4 hours as needed for fever C. Give Ibuprofen 40 mg PO as needed for fever D. Refer Noah to the Emergency Department 2/9/2 02 5 57 Case: Noah (8 months, 8.5 kg) Noah is an 8-month-old infant who presents with fever, fussiness, and reduced oral intake over the past three days. His parents report that he has been waking up frequently at night and pulling at his left ear. They also mention a recent cold with nasal congestion and mild cough. On physical examination, the resident observes a bulging, erythematous left tympanic membrane (TM) with decreased mobility, while the right ear appears normal. Based on these findings, the resident diagnoses unilateral acute otitis media (AOM) and asks for your recommendation on treatment. • What is the appropriate treatment for Noah? Provide a treatment recommendation for Noah (8.5 kg) to the resident. Specify: • Medication • Formulation • Dose & Frequency 2/9/2 02 5 59 penicillinaltaray Gm Blactamase Acute Otitis Media (AOM) cephcarbopere pen Anaphylaxis Etiology • Viral Pathogens Eon • Bacterial Pathogens: Streptococcus pneumoniae, Haemophilus influenza, Moraxella catarrhalis Management Pain Management First-Line Analgesics: Ibuprofen, Acetaminophen No Blactose cangive B lactose Like RIFFEP cophicarb Topical Analgesics: For severe acute ear pain, short-term use of topical agents such as 2% lidocaine (1-2 drops) or benzocaine with phenazone (e.g., Auralgan®) applied to an intact tympanic membrane (TM) may be e ective. 2/9/2 02 5 60 Egm AA Antibiotic Therapy(AOM) Immediate Antibiotic Treatment Recommended For: • Children aged 6 months and older with severe signs or symptoms (moderate to severe otalgia, otalgia for at least 48 hours, or temperature ≥39°C [102.2°F]) Bothear • Children younger than 24 months with bilateral AOM without severe signs or symptoms Observation Option: gag • Children aged 6 to 23 months with unilateral AOM without severe signs or symptoms • Children aged 24 months and older without severe signs or symptoms Note: Observation should only be considered when follow-up can be ensured and if the caregiver understands the risks and benefits of this approach. 2/9/2 02 5 61 Antibiotic Therapy(AOM) Eton • First-Line Antibiotic: High-dose amoxicillin (80 to 90 mg/kg per day in two divided doses) • Alternative Antibiotics for Penicillin-Allergic Patients: Cefdinir, Azithromycin • Duration of Therapy: • 10 days for children younger than 2 years or those with severe symptoms • 5 to 7 days for children aged 2 years and older with mild to moderate symptoms Penicillin Allergy Considerations: cephalosporin such as Cefdinir: Infants ≥6 months and Children: Oral: 14 mg/kg/day in divided doses every 12 to 24 hours; maximum daily dose: 600 mg/day Macrolide: Azithromycin: Single-dose regimen: Oral: 30 mg/kg once as a single dose; maximum dose: 1,500 mg/dose Three-day regimen: Oral: 10 mg/kg/dose once daily for 3 days; maximum dose: 500 mg/dose Five-day regimen: Oral: 10 mg/kg once on day 1 (maximum dose: 500 mg/dose), followed by 5 mg/kg/dose (maximum dose: 250 mg/dose) once daily on days 2 to 5 2/9/2 02 5 62 Antibiotic Therapy(AOM) É Adjunctive Therapies • Not Recommended: Decongestants and antihistamines, as they have not shown benefit in AOM management. Follow-Up If symptoms persist or worsen after 48 to 72 hours of initial management, re-evaluate the patient to confirm the diagnosis and consider initiating or changing antibiotic therapy. 2/9/2 02 5 63 Case: Noah (8 months, 8.5 kg) Noah returns with his mother two days after starting amoxicillin. His mother is concerned because he is not improving. On examination, Noah remains febrile with persistent unilateral otitis media. What’s next for Noah? • Should his antibiotic be changed? • If so, what is the next recommended treatment? • Specify medication, dose, frequency, and duration. 