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Pediatric Dosing: Tips for Tots
Pediatric Dosing: Tips for Tots Pharmacists can give parents an edge by meeting pediatric medication needs. by Rebe cca W heel er Chate r
P
arents with sick children are usually anxious, nervous, and often sleep-deprived. The children , on the other hand, not only are sick but also are often unwilling to take their nledicine. Pharmacists can help parents (or caregivers) understand and cope with sick children and their medication needs. To make sure that children receive their medication properly, a practitioner must depend on traits beyond devotion to phamlacy and on a special interest in the younger population. This article provides sonle practical advice for helping parents cope.
Educating the Parent Being sensitive to the needs of the parent and the patient is critical to effective parent and patient education. Although tnuch of the dosing infomlation provided by the phannacist is similar whatever the patient's age, unique challenges do exist in pediatrics. The pharmacist's goal in counseling the parent should be to provide all necessary information in an easy-to-understand, easy-to-use, titnely fashion. Always clarify the exact meaning of the dosing interval. Depending on the medication and the illness, the child may or may not need to be awakened to take the medication. For example, in administering antibiotics, does TID mean three titnes in a 24-hour period or three titnes during the waking hours in a 24-hour period? This point should be made crystal clear to the parent. Most medications prescribed in pediatrics are oral liquids, and several dosing implements are available to ease their administration. Droppers, cylindrical nledicine spoons, oral syringes, and small-volume dosers with attachable nipples can all be used effectively. The dosers with nipples are particVol. NS33, No. 5
May 1993
ularly useful in dosing itliants. The baby can suck on the nipple until the medication is consumed , just as if it were a bottle. This avoids the waste and degradation that can be caused by mixing medications with infants' bottle contents. Make sure that the parent understands certain volume equivalents to enable proper dosing. Medications are generally prescribed based on fractions of a teaspoon. Measuring devices, however, may express these increnlents by "mL" or "cc ," and something as fundamental as "mL= cc " can be unclear. Explain the proper measurement when the product is dispensed, and make sure the parent has an accurate measuring device. Including complinlentary measuring spoons and devices in your pharmacy budget is a good idea. Otherwise, the parent Inay use a household teaspoon, which often results in itlaccurate dosing. When using a dropper, advise the parent to administer the oral liquid "toward the inner cheek," rather than in the front of the mouth (where the child can spit it out easily) or in the back very near the throat (which can make the child choke). Do not give or recommend a dropper or oral syringe that is too large for the child's mouth. An oral syringe of the right size can make the intended placenlent of the liquid much more accurate. Another mundane but defmitely itnportant suggestion to the frustrated parent concerns the size of the bottle dispensed relative to the measuring device. If, for instance, the medication is dispensed in a 240-mL bottle, how does the parent uSitlg a standard size dropper or oral syringe effectively withdraw the last few doses? Either dispense the medication in two smaller bottles, or supply the parent with a second, small, appropriately labeled bottle to which the final p ortion of the medication can be transferred and drawn up easily and accurately. AMERICAN PHARMACY
Handling Degradable Antibiotics
dispense and by considering palatability when choosing the brand of multisource medications to stock. Taste preferences, Parents of toddlers who are prescribed antibiotic liquids however, are defmitely subjective. When a child does not like that must be refrigerated often must transport medication the taste of a medication, parental assertiveness (depending back and forth daily because the child must receive a dose on the age and attitude of the child) is sometimes enough to while in day care. Perhaps the antibiotic can be dosed less cause the child to take the medication anyway. Explaining frequently to avoid the "day care" dose (e.g. , BID instead of that "sometimes medicines don't taste good, but they are necTID, as in the case of cefaclor in treating otitis media); disessary to help you feel better" will occasionally suffice. cussing this option with the physician on the patient's behalf If assertiveness fails , suggest that the parent enhance is in the best interest of everyone concerned. If the day care palatability by using a food to mask the flavor-unless, of dose cannot be avoided, provide a second labeled bottle to course, stability makes this impossible. Foods such as yogurt, use at day care. This "two-bottle" system is particularly useful instant pudding, applesauce, and cola syrup may often be with amoxicillin/clavulanic acid, which is likely to degrade used. As a general rule, products that can be given with food substantially (indicated by a color change) when it is left can also be mixed with food unrefrigerated during transat the time of adnlinistration. port. Please note that I am not If a parent will not be able advocating premixing medito refrigerate a medication cations with foods, infant forsoon after it is dispensed , Creatively finding a tvay around a mula, or the