Medications in pediatrics

Atropine
• Treatment of sinus pulseless electrical activity,
bradycardia, or asystole..
Neonates and children: 0.02mg/kg
intratracheal (max: 0.5mg); may repeat5min later, one
time
Cardiac pacing is required in neonates with ventricular
rates of 50 beats/min or experience heart failure after
birth. to increase the heart rate temporarily until
pacemaker placement can be arranged
 Preoperative medication to inhibit secretions and
salivation
• Antidote to organophosphate poisoning.
0.02–0.05 mg/kg every 10–20min until atropine effect is seen
then q1–4h for at least 24hr.

Cautions: gastrointestinal obstruction,
thyrotoxicosis, and tachycardia.
Adverse events: Tachycardia, palpitations, delirium,
ataxia, dry hot skin, tremor, urinary retention

Epinephrine
Indications: Treatment of cardiac arrest,
bronchospasm, anaphylactic reaction
 For asystole or for failure Epinephrine (0.1–
0.3mL/kg of a 1:10,000 solution, intravenously or
intratracheally) is given to respond to 30sec of
combined resuscitation. The dose may be repeated
every 5 min
Routes- IV, intratracheal, continuous infusion and
nebulisation

Adverse events:
Tachycardia, hypertension, nervousness, restlessness,
irritability, headache, tremor, weakness, nausea,
vomiting, acute urinary retention.
Peripheral soft tissue damage if they extravasate from
peripheral lines into the local tissues

Hydrocortisone
• Indications: Status asthmaticus, shock
[50mg/kg/dose 4h],Treatment of adrenal
insufficiency, congenital adrenal hyperplasia,
• Caution: Abrupt withdrawal -acute adrenal
insufficiency.
• Adverse events: Hypertension, hyperglycemia,
hypokalemia, euphoria, insomnia, headache, Cushing
syndrome, peptic ulcer, cataracts,
immunosuppression, skin and muscle atrophy, acne,
edema.

Status asthmaticus

Oxygen inhalation +
adrenaline/terbutaline inj

inhalation salbutamol+ if not
ipratropium and loading dose theophylline
hydrocortisone (10mg/kg)
improve

continue terbutaline inj[20-
30min]
hydrocortisone 5mg/kg 6-8
hrly

Anaphylactic shock
Consider when compatible history of severe allergic-type reaction with
respiratory difficulty and/or hypotension especially if skin changes present

Oxygen treatment when available

Stridor, wheeze, respiratory distress
or clinical signs of shock [1]

Adrenaline (epinephrine) [2,3] 1:1000 solution
0.5 mL (500 micrograms) IM

Repeat in 5 minutes if no clinical improvement

Antihistamine (chlorphenamine)
10-20 mg IM/or slow IV

IN ADDITION

For all severe or recurrent reactions and If clinical manifestations of shock do not
patients with asthma give respond to drug treatment give 1-2 litres IV
Hydrocortisone fluid. [4] Rapid infusion or one repeat dose
100-500 mg IM/or slowly IV may be necessary

Dopamine
• Indication: hypotension and shock
• 1–20μg/kg/min IV
• Adverse events: Tachycardia, ectopic beats,
ventricular arrhythmias, tissue necrosis with
extravasation, vasoconstriction, gangrene of
extremities, excess urine output (doses <5μg/kg/min),
oliguria (doses 10μg/kg/min).

Dose microgm/kg/min

Strengthens throughout dose 1-5
contractions range

Increases renal blood Low/intermediate 5-15
flow doses

Vasocontriction High dose 15-25

Furosemide
Indications: Pulmonary edema-cardiac failure,
SIADH, reduction of ICT in combination with
mannitol, broncho-pulmonary dysplasia
Adverse events: Dehydration, electrolyte loss,
hyperuricemia, photosensitivity, ischemic hepatitis,
hypercalciuria, renal stones, ototoxicity (IV infusion
rate >4mL/min), gastrointestinal intolerance

Heart failure. It inhibits the reabsorption of
sodium and chloride in the distal tubules and the
loop of Henle.
Acute diuresis should be given intravenous or
intramuscular furosemide at an initial dose of 1–
2mg/kg, which usually results in rapid diuresis
.Chronic furosemide therapy is then prescribed at
a dose of 1–4mg/kg/24hr given between one and
four times a day

 Careful monitoring of electrolytes is necessary
with long-term furosemide therapy because of the
potential for significant loss of potassium.
 Potassium chloride supplementation is usually
required unless the potassium-sparing diuretic
spironolactone is given concomitantly.
When furosemide is administered every other
day, dietary potassium supplementation may be
adequate to maintain normal serum potassium
levels

Digoxin
• Indications :Treatment of systolic heart failure and
supraventricular tachyarrhythmias
• Cautions: Contraindicated in AV block, idiopathic
hypertrophic subaortic stenosis,or constrictive
pericarditis
• Adverse events: Anorexia, nausea, vomiting,
diarrhea, feeding intolerance,bradycardia,
arrhythmias, lethargy, depression, vertigo, blurred
vision, diplopia, photophobia, yellow or green vision

The drug crosses the placenta, and therefore a fetus
with heart failure(secondary to arrhythmia) can be
treated by administering digoxin to the mother.
The kidney eliminates digoxin, so dosing must be
adjusted according to the patient'srenal function.

