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35 Cards in this Set
- Front
- Back
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Premature: born < __ weeks gestational age
Neonates: days __to__ ???: 1 month to 1 year |
37
1-30days Infants |
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ABSORPTION
Do adults or pre-adults have increased pH At what age are they the same as adults? Pre-aduts have reduced bioavailability of__ -Peds have inc/dec skin absorption? |
increased in neonates, infants, and young children
Age 2 Weak acids reduced(higher dose needed) Skin increased Absorption *IM sites unpredictable **Gastric emptying slow premature |
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Distribution:
Increased TBW:body fat ratio -Fetus __% Premature infant: __% Full-term infant __% 4 months of age __% Adult__% Vd of lipophilic drugs similar to adults except decreased in... Protein binding is dec/inc in newborns? |
94%
85% 78% 60% 60% Vd lipos decreased in PREMATURE NEONATES Decreased protein binding |
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METABOLISM
slower/faster in infants than older children and adults? __ pathway well developed but ___ pathway undeveloped until 1 year old. -Changes in __ enzymes |
Slower in infants
Sulfation well developed but not Glucoronidation. CYP enzymes |
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• 1A2: reduce doses by __% in neonates
• 2B6: (higher/lower) doses in adolescent • 2C9: __-__% higher doses in children • 2C19: weight corrected doses in children older than __ year = adult doses • 2D6: weight corrected doses in neonates (dec/inc)? • 3A4: weight-corrected doses in children are __ fold higher than adult doses • UDG: weight-corrected dosing decreased in neonates • NAT2: fast vs. slow acetylators |
• 1A2: reduce doses by 50% in neonates
• 2B6: higher doses in adolescent • 2C9: 50-100% higher doses in children • 2C19: weight corrected doses in children older than 1 year = adult doses • 2D6: weight corrected doses in neonates decreased • 3A4: weight-corrected doses in children are 3 fold higher than adult doses • UDG: weight-corrected dosing decreased in neonates • NAT2: fast vs. slow acetylators |
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ELIMINATION
• GFR (mL/min/1.73 m2) – Pre-term infant: ___ TO __ – At birth: # – Increased to _-_% by 6 months • tubular secretion – Lags behind by _ months – _ year • Renal function fully matures by __ |
• GFR (mL/min/1.73 m2)
– Pre-term infant: 0.6-0.8 – At birth: 40 – Increased to 50-75% by 6 months • tubular secretion – Lags behind by 7 months – 1 year • Renal function fully matures by 1 year |
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Four methods for estimating doses
A. risk overdose B. Limits risk of overdose C. Vd scaled to bodyweight, bodyweight used to scale clearance |
Age-based
Bodyweight-based(A) BSA-based(B) Allometric scaling (c) |
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what are two methods for calculating dose
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mg/kg/day
mg/kg/dose *Peds doses may be > adult doses for certain meds |
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Common problems with medication admin in Peds(4)
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Constipation
DIarrhea Fever Dosage forms |
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Whats used for constipation in Peds?
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• Fiber: conflicting reports about role
• PEG: effective but routine use not recommended yet • Cisapride: risks outweigh benefits • Biofeedback: effective short-term intractable constipation • Cow’s milk: may need to avoid |
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DIARRHEA
• Assessment: capillary refill time, skin turgor, respiratory pattern • Non-Pharmacologic: oral rehydration = standard treatment x mild-moderate dehydration • Pharmacologic: – __ not recommended x acute gastroenteritis • __ useful adjunct to rehydration • High risk dehydration – Infants < __ months of age – > __ diarrheal stools in past 24 hours – > 4 significant vomits associated with diarrhea in past 24 hours – Comorbid conditions (short gut, metabolic illnesses, developmental delay) – Refusal of PO fluids |
• Assessment: capillary refill time, skin
turgor, respiratory pattern • Non-Pharmacologic: oral rehydration = standard treatment x mild-moderate dehydration • Pharmacologic: – Loperamide not recommended x acute gastroenteritis • Probiotics useful adjunct to rehydration \ • High risk dehydration – Infants < 6 months of age – > 8 diarrheal stools in past 24 hours – > 4 significant vomits associated with diarrhea in past 24 hours – Comorbid conditions (short gut, metabolic illnesses, developmental delay) – Refusal of PO fluids |
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FEVER
• Tepid sponging is not recommended • Children with fever should not be under dressed or over- wrapped. • Use of __ should be considered in children with fever who appear distressed or unwell. • __ should not be used with sole aim of reducing temperature in children otherwise well. • Either acetaminophen or __ – Do not give at same time. – Do not routinely given alternately – If does not respond to one, give the other |
Antipyretics(2)
Ibuprofen |
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Estimating due date
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• Add 7 days to 1st
day of last menstrual period (LMP) and count back 3 months |
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miscarriage(<___ weeks gestation)
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<20
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Critical Periods
• __-__ days postconception or __-__ days after 1st day of LMP: organogenesis • < __ days: neural tube defects • < __ days: cleft lip • < __ weeks: ventricular septal defect • < __ weeks cleft palate • After __ weeks: cannot have these defects from exposure |
Critical Periods
• 20-55 days postconception or 34-69 days after 1st day of LMP: organogenesis • < 30 days: neural tube defects • < 36 days: cleft lip • < 6 weeks: ventricular septal defect • < 10 weeks cleft palate • After 10 weeks: cannot have these defects from exposure |
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Which FDA risk category?