2/9/2 02 5 64 Management for Treatment Failure(AOM) 1. First-Line Antibiotic Failure: Amoxicillin-Clavulanate (Augmentin) • Infants ≥3 months, Children, and Adolescents:( Oral suspension 600 mg per 5 mL) :80 to 90 mg amoxicillin/kg/day divided every 12 hours. Maximum dose has not been established for AOM; however, 4,000 mg/day has been suggested • Duration of Therapy: • 10 days for children younger than 2 years or those with severe symptoms • 5 to 7 days for children aged 2 years and older with mild to moderate symptoms 2. Second-Line Antibiotic Failure or Severe Cases: Ceftriaxone 50 mg/kg intramuscularly (IM) or intravenously (IV) once daily for 3 days. -Clindamycin or Levofloxacin may be considered for patients with a severe penicillin allergy, persistent or recurrent infection, or when the causative bacteria are resistant to first-line treatments. 2/9/2 02 5 65 Respiratory Illnesses in Children Common Conditions: • Upper Respiratory Infections (URIs): Colds, viral infections • Influenza: Seasonal flu, potential complications • Bronchiolitis: Common in infants, often caused by RSV • Pneumonia: Viral or bacterial, requiring di erent treatments • Asthma & Reactive Airway Disease: Triggered by infections, allergens, or irritants When to Seek Medical Attention: • Persistent high fever • Labored breathing or wheezing • Signs of dehydration (dry mouth, reduced urination) 2/9/2 02 5 • Symptoms worsening or not improving after several days Key Considerations: • Symptoms: Cough, congestion, fever, di iculty breathing, wheezing • Management: • Supportive care (fluids, rest, humidifier) • Fever reducers (acetaminophen/ibuprofen as appropriate) • Nebulizers or inhalers for asthma/reactive airway issues • Avoid OTC cold medications in young children due to safety concerns 66 Cold Medications in Children • Originally “grandfathered in” for pediatric use • Major Concerns: E icacy not proven, Safety not established, Dosing outdated and unscientific • January 2007: CDC reports serious adverse events in children • October 2007: FDA convenes an advisory meeting to assess safety data • 2008: FDA did not approve cold medications for children under 2 years old and strongly discouraged use in children aged 2-5 years unless directed by a physician ,Manufacturers updated labeling to reflect these recommendations Current Guidance: • No o icially approved dosing for children under 6 years old 2/9/2 02 5 67 The Common Cold • Fever & Pain Relief (Antipyretics): • Ibuprofen (if age-appropriate) • Acetaminophen • Supportive Care: • Adequate Hydration – Helps thin mucus and prevent dehydration • Humidifier – Eases congestion and soothes airways • Nasal Saline:Drops for infants, Spray for children • Bulb Suction – Helps clear nasal passages in infants 2/9/2 02 5 Caution with Medications: • Cough & Cold Medications: No proven e icacy in young children • Multi-Product Preparations: Avoid due to risk of overdose and side e ects 68 Potentially Beneficial Therapies • Saline Rinse (Neti Pot): May provide relief by clearing nasal passages, Particularly helpful for allergies • Cough Drops: May o er mild relief only for older children >6 YO, Avoid in young children due to choking risk • Honey: Some studies suggest it may help reduce cough and improve sleep quality .Recommended dose: 2.5 mL at bedtime in warm water or tea, Avoid in infants under 1 year due to the risk of botulism • Nose Strips: Anecdotal reports suggest they may be helpful for nasal congestion • Aromatic Vapors (e.g., menthol rubs): Mixed results; some people find them soothing, Do not apply inside nostrils Not E ective (No Proven Benefit): • Echinacea • Zinc • Vitamin C 2/9/2 02 5 69 whichmed for contraindication neonatecot Aspin a Acetaminophendose dose Ibuprofen tramadolcodon ageso28dg neonate whyuseuit BornBonedefiency Rightwhenthey untilthey canhaveregular Milk agro 6 By Benyo1081 As Hydrophilicdog Amino TBW as Lipophilic 7 Lin tramadol 8 Rey's syndrome a children phydng Aydin ASPIN Braininformation goldstandardmedforconstipation or Millat chronic Moreton month Suppository Ng Lingacine 3dose 2,46 RU5,1 i Rotary Rotari CRI 2 dose 121 it g oftylenol Fever Livertoxicity NIRash fetal Godstandard firstline Tylenol 23month WI unittatoalseversing 6 Antibioticobservations month upseveresign older24 D FirstlineAom AmoxicillinPo90BID carb Hemorinfluenza strepcouspremaMox penicillin Allergy