Growing Up With Us...
©
A Newsletter For Those Who Care For Children
Volume 15, Issue 7
PEDIATRIC MEDICATION ADMINISTRATION
July 2009
Editor-in-Chief: Mary Myers Dunlap, MAEd, RN
BEHAVIORAL OBJECTIVES
AFTER
READING THIS NEWSLETTER THE
LEARNER WILL BE ABLE TO:
1.
Discuss the importance and process of verifying
dosages prior to administration of medication to
children.
2.
Describe age-specific considerations related to
administration of oral, subcutaneous, otic, optic and
rectal medications, as well as implications for the
healthcare provider.
A child receives an average of seven medications while
hospitalized. The safe administration of medications to
infants and children, regardless of the healthcare setting,
requires additional specific safeguards that are above and
beyond those for adult patients. To ensure safe and
successful administration, careful consideration needs to be
given to the dosage, measurement, the age appropriateness of the method of administration, and for
oral medications, the form – liquid versus solid.
This newsletter will discuss the importance and process
of verifying drug dosages prior to administering medication
to infants and children. Age-appropriate administration of
oral, subcutaneous, otic, optic and rectal medications will
also be described.
PEDIATRIC MEDICATION ADMINISTRATION
There are few standardized medication dosages for
infants and children. Many medications for the pediatric
population are diluted adult dosages, based on the child’s
weight in kilograms. Accurate assessment
of the child’s weight is critical – at the time
of admission or if the child’s condition
necessitates, such as with moderate to
severe dehydration. Asking parents their
child’s weight is not sufficient. If at all
possible, weigh the child in kilograms.
Otherwise, the child’s weight in pounds
must be divided by 2.2 in order to convert
his or her weight into kilograms – an
opportunity for error. For example, a child that weighs 16
pounds 12 ounces (16.75 pounds) weighs 7.7 kg.
Remember: 16 ounces = 1 pound, so 12 ounces is ¾ of a
pound, 8 oz. = ½ lb., 4 oz = ¼ lb.
The child’s weight in kg should be prominently
documented on all medical records. It is safe practice that
drugs not be administered to a child until he or she is
weighed, unless in an emergency situation.
Miscalculation of drug dosages, including computation
errors, is a common medication error occurring in the
pediatric population. Due to variances in weight and organ
system maturity, which affect the ability to metabolize and
excrete medications, the slightest computation error can
have devastating results for infants and children.
Because many drugs are formulated and packaged
primarily for adults, calculations are often necessary before
administering medications to children, to
verify that the dosage ordered is safe,
as well as to determine how much to
administer. This requires a series of
calculations and tasks that increase the
chance for error. For example:
Physician order: Drug Abc 150 mg po q 8 hours
Child’s weight: 15 kg
Information from drug guide: children < 40 kg receive 6.7 to
13.3 mg/kg po q 8 hours
 Low dose → 100.5 mg (6.7 x 15 kg)
 High dose → 199.5 mg (13.3 x 15 kg)
 Safe range → 100.5 mg to 199.5 mg; 150 mg is a safe
dose.
The medication is available: Drug Abc 125 mg / 5 mL
You would give → 6 ml
Calculation:
=
→
→ x 6
Be especially vigilant for calculation errors when the
exact dose or form of medication that is ordered is not
available. It is always good practice to have another nurse
double-check calculations, as well as high-risk drugs, such
as insulin, heparin and chemotherapy drugs and those
deemed high-risk by the facility, before administration.
Dosages for liquid preparations are commonly prescribed in
teaspoons, or fractions thereof, as well as tablespoons. 1
teaspoon = 5 ml; 3 teaspoons = 1 tablespoon = 15 ml; 1 ml
= 15-16 gtts (drops).
ORAL: The oral route is the most common and preferred
route for administering medications to children of all ages.
The appropriate form of oral medication, solid or liquid,
depends on the child’s age and developmental level. It is
generally not until 5 to 6 years of age that children are able
to safely swallow a tablet or capsule. Until this age,
commercially-prepared elixirs are the safest form of oral
medication for infants, toddlers and many preschoolers.