risk in anials; use only if life-threatening with no safer alternative Animals or humans; risk> benefit Controlled trials in women fail to show risk in 1st trimester animals-no risk; no human data |
FDA Risk Categories
• A: controlled trials in women fail to show risk in 1st trimester • B: animals – no risk; no human data • C: risk in animals; no human data; benefit must > risk to use • D: risk in animals; use only if life- threatening with no safer alternative • X: animals or humans; risk > benefit |
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Elements of developmental toxicity
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Growth alteration
structural anomalies neurobehavioral deficits Death |
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PHarmacy Roles for pregs(4)
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• Screening therapy of women of
reproductive age for known or suspected developmental toxicity • Provide pregnant women or those expecting to become pregnancy with information • Folic acid • Toxicity social drugs |
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• List five advantages of breast milk over formula.
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• Decrease risk gastroenteritis, LRTI, otitis media, sudden
infant death syndrome in first year, Type 1 and 2 DM, childhood leukemia, obesity • Protected against lymphoma, Hodgkin’s atopic dermatitis, bacteremia, bacterial meningitis, botulism, urinary tract infections, late-onset sepsis, adult hypercholesterolemia, ulcerative colitis, celiac disease, and other chronic digestive diseases. • To mother: more rapid uterine involution, decreased postpartum blood loss, fertility reduction, decreased risk of breast and ovarian cancer, DM 1 and 2 • Teratogenecity cannot occur with breastfeeding • FDA categories do not apply during breast feeding **• First 5 days postpartum: small amounts of breast milk • Then significant amounts during first 4 weeks. • Newborns nurse Q2-3 hours. Trying to time meds is impractical at this point. |
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Drug Passage into milk
• Physiochemical factors – Small __-soluble pass by simple diffusion – Milk levels of drugs approximate __ levels – For larger molecules, only __-soluble, unbound, nonionized forms pass – pH of milk __ than plasma (ion trap for basic drugs) and acidic drugs are inhibited form entering milk – Highly protein bound drugs usually do not pass into milk in high concentrations • Pharmacokinetic factors • Methods of expressing the extent of passage • Infant factors |
Drug Passage into milk
• Physiochemical factors – Small water-soluble pass by simple diffusion – Milk levels of drugs approximate plasma levels – For larger molecules, only lipid-soluble, unbound, nonionized forms pass – pH of milk lower than plasma (ion trap for basic drugs) and acidic drugs are inhibited form entering milk – Highly protein bound drugs usually do not pass into milk in high concentrations • Pharmacokinetic factors • Methods of expressing the extent of passage • Infant factors |
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Drugs of concern(6)
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Drugs of concern
• Antidepressants • Narcotics • Long-acting sedatives • Water-soluble beta-blockers •Lithium • Iodine-containing drugs |
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Drugs that affect lactation(7)
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Drugs that affect lactation
Alcohol Anticholinergic Diuretics Dopaminergic agents Estrogens Cigarette smoking Sympathomimetic vasoconstrictors |
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Stepwise approach to minimize infant exposure to drugs in breast milk
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Stepwise approach to minimize infant
exposure to drugs in breast milk • Withhold the drug • Delay therapy • Choose an alternative drug that passes poorly into milk. • Choose an alternate route of administration • Avoid nursing at times of peak drug concentration. (only effective for meds with short t1/2) • Temporarily withhold breastfeeding • Administer the drug as a single dose before the infant’s longest sleep period. • Stop breastfeeding. |
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Equation for drug in milk
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Approximate infant dose (ie., amount drug getting
