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Pharmacotherapy - Pediatrics

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by أحمد الجويلى on 2 January 2013

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Transcript of Pharmacotherapy - Pediatrics

Sepsis / Meningitis Otitis media RSV infection ADHD Pediatric
disorder Immunization Signs & symptoms Early Vs Late Sepsis CSF findings Common pathogens Potential antibiotic
regimens Sequelae of Meningitis Chemoprophylaxis Neonates Children Lethargy Grunting Flaring retractions apnea Temperature instability Bulging fontanelle Seizures Feeding intolerence Fever Loss of appetite Emesis Myalgias Arthralgias Cutaneous manifestations petechiae


rash nuchal rigidity back pain kernig sign Brudzniski sign Headache Photophobia Altered mental status Seizures confusion / amnesia / poor judgment / poor regulations of emotions Ampicillin + Cefotaxime / Gentamicin Ampicillin + Cefotaxime / Ceftriaxone Ceftriaxone + or - Vancomycin Ceftriaxone + or - Vancomycin 1. Hearing loss
2. Mental retardation/learning defcits
3. Visual impairment
4. Seizures
5. Hydrocephalus Prevent the spread of
H. infuenzae &
Neisseria meningitidis Household contacts Nursery or day care center contacts Direct contact with
index patient’s secretions Definitions Risk factors Common
Pathogens Treatment Prophylaxis Acute otitis media Otitis media w' effusion Recurrent acute otitis media 3 : in 6 months 4 : in 1 year Fluid in the middle ear without evidence of local or systemic illness indicated by erythema of tympanic memb. or otalgia may be indicated by :
- bulging tympanic membrane
- dec. or no mobility of it
- purulent fluid Effusion Inflammation Day-care attendance Craniofacial abnormalitis / Cleft palate Family history of acute OM Bottle-feeding Lower Socio-economic status Smoker parents 1. Viral
2. S. pneumoniae
3. Nontypeable H. infuenzae
4. Moraxella catarrhalis Haemophilus influenzae, formerly called Pfeiffer's bacillus or Bacillus influenzae, is a Gram-negative, rod-shaped bacterium first described in 1892 by Richard Pfeiffer during an influenza pandemic. A member of the Pasteurellaceae family, it is generally aerobic, but can grow as a facultative anaerobe.

H. influenzae was mistakenly considered to be the cause of influenza until 1933, when the viral etiology of the flu became apparent; the bacterium is known as bacterial influenza. Still, H. influenzae is responsible for a wide range of clinical diseases.

H. influenzae was the first free-living organism to have its entire genome sequenced. The sequencing project was completed and published in 1995. Moraxella catarrhalis is a fastidious, nonmotile, Gram-negative, aerobic, oxidase-positive diplococcus that can cause infections of the respiratory system, middle ear, eye, central nervous system, and joints of humans. It causes the infection of the host cell by sticking to the host cell using a Trimeric Autotransporter Adhesins (TAA).

These bacteria are known to cause otitis media, bronchitis, sinusitis, and laryngitis. General Principles Clinical resolution will occur in a signifcant number of cases without antibiotic therapy. Immediate antibiotic therapy is warranted for acute OM with perforation or bulging tympanic membrane Delayed antibiotic therapy (i.e. treatment only if otalgia or fever persists for more than 2-3 days) is good if child is > 2 years old with acute OM without severe symptoms Antibiotics may be
deferred in healthy children between 6-24 months , if mild symptoms or uncertain diagnosis recognize worsening of condition & gain immediate access to medical care if needed This is not recommended for babies less than 6 months Persistence of middle ear fluid is likely after treatment for acute OM (doesn't require repeated treatment) Antibiotics are not generally required for OM with effusion because of the high rate of spontaneous resolution Antibiotics are recommended only if bilateral effusions persist for more than 3 months X Corticosteroids
Decongestants + OME = No antibiotic + AOM + = Use antibiotic Now bulging tympanic membrane perforation + AOM (delayed + not severe) = Use antibiotic Treatment 1st choice : High dose amoxicillin 80-90 mg/Kg/day Alternatives Amoxicillin / Clavulanate
Cefpodoxime If failed Ceftriaxone (IM) for 3 days


Tympanocentesis (drainage of fluid) Duration Babies: 7-10 days
Childs: 5 days if persistant OM + effusion + Hearing loss (significant) = Tympanostomy 1. Reserved for patients with recurrent acute otitis media