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Most liquid forms are colorful, as well as palatable. Any
unpleasant taste may be disguised by mixing the liquid
medication with a small amount of non-essential food, such
as syrup, jam, or from the pharmacy, a medication
flavoring. However, honey should not be used with infants
because of the risk of botulism. Liquid preparations, as well
as crushed pills or the contents of capsules, should not be
mixed with essential foods, such as applesauce. There is a
real chance an aversion will develop to that food. Likewise,
medications should never be mixed in a bottle. If the child
does not drink the entire contents of the bottle all the
medication will not be ingested, nor will the exact dosage
taken be known. Molded plastic medicine cups are accurate
in measuring larger doses of liquids, such as a tablespoon.
However, the most accurate means for measuring small
amounts of medication is in milliliters with a plastic,
disposable, needleless syringe. A medication which comes
with a calibrated dropper, is also an accurate measure. For
small children, the plastic syringe, the smallest possible,
provides a reliable measurement tool, as well as a
convenient means for administering the medication. The
smallest possible syringe should be used, such as a
tuberculin syringe for doses less than 1 ml, or a 3 cc
syringe for a ½ teaspoon. Placing the syringe along the side
of the child’s tongue, halfway back to
avoid stimulating the gag reflex, and
administering ½ - 1 ml of medication
at a time, is effective. If a child
refuses to swallow the medication,
gently stroking his or her throat will
stimulate swallowing. Alternating
sides of the tongue may be
necessary, if the child “catches on”.
When administering medication to children, care must
be taken to prevent aspiration. The child should be held or
positioned in a semi-reclining or upright position. Medication
should never be administered while the child is crying.
Infants and older children are usually cooperative during
oral medication administration. However, toddlers typically
have difficulty holding still and have strong opinions – “No!”.
Parents may be a great resource in administering oral
medication to children who are uncooperative. Most have
had previous experience giving medications to their child, or
will need this skill in the future. However, parents should
never be involved in something that causes pain to the
child, such as an IM injection. Parents should be seen as
comforters and in the child’s mind, not associated with
inflicting pain.
SUBCUTANEOUS (Sub-Q or subQ): Medications given in
small doses, under 0.5 cc, and those which are not irritating
are commonly given subcutaneously. Examples include
insulin, heparin and allergy desensitization. A small syringe
and needle, 5/8 inch, 25 gauge, is typically used. The
technique for subcutaneous injections administered to
children differs little from the method used for adults. A fold
of skin should be pinched between the thumb and forefinger
and the needle inserted into the subcutaneous tissue. The
angle of the needle is typically 90o. For children with little
subcutaneous fat, a 45o angle may be more appropriate.
Common subcutaneous injection sites include the
abdomen, center of the lateral aspect of the upper arm and
the center of the anterior thigh.
Close attention should be paid to rotating injection sites if
subQ injections are given on an on-going basis. Children,
often as young as preschoolers, can assist with keeping
track of previous injections. This gives them a sense of
control and involvement in their care. Generally, by 9 or 10
years of age, most children have the physical ability to draw
up and give their own insulin. However, children this age
lack judgment and usually need supervision into the
teenage years.
OTIC: Ear drops should be instilled with the child
positioned on his or her side, exposing the ear that will
receive the ear drops. To straighten the external auditory
canal... under the age of 3 years the pinna, the round
cartilaginous part of the ear, is pulled down and back; up
and back for children over 3 (under = down; over = up).
To help decrease pain, ear medication should be room
temperature before instillation. After instillation, the child
should remain lying on the opposite side for a few minutes
to facilitate the entry of the drops into the ear canal. A
cotton ball is not necessary or effective - it simply collects
the medication.
An order for ear medication should read: "left ear", "right
ear" or "both ears". The Latin abbreviations, A.S., A.D.,
A.U., are “forbidden” by the Joint Commission as they
are commonly mistaken for one another. Likewise, "left
eye", "right eye" or "both eyes” should be written out in
the physician’s order, rather than O.S., O.D., O.U. – the
Latin abbreviations for left, right, or both eyes. Contact
the prescribing physician if the medication order is
written incorrectly.
OPTIC: To instill eye medication, drops or ointment, the
child should be sitting or lying on his or her back, with the
head extended and asked to look up. One hand should be
used to pull down the lower lid. The hand which holds the
eye medication rests on the head, so it can move with the
child's head, thus reducing the possibility of trauma if the
child moves suddenly. As the lower lid is pulled down, a
small conjuctiva sac is formed. The solution or ointment is
applied to this area, never directly on the eyeball.