to infant through breastmilk) = M/P x steady state concentration x 150 mL/kg/day Assuming a milk consumption of 150 mL/kg/day. 1.5 x 0.002 mg/mL = 0.003 mg/mL 0.003 mg/mL x 150 mL/kg/day = 0.45 mg/kg/day = 450 mcg/kg/day *M/P milk/plasma |
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Weight adjusted percentage of the maternal dosage for this drug
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[Infant dose/mother’s dose] x100 = % mother’s dose
<10% accepted >25% not accepted |
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3. Describe the common types of med errors and the potential causes of med errors in children. (covered in class)
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Med Errors in Peds
No standard dosing Off label uses Doses must be adjusted for child’s weight or body surface area Calculation errors PK changes |
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Constipation
• ???: conflicting reports about role • ???: effective but routine use not recommended yet • ???(drug): risks outweigh benefits • ???: effective short-term intractable constipation • ???: may need to avoid |
Constipation
• Fiber: conflicting reports about role • PEG: effective but routine use not recommended yet • Cisapride: risks outweigh benefits • Biofeedback: effective short-term intractable constipation • Cow’s milk: may need to avoid |
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Give Advantages and disadvantages
1. Age-based method 2. BOdyweight-based 3.BSA-based 4. Allometric scaling |
1. • Advantages: ease
• Disadvantages; assumes maturational effects on drug disposition are consistent within each age-based categories 2. NA advantage. • Method: normalized to bodyweight • Disadvantage: risk overdose adolescent and overweight children 3. • Advantage: limits risk of overdosing older children • Disadvantage: – Difficult way in which BSA is calculated – Various formulas used – Neonates and infant being overdoses with certain drugs when BSA used. 4. • Advantage: limits risk of overdosing older children • Disadvantage: – Difficult way in which BSA is calculated – Various formulas used – Neonates and infant being overdoses with certain drugs when BSA used. |
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Non-pharmacologic and non-pharmacologic interventions in pregnancy:
N/V |
NON-PHARMACOLOGIC. lifetyle and dietary changes, acupuncture, and acupressure. Counsel
PHARMACOLOGIC: Combo pyridoxine(b6) and doxylamine. second line antihistamines |
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Non-pharmacologic and non-pharmacologic interventions in pregnancy:
HEARTBURN |
NON-PHARMACOLOGIC:
eat small, frequent meals, upright postmeal PHARMACOLOGIC: Ca+ or Mg + containing antacids. 2nd ranitidine |
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Non-pharmacologic and non-pharmacologic interventions in pregnancy:
CONSTIPATION |
NON-PHARMACOLOGIC
high-fiber diet, plenty of fluids, avoids white rice and cheese PHARMACOLOGIC psyllium and calcium polycarbophil. 2nd bisacodyl and senna. |
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Non-pharmacologic and non-pharmacologic interventions in pregnancy:
PAIN |
NON-PHARMACOLOGIC
water aerobics, supportive pillows, physiotherapy, acupuncture PHARMACOLOGIC APAP, NSAIDs with caution. |
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Non-pharmacologic and non-pharmacologic interventions in pregnancy:
COUGH COLD |
NON-PHARMACOLOGIC
Rest, fluid, humidified air, and nasal saline PHARMACOLOGIC??? |
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major cause of neural tube defects
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Folic acid deficiency
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List some measures to decrease risk of harm to baby?
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•CPOE
• Automated dispensing • Peds experts in formulary mgmt • Competent pharmacy personnel/environment • Pharmacist available “on call” when pharmacy is closed • Policies on verbal orders • Clear and accurate labeling of meds • Quality improvement efforts with DUE and med error reporting • Healthcare workers – access to clinical information and references • Emergency med dosage calculation tools • Patient education on drugs • Direct participation of pharmacist in clinical care • And more…. |