2. Reduces occurrence by about one episode per year

3. The risk of promoting bacterial resistance may outweigh the slight beneft. Symptoms Classification Treatment Comorbid diseases Oppositional
disorder Tics Anxiety
disorder ongoing pattern of anger guided disobedience sudden, repetitive, nonrhythmic motor movement or vocalization involving discrete muscle groups characterized by excessive rumination, worrying, uneasiness, apprehension and fear about future uncertainties either based on real or imagined events Tourette
syndrome Pharmacotherapy + Behavioral therapy Stimulant Drugs Non-stimulant Drugs 1st choice 2nd choice Methylphenidate Amphetamines Antidepressants Atomoxetine Alpha - agonists Ramp effect As CNS absorption increases , behavioral effects increase Ritalin Focalin Ritalin SR / Metadate ER Concerta Focalin XR Metadate CD Ritalin LA Daytrana Methylphenidate immediate release ..
short duration of action
Racemic mixture ,, Methylphenidate immediate release ..
short duration of action
Racemic mixture ,, DexmethylphenidateOnly D-threoisomer
more activity (half dose)
same duration of action (same intervals) Methylphenidate sustsined / extended release
duration of action (up to 8 hours , but typically needs 2 doses only for afternoon symptom control
may be used in place of ritalin-twice daily regimen after dose titration with it (OROS) {Osmotic controlled Release Oral delivery System}
if 6 years old or older
contains osmotic agents & a rate-controlling membrane with a laser-drilled hole for drug release
Duration of action 10-12 hours .. so , once daily Methylphenidate modified release (30% - 70% beads in the capsule)
6 years old or older .. duration : 6-8 hours .. effect disappears in afterschool / late afternoon hours (so add ritalin)
once-daily "can be sprinckled on applesauce Dexmethylphenidate ER
Faster onset than Concerta ,, but shorter duration of action .. so afternoon symptom control is less than Concerta Methylphenidate ER
more than 6 years old
designed to mimic 2 times/day of ritalin
efficacy may decrease during the day needing adding ritalin to cover late-day symptoms
once-daily : can be sprinkled Transdermal system
6 years or older
apply to hip
2 hours before effect is needed
remove after 9 hours (but can be worn till 16 hours
duration of effect is 3 hours after removal
dose may be titrated weekly
good in swimming or exercise Side Effects Headache
Loss of appetite

Use with caution with:
MOAIs Adderall Adderall XR Vyvanse Mixed Amphetamine salts immediate release Mixed amphetamine salts EXTENDED release
in 6 years old or older
capsule contains: 50% immediate & 50% ex. release beads ..
duration: 10-12 hours
once daily : contents can be sprinkled on applesauce Lisdexamphetamine dimesylate
Prodrug (D-amphetamine bound to L-lysine
made for less abuse potential than amphetamine
duration : 10 hours
not superior over others in efficacy Side Effects Loss of appetite
Abdominal pain
may inc. PREEXISTING HTn & TIC disorders
Recent labeling : warns of SCD (Sudden Cardiac Death) .. so not with "known strucural heart defects" NE reuptake inhibitor

taken once or twice daily

1st line therapy if : abuse / comorbid anxiety / tics

adv. effects: Dyspepsia / dec. appettite / wt loss / fatigue / potential liver injury (so routinely monitor) / suicidal ideation (black box)

Metabolized by Cytochrome P450 2D6 Noradrenergic antidepressants Tricyclic antidepressants *Bupropion* *Imipramine* *Nortryptiline* may use immediate or extended-release product , given in 2 or 3 doses

contraindicated with active seizure disorder Baseline ECG before start or each dose increase

Desipramine : reports of sudden death (use with extreme caution) Clonidine Guanfacine Extended release (KAPVAY) - FDA approved (2010) for children from 6
to 17 years old

treeeeeeeat tics espeeeeecially
--------yyyyyyy if combined with methylphenidate

more effective for hyperact
- ivity than for inattention

causes sedation (adv. eff) Extended Release (Intuniv) - FDA Approved (2009) in 6-17 years old

Improve tic disorder

Less sedation

longer duration of action

abrupt discontue :
rebound hypertention Season ? From November to April Symptoms Infants
Neonates Children + wheezing + lethargy + irritability + poor feeding + apnea Risk factors Premature birth Lung problems Chronic lung disease Bronchopulmonary dysplasia Cyanotic or congenital heart disease Immunodeficiency Compromised handling of respiratory secretions airway abnormalities neuromuscular conditions Others lower socioeconomic status Passive smoking Daycare attendance Siblings younger than 5 years Prophylaxis Hygeine
+ avoid crowds When Palivizumab ??!! Treatment Supportive care Beta-2 agonists / racemic ephedrine Antibiotics Steroids Ribavirin hydration
+ Oxygen
+ mechanical ventilation (if needed) Uselessactive UselessagainstUseless RSV replication
doesn't decrease mortality in immunocompetent patients
doesn't reduce ventilator days / stay in ICU / hospital / hospital cost
used for high risk patients (like complicated congenital heart disease / chronic lung disease / bronchopulmonary dysplasia / immunocompromized Useless Useless Useless Recommended
Schedule Barriers to routine immunization Immunization types Major changes since 2009 Combination vaccines Product interchangeability Other factors Contraindications Misconceptions
about them Patients with
HIV Preterm infants Immunocompromised childern Corticosteroids Misconceptions
about them Special population considerations Replacement of 7-valent conjugated pneumococcal vaccine with 13-valent conjugated pneumococcal vaccine (PCV 13, prevnar 13) for children younger than 6 years HPV vaccine (HPV4 , Gardasil) , now approved in males 9-26 years old for orevention of genital warts. Now recommended for routine vaccination of adolescent males For children & adolescents who have a delayed start to immunization , a CATCH-UP schedule exists Advantage ?? Less No. of injections But .. Safety & efficacy
must be the same DTaP-Hib (H. influenza
type B [vaccine]) - The Hib antibody response is markedly lower after adminstering the combination product than when adminstering it separately for primary immunization

