Pharmacology and Medication Safety in Pediatrics
Medication items are calculation-heavy and safety-heavy. The exam expects weight-based accuracy, recognition of unsafe orders, and pediatric-specific contraindications.
Core rules
- Dose in mg/kg (or units/kg); chemotherapy may use body surface area in m².
- Weigh in kilograms only; never convert from pounds mentally at the bedside.
- Verify the safe dose range against a pediatric reference before giving; call the prescriber if the ordered dose falls outside it.
- Use an oral syringe marked in mL; never household teaspoons.
- Two-nurse independent double-check for high-alert drugs: insulin, heparin, opioids, chemotherapy, concentrated electrolytes, and any infusion in a neonate.
Pediatric-specific pharmacology
- Acetaminophen 10–15 mg/kg/dose every 4–6 h, maximum 75 mg/kg/day (not to exceed 4 g/day).
- Ibuprofen 10 mg/kg/dose every 6–8 h, only after 6 months of age.
- Codeine and tramadol are contraindicated under 12 years and after tonsillectomy under 18 (CYP2D6 ultrarapid metabolism).
- Avoid aspirin under 16–18 years because of Reye syndrome.
- OTC cough and cold products are not recommended under 4 years and not for 4–6 without prescriber advice.
- Therapeutic monitoring: vancomycin (AUC), aminoglycosides (peak/trough), phenytoin, digoxin.
Worked example
Order: acetaminophen 15 mg/kg PO every 6 h for a 12 kg child. Safe single dose = 180 mg; the ordered 160 mg is within range and below the 75 mg/kg/day ceiling. Available as 160 mg/5 mL, so give 5 mL by oral syringe. Document the weight used and the source you verified against.
Traps
- Decimal point errors - always use a leading zero (0.5, not .5).
- Splitting an adult tablet for a child.
- Failing to check the daily maximum when doses run around the clock.
- Giving ibuprofen to a 3-month-old.