DRUGS USED IN PEDIATRICS

INTRODUCTION:
Medications in children are given by a variety of routes: orally, injection, topically
and inhalation. Safe medication administration is always a concern in child health nursing
because “children” vary form 7-lb newborns to 150-lb 18-years-olds. This wide weight
range combined with relative immaturity of body systems in children means that there is
rarely a “standard” pediatric dosage of a particular drug. Each dose must be calculated
individually. To administer drugs safely it is important to have a good understanding of
pharmacokinetics (the way a drug is absorbed, distributed throughout the body,
metabolized, inactivated and excreted). Each drug, each dose and each child must be
carefully and individually evaluated to ensure that the six rights of medicine
administration:
1. Right medicine
2. Right client
3. Right dose
4. Right route
5. Right time
6. Right client instruction-are provided.

CRITERIA FOR DOSE CALCULATION:

Most of the drugs are available in the adult dose. The nurse needs to know how to prepare
the pediatric dosage.

a) Young’s rule: (For children over 1 year of age) upto 12 years

Age of the child (in years) X Adult dose = Child’s dose

Age of the child (years) +12

e.g. If the adult dose of a drug is 1/6 grain, calculate the amount of drug for a child aged 6
years.
6 1 1
X = grain
(6+12) 6 18

b. Fried’s rule: (For children under 1 year of age)

Age of the child (months) X Adult dose = Child’s dose

150
e.g If the adult dose of a drug is 1/6 grain, calculate the amount of drug for an infant of 6
months.
60 X 1 = 1 grain
150 6 150

o From careful clinical observation in recent years, it has been repeated noted that
dosage based on weight is not a reliable method of dosage determination,
especially so in infants.
o For example we know that the appropriate dosage of sulphadiazine in children is
150 mg/kg/day. On this calculation, a 70 kg adult should receive 10.5 g which is
too much. Conversely, the recommended maintenance dosage of this for a 70 kg
 adult is 6 g for 24 hours when divided by 70 yields but 85 mg/kg/day for a child.
o Dosage is based on age has greater limitation when one considers the variability
of weight even in normal children of given age.

Perhaps in markedly undernourished babies the surface area is best calculated from the
weight and height.

Surface area in sq.m X adult dose

Child dose=
1.75

Of surface in sq.m X 60 = % of adult dose.

The following formula has been used for calculating surface.
4W +7
Surface area (Sq.m) =
W + 90 Where W is expressed as weight in kg.

Calculating the Pediatric Dosage

➢ Body Surface Area

1. Surface area in square meters X dose per square meter = approximate child dose.

2. Surface area of child X Dose of adult

Surface area of adult

3. Surface area of child in square meters X Adult dose

1.75

➢ Clark’s Rule:

Child’s weight in pounds X Adult dose = child’s dose

150
e.g If the adult dose of a drug is 1/6 grain, calculate the amount of drug for an infant of 6
months.

60 X 1 = 1 grain
150 6 150

Calculation of flow rates

Volume (capacity) of solution X Drop factor = Drops per minute

Time interval in minutes

(OR)

Drops/ml x infused (1 hr) = Drop per minute.

60 (mts/hour) 1
Preparation Of The Solutions Using Formula:

D X Q =A
H

D (desired strength) X Q (quantity required) = A (amount of stock solution required)

H ( strength of what
we have in stock)

e.g Make up 8 pints of 1 in 4000 Condy’s lotion for a treatment, Condy’s `lotion (Pot.
Permagnate) in stock is 1 in 1000.

D X Q =A
H

1/4000 X 8 = A
1/1000

1 X 1000 X 8 = A or A= 2 pints
4000 1

Condy’s lotion (1 in 1000) = 2 pints} are required to make

= 6 pints } up condy’s lotion (1 in 4000) 8 pints.
Chemotherapy Drugs Most Used in Children

Drug Dosage Side effects Interactions Considerations

Allopurinol 4 mg/kg/day Skin rash, nausea, vomiting, May potentiate action of oral Maintain good urine flow
(Xanthine oxidase PO diarrhea, intermittent abdominal anticoagulants, thiazides, (alkaline)
inhibitor) pain, drowsiness, peripheral salicylates; may reduce effects
neuritis. of allopurinol.

Dosage Hepatotoxicity, nausea, vomiting, Monitor intake and output;

L—Asparaginase variable, IM, fever, abdominal cramps, When used with corticosteroids, monitor renal function; drug
(enzyme) IV malaise, CNS toxicity, increased risk of may cause drowsiness even
hypersensitivity, prerenal hyperglycemia, ketoacidosis, several weeks after
azotemia and diabetic coma; concurrent administration.
TOXIC EFFECTS: Pancreatitis use of vincristine increases risk
of toxicity.