like. place a cold pack in the bag Some liquids that do not along with the prescription dosing or administration impasse is a require refrigeration are actuto eliminate the risk of degraally more palatable if they are dation. Many times, reusable definite asset for the pharmacist. refrigerated. Generally, as cold packs are shipped with with foods , the lower the refrigerated products from temperature, the less aromatthe wholesaler to the pharic and less "flavorful " the macy. Stockpiling them, as solution. Infants, on the othspace permits, in the pharmaer hand, accept most medicacy freezer to give to parents tions better at room temperawho need them is a great serture because they are vice and costs nothing. If accustomed to warm breast refrigeration is impossible for an extended time during a course of treatment, suggest that milk or infant formula. Renlember to convey clearly to parents that when these the parent store the medicine bottle in a standard thermos containing ice. This is a particularly useful suggestion for creative strategies are exhausted, assertiveness must win out. For a sick child to get well, he must receive his medication as patients traveling by airplane where space is limited. prescribed. In the battle of wills, the parent must reign. Advise parents to refrain from teaching children that mediOvercoming Resistance to Medication cations will or do taste good. They need to tmderstand and respect the fact that medications are just that-not candy. Sick children can be irritable , tired, and apprehensive about taking their medicine. Understanding why a child is Although there is no magic to successfully managing pediunwilling to take it is a useful tool in successful administraatric dosing, the challenges encountered serve as a vivid reminder to us all that along with the analytical skill obviously tion. Creatively fmding a way around a dosing or administration impasse is a defmite asset for the pharmacist. Providing required in our profession, its practice is still very much an art. tips to parents on specific techniques to lessen the burden of such a task is invaluable. Rebecca Wheeler Chater, BS, is pharmacy manager of Kerr Although much has been done by manufacturers over the Drugs, Pinehurst, N C. She previously was pharmacy manager, years to improve flavor, palatability is still a problem at times. Charlotte Pediatric Pharmacy, Charlotte, N C. A practitioner or parent can be supremely clever at getting a medication in the child's mouth, but having him swallow is The editor for this series is Bruce R. Canaday, PharmD. He is an entirely different matter. clinical professor ofpharmacy and medicine, University of North You can save yourself, your patients, and their parents Carolina AHEC Program, Coastal Area Health Education Center, many headaches by knowing the taste of the products you Wilmington, N C.
AMERICAN PHARMACY
May 1993
Vol. NS33, No .5
P
arents with sick children are usually anxious, nervous, and often sleep-deprived. The children , on the other hand, not only are sick but also are often unwilling to take their nledicine. Pharmacists can help parents (or caregivers) understand and cope with sick children and their medication needs. To make sure that children receive their medication properly, a practitioner must depend on traits beyond devotion to phamlacy and on a special interest in the younger population. This article provides sonle practical advice for helping parents cope.
Educating the Parent Being sensitive to the needs of the parent and the patient is critical to effective parent and patient education. Although tnuch of the dosing infomlation provided by the phannacist is similar whatever the patient's age, unique challenges do exist in pediatrics. The pharmacist's goal in counseling the parent should be to provide all necessary information in an easy-to-understand, easy-to-use, titnely fashion. Always clarify the exact meaning of the dosing interval. Depending on the medication and the illness, the child may or may not need to be awakened to take the medication. For example, in administering antibiotics, does TID mean three titnes in a 24-hour period or three titnes during the waking hours in a 24-hour period? This point should be made crystal clear to the parent. Most medications prescribed in pediatrics are oral liquids, and several dosing implements are available to ease their administration. Droppers, cylindrical nledicine spoons, oral syringes, and small-volume dosers with attachable nipples can all be used effectively. The dosers with nipples are particVol. NS33, No. 5
May 1993
ularly useful in dosing itliants. The baby can suck on the nipple until the medication is consumed , just as if it were a bottle. This avoids the waste and degradation that can be caused by mixing medications with infants' bottle contents. Make sure that the parent understands certain volume equivalents to enable proper dosing. Medications are generally prescribed based on fractions of a teaspoon. Measuring devices, however, may express these increnlents by "mL" or "cc ," and something as fundamental as "mL= cc " can be unclear. Explain the proper measurement when the product is dispensed, and make sure the parent has an accurate measuring device. Including complinlentary measuring spoons and devices in your pharmacy budget is a good idea. Otherwise, the parent Inay use a household teaspoon, which often results in itlaccurate dosing. When using a dropper, advise the parent to administer the oral liquid "toward the inner cheek," rather than in the front of the mouth (where the child can spit it