Neonates and pediatric patients

The combination of a prokinetic agent and acid-suppressing drug is used commonly in pediatric patients with GERD.27 Monotherapy with an H2RA is also used frequently ranitidine 2 to 4 mg/kg/day is effective in neonates and pediatric patients. 

Several commercially available CAA solutions are designed to provide conditionally essential amino acids (CEAAs). CEAAs are considered nonessential during health because they are produced from other amino acids. However, under certain physiologic conditions such as prematurity or sepsis, these amino acids cannot be synthesized in sufficient quantities. CAA solutions specifically designed for use in neonates and pediatric patients contain increased amounts of taurine, aspartic acid, and glutamic acid. Other CEAAs, such as cysteine, carnitine, and glutamine, are not available in commercial CAA solutions in pharmacologic amounts because they are relatively unstable or poorly soluble. ... 

Nosocomial lower respiratory tract infections (LRI) represent a significant concern to those caring for hospitalized infants and children because of both their frequency and their potential severity. Pneumonia is the second most common nosocomial infections in all patients hospitalized in the United States regardless of age (1,2). Data from the National Nosocomial Infections Surveillance (NNIS) System documents that nosocomial pneumonia is the second most frequent hospital-acquired infection in critically ill infants and children as well (2,3). Many of the significant risk factors for the development of nosocomial pneumonia previously identified in adult patients, such as severe underlying cardiopulmonary disease, immunosuppression, depressed sensorium, and prior thoracoabdominal surgery, are present in pediatric patients and place them similarly at risk for nosocomial lower respiratory tract infections. In addition, there are specific clinical situations that are unique for neonatal and pediatric patients that provide additional risks for severe nosocomial lower respiratory tract infections (Table 1). 

Even if a medication is available in multiple formulations and dosage forms, the prescriber must consider the absorption and distribution differences between adult and pediatric patients. Blood supply at injection or infusion site, available blood supply for unit muscle mass, and skeletal muscle mass relative to body mass vary with patient age and size, causing drug absorption to vary, as well. A rapid intravenous bolus in a pediatric patient might result in acute toxicity a slow intravenous infusion, often required in neonates, can cause erratic, unreliable drug delivery in an older child. In addition, the volume of fluid tolerated for intravenous delivery varies significantly with the age and size of the patient. The blood supply and blood flow to and from the injection site are of prime importance since a gradual decrease in blood supply per unit muscle mass is seen with maturation. In addition, the skeletal muscle mass relative to... 

Once-daily regimens are safer with equal efficacy, cost less, and are administered more easily. Exceptions include use in pregnancy, neonatal and pediatric infections, cmd low-dose combination therapy of bacterial endocarditis. Once-daily dosing also should be avoided in patients with creatinine clearances of <20-25 mL/min, where dosing every 48 hours is more appropriate. 

ECMO is considered a standard therapy for the treatment of respiratory failure in neonatal patients (Anderson and Bartlett, 2000). In adult and pediatric patients, it is a treatment of last resort for individuals who would otherwise die despite maximal therapy (Anderson and Bartlett, 2000 Bartlett et al., 2000). Even in neonatal cases, ECMO is a therapy reserved for those patients with severe respiratory compromise and a high risk of death who are failing traditional ventilator-based interventions. Common causes of respiratory failure in the neonatal population that are treatable with ECMO support include pneumonia or sepsis, meconium aspiration syndrome, respiratory distress syndrome, persistent fetal circulation, and congenital diaphragmatic hernia (Anderson and Bartlett, 2000). Contraindications to ECMO support include root causes that are unresolvable, such as a major birth defect or genetic abnormality, and comorbid conditions such as intracranial hemorrhage or fetal underdevelopment that suggest a poor outcome (Anderson and Bartlett, 2000). Indications for ECMO use in the pediatric and adult populations are not dissimilar from those of the neonate, but... 

Neonatal and Pediatric Intensive Care Unit Patients... 

Drug absorption is highly variable in neonates and infants [21,22]. Older children appear to have absorption patterns similar to adults unless chronic illness or surgical procedures alter absorption. Differences in bile excretion, bowel length, and surface area probably contribute to the reduced bioavailability of cyclosporine seen in pediatric liver transplant patients [22a]. Impaired absorption has also been observed in severely malnourished children [22b]. A rapid GI transit time may contribute to the malabsorption of carbamazepine tablets, which has been reported in a child [23]. Selection of a more readily available bioavailable dosage form, such as chewable tablets or liquids, should be promoted for pediatric patients. 

Children Safety and efficacy have not been established in pediatric patients younger than 6 years of age. Sodium ferric gluconate complex contains benzyl alcohol therefore, do not use in neonates. 

Children-The recommended dose in pediatric patients is for a total daily dose of 2 to 4 mg/kg, to be divided and administered every 6 to 8 hours up to a maximum of 50 mg given every 6 to 8 hours. Limited data in neonatal patients (under 1 month of age) receiving extracorporeal-membrane oxygenation (ECMO) have shown that a dose of 2 mg/kg is usually sufficient to increase gastric pH to greater than 4 for at least 15 hours. Therefore, consider doses of 2 mg/kg given every 12 to 24 hours or as a continuous infusion. 

Patients younger than 3 months of age - The half-life was about 13 hours. In neonates 14 days of age or less, bioavailability was greater, total body clearance was slower, and half-life was longer than in pediatric patients more than 14 days old. 

Developmental differences in drug absorption between neonates, infants and older children are summarized in Table 1. It must be recognized that the data contained therein reflect developmental differences which might be expected in healthy pediatric patients. Certain conditions and disease states might modify the function and/or structure of the absorptive surface area(s). GI motility and/or systemic blood flow can further impact upon either the rate or extent of absorption for drugs administered by ex-travascular routes in pediatric patients. 

The plasma clearance of theophylline varies widely. Theophylline is metabolized by the liver, so usual doses may lead to toxic concentrations of the drug in patients with liver disease. Conversely, clearance may be increased through the induction of hepatic enzymes by cigarette smoking or by changes in diet. In normal adults, the mean plasma clearance is 0.69 mL/kg/min. Children clear theophylline faster than adults (1-1.5 mL/kg/min). Neonates and young infants have the slowest clearance (see Chapter 60 Special Aspects of Perinatal Pediatric Pharmacology). Even when maintenance doses are altered to correct for the above factors, plasma concentrations vary widely. 

JOB REQUIREMENTS Ability to work independently with minimal direct supervision. Ability to work with hospital and pharmacy staff. Ability to handle frequent interruptions and adapt to changes in workload and work schedule. Ability to set priorities, make critical decisions, and respond quickly to emergency requests. Ability to exercise sound professional judgement. Ability to meet the pharmaceutical care needs of neonatal, pediatric, adolescent, adult, and geriatric patients. 

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