- So, only approved for use as the fourth dose

- TriHIBit DTaP-IPV (inactivated poliovirus [vaccine]) - This combination has no consistent effect on body responses
- So , indicated for the fifth dose of DTaP & the fourth dose of IPV in the routine series
- Kinrix The DTaP-HepB (hepatitis B) combination - Product is available outside the united states & provides good safety & antibody concentrations - The Hib antibody levels are lower than after separate adminstration The DTaP-HepB-Hib combination at least , as immunogenic as individual components when adminstered at 2, 4, and 6 months

not indicated for infants younger than 6 weeks or children older than 7 years

pediarix The DTaP-HepB-IPV combination - not indicated for infants younger than 6 weeks due to possible decreased immune response
- Comvax The HepB-Hib combination - Approved for use in children aged 6 weeks thru 4 years
- Pentacel The Hib-DTaP-IPV combintion - Approved for use in individuals 18 years and older
- Twinrix The HepA-HepB combination - febrile seizures increase if combined than if separated
- So, first doses : separated .. 2nd one : combined
- ProQuad The MMR - varicella combination Adding HepB to combination products may result in an extra dose being provided (e.g. monovalent HepB given at birth and then combination products at 2,4 and 6 months) .. however, the ACIP states that this is a safe practice Same product is prefered .. if not known / not available , use any alternative For DTaP "diphtheria, pertussis (whooping cough) and tetanus" : Standard: use same product for at least the first 3 doses of the 5-dose series .. if not known / unavailable , use any product For Tdap (Booster dose at 11 years): BOOSTRIX or ADACEL may be used for the booster dose , regardless of the manufacturer of the DTaP (first doses) adminstered during the primary immunization series For HepB: Use ENGERIX-B and RECOMBIVAX HB interchangeably For Polio: Oral polio vaccine and inactivated poliovirus provide equivalent protection .. but "oral polio vaccine" is no longer recommended .. since 1979 .. (cases of paralysis related to it) For Hib: These products may be used interchangeably , however , if the regimen is completed using PedvaxHIB exclusively , only three doses are required , .. Regimens using HibTITER or ActHIB require four doses For HPV: The products differ in the HPV types against which they provide protection. HPV4 (Gardasil) protects types 6, 11 , 16 and 18. HPV2 (Cervarix) protects against types 16 and 18.

HPV types 6 and 11 are associated with genital warts .. types 16 and 18 are associated with gynaecologic , anal , and penile cancer Anaphylactic reaction to vaccine or any of its components Neomycin: in MMR / varicella / inactivated poliovirus Egg protein: in influenza vaccine Acute moderate to severe febrile illness Severe egg allergy is not considered a contraindication to MMR , which is grown in chick embryo tissue Immunodeficiency : oral polio vaccine , MMR , varicella Pregnancy : MMR , Varicella Recent adminstration of immuonoglobulin
(for RSV) : MMR , varicella Encephalopathy within 7 days after
adminstration of a previous dose of DTaP Delay adminstration of vaccine product Interval between IG dose & adminstration of vaccine is dependent on indication for and dose of IG Mild acute illness current antimicrobial
therapy Reaction to DTaP involving soreness , redness or swelling at the site of injection Pregnancy of the mother of the vaccine recipient Breastfeeding Allergies to to antibiotics other than neomycin or streptomycin Family history of an adverse effect after vaccine adminstration leading to underimmunization Low socioeconomic status Late start of
series Missed opportunities Unaware dads Falure to adminster
simultaneous vaccines Contr-indications
(See B4) MMR X not approved Guillain Barre Syndrome Meningeococcal vaccine X not approved Intussusception Rotavirus vaccine
(Rotashield) X not approved a. Immunize on the basis of chronologic age

b. don't reduce vaccine doses

c. if birth weight is less than 2 Kg, delay HepB vaccine because of reduced immune response until the patient is 30 days old or at hospital discharge if it occurs before 30 days of age (unless the mother is positive for HepB surface antigen) a. Shouldn't recieve live vaccines

b. Inactivated vaccines & IGs are appropriate

c. Household contacts shouldn't recieve oral polio vaccine .. however , influenza vaccine , varicella & rotavirus are recommended a) live vaccines may be adminstered to patients recieving the following :
i. Topical steroids
ii. Physiologic maintenance doses
iii. Low or moderate doses (less than 2 mg/kg/day of prednisone equivalent)

b. Live vaccines may be given immediately after discontinuation of high doses (2 mg/kg/day "or more" of prednisone equivalent) of systemic steroids given for less than 14 days

c. Live vaccines should be delayed at least 1 month after discontinuing high doses (2 mg/kg/day "or more" of prednisone equivalent) of systemic steroids given for more than 14 days a. MMR should be adminstered unless patient is severely immunocomromized

b. Varicella should be considered for asymptomatic or mildly symptomatic patients

c. Inactivated vaccines should be adminstered routinely
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