Pediatric Considerations

Things nurses should consider when administering medications to pediatric populations. 

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Hey, and welcome to nursing with Dr. Hobbick. It's Wednesday night, and I am thinking about medications and special populations for nurses to take care of I'm thinking about pediatric populations. So let's talk about some of the considerations that we have for these folks, as nurses. Last week, we talked about pharmacokinetics pharmacodynamics. And when we're thinking about pediatrics, we need to think about these concepts. These can be different for children, the younger they are, the more different they might be processes that can affect the absorption, distribution, metabolism and excretion of medications. The first thing I want to talk about is the fact that for pediatric medications, there's very limited research. Now, as you imagine, part of that is because parents may be reluctant to go ahead and give informed consent for their child to participate in a medication trial. Another reason is because well, frankly, there's not a very big market share for pediatric medications. As a result, only about half of all medications carry FDA approval. This really limits the knowledge that we have about pediatric medications and sometimes medications may be prescribed based on small studies based on adult studies, or based on studies done with healthy children rather than children with the condition that is being treated. Of course, we have drug dosages that could be different for children than they are for adults. Something else we need to make sure that we have educated on his units of measure, it's best to use a very accurate unit of measure, we want to make sure that parents or caregivers are able to accurately measure medications, things like educating them on using a oral syringe, or how to use the medicine cup that comes with a medication, educating them on units of measure conversions. So understanding that we should use milliliters instead of teaspoons or tablespoons. We always want to make sure that we use the smallest size syringe. Typically when we are fearing dosage calculations for adults, we will round our response are answers to the nearest 10th. For pediatrics, we typically round to the nearest 100. For pediatric patients, we may need to rely on other measures of verifying identification. Children very young children who aren't able to speak may not be able to verify their name, date of birth, they may not many children may not know their medications or allergies. And the most important thing about pediatric medications is that we monitor for therapeutic effect and adverse effects. We really want to monitor closely for that because with the differences in organ function in body surface area in digestion, excetera we may not have exact dosing, and so the dosing is based on what we think might be the safest, but that may not get us over that minimum effective concentration. And we want to make sure that we're monitoring for those adverse effects. It may be very difficult as a nurse to monitor for adverse effects, we may not see the child very often. And so we need to lean on the caregivers or parents to notify us of anything that seems different any behavioral changes that may have resulted from a subjective symptoms such as nausea, or tinnitus, we won't necessarily be able to see those things and a child who's not able to make their needs known, won't be able to tell us thinking about absorption as far as our pharmacokinetics and children. Obviously their age is something we need to think about. newborns have some organ functions that are not mature. And this can change the way that they absorb medications, their health status. Obviously, the route of administration that we choose oral is still the preferred route whenever we can nutritional habits, hormonal differences when thinking about adolescents at this point can alter the way medications are absorbed, hydration status, any kind of Gi disorders. Gastric acidity is lower in newborns and infants than in adults and so may lend itself more to the absorption of alkaline or basic medications versus acidic medications. gastric emptying, and motility is a little bit slower in infants and chest fed infants have a little bit faster gastric emptying than formula fed infants the lack of intestinal flora in newborns, enzyme levels are low in new newborns, there is a smaller amount of surface area in the intestines for absorption. The younger the child is very young children, especially newborns and infants have higher body water than adults do, which can affect water soluble medications. They have less body fat, which will affect lipid soluble medications. neonates and infants have less protein and they have fewer protein binding sites. If the child has jaundice, that means they have more bilirubin in their bloodstream and that bilirubin can actually bind to those protein sites, meaning there's even fewer protein sites. And if you remember from last week, that means that there may be more free medication available that can have an effect on the patient. Rather than being bound to that protein. The blood brain barrier is also immature and medications may be able to pass across that barrier and into the central nervous system, hepatic blood flow and drug metabolizing enzymes are low in infants, which means that they may not be able to metabolize medications as quickly, this might lead to a longer half life or a longer duration of those medications. And infants have immature kidneys, they may have a lower rate of excretion, than adults do. Now, these changes, these differences get less as the children age. But it's something to consider this will affect the onset, peak and duration of the medication. Careful monitoring of that therapeutic effect and adverse effects is vital for the pediatric population. Medications for children are typically dosed based on weight or body surface area, when we do calculations, they need to be checked with another RN. That doesn't mean you go to the other RN and you say, Here's my calculation, here's my answer. You give them the same information and allow them to come to their own conclusion. And then you compare the responses, your answers to make sure that you're both on the same page. When we're administering medications to children, you're obviously going to think about how old the child is how developed they are, how you're going to be able to explain to them what you're going to do. It's important to always be honest, to always include that child in the discussion. Unless they're a newborn, you want to engage them in what's going to happen. If it's a toddler, consider imaginative play if they have a lovey or a stuffed animal, you might show them how you're going to administer the medication on a stuffed animal, preschool aged children, it's good to give them choices if you can. So would you like your shot on this side or this side, we're not going to offer them the choice of getting the medication or not, but we might give them some form of control. With school age, children may have some fears of bodily injury, so you'll want to be honest with them. Never lie to a child, never try to administer an injection or something while they're sleeping. We really want to try to make them as comfortable as possible. Make them feel as safe as we can. If we can involve the caregiver or the parent in that medication administration. That's great. If the parent doesn't want to be a part of it. That's okay too. Sometimes we can alleviate some of the anxiety though by having the child sitting on the parent's lap. Distraction can be helpful with children, especially school aged children, my my own daughter when she got her COVID vaccine, I had her tell the person who was administering it her favorite joke, which is did you hear the joke about the water buffalo with no ears? Well, neither did he. That's her job. We can use relaxation, creative imagery, even imaginative play to distract children from pain or anxiety. When we're giving oral medications, it may be appropriate to crush the medication and put it in something. Remember from our previous talks that you can't crush something that is enteric coated, or extended release or delayed release. You always want to check with your pharmacist if you have one available to see if you can mix a crushed medication with certain foods. If it's appropriate, you could mix it with chocolate syrup with jam or jelly with applesauce with pudding. Again, making sure that it's compatible before you do so that it's something that you can crush and you could use honey but make sure that you avoid that in children under one year of age or who may be immunocompromised, intravenous sites we have to protect because children may be curious or they may, you know want to remove this thing that is bothering them. Or in the case of newborns, they move around a lot we want to make sure that we protect that IV site, so it can be hard to access IVs on them, we want to make sure that we keep that one safe. We may even have some numbing spray or vapor coolant spray that we can apply before we give an injection to decrease pain stimulus when we do the actual medication administration. I know I said this before, but the most important thing is to be respectful, to be honest, to explain as best you can at an appropriate level for the child and to use the least amount of restraint possible. Now, adolescents may still be in a concrete thought process, they may not really think about future consequences as much. So when we're thinking about talking to them about medication regimens, and the importance of them, telling them avoiding a future health problem is not going to be something that sits well in their mind, they're really not going to think about it, they still have that kind of superhero complex, nothing bad is going to happen to me. We want to make sure that we address their if they have a chronic condition in the dementia medication regimen in an every day act that they enjoy something like keeping on normal blood sugar in order to be able to participate in sports. Finally, the last important piece is to always involve the family or caregiver. Children cannot administer their own medications all of the time. So we want to make sure that that parent, caregiver, whoever it is that's with the child is going to be taken care of them, understands the medication administration understands the dosing the frequency, understands how to safely administer the medication, and is able to help the child with it knows what to report to the provider as far as adverse effects and what kind of therapeutic effects to look for. That's all there is for today on nursing with Dr. Hobbick. Thanks for joining me here and next time we'll talk about geriatric considerations and medication administration for nurses