7- physiological principles and medication in childhood

When prescribing drugs what must you consider?

Diagnosis

Risk-benefit

Natural history of disease

Long term effects- children have more time for adverse effects to appear

What must you consider when selecting a drug for children?

Formulation- ease of admin, routes available, taste and excipient- may be allergic to an excipient

Cost, acceptability, safety

Concentration, site specific toxicity- IM injections with viscous prep into blood

One a drug is selected, what must the clinician decide on?

Dose regimen-

Dose

Formulation

Route of administration

Frequency and duration of therapy- effects response, product selection, quantity, compliance and cost

What differs in dosage between paediatrics and adults?

Majority not ‘one dose fits all’

Must calculate based on body weight, surface area, developmental stage, metabolic rates, concomitant meds, physiological function- these all rapidly change in children

Less than 40kg, below 12 yrs

What are some concerns in route of administration in children?

Slow intravenous infusion rates

Low muscle mass

Skin absorption

Lack of anal sphincter control

Rapid GI transit

Poor compliance

What are the components of good prescription writing?

Do important instructions

Don’t use confusing abbreviations

Indicate duration of use

Why is pain assessment is an integral component of dental history and evaluation?

Undertreatment can amplify future pain experience

If have established dental care- better access for acute and chronic orofacial pain

Ranges from non pharmacological to pharmacological treatment

What does non pharmacological vs pharmacological therapy include?

Maintain calm environment, deep breaths, guided imagery, distraction, play therapy, hypnotherapy

Admin topical and local anesthesia, analgesics, sedation regimes

When should antibodies be prescribed?

Truly needed for bacterial infection- adjunct to interventions implemented to control infection source

Select based on agent properties- spectrum of coverage, safety, previous ATB use, patient considerations

IV vs IM vs Oral

Minimal duration- 5 days beyond substantial improvement

Amoxicillin

Suspension, chewable tablet, tablet, capsule

40-80 mg/kg/day x 8hrs

Endocarditis- 50mg/kg (max 2g) 30-60 mins before

Amoxicillin clavulanate potassium

Same as amoxicillin

Lowest dose of clavulanate combined with amoxicillin available to decrease GI adverse drug effects

Azithromycin

tablet, capsule, suspension, injectable

10 mg/kg/day every 24 hours. 500mg in adult

Endocarditis- 15mg/kg (max 500 mg) 30-60 minutes before

Option if type no allergy to penicillin or cephalosporin ATB

But can chase arrhythmias in patients with pre existing cardiac conduction defects

Cephalexin

Suspension, tablet, capsule

25-50mg/kg/day x 6hrs. 250-1000mg in adults (4g max a day)

Endocarditis- 50mg/kg (max 2g)

Not of history of anaphylaxis, angioedema or urticaria with penicillin or ampicillin

Clarithromycin

Suspension or tablet- 15mg/kg/day x 12 hrs. 500mg every 12 adults

Endocarditis- 15mg/kg (max 5g) NOT REC

OR

Suspension, capsule, injection- 20-30mg/kg/day every 6-8hrs

Adults 300-450mg (max 1.8g day)

Option for penicillin allergy. Effective for infections with gram + aerobic bacteria or any anaerobic

Clostridioides difficile colitis is a serious adverse reaction with this antibiotic

Metronidazole

Tablet, tablet extended release, capsule, injectable

30mg/kg/day every 6-8hrs

Good coverage for anaerobic bacteria

Avoid alcohol even in meds

Fluconazole

Suspension, injectable

Infants, children and adolescents: Single dose of 6-12 mg/kg/dose one time daily for 7-14 days

Adults: Loading dose of 200 mg on day 1, then 100-200 mg/dose one time daily for 14 days

Needs acidic ph in stomach so meds that increase gastric ph causes decreased absorption

Clotrimazole- topical for angular cheilitis

Cream 1%

Thin layer to corners of mouth 2-4x daily for 7-14 days

Clotrimazole- transmucosal or topical agents for candidiasis

Lozenge 10mg

Not for under 3 yrs

Dissolve 1 troche 5 x daily for 14 days

Miconazole nitrate- topical

Cream 2%

Children >2 years and adults- a thin layer to the corners of the mouth 2-4 times daily 7-14 days or until complete healing.

Miconazole nitrate- topical or transmucosal agent for candidiasis

Buccal tablet 50mg (contains milk protein conc)

Over 16yrs- 1 tablet for 14 days- apply to gum region above ULI

Nyastatin- topical

Cream (100,000 units/g)

Thin layer to corners of mouth 2-4 times daily for 7-14 days or until

complete healing

Nystatin- topical or transmucosal agent for candidiasis

Suspension 100,000units/mL

Infants- 200,000 - 400,000 units (2-4 mL) 4 times daily, for 7-14 days

Children and adults- Swish 400,000-600,000 units (4-6 mL) 4 times daily for several minutes and swallow, continue at least 48 hours after symptoms resolve. Use for 7-14 days.

Acyclovir- systemic agent for primary herpetic gingivostomatitis

Forms: Suspension 200 mg/5 mL; tablets 400 mg, 800 mg; capsules 200 mg; injectable 50 mg/mL

Usual dosage:

• Infants, children and adolescents: 15-20 mg/kg/dose 4 times daily for 5-7 days (maximum 800 mg/dose)

• Immunocompromized children: 20 mg/kg/doses 4 times daily for 7-10 days

• Immunocompromized adolescents: 400 mg 3 times daily for 10 days or until resolution

• Adults: 400 mg 3-5 times daily for 5-10 days

Topical agents for herpes labialis

Docosanol (Abreva®– over-the-counter agent)

Form: Cream 10%

Usual dosage:

• Children ≥12 years and adults: Apply a thin layer on the lesion 5 times daily for up to 10 days.

Acyclovir

Form: Cream 5%

Usual dosage:

• Children ≥12 years and adults: Apply a thin layer on the lesion 5 times daily for 4 days.

Acyclovir with hydrocortisone (Xerese®)

Form: Cream (5% acyclovir with 1% hydrocortisone)

Usual dosage:

• Children ≥ 6 years and adults: Apply a thin layer on the lesion 5 times daily for 5 days.

Penciclovir

Form: Cream 1%

Usual dosage:

• Children ≥12 years and adults: Apply a thin layer on the lesion every 2 hours while awake for 4 days.

Topical corticosteroids for aphthous ulcers

Triamcinolone acetonide medium potency corticosteroid

Form: Dental paste or ointment 0.1%

Usual dosage:

• Children, adolescents and adults: Apply paste to ulcers 2-4 times daily, after meals and at

bedtime; not to exceed 7 day course. Avoid eating or drinking for 30 minutes after

application

Fluocinonide high potency corticosteroid; not FDA-approved for oral application

Form: Gel, ointment 0.05%

Usual dosage:

• Adolescents and adults: Apply thin amount of gel or ointment to ulcers 2-4 times daily; not to exceed 7 day course.

Clobetasol super-high potency corticosteroid; not FDA-approved for oral application

Form: Gel, ointment 0.05%

Usual dosage:

• Adolescents and adults: Apply thin amount of gel or ointment to ulcers 2-4 times daily, not to exceed 7 day course.