US Pharm. 2018;44(4):20-23. Show
ABSTRACT: Annually, more than 200,000 medication errors are reported to U.S. poison-control centers. Approximately 30% of these errors involve children. Dosing errors are the most common medication error. It is crucial for healthcare providers to ensure that the appropriate drug and dose are prescribed to children, especially neonates, because of their differences in response to drugs compared with adults. Understanding pediatric pharmacokinetics and stages of development can help providers more accurately prescribe medications for children and minimize dosing errors. Pharmacists can help prevent medication errors by checking dosing calculations, screening for drug-drug interactions, and counseling caregivers on proper administration and medication-storage safety tips. Drug safety is paramount in pediatric patients, owing to an alarming number of adverse events caused by medications. U.S. poison-control centers handle more than 200,000 cases of out-of-hospital medication errors annually, and children under 6 years old constitute approximately 30% of these cases.1 To clarify the differences between adverse events, adverse drug reactions, and medication errors, the National Coordinating Council for Medication Error Reporting and Prevention, the Institute of Medicine, and the World Health Organization have provided definitions of these drug-safety terms (see TABLE 1). Adverse drug reactions and adverse drug events occur once patient harm from a drug has occurred. All adverse drug reactions are adverse drug events; however, not all adverse drug events are caused by an error.2 Pediatric Pharmacokinetics and Developmental StagesThe process of drug absorption, distribution, metabolism, and elimination is referred to as pharmacokinetics.3 It is important to recognize differences in the factors that affect drug disposition in children. To help differentiate stages of development, pediatric patients are grouped according to age, as shown in TABLE 2.4 Depending on the patient’s stage of development, there are important age-related variations in pharmacokinetics.4 It is crucial that healthcare providers take particular care to ensure that the appropriate drug and dose are prescribed to children, especially neonates, because of the differences in their response to drugscompared with adults. Absorption: Several factors affect the absorption of drugs from the gastrointestinal tract, such as gastric-acid secretion, bowel length and absorptive surface, gastric emptying time, bile-acid formation, and microbial flora.The bioavailability of acid-labile drugs such as penicillin increases and the bioavailability of weakly acidic drugs such as phenobarbital decreases owing to reduced gastric-acid secretion. The bioavailability of lipophilic drugs such as diazepam lessens because of reduced bile-salt formation.3 The time a drug takes to reach therapeutic concentrations is increased in young infants due to prolonged gastric-emptying time. Alterations in intestinal flora that facilitate metabolism may affect absorption in the gut.3 Neonates and young infants have a thinner stratum corneum, and the ratio of surface area to weight is greater than in older children and adults; therefore, transdermal absorption may be enhanced.3,5 Distribution: The proportions of body water, fat, and muscle in pediatric patients differ throughout the stages of development. Therefore, providers must consider these differences because they can impact the dosing of drugs.4 Neonates and premature infants have a higher amount of water composition than adults, which affects the dosing of water-soluble drugs.On a milligram-per-kilogram basis, neonates require higher doses of water-soluble drugs compared with adults.4,5 As children grow older, lower doses are needed to avoid toxicity because there is a decline in water as a percentage of body weight.3 When drugs bind to proteins such as albumin, lipoprotein, and alpha-1 acid glycoprotein, the distribution of free drug throughout the body is limited. Neonates have decreased protein binding due to competitive binding by bilirubin and free fatty acids, which circulate in higher concentrations in neonates and infants. This may result in increased free drug concentrations, which can contribute to a higher frequency of adverse effects at lower drug concentrations.3 Metabolism: The most important system for drug metabolism is the CYP450 enzyme system in the liver and small bowel.3 Enzyme systems mature at different stages of development, and they may be absent at birth or exist at fairly reduced levels.5 Because the increase in metabolic rate in children is often greater than that in adults, children may require higher doses on a milligram-per-kilogram basis or more frequent dosing compared to adults.5 Elimination: The liver and kidney are the main organs that break down and eliminate drugs from the body. These organs mature with age. Therefore, drugs in neonates and infants are broken down and eliminated more slowly than in older children and adults.3 The bile and the kidney eliminate drug metabolites. Renal elimination of drugs depends on the glomerular filtration rate, renal blood flow, plasma protein binding, and tubular secretion.4 In the first 2 years of life, these factors are altered. At birth, renal plasma flow is low and reaches adult levels by the age of 1 year. The glomerular filtration rate is low at birth and increases to an adult level when the infant reaches age 3 to 5 months.3 Potential Causes of Medication ErrorsThere are a host of factors from which medication errors can derive. Illegible prescriptions, abbreviations in prescriptions, language barriers, lack of communication skills, tiredness, and multiple drug combinations are some of the major factors leading to medication errors. Children with multiple prescriptions are at risk for preventable adverse drug events. Dosing errors, such as incorrect dosage or frequency of administration and either underdosing or overdosing, are common medication errors. Other errors include inappropriate medication selection for the indication, incorrect route of administration, failure to screen drug interactions or monitor side effects, and lack of communication between members of the healthcare team.6 The Pharmacist’s RolePharmacists are able to intercept and prevent medication errors by checking the dosing to ensure the accuracy of a prescription. Pharmacists can provide medication counseling to caregivers regarding the medication’s use, proper administration, potential side effects, and adverse effects; they can also provide general medication-safety tips. Studies have shown that in low-income populations, medication errors are more prevalent because potentially inadequate or marginal literacy can lead to the misunderstanding of medication-dosing instructions.6 Pharmacists and pharmacy technicians should obtain a patient’s age and weight at every visit. Children’s weight frequently changes, and drug doses are calculated based on milligram per kilogram. It should be noted that even in very large children, the highest dose should not exceed the maximum adult dose.4 Healthcare providers should consult pediatric references such as LexiComp, Micromedex, Harriet Lane, and NeoFax. In reference to children with renal failure, a good source of renal dosing is Drug Prescribing in Renal Failure. Also, for pregnant and lactating mothers, Drugs in Pregnancy and Lactation—a reference guide to fetal and neonatal risk—should be consulted. Pharmacists should keep in mind the following counseling and medication-safety points7-11: • When dispensing medications for pediatric
patients, always include any appropriate auxiliary labels. Common labels such as Shake well, Refrigerate, Take with food, Avoid sunlight, and Wear sunscreen serve as reminders to caregivers. ConclusionMedication errors in pediatric patients can lead to unwanted adverse events and reactions. It is important for physicians, pharmacists, and other healthcare providers to be aware that children need special dosing considerations and careful monitoring because their bodies are in different stages of development compared with adults. Pharmacists are in the position to counsel parents and caretakers about proper medication administration and storage. Communication between all persons involved in the care of pediatric patients will yield a better outcome. REFERENCES1. American Academy of Pediatrics. Every 8 minutes a child experiences an out-of-hospital
medication error. www.aap.org/en-us/about-the-aap/aap-press-room/Pages/Every-8-Minutes-a-Child-Experiences-an-.aspx. Accessed January 5, 2019. To comment on this article, contact . What is the most important reason that medication should be placed out of reach of small children quizlet?What is the most important reason that medication should be placed out of reach of small children? They are likely to put the medication in their mouths. Which of the following is NOT a reason that a pediatric office needs a bigger reception area? Patients are smaller.
Which of the following are requirements of a biohazard label?The biohazard label must be fluorescent orange or red-orange and clearly display the word “biohazard” and the universal biohazard symbol in a contrasting color (usually black). Apply labels as close as possible to the container with an adhesive, wire, string, or other method.
Which of the following is an example of reading materials that should not be placed in reception area?Professional journals and newsletters, however, should not be placed in the reception area.
Which of the following is a general precautions to take when preparing to work with a chemical?Which of the following is a general precaution to take when preparing to work with a chemical? Always carry chemical containers with both hands. What is the proper way to smell a chemical, if required?
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