Nausea, vomiting, pruritis, fever,

Bleomycin 0.25-0.5 chills, weight loss, stomatitis, Give antiemetic before
(antibiotic) units/kg phlebitis at injection site. administration of drug, if
IV/IM TOXIC EFFECT: Pulmonary Erythema and induration occur needed.
pneumonitis or fibrosis, allergic in previously radiated areas.
reaction, fever, hypotension,
anaphylaxis.
Carmustine 5mg/kg IV Nausea, vomiting, venous Give antiemetic before
(BCNU) every 6 week irritation related to drug administration of drug, if
(nitrosourea) concentration, alcohol solvent needed.
and rate of infusion.

Avoid use of any aluminum

0.5-2.5 mg/kg Nausea, vomiting, bone marrow equipment with drug; assess
Cisplatin IV (may be depression, abnormal liver Aminoglycoside antibiotics renal function; often
(alkylating agent) given as single function, hypersensitivity tetany, protentiate nephrotoxicity mannitol flush or Lasix is
or divided ophthalmologic changes, administered before
dose; repeated hyperuricemia. treatment.
every 3-4 TOXIC EFFECTS: Irreversible
week. renal damage, ototoxicity, cardiac
toxicity, neurotoxicity.

Cyclophosphamide 37.5 mg/kg IV Nausea, vomiting, anorexia, Enhances the effects of insulin. Oral dosage may be
(cytoxan) (every 3 wk) stomatitis, alopecia, bone marrow If administered with allopurinol, administered with meals to
(alkalyting agent) 1.25-5mg PO depression, amennorhea, increased bone marrow decrease gastric upset; force
daily (for 14 azoospermia depression. fluids for 12-24 hrs after
days) TOXIC EFFECTS: liver administration; encourage
dysfunction, hemorrhagic cyst. frequent voiding.
Cardiomyopathy (high doses).
OTHER DRUGS:

ANTIBIOTICS:

1. ACETAZOLAMINE:

Trade name: Zolamide, Diamox.

Supplied as:Tablets 250mg.Intravenous injection 500mg. suspension for infants to be

made in pharmacies.

Uses: As a diuretic, to reduce to reduce CSF production, as an anticonvulsant & to

alkalinise urine.

Action: Carbonic anhydrase inhibitor. Produces urinary alkalosis. Appears to retard

abnormal discharges from CNS.

Dosage: Diuretic: 5mg/kg/dose every 24 hours.

❖ To reduce CSF production: 50-100mg/kg/day in divided doses given every
6 hours.
❖ Anticonvulsant: 8-30mg/kg/day in divided doses given every 8 hours.
❖ To alkalinise urine: 15mg/kg/day in divided doses given every 8 hours.

Route of administration: Oral & intravenous.

Adverse effects: Gastrointestinal irritation, anorexia, mentabolic acidosis, hypokalemia

& drowsiness.

Direction for use: 500mg vial

❖ 5 ml of sterile water for injection should be added to the vial.
❖ The resultant concentration is 1oomg/ml.
❖ The required dose is given over one minute.
❖ Stable for 12 hours at room temperature & remains so for 3 days if refrigerated at
45c.

Compatibility: Dextrose solution & normal saline.

Comments: Limited experience in neonates.

2.AMIKACIN:

Trade name: Amicin and Ivimicin

Supplied as: 100mg/2ml.
Uses: Treatment of infections caused by Gram-negative bacilli usually in combination
with beta-lactam antibiotics.
Action: Bacterial against Gram-negative bacilli by inhibiting protein synthesis.
Route of administration:
❖ Intravenous infusion over 30 minutes.
❖ Intramuscular injection can be given but absorption is variable in preterm babies.
 Dosage :
❖ 7.5 mg/kg/dose at 29-34 weeks
❖ 7.5 mg/kg/dose at > 34 weeks.

Adverse effects:
❖ Transient and reversible renal tubular dysfunction
❖ Vestibular and ototoxicity
❖ Increased neuromuscular blockade if baby is receiving a drug like panuronium.

Directions for use:

❖ 1ml (50mg) drug should be taken in a10 ml syringe.
❖ This should be diluted with 9 ml of water for injection.
❖ The resultant concentration will be 5mg/ml.
❖ The required dose should be given over 30 minutes.
Comments: Serum monitoring
❖ Peak levels 20-30micro gm/ml.
❖ Trough level 2-5micro gm/ml
❖ Level of the drug in serum should be estimated 30 minutes before and after the
fourth.

3. AMPICILLIN:
❖ Preterm infants upto 7 days administer every 12 hrs, term infants upto 7 days and
preterm infants >7 days every 8 hrly and term infants after 7 days every 6 hrly.
❖ 25-50 mg/kg/dose
❖ Oral , IM, IV
❖ Solution is stable only for 4 hours. The dose is doubled in meningitis.

4. BENZYLPENCILLIN:(lower dose in preterm babies)

❖ Administered 12 hrly in preterm babies and 8 hrly in term babies (IV).
❖ 25000 units/kg/dose
❖ IM, IV
❖ Use 5 to 10 times this dose for serious infections and meningitis.

5. CEFOTAXIME:(lower dose in preterm babies)

❖ Administered 12 hrly in preterm babies and 8 hrly in term babies (IV).
❖ 50 mg/kg/dose
❖ IM/IV
❖ Readily crosses blood brain barrier.