out easily) or in the back very near the throat (which can make the child choke). Do not give or recommend a dropper or oral syringe that is too large for the child's mouth. An oral syringe of the right size can make the intended placenlent of the liquid much more accurate. Another mundane but defmitely itnportant suggestion to the frustrated parent concerns the size of the bottle dispensed relative to the measuring device. If, for instance, the medication is dispensed in a 240-mL bottle, how does the parent uSitlg a standard size dropper or oral syringe effectively withdraw the last few doses? Either dispense the medication in two smaller bottles, or supply the parent with a second, small, appropriately labeled bottle to which the final p ortion of the medication can be transferred and drawn up easily and accurately. AMERICAN PHARMACY
Handling Degradable Antibiotics
dispense and by considering palatability when choosing the brand of multisource medications to stock. Taste preferences, Parents of toddlers who are prescribed antibiotic liquids however, are defmitely subjective. When a child does not like that must be refrigerated often must transport medication the taste of a medication, parental assertiveness (depending back and forth daily because the child must receive a dose on the age and attitude of the child) is sometimes enough to while in day care. Perhaps the antibiotic can be dosed less cause the child to take the medication anyway. Explaining frequently to avoid the "day care" dose (e.g. , BID instead of that "sometimes medicines don't taste good, but they are necTID, as in the case of cefaclor in treating otitis media); disessary to help you feel better" will occasionally suffice. cussing this option with the physician on the patient's behalf If assertiveness fails , suggest that the parent enhance is in the best interest of everyone concerned. If the day care palatability by using a food to mask the flavor-unless, of dose cannot be avoided, provide a second labeled bottle to course, stability makes this impossible. Foods such as yogurt, use at day care. This "two-bottle" system is particularly useful instant pudding, applesauce, and cola syrup may often be with amoxicillin/clavulanic acid, which is likely to degrade used. As a general rule, products that can be given with food substantially (indicated by a color change) when it is left can also be mixed with food unrefrigerated during transat the time of adnlinistration. port. Please note that I am not If a parent will not be able advocating premixing medito refrigerate a medication cations with foods, infant forsoon after it is dispensed , Creatively finding a tvay around a mula, or the like. place a cold pack in the bag Some liquids that do not along with the prescription dosing or administration impasse is a require refrigeration are actuto eliminate the risk of degraally more palatable if they are dation. Many times, reusable definite asset for the pharmacist. refrigerated. Generally, as cold packs are shipped with with foods , the lower the refrigerated products from temperature, the less aromatthe wholesaler to the pharic and less "flavorful " the macy. Stockpiling them, as solution. Infants, on the othspace permits, in the pharmaer hand, accept most medicacy freezer to give to parents tions better at room temperawho need them is a great serture because they are vice and costs nothing. If accustomed to warm breast refrigeration is impossible for an extended time during a course of treatment, suggest that milk or infant formula. Renlember to convey clearly to parents that when these the parent store the medicine bottle in a standard thermos containing ice. This is a particularly useful suggestion for creative strategies are exhausted, assertiveness must win out. For a sick child to get well, he must receive his medication as patients traveling by airplane where space is limited. prescribed. In the battle of wills, the parent must reign. Advise parents to refrain from teaching children that mediOvercoming Resistance to Medication cations will or do taste good. They need to tmderstand and respect the fact that medications are just that-not candy. Sick children can be irritable , tired, and apprehensive about taking their medicine. Understanding why a child is Although there is no magic to successfully managing pediunwilling to take it is a useful tool in successful administraatric dosing, the challenges encountered serve as a vivid reminder to us all that along with the analytical skill obviously tion. Creatively fmding a way around a dosing or administration impasse is a defmite asset for the pharmacist. Providing required in our profession, its practice is still very much an art. tips to parents on specific techniques to lessen the burden of such a task is invaluable. Rebecca Wheeler Chater, BS, is pharmacy manager of Kerr Although much has been done by manufacturers over the Drugs, Pinehurst, N C. She previously was pharmacy manager, years to improve flavor, palatability is still a problem at times. Charlotte Pediatric Pharmacy, Charlotte, N C. A practitioner or parent can be supremely clever at getting a medication in the child's mouth, but having him swallow is The editor for this series is Bruce R. Canaday, PharmD. He is an entirely different matter. clinical professor ofpharmacy and medicine, University of North You can save yourself, your patients, and their parents Carolina AHEC Program, Coastal Area Health Education Center, many headaches by knowing the taste of the products you Wilmington, N C.
AMERICAN PHARMACY
May 1993
Vol. NS33, No .5