If both eye ointment and drops are ordered, the drops
should be administered first. After waiting at least 3
minutes, the ointment should be given. If possible,
ointments should be administered before naptime or bed,
since the child’s vision will be temporarily blurred.
Administering medication to pediatric patients can be a
challenge for healthcare professionals, as well as source of
anxiety for hospitalized children and their parents. To ensure
safe, accurate and successful administration, careful
consideration needs to be given to the dosage, means of
measuring, and the age-appropriateness of the method of
administration and form. An upcoming newsletter will discuss
guidelines to increase children’s cooperation during medication
administration.
Growing Up With Us..., Inc.© 2009
PO Box 481810 • Charlotte, NC • 28269
Phone: (919) 489-1238 Fax: (919) 321-0789
Editor-in-Chief: Mary M. Dunlap MAEd, RN
E-mail: [email protected]
Website: www.growingupwithus.com
Testing Center: www.growingupwithus.com/quiztaker/
Copyright © 2009 Growing Up With Us, Inc. All rights reserved.
Page 2 of 4
Name:_____________________________________________________
Date:___________________________________
Employee ID#:____________________________________________
Unit:____________________________________
POPULATION/AGE-SPECIFIC EDUCATION POST TEST
GROWING UP WITH US... Caring For Children July 2009 Competency: Demonstrates Age-Specific Competency by correctly answering 9 out of
10 questions related to Pediatric Medication Administration.
PEDIATRIC MEDICATION ADMINISTRATION
1. On admission, a child weighs 12 pounds 8 ounces. How many kg should be documented for weight?
a.
b.
c.
d.
5.68
5.82
27.5
28.16
2. Theodore, a 1 year old child who weighs 10 kg, has otitis media and is prescribed an antibiotic suspension.
The recommended dose is 40 mg/kg/day p.o. Theodore is prescribed antibiotic suspension 200 mg p.o.
BID for 10 days. The healthcare professional correctly verifies the dose ordered for Theodore is safe.
a. True
b. False
3. Theodore’s antibiotic suspension comes in a concentration of 400 mg/5 ml. How many ml should be given
to Theodore in the a.m.?
a.
b.
c.
d.
1.5
2.5
5
10
4. A 2 year old, Mark, has ear surgery. To prevent infection after the surgery, the physician writes an order for
Ciprofloxacin otic suspension 3 gtts A.S. BID. The healthcare professional should:
a.
b.
c.
d.
administer 3 gtts in the child’s left ear, with the child lying on his her unaffected side.
have the physician write out “left ear” in the order.
verify what A.S. means before administration.
put a cotton ball in the child’s ear, after administration, to prevent leakage of the drug.
5. When giving his ear medication, to straighten Mark’s external auditory canal, the pinna should be pulled up
and back.
a. True
b. False
Copyright © 2009 Growing Up With Us, Inc. All rights reserved.
Page 3 of 4
Name:_____________________________________________________
Date:___________________________________
Employee ID#:____________________________________________
Unit:____________________________________
POPULATION/AGE-SPECIFIC EDUCATION POST TEST
GROWING UP WITH US... Caring For Children PEDIATRIC MEDICATION ADMINISTRATION
6. Taylor, 8 months old, is to receive 0.3 ml of a drug orally. The healthcare professional prepares to
accurately measure the prescribed dose using which device?
a.
b.
c.
d.
tuberculin syringe
plastic medicine cup
3 cc syringe
5 cc syringe
7. Taylor resists opening his mouth. The healthcare provider should:
a.
b.
c.
d.
put the medication in his bottle, which only contains 2 ounces of formula.
mix the medication with a small amount of honey to disguise the taste.
put the medication in his baby food.
squirt the medication in a syringe along the side of his tongue.
8. Most children can typically first safely swallow solid forms of oral preparations by how many years of age?
a.
b.
c.
d.
2
3
5
8
9. Subcutaneous injections are appropriate for non-irritating drugs which are given in small doses, under 0.5
cc.
a. True
b. False
10. By what age do children usually have the physical ability to draw up and give themselves a subcutaneous
injection of insulin?
a.
b.
c.
d.
6
8
10
12
Copyright © 2009 Growing Up With Us, Inc. All rights reserved.
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