6. CARBENICILLIN:(lower dose in preterm babies)

❖ Administered 12 hrly in preterm babies and 8 hrly in term babies (IV).
❖ 100mg/kg/dose, 5 mg/ intrathecal dose
❖ IM/ IV
❖ Should be mixed with gentamicin and watch for hypokalemia.
7. CEFAZOLINE SODIUM:(lower dose in preterm babies)
❖ Administered 12 hrly in preterm babies and 8 hrly in term babies (IV).
❖ 20mg/kg/dose.
❖ Does not penetrate Cerebrospinal fluid space.
 ANTIVIRAL AGENTS

1. ACYCLOVIR:

Trade name: Zovirax, Zovirax iv, Cyclovir, Lovir, ocuvir&vir inj.

Supplied as: Injection(250mg), suspension, tablets & cream.

Uses: For treatment of herpex simplex & varicella infections.

Action: It is a virostatic & acts by inhibiting viral DNA synthesis.

Route of administration: Topical, intravenous & oral.

Dosage:
❖ Topical: Apply sufficient quantity to cover lesion every 3 hours.
❖ Intravenous: 30-40mg/kg/day divided & given every 8 hours for 10-14 days.
❖ Oral(varicella): 20mg/kg/dose given every 6 hours initiated at the first sign of
disease.
It is continued for 5days.

Adverse effects: Hives, jitteriness, thrombocytopenia, elevation of serum creatinine.

Direction for use: 250mg vial.

❖ 250mg should be dissolved in 5ml of sterile water.
❖ The resultant concentration is 50mg/ml.
❖ 1ml of this solution is diluted in 9ml of normal saline.
❖ The resultant concentration is 5mg/ml.
❖ The required dose is given by infusion in a syringe pump over one hour.
❖ Infusion solution concentration should be less than 7mg/ml.

Storage: Reconstituted solution is stable at room temperature for 12 hours. The solution
should not be refrigerated.

Compatibility: Dextrose solutions & normal saline.

Comments: Phlebitis may occur at the IV injection site. Renal & hepatic functions
should be followed closely.

2. Ganciclovir:15mg q 12 hrs for 14-21 days. For long term suppression 10 mg/kg 3
days in a week.
3. Vidarabine : 15-30 mg in a concentration of 0.5mg/ml. Iv infusion over 12 hrs.

4. Zodovudine: 1.5 mg/kg/dose q 6 hr for 6 weeks. Oral, Iv infusion over 1 hr.

 CORTICOSTEROIDS

1. Aldosterone: 1mg per dose. IM, IV

2. Cortisone acetate: 5-10 mg/kg/day. IM, IV and Oral.
3. Dexamethasone: 0.1-0.25 mg/kg/dose q 6 hr.
4. Fludrocortisone: 0.1-0.2 mg/day.
5. Hydrocortisone: 5-10 mg q hr. For shock 50-150 mg q 6 hr.

DECONGESTIVE AND CARDIOTONIC DRUGS:

1. Captopril: 0.15-0.20 mg/kg/d q, 8-12hr. oral.

2. Digoxin: 0.30-0.05 mg, ½ start, ¼ after 8 hrs and ¼ after 12-16 hours. Oral, iv.
3. Dobutamine: 2-20 ug/kg/min. iv route.

MISCELLANEOUS:

1. Acetaminophen: 10-15 mg/kg/dose q 6-8 hr. Oral.

2. Acetazolamide: 10-25 mg/kg/dose q hr. Oral.
3. Acetyl cysteine: 10 ml of 10% solution every 6 hr.

➢ ADENOSINE

Trade name: Adenoject, Adenocard.

Supplied as: Injection 6mg/2ml.

Uses: Acute treatment of paroxysmal supraventricular tachycardia.

Action: It is a purine, naturally occurring in all human cells. It slows down conduction
through the atrioventricular node & interrupts re-entry pathways to restore sinus
rhythm.

Dosage:
Starting dose 50mg/kg quickly injected over 1-2 seconds.
Doses should be increased by 50mg/kg every 2 minutes until return of sinus
rhythm.
Usual maximum dose 250mg/kg.

Adverse effects: Flushing, dyspnea, irritability & occasionally apnea especially in

preterms.

Directions for use: 3mg/ml. Should be given with continuous ECG & blood pressure
monitoring.
❖ 1ml (3000mg) mixed with 9ml normal saline.
❖ The resultant concentration is 300mg/ml.
❖ Always stored at room temperature as refrigeration crystallizes the solution.

Comments: Theophylline diminishes activity of adenosine by competitive inhibition.

Trade names: Amicin & Ivimicin.

Supplied as: Injection 100mg/2ml.

Uses: Treatment of infections caused by Gram-negative bacilli by inhibiting protein

synthesis.

Route of administration:
❖ Intravenous infusion over 30 minutes.
❖ Intramuscular injection can be given but adsorption is variable in preterm babies.

ADMINISTRATION OF DRUGS:

I) Administration Oral Medication:

o Children younger than 9 years old often have difficulty swallowing tablets.
For children younger than 3 years of age, this is virtually impossible. Most
oral medications for young children, therefore, is furnished in liquid form.

Procedure:
o In infants, oral medication can be given with a medicine dropper or a syringe
(without needle). Gently restrain the child’s arms and head by holding the
child’s arms and head by holding the child against your body. Never give
medicine with the child lying completely flat or the child may choke and
aspirate.
o If the child is crying, he/ she actively opens the mouth. If not, gently open the
mouth by pressing on the child’s chin. Press the bulb of the medicine dropper or
use the plunger of the syringe to gently allow the fluid to flow slowly into the
side of the child’s mouth. The end of the syringe or dropper should rest at the
side of the infant’s mouth to help prevent aspiration (some infants prefer to suck
the contents of the syringe into their mouth). An infant also may be given fluid
from a small glass or spoon. Allow the fluid to flow a little at a time so that the
child has time to swallow between small sips.
o Preschoolers and early school agers respond well to rewards such as stickers
that they can paste into a book each time they take their medicine.
o For older children, hand them the glass of medicine as if they are expected to
take it. Offer a “chaser” if necessary and not contraindicated. If children have
difficulty swallowing tablets, they can be crushed and added to a teaspoonful of
applesauce or flavored syrup. If pills are not to be chewed (capsules or enteric-
coated tablets), the child must be instructed not to chew them. Some children
are old enough to swallow tablets but have never done it before. To teach a
child how to swallow them, it is often easier to use small bits of ice for practice;
they melt rapidly and do not stick in the back of the child’s throat or esophagus.
o Have the child put the ice on the back of the tongue, take a sip of water, and
swallow the water. Once the child knows how to do this, he or she will not
believe it was ever hard to do.
o Children who master this adult skill under a nurse’s tutelage have a right to be
proud of their accomplishment.
 o Another useful technique is to coat pills or capsules with vegetable oil and push
them into a spoonful of ice cream or pudding. Children tend not to chew this
type of food. The oil prevents the medication from dissolving and sticking to the
roof of the mouth. If using this technique, push the pill into the ice cream or
pudding in front of the child. The method is not to hide the pill but to help
children learn to swallow medicine.

II) Administering Nose Drops:

o It is uncomfortable to have someone drop medicine into your nose. Explain to
the child that you understand this but that the medicine is important because it
will help the child get better.
o Inform the child of the procedure.

Procedure:
o Place the child on his or her back.
o A school-age child could extend the head over the side of the bed so that it is
lower than the trunk.
o Preschoolers generally are too frightened by this strange position and do better
with a pillow under their shoulders so that their head extends over the pillow
and rests downwards.
o An infant generally must be restrained in a mummy restraint for nose drop
administration.
o Drop the appropriate nostril. Turn the child’s head to the side- to the left after
the left nostril, to the right after the right nostril- so that the medication stays
in the nose longer. If the child is a preschoolers or older, ask him or her to
further sniff the medicine. Have the child remain in the head-flat position for
at least 1 full minute to let the medicine come in contact with the mucous
membrane of the nose. If the child gets up immediately, the medicine will
flow out and will be less effective. Give the child high praise even if he or she
did not co-operate at all. Praise tells the child you understand how hard it was
to remain still.

III) Administering Eye Drops:

o Eye drops are uncomfortable and frightening to children who have been
warned many times never to put anything into their eyes.

Procedure:

o Infants and preschoolers generally must be restrained in a mummy restraint

for eye drop administration.
o Place the child on the back. Open the eye s of infants and preschoolers. Do
so by gently but firmly pressing on the lower lid with thumb and on the
upper lid with the index finger. A school-age child or adolescent will open
his or her eyes co-operatively but may need to have a hand rested on the
eyelid to keep an eye open long enough for the drugs to be administered. Be
sure that your fingernails are short to avoid inadvertently scratching the
child’s cornea.
o Drop the correct number of drops of medication into the conjunctiva of the
 lower lid. Allow the eyelid to close. Try not to put drops directly on the
cornea because that may be painful.
o To prevent the conjunctiva from drying, do not hold the eyelids apart any
longer than is necessary.
o After the child has blinked two or three times, allow child to get up. Praise
the child for his or her cooperation even if cooperation was not evident.

IV) Administering Ear Drops:

o Ear drops, like eye drops, are difficult for children to accept because they have
been told not to put anything into their ears.
o Ear drops are generally administered for ear ache, which is sharp, excruciating
pain. A child may worry that having medicine put into the ear will make the
pain worse. Also, he/she cannot watch what is happening.

Procedure:
o Place the child on the back, in a mummy restraint if necessary. Turn the head
to one side. The slant of the ear canal in children should be done.
o If the child is younger than age 3 years, straighten the external ear canal by
pulling the pinna down and back. If the child is older than age 3 years, pull the
pinna of the ear up and back.
o Drop the specified number of drops into the ear canal. Hold the child’s head in
the sideways position for atleast 1 full minute to ensure that the medication
fills the entire ear canal.
o Ear drops must always be used at room temperature or warmed slightly.
o Cold fluid such as medication taken from a refrigerator causes pain and may
cause severe vertigo as it touches the tympanic membrane. Praise the child for
cooperation after the procedure.

