Poisoning&DrugOverdose,6e>

Chapter2.SpecialConsiderationsinPediatric
Patients
DeliaA.Dempsey,MD,MS

SpecialConsiderationsinPediatricPatients
Themajorityofcallstopoisoncontrolcentersinvolvechildrenyoungerthan5yearsofage.
Fortunately,childrenaccountforaminorityofseriouspoisoningsrequiringemergencyhospital
treatment.Mostcommonchildhoodingestionsinvolvenontoxicsubstancesornontoxicdosesof
potentiallytoxicdrugsorproducts(SeeNontoxicorMinimallyToxicHouseholdProducts).TableI43
listsimportantcausesofseriousorfatalchildhoodpoisoning,whichincludeironsupplements(See
Iron)tricyclicantidepressants(SeeAntidepressants,Tricyclic)cardiovascularmedicationssuchas
digitalis(SeeDigoxinandOtherCardiacGlycosides),betareceptorantagonists(SeeBetaAdrenergic
Blockers),orcalciumantagonists(SeeCalciumChannelAntagonists)methylsalicylate(See
Salicylates)andhydrocarbons(SeeHydrocarbons).
TableI43ExamplesofPotentPediatricPoisonsa
DrugorPoison PotentiallyFatalDoseina10kgToddler
Antiarrhythmics
Flecainide Oneortwo150mgtablets
Quinidine Two300mgtablets
Antipsychotic
Chlorpromazine Oneortwo200mgtablets
Thioridazine One200mgtablet
Benzocaine 2mLofa10%gel
Calciumchannelblockers
Nifedipine Oneortwo90mgtablets
Verapamil Oneortwo240mgtablets
Camphor 5mLof20%oil
Chloroquine One500mgtablet
Diphenoxylate/atropine(Lomotil) Five2.5mgtablets
Hydrocarbons(eg,kerosene) Oneswallow(ifaspirated)
Hypoglycemicsulfonylureas One5mgglyburidetablet
Iron Tenadultstrengthtablets
Lindane Twoteaspoons(10mL)
Methylsalicylate <5mLofoilofwintergreen
Opiates
Codeine Three60mgtablets
Hydrocodone One5mgtablet
Methadone One40mgtablet
Morphine One200mgtablet
Seleniousacid(gunbluing) Oneswallow
Theophylline One500mgtablet
Tricyclicantidepressants
Desipramine Two75mgtablets
Imipramine One150mgtablet

aReferences:BarOzB,LevichekZ,KorenG:Medicationsthatcanbefatalforatoddlerwithone
tabletorteaspoonful:a2004update.PaediatricDrugs20046(2):123126KorenG:Medications
whichcankillatoddlerwithoneteaspoonortablet.ClinToxicol199331(3):407OsterhoudtK:
Toxtalk19978(7)LitovitzT,ManoguerraA:Comparisonofpediatricpoisoninghazards:ananalysis
of3.8millionexposureincidents.Pediatrics199289(6):999.

I.Highriskpopulations.Twoagegroupsarecommonlyinvolvedinpediatricpoisonings:children
between1and5yearsofageandadolescents.

A.Ingestionsintoddlersandyoungchildrenusuallyresultfromoralexploration.
Unintentionalingestioninchildrenyoungerthan6monthsofageorbetweentheagesof5
andadolescenceisrare.Inyounginfants,considerthepossibilityofintentional
administrationbyanolderchildoradult.Inschoolagechildren,suspectabuseorneglect
asareasonfortheingestion,andinadolescents,suspectasuicideattempt.
 B.Inadolescentsandyoungadults,overdosesareusuallysuicidalbutmayalsoresult
fromdrugabuseorexperimentation.Commonunderlyingreasonsforadolescents'suicide
attemptsincludepregnancysexual,physical,ormentalabuseschoolfailureconflictwith
peersconflictwithhomosexualorientationasuddenorseverelossandalcoholismor
illicitdruguse.Anyadolescentwhomakesasuicideattemptorgestureneedspsychiatric
evaluationandfollowup.

II.Poisoningprevention.Youngchildrenwithanunintentionalingestionareathigherriskfora
secondingestionthanisthegeneralpediatricpopulation.Afteranincident,preventionstrategies
needtobereviewed.Ifthefamilydoesnotunderstandtheinstructionsoritisthesecond
poisoningincident,considerahomeevaluationforchildproofingbyapublichealthnurseor
otherhealthcareprofessional.

A.Childproofthehome,daycaresetting,andhouseholdsthechildcommonlyvisits(eg,
grandparentsandotherrelatives).Storemedicines,chemicals,andcleaningproductsout
ofthereachofchildrenorinlockedcabinets.Donotstorechemicalsinfoodcontainers,
anddonotstorechemicalsinthesamecabinetsasfood.Commonplaceswherechildren
findmedicationsincludevisitors'pursesorbackpacksandbedsidetables.

B.Usechildresistantcontainerstostoreprescriptionandnonprescriptionmedications.
However,childresistantcontainersarenotchildprooftheyonlylessenthetimeittakesa
determinedchildtogetintothecontainer.

C.Medicationerrorsareapreventablecauseofsevereinjuryordeathinchildren,especially
thoseyoungerthan1yearofage.Theerrorsarecommonlyassociatedwithverysmall
volumes(<1mLdose)or10folddosingerrors.Inonestudy,theleadingcausesofdeath
duetomedicationerrorsinchildrenwerethefollowing:acetaminophen,coughandcold
preparations(especiallythosecontainingopiates),fosphenytoin,metoclopramide,viscous
lidocaine,diphenoxylate/atropine,morphine,digoxin,andsodiumphenylbutyrate.