Digoxin in heart failure
Rapid digitalization of infants and children in heart
failure may be carried out intravenously. The
recommended schedule is to give half the total digitalizing
dose immediately and the succeeding two one-quarter
doses at 12hr intervals later.
Maintenance digitalis therapy is started approximately
12hr after full digitalization. The daily dosage is divided in
two and given at 12hr .The dosage is one quarter of the
total digitalizing dose
Slow digitalization –patient not critically ill or initiation
of a maintenance digoxin schedule without a previous
loading dose .full digitalization in 7–10 days

Monitoring:
• Dosing should be guided by measuring serum digoxin
concentrations: therapeutic: 0.8–2ng/mL; toxic: >2–
2.5ng/mL.
• DLIS - elevate digoxin levels, so pretreatment digoxin
levels can be obtained and subtracted from treatment
levels or samples can be run through a free-level filter to
remove DLIS before assay.
• Check post-distribution levels (drawn at least 6–8hr post
dose) at steady-state (2–4 wk) or if ECG or clinical signs of
toxicity. Check ECG, serum electrolytes, calcium, and
magnesium.

Digoxin Immune Fab
Treatment of digitalis intoxication from digoxin
 Dose is based on amount of digoxin ingested or
estimated total body load based on post-distributive
serum concentration
Adverse events: Worsening of heart failure or atrial
fibrillation, hypokalemia, facial swelling, and redness.

Naloxone
• Indication: opiate excess(overdose, poisoning).
• Neonates and children: 0.1mg/kg IV (max dose: 2mg).
If no response, repeat q 2–3min until desired effect.
May give by continuous IV infusion
• Adverse effects May precipitate acute opiate
withdrawal. Duration of effect of many opiates may
be longer than naloxone requiring individualized
naloxone dosing.

Phenytoin
• Indications: Anticonvulsant and antiarrhythmic.
• Status epilepticus:

mg/kg IV Loading dose Maintenance dose

Neonates 15-20 5

Children 15-18 .5-6yr 8-10

7-9yr 6-8

10-16yr 6-7

Cautions:
Infuse slowly IV; variable oral bioavailability;
chewable tablet most consistent. Must shake oral
suspension very well before use.
Certain disease states (renal failure, acute head
trauma) may lead to imbalance between free and
protein-bound drug.
Fosphenytoin has advantages over the older
formulation - it is water soluble, less irritating after IV
injection, and well absorbed after intramuscular
injection

• Adverse effects: Lethargy, dizziness, nystagmus,
hypotension, hirsutism, gingival hyperplasia, rash,
Stevens-Johnson syndrome, hepatitis, thrombophlebitis.
• Drug interactions:
May increase metabolism of certain hepatically cleared
drugs; griseofulvin, corticosteroids, cyclosporin;
Highly protein boundand may cause displacement
interaction.
• Monitoring: Phenytoin concentrations: therapeutic 8–
20μg/mL.

Phenobarbitone
Indications: anticonvulsant,sedative, hypnotic,
anesthetic, hyperbillubinemia
Anticonvulsant
loading dose Children:15 -20mg/kg PO, IV.
Maintenance dose
Neonates: 3–4mg/kg, Children: 5–
6mg/kg/24hr PO, IV, q12–24h.

• Cautions: Dose titrated to desired effect. Administer IV
=30mg/min
• Adverse effects: Hypotension, drowsiness, respiratory
depression, paradoxical hyperactivity
• Drug interactions:
May increase metabolism of many hepatically cleared
drugs; griseofulvin, corticosteroids.
Certain drugs may interfere with phenobarbital
metabolism: valproic acid, chloramphenicol, felbamate.
.

Potassium chloride
Indications:
- Hypokalemia
< 2.5meq/l, cardiac rhythm disturbances
40mEq/L @ 0.6 mEq/kg/hr under continuous
EEG monitoring
- Tachyarrhythmias – chronic use of digoxin[max
100m mol)

 Chloride responsive metabolic alkalosis , as a
component of mantainance fluids[10/20 meq/l],
bronchopulmonary dysplasia ( with
hydrochlorothiazide), supplementation (with
furosemide in heart failure with digoxin), nonketotic
hyperosmolar coma
Adverse effects : Hyperkalemia, gastritis

Sodium bicarbonate
• Presence of a severe metabolic acidosis(1mEq/kg,) as
documented by arterial blood gas analysis and during
a prolonged resuscitation when it may be given every
10 min during the arrest
• Symptomatic hyperkalemia(>7meq/L),
hypermagnesemia, tricyclic antidepressant drug
intoxications, or with adverse events due to sodium
channel blocking agents
• Alkalinization of urine with sodium bicarbonate
increases effectiveness of aminoglycosides against in
the urinary tract

Alkali therapy may result in hypernatremia, skin
slough from infiltration, increased serum osmolarity,
hypocalcemia, hypokalemia,
 Liver injury when oncentrated solutions are
administered rapidly through an umbilical vein
catheter wedged in the liver

Calcium gluconate
Hyperkalemia- counteracts the potassium-induced
increase in myocardial irritability Calcium
gluconate 10% solution, 1.0mL/kg IV, over 3–5 min
Neonatal tetany consists of intravenous injections of
5–10mL of a 10% solution of calcium gluconate at the
rate of 0.5–1mL/min while the heart rate is monitored.

Symptomatic hypocalcemia in neonates, calcium
gluconate is given at a dose of 100–200mg/kg (1–
2mL/kg of a 10% solution).dose may be repeated
every 6–8hr until the calcium level stabilizes
Alternatively, intravenous infusion can be given
 Adverse effects :hypercalcemia

Medications in pediatrics

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