V) Administering Rectal Medication:

o A good route for administering medication to children is by rectal insertion,
because this allows the drug to be absorbed across the mucous membrane of
the intestine. Some medications are given by rectal suppository; a few are
given by retention enema.
o Because the child cannot see what is happening, it is easy to be frightened by
this procedure. Shoe the child the medication to make clear the child that it is
not an injection.

Procedure:
o Use glove and insert a well-lubricated suppository gently but quickly beyond
the rectal sphincters( as far as the first knuckle of the little finger for infants,
and the first knuckle of the index finger for older children)
o Withdraw the finger and press the child’s buttocks together firmly for
approximately a count of 10 until the child’s urge to evacuate the suppository
passes. If a suppository is not prelubricated, dip the tip of it into a water
soluble lubricant such as K-Y jelly before insertion.
o Invasive procedures are particularly threatening to the preschooler. Give
lavish praise for cooperation. If the medication is to be administered by
enema to a child of this age, use the usual enema technique, but with as small
 an amount as possible so the child can retain it.
o Press the child’s buttocks firmly together after administering the enema for
approximately 15 seconds or a child will expel the solution and the
medication will be lost.
o Using a distraction technique, such as asking the child to count backward or
saying the alphabet backward, can also help a defecation reflex to pass.

VI) Administering Intramuscular:

o Intramuscular injections are rarely prescribed for children because children do
not have sufficient muscle masses for easy deposition of medication and IM
injections are often painful.
o For intramuscular injections in infants the mandatory site for administration is
the quadriceps muscles of the anterior thigh.
o Be certain to use the lateral aspect of the anterior thigh rather than the
extremely tender medial portion, where an injection would cause more pain.
o Using the gluteal muscle in children younger than 1 year is extremely
hazardous. The muscle is not well developed until the child walks, so the
sciatic nerve occupies a larger portion of the area than later on and could
become permanently damaged by gluteal injections. An effective restraining
technique for giving injections to infants.
o In older children, as in adults, the deltoid muscle or a ventro-gluteal site may
be used.
o Place a thumb on the child’s anterosuperior iliac crest and spread the fingers.
The space between the index finger and thumb is the correct site.

Procedure:
o Spread the tissue between the thumb and index finger to make the skin taut.
Needle is inserted at a 90 degree angle, holding the syringe in the right hand,
using a steady push on the needle. With the right hand on the syringe, aspirate
the blood by pulling back the piston with left hand. If blood appears in the
syringes, quickly withdraw the needle. If no blood comes, give the medication
slowly by pushing the piston.
o Massage the area briefly after the injection to ensure absorption of the
medication, but remember that the rubbing may be as painful as the actual
injection. If needed restraints can be used.
o School-age children however may be proud that they are able to lie still. Being
restrained would shame them
o Be certain to hold and comfort the young child after all painful procedures, or
let a parent do this.
o Record the site of an intramuscular injection as well as the medicine injected,
so that sites can be rotated for better absorption.

VII) Subcutaneous (Hypodremic) injections:

o A 90 degree angle is normally used with a 5/8 inch needle for obese patients.
o A 45 degree angle is used with a needle 3/4 inch long or longer for an average
patient or in a thin patient.
Procedure:
o The technique of subcutaneous injection is same as in I.M Injections expect the
following:
▪ Use only non irritating medications.
▪ Use only a small quantity of medication.
▪ Deposit the medication in a fold formed by picking up a layer of skin
and fat.
▪ Be sure to insert the needle beyond the thickness of the skin. (The
medication is to be deposited in the subcutaneous tissue).

VIII) Intradermal Injections:

o This method is used for skin tests to detect allergies.

Procedure:
o The skin is held in taut, by grasping it under the forearm. With the level of
the needle facing up, insert the needle at an angle of 10 to 15 degree to the
skin.
o The needle enters between the two layers of the skin- the level should be
practically visible through the skin.
o Inject the medication slowly, to produce a wheel on the skin. 0.01 to 0.1
ml of medication is injected intradermally.
o Take out the needle quickly. Do not try to clean or massage the area.

IX) Intravenous therapy:

o Intravenous therapy is the quickest and most effective means of administering
fluid or medicine to the ill infant and child, and as such, is relatively common
pediatric therapy.
o It has several major uses, including maintenance of fluid and electrolyte
balance; as an avenue to bring drugs quickly up to therapeutic levels in the
body; and for nutritional support. Intravenous fluid may be infused into a
peripheral vein, a central access device, or a peripherally inserted central
catheter.
o The amount, type, and rate of intravenous fluids for children are prescribed
carefully.