III.Childabuse.Considerthepossibilitythatthechildwasintentionallygiventhedrugortoxin,or
theexposurewasduetoneglect.Moststatesrequirethatallhealthcareprofessionalsreport
suspectedcasesofchildabuseorneglect,whichmeansthatthisisnotadiscretionarydecision
butalegalobligationtoreportanysuspiciousincident.Theparentsorguardiansshouldbe
informedinastraightforward,nonjudgmentalmannerthatareportisbeingmadeunderthis
legalobligation.Inseriouscases,thereportofsuspectedabuseshouldbemadebeforethe
childisreleased,andthelocalchildprotectionservicesshoulddecidewhetheritissafeto
releasethechildtotheparentsorguardians.Inunclearsituations,thechildcanbeadmittedfor
observationtoallowtimeforsocialservicestomakeanexpeditiousevaluation.Thefollowing
shouldalertmedicalpersonneltothepossibilityofabuseorneglect:

A.Thestorydoesnotmakesenseordoesnotringtrue,oritchangesovertime,ordifferent
peoplegivedifferentstories.

B.Thechildisnonambulatory(eg,achildyoungerthan6monthsofage).Carefullyreview
howthechildgainedaccesstothedrugortoxin.

C.Thechildisolderthan45yearsofage.Accidentalingestionsarerareinolderchildren,
andingestionmaybeasignalofabuseorneglect.

D.Thedrugingestedwasatranquilizer(eg,haloperidolorchlorpromazine),adrugofabuse
(eg,cocaineorheroin),asedative(eg,diazepam),orethanol,ortheparentsare
intoxicated.
 E.Thereisalongintervalbetweenthetimeofingestionandthetimethechildistakenfor
medicalevaluation.

F.Therearesignsofphysicalorsexualabuseorneglect:multipleorunusualbruisesa
brokenboneorburnsaverydirty,unkemptchildorachildwithaflataffectorindifferent
orinappropriatebehavior.

G.Ahistoryofrepeatedepisodesofpossibleordocumentedpoisoningsorahistoryofprior
abuse.

H.Munchausensyndromebyproxy:Drugsortoxinsaregiventothechildtosimulateillness.
Mostperpetratorsaremothers,oftenwithamedicalbackground.Thisisararediagnosis.

IV.Clinicalevaluation.Thephysicalandlaboratoryevaluationisessentiallythesameasfor
adults.However,normalvitalsignsvarywithage(TableI44).

TableI44PediatricVitalSignsa
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TableI44PediatricVitalSignsa
BloodPressure(mmHg)
RespiratoryRate HeartRate Lower Upper
Age Average Severe
(breaths/min) (beats/min) Limit Limit
Newborn 3080 110190 52/25 5055b 95/72 110/85
1mo 3050 100170 64/30 85/50 105/68 120/85
6mo 3050 100170 60/40 90/55 110/72 125/85
1y 2040 100160 66/40 90/55 110/72 125/88
2y 2030 100160 74/40 90/55 110/72 125/88
4y 2025 80130 79/45 95/55 112/75 128/88
8y 1525 70110 85/48 100/60 118/75 135/92
12y 1520 60100 95/50 108/65 125/84 142/95

aReferences:DieckmannRA,CoulterK:Pediatricemergencies.In:SaundersCE,HoMT
(editors):CurrentEmergencyDiagnosis&Treatment,4thed,p811.Appleton&Lange,1992
GundyJH:Thepediatricphysicalexam.In:HoekelmanRAetal(editors):PrimaryPediatric
Care,p68.Mosby,1987HoffmanJIE:Systemicarterialhypertension.In:RudolphAMetal
(editors):Rudolph'sPediatrics,19thed,p1438.Appleton&Lange,1991LiebmanJ,Freed
MD:Cardiovascularsystem.In:BehrmanRE,KleigmanR(editors):Nelson'sEssentialsof
Pediatrics,p447.WBSaunders,1990LumGM:Kidneyandurinarytract.In:HathawayWEet
al(editors):CurrentPediatricDiagnosis&Treatment,10thed,p624.Appleton&Lange,1991.

bMeanarterialpressurerangeonthefirstdayoflife.

A.Heartrate.Newbornsmayhavenormalheartratesashighas190beats/min,and2year
oldsupto120beats/min.Abnormaltachycardiaorbradycardiasuggeststhepossibilityof
 hypoxemiainadditiontothenumerousdrugsandpoisonsthataffectheartrateandrhythm
(seeTableI4,I5,I6,I7).

B.Bloodpressureisaveryimportantvitalsigninapoisonedchild.Thebloodpressurecuff
mustbeofthepropersizecuffsthataretoosmallcanfalselyelevatethepressure.The
bloodpressuresofinfantsaredifficulttoobtainbyauscultationbutareeasilyobtainedby
Doppler.

1.Manychildrennormallyhaveabloodpressurelowerthanthatofadults.However,
lowbloodpressureinthecontextofapoisoningshouldberegardedasnormalonlyif
thechildisalertandactive,behavesappropriately,andhasnormalperipheral
perfusion.

2.Idiopathicoressentialhypertensionisrareinchildren.Elevatedbloodpressure
shouldbeassumedtoindicateanacutecondