Editing Pediatric Nursing (section)

== Medication administration and weight-based dosing ==

Children receive doses individualized to '''body weight in kilograms''' or, for chemotherapy and some other agents, '''body surface area in square meters'''. Immature hepatic enzymes and reduced glomerular filtration in neonates prolong drug half-life; body water percentage is higher, which changes the volume of distribution of water-soluble drugs.

=== The safe dose calculation ===

The nurse's independent responsibility is to '''verify that the ordered dose falls within the safe range before administering it'''.

# Convert the weight to kilograms. '''Divide pounds by 2.2.''' Never estimate; obtain an actual measured weight, and document it in kilograms only, to prevent pound-kilogram mix-ups.
# Multiply the weight in kilograms by the reference safe dose range, noting whether the reference is stated '''per dose''' or '''per day in divided doses'''. Confusing these two is a common and serious error.
# Compare the calculated safe range with the ordered dose.
# If the order falls outside the safe range, '''hold the medication and contact the prescriber'''. Do not adjust a dose independently and do not simply administer it.
# Remember that a pediatric calculated dose should not exceed the usual adult dose.

'''Worked example.''' A child weighs 44 lb. The order reads amoxicillin 45 mg/kg/day by mouth divided every 12 hours; the suspension is 250 mg per 5 mL. 44 divided by 2.2 equals 20 kg. 20 x 45 equals 900 mg per day. Divided every 12 hours equals two doses, so 450 mg per dose. 450 divided by 250 equals 1.8; 1.8 x 5 mL equals '''9 mL per dose'''.

=== Common reference doses ===

* '''Acetaminophen:''' 10 to 15 mg/kg per dose every 4 to 6 hours, not more than 5 doses in 24 hours.
* '''Ibuprofen:''' 5 to 10 mg/kg per dose every 6 to 8 hours; '''not given to infants under 6 months''' without specific direction, and avoided in dehydration because of renal risk.
* '''Maintenance intravenous fluid (Holliday-Segar method):''' 100 mL/kg/day for the first 10 kg, plus 50 mL/kg/day for the second 10 kg, plus 20 mL/kg/day for each kilogram above 20.
* '''Fluid resuscitation bolus:''' 20 mL/kg of isotonic crystalloid.
* '''Digoxin:''' take an '''apical pulse for one full minute''' and hold the dose and notify the provider if the rate is below approximately '''90 to 110 in an infant, 70 in a child, or 60 in an adolescent'''. Early toxicity in children usually appears as '''bradycardia, vomiting, and anorexia'''. Do not repeat a dose that the child vomits.

=== Administration safety practices ===

* Use an '''oral syringe''' calibrated in milliliters. Household teaspoons are inaccurate and must never be used. Direct liquid toward the side of the mouth, slowly, to prevent aspiration.
* Use a leading zero (0.5 mg) and never a trailing zero (5.0 mg), which invites tenfold overdose.
* Perform an '''independent double check by two nurses''' for high-alert medications including insulin, opioids, heparin, chemotherapy, and any intravenous infusion in a neonate.
* Intramuscular site selection: the '''vastus lateralis''' is preferred for infants and young toddlers. The '''deltoid''' can be used in older children with adequate muscle mass. The dorsogluteal site is not used in children because of sciatic nerve risk.
* Never mix medication into a full bottle of formula or an essential food, because refusal or incomplete intake produces an unknown dose and can create food aversion.
* Do not describe medicine as candy.
* Volume-control infusion sets or syringe pumps are used for intravenous medications so that a child cannot receive an inadvertent fluid overload.