Fluid and Caloric Needs of the Child:

A formula that can be used to easily calculate water need in children is as follows:
o Fro every 100 kcal expended in metabolism, the child must replace 115 ml water.
3 mEq sodium and 2 mEq potassium.
o Method for calculating caloric expenditure.
o Fluids administered using this table should contain 25 mEq sodium and 20 mEq
of potassium per liter and 5% dextrose. Common intravenous solutions and oral
electrolyte formulas used with infants contain theses proportions. According to
the table, a child weighing 45 kg would have a caloric expenditure of 2000 Kcal;
the child would need 2300 mEq sodium, and 20 mEq potassium per liter. A flow
rate would be calculated for this amount (2300 ml fluid in 24 hrs = 95 ml/hr).
A method to Calculate Caloric Expenditure:

Body Weight Caloric expenditure per 24 hour

Upto 10 kg 100 kcal/ kg
11-20 kg 1000 kcal + 50 kcal for each kg more than 10 kg
More than 20 kg 1500 kcal + 20 kcal for each kg more than 20 kg.

Obtaining Venous Access:

o Sites frequently used for intravenous insertion in young children or infants are the
veins on the dorsal surface of the hand or on the flexor surface of the wrist. Leg
and foot veins also may be used.
o Another site for intravenous infusion is a scalp vein over the temporal area.
o Children who have intravenous infusions for a long period may require the
placement of an intracath (a slim, pliable catheter threaded into a vein). The
advantage of these is that the child can usually move about freely because the
intracath cannot be dislodged as easily as a normally inserted intravenous needle.
o For all children intravenous infusions must be secured with an armboard.

Determining Rate and Amount of Fluid Administration:

o Automatic rate flow infusion pumps facilitate the infusion of potent
medications. They should be mandatory for small children because they
regulate the flow accurately to a few drops per minute. Over-loading of
intravenous fluid in infants and children can be further prevented by use of
fluid chambers devices that allow only 50 to 100 ml fluid into the drop
chamber at a time.
o Even if the pump fails with these in place, only the amount in the drip
chamber will be allowed to enter the child’s circulation, not the entire contents
of the bag suspended above the child’s head.
o A third fluid safety measure is a mini-dropper, a device that reduces the size
of the drop in the control chamber to 60 drops per mL (usually there are 10 to
15 drops per mL). With a normal dropper in place, an infusion regulated to
administer 30 mL/hr drips at a rate of 7 to 8 drops per minute and is therefore
difficult to regulate. With a mini-dropper in place, the drops are smaller; the
same infusion (still providing the same amount of fluid per hour) drops at 30
drops per minute. This flow is easier to regulate and provides more accurate
intravenous administration.
o It is important to keep a careful record of rate and amount of intravenous fluid
administered, atleast an hour, record the type and amount of fluid; the rate of
flow and for a cross-check, the amount of fluid remaining in the bag.

Intermittent Infusion Devices:

❖ Intermittent infusion devices/ heparin locks:
These are the devices that maintain open venous access for medicine
administration, yet allow children to be free of intra-venous tubing so that they can be
out of bed and more active. The vessels of the back of the hand are generally chosen
as the intravenous site. Scalp vein tubing is used and capped at the end with a
specially designed rubber stopper or a commercial trap. The tubing is filled with a
 dilute solution of heparin or normal saline through the rubber stopper and flushed
again with solution every 2 to 8 hours (depending on hospital policy) to keep it
patent. Intravenous medication can be firmly secured to the wrist and an armboard
taped in place to remind the child to protect the site from careless trauma.

Venous Access Catheters and Devices:

Venous access for long term intravenous therapy can be gained by
insertion of a catheter into the venacava just under the clavicle. Typical catheters used in
this way are Broviacs, Hickmans or Groshongs. Such catheters have a wrinkle-resistant
fabric (Dacron) cuff that adheres to subcutaneous tissue and helps to seal the catheter in
place and keep infection out. Care of the catheters (depending on agency policy) consists
of daily or weekly changes of dressings over the exist site and periodic irrigation with
heparin or saline to ensure patency. Such catheters have the advantage of not involving
any further skin punctures, so they cause no further discomfort.
One disadvantage is that the catheter could be snagged on something and accidentally
pulled out.

➢ Central venous access devices:

(Infusion ports that can be implanted) are small plastic devices that
are implanted under the skin, usually on the anterior chest just under the clavicle. A small
catheter threads from the port internally into a central vein. Common brands are Port-A-
Cath, Infus-A-Port and Groshong venous port. Blood samples can be removed or
medication can be injected by a puncture through the chest skin into the port. Although
this requires a skin puncture (cause pain), it may be well accepted by children because it
is a not as visible as a central venous catheter, no dressing is required and is allows a full
range of activities such as showering and swimming. Be certain when accessing these
ports to use only the needle supplied by the manufacturer.

A regular needle has the tendency to “core” or remove a small circle of the membrane
over the port and destroy the integrity of the device. Use EMLA cream to decrease
discomfort.

