A four-year-old, two syrup strengths and an aspirin suggestion
A four-year-old boy weighing 15 kg is brought to the dispensary of a rural PHC at 6 p.m. with fever of 39.2°C, sore throat and tonsillar exudate. The medical officer has written: "Amoxicillin dry syrup 125 mg/5 mL - 5 mL three times a day for 5 days" and "Paracetamol syrup 250 mg/5 mL - 5 mL SOS, maximum 4 doses in 24 hours". The mother says she gave one teaspoonful of the paracetamol syrup about 3 hours ago and the child still feels hot. In the cupboard you find only amoxicillin dry syrup 250 mg/5 mL; the paracetamol 250 mg/5 mL is in stock. A nursing attendant, seeing the high fever, suggests giving half a tablet of adult aspirin (300 mg) to bring it down quickly, and adds that "one extra paracetamol won't harm, the fever is high".
1. Calculate the correct paracetamol dose and volume for this child and decide whether another dose should be given now. Show your working.
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Dose: standard paediatric paracetamol is 15 mg/kg per dose. 15 kg × 15 mg/kg = 225 mg per dose.
Volume: the syrup is 250 mg in 5 mL, i.e. 50 mg/mL. 225 ÷ 50 = 4.5 mL per dose.
Ceiling check: 4 doses × 225 mg = 900 mg = 60 mg/kg/day, which is exactly the maximum, so no more than four doses in 24 hours.
What the mother gave: one teaspoonful is roughly 5 mL = 250 mg = about 16.7 mg/kg. That is within the per-dose range, so she has not overdosed - but a household teaspoon can hold anywhere from 3 to 7 mL, which is why the volume must be measured.
Decision now: the last dose was only 3 hours ago, and doses must be at least 4–6 hours apart. Do not give another dose now. Give tepid sponging, offer fluids, recheck the temperature in 30–60 minutes, and give the next dose no earlier than 6 hours after the previous one. Record the clock time of every dose on the bottle label and the card. Dispense with the 5 mL measure or an oral syringe and show the mother the 4.5 mL mark. Fever persisting beyond 3 days, or drowsiness, rash or poor intake, needs medical review.
2. The prescribed amoxicillin strength is not in stock. What are your options, which do you choose, and why is a silent substitution dangerous?
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What the prescription means: 5 mL of 125 mg/5 mL = 125 mg per dose, three times daily = 375 mg/day = 25 mg/kg/day, a standard dose for streptococcal tonsillitis.
What the stock contains: 250 mg/5 mL, i.e. 50 mg/mL. To deliver 125 mg from this bottle the volume is 125 ÷ 50 = 2.5 mL, not 5 mL.
The danger: if the same 5 mL spoon is used with the stronger bottle, the child receives 250 mg per dose - double the intended dose, 750 mg/day (50 mg/kg/day). One dose may be tolerable; five days of it is a real overdose risk and, more importantly, shows a system that permits strength confusion.
Correct action: (1) Do not dispense silently. Ring the prescribing medical officer, state the mismatch and ask for a written revised prescription. (2) If authorised, label clearly: "Amoxicillin 250 mg/5 mL - give 2.5 mL three times daily", with both mg and mL written. (3) Demonstrate with an oral syringe and ask the mother to repeat it back. (4) Record the prescriber's name, the change and the counselling in the register. (5) Never write "as directed".
If the medical officer cannot be reached and the child is not severely ill, the safer option is to obtain the correct strength or refer, rather than improvise a dose the prescription does not support.
3. How do you respond to the suggestion of aspirin, and what would you say to the attendant and the mother?
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Refuse the aspirin. Aspirin is avoided in children under 12 with febrile illness because of Reye's syndrome - acute encephalopathy with fatty infiltration of the liver, often fatal. Half a 300 mg tablet would be 150 mg (10 mg/kg) for this child, but the concern is the drug itself in a febrile child, not the dose.
The "extra paracetamol" suggestion is also refused: the child has had a dose 3 hours ago and the interval and daily maximum are already known. A second antipyretic now creates double dosing, confusion about timing and a genuine risk of exceeding 60 mg/kg/day.
What to say to the attendant: explain that high fever is not treated by adding drugs faster; it is treated by the correct dose at the correct interval, plus sponging and fluids. If a second agent is ever needed, it is ibuprofen 10 mg/kg (150 mg) - and only after medical review, in a child over 6 months who is well hydrated and has no renal disease, bleeding problem or dehydration.
What to say to the mother: in simple words - "the medicine you gave was the right amount, but you must not give more until 6 hours have passed; aspirin is not safe for children." Check she understands, and write the times and volumes on the bottle.