Intraosseous Infusion:

❖ Intraosseous infusion (IO) is the infusion of fluid into the bone marrow cavity of a
long bone, usually the distal or proximal tibia, the distal femur, or iliac crest.
❖ Because the bone marrow communicates directly with the circulatory system, the
time at which fluid reaches the bloodstream when administered this way is the same
as if it were administered intravenously.
❖ All fluids that can be administered intravenously, including whole blood or
medicine, can also be administered by this route.
❖ IO infusion is used in an emergency when it is difficult to establish usual IV
access or in a child with such extensive burns that the usual sites for intravenous
infusion are not available.
❖ IO infusion is a temporary measure until a usual route of administration can be
opened because of the danger of causing osteomyelitis, a devasting infection with
long term effects to bone marrow. It must be initiated with sterile technique, and if
continued for an example time, the infusion point is rotated about every 2 to 3 days
 to try to minimize infection. It is painful as the needle enters the bone marrow
cavity and again at the time of the bone marrow aspiration.

EFFECTS OF DRUGS ON THE BODY:

1. Therapeutic effect:
It is the effect which is desired or the reason a drug prescribed.
The drugs are administered for the following purposes:
a. To promote health: Drugs are given to the individual to increase the resistance
against diseases e.g vitamins
b. To prevent diseases: e.g vaccines and anti-toxins
c. To diagnose disease: e.g barium used in the X-ray
d. To alleviate diseases: Certain drugs are given for the palliative effect for the
temporary relief of distressing symptoms but does not remove the cause or cure
the disease e.g., analgesics.
e. To treat or cure a disease
By restoring normal functions e.g; digoxin
By supplying a substance that is deficient in the body e,g. insulin
By destroying the causative organisms e.g. quinine in malaria.
By counteracting with a toxic substance circulating in the body e,g. antidotes
By stimulating the functions of an organ or a system e,g. stimulants
By depressing the functions of an organ or a system e,g. sedatives

2. Local and systemic effects:

Local effects of a drug are expected when they are applied topically to the skin or
mucus membrane.
A drug used for systemic effect must be absorbed into the blood stream to
produce the desired effect in the various systems and parts of the body.

3. Toxic effect:
High levels of the drug in the blood stream produce toxic effects. Often the toxic
effects of the drug occurs due to the cumulative effect of the drug or due to the excess
intake of the drug than what is needed for the therapeutic effects.

4. Synergistic effect:
Synergistic effect occurs when a combination of medications are given. In
synergistic effect, the combined effect of two or more drugs is different from the
effect of each drug when taken alone. The combined effect may be less than what
would be expected or greater than the effect of each drug. Synergism may be a
desired therapeutic effect or an undesirable complication e.g alcohol and barbiturates
are potentially lethal; Phenytoin (Dilatin) has an inhibitory effect upon digitalis.
 SIDE EFFECTS OF DRUGS:
These are the effects other then the principal action desired. The various side effects
observed due to the administration of drugs their signs and symptom and the nursing
implication are given below.

1. Allergic reactions:
A severe allergic reaction usually occurs immediately after the administration of the drug.
It is called anaphylactic reaction.
o Anaphylaxis reaction
o Skin rashes
o Pruritis
o Angioedema
o Rhinitis
o Lacrimal tearing
o Nausea and vomiting
o Diarrhea
o Shortness of breath and wheezing due to laryngeal oedema.

2. Atropine like side effects:

Certain drug causes dryness of the mouth and nose, flushing and dryness of the skin,
tachycardia, urinary retention and blurring of vision.
Liver damage: this is characterized by jaundice especially in the sclera of the eyes,
hemorrhages under the skin, dark urine and pruritis.

Effects on the urinary system:

Certain drugs may cause renal damage which is characterized by anuria, oliguria,
heamaturia, crystalluria, albuminuria etc. frequent urine analysis and blood chemistry
studies can prevent such occurrences. Patients should be asked to take plenty of fluids to
prevent stone formations.

3. Effects on the cardio vascular system:

o Arrhythmias: any change in rate, rhythm, volume or character of the pulse.
o Hypotension: it is characterized by decrease in the blood pressure, dizziness,
syncope and shock. Checking the B.P before and after the administration is
indicated. The patient should be warned about postural hypotension.
o Hypertension: this is characterized by elevated B.P, epistaxis, emotional
irritability, headache, visual disturbances and dizziness.

4. Effects on the central nervous system:

o Abnormal involuntary movements: Tremor, chorea, dystonia, alteration in the
muscle tone, difficult in positioning.
o Stimulations of the CNS system: these are characterized by anxiety, nervousness,
insomnia, headache, double vision etc. Convulsion if patient has the history of
epilepsy.
o Depression of the CNS system: it is characterized by dizziness, vertigo,
drowsiness, fatigue and ataxia. Restriction of ambulation and use of bed rails may
be necessary. The patient should not operate care or machinery.
5. Effects on the gastro-intestinal system:
o Irritation of the gastric mucosa: This is characterized by nausea, vomiting,
anorexia. This can be prevented by giving with or after the meals or with one
glass of milk or an antacid. The drugs are contraindicated if the patient has a
history of peptic ulcer.
o Small bowel ulceration: it is characterized by abdominal pain, melaena, distension
and diarrhea.
o Constipation

OXYGEN ADMINISTRATION:

Oxygen can act as a life saving drug, but is to be used with utmost care, treating it as a
potentially toxic drug whose use should continue no longer than absolutely necessary.
Regular charting of vital with monitoring of response to therapy should continue as long
as it is given. Since oxygen is also a potential fire hazard, its use should prompt adequate
electrical and fire safety precautions to be followed in the vincity. There are various
modes of administering:

1. By Face Mask:
Simple re-breathing type of face mask deliver about 30-60% concentration at flow
rates of 6-10 L/min. Since they have holes for the exit of exhaled air. They should be
of adequate size, extending from the bridge of the nose to the tip of the chin, with a
snug fit and no pressure on the eyes.
The non rebreathing type of face masks have an oxygen reservoir attached to them
which helps to deliver a higher concentration of oxygen, up to 95% with flow rates of
10-12 L/min.
2. By Nasal Prongs:
These deliver low-flow (1-2 L/min), low-concentration (30-35%) oxygen with two
prongs that are inserted in the anterior nares and held by adhesive tape.

3. Other Methods:
These include:
o Oxygen hood: For neonates and young children. Delivers about 30%
oxygen concentration and does not require humidification.
o Blow-by cannula: In those who do not tolerate facemasks or nasal prongs
the tube is held close to the nose to deliver free-flow oxygen.
o Oxygen tent
o Nasal and Nasopharyngeal catheter.

ADMINISTRATION OF BLOOD:

Patient Information:
Blood products available from blood bank include:
1.RBC aliquots in syringe:
o All requests for RBC aliquots are filled using the “generic” baby unit in
the blood bank unless the infant has direct donations or is on “own unit
status”
 o The genric baby unit meets all the necessary criteria for NICU patients
[group O neg, unless patient has ABO compatible direct donation
available], CMV neg, irradiated, Hgbs neg, leukodepleted, filtered,
CPDA-1 anticoagulant} and can be used for 35 days after collection or up
to 7 days after irradiation.
o All RBC aliquots are pre-filtered in the blood bank and do not require
filtering on the nursing unit prior to administration.
2. FPP aliquots in syringes: group AB or ABO compatible.
o All FPP aliquots are pre-filtered in the blood bank and do not require filtering
on the nursing unit prior to administration.
3. Platelet aliquots in syringes: GroupAB or ABO compatible:
o The blood bank reserves a group AB, CMV neg, irradiated, leukodepleted
single donor platelet to be used for all platelet aliquots.
o All platelet aliquots are pre-filtered in the blood bank and do not require
filtering on the nursing unit prior to administration.
4. Cyoprecipitate: issued in 10-15 ml bags, group AB or ABO compatible:
o Not pre-filtered in the blood bank. Use blood component administration set
for administration of this component.
5. Whole blood for exchanges: same criteria as RBC aliquots. NICU will specify
Hct and volume required.
o Used only for exchange transfusions. Call blood bank in advance because
fresh group O negative RBC’s must be reconstituted with group must
specify total volume required for exchange transfusion and desired
hematocrit.
o Group O negative uncross matched blood may be used in emergency
situations only.
o This component is leukodepleted in the blood bank must be filter but must
book but nursing unit.
6. twenty-five percent albumin:
o 5% albumin is available in clean holding/ unit manager. A filter is provided.
o 25% is ordered from blood bank.
It must be filtered unless added to the IV buretrol.

Procedure:
To obtain blood or blood products to an infant without complications.
o Order the desired volume. Note: Always order enough extra blood to clear tubing
that will be used for the infusion.
o An initial pre-transfusion specimen must be worked up by the blood bank before
RBC’s can be issued. The ABO, Rh factor and DAT can be done using a cord
blood. An indirect coomb’s test must be done on either the mother or then baby.
Cross matches are not required during the neonatal period (up to 4 months of age)
unless non-group O RBC ae being issued. No further specimen need to be
submitted during any one admission for neonates.
o Complete a “blood component request” form and send it to the blood bank. When
you are ready to transfuse the component. The component will not be prepared
until the request is received. The blood bank will call when the component is
received by NICU. As soon as the component is received by NICU, the initials,
date and time received must be documented on the tube request and returned to
 the blood bank along with the plastic Velcro bag. These must be sent back within
15 min of when the product left the blood in order to avoid having to track the
component.
o All components issued in syringes expire in 4 hours and cannot be reissued from
the blood bank if not used by the nursing unit. Components requested and not
used must be returned to the blood bank so the patient’s account can be credited
and the disposition of the product changed in the blood bank records.

BIBLIOGRAPHY:

• Parul Dutta.Pediatric nursing.Jaypee publication. New delhi.1st edition.

2007.

• Latitha Krishnan. Practical neonatal care. Chennai: Orient Longman Private

Limited; 2002.

• O P Ghai essential of pediatric nursing new Delhi 6 edition cbs publisher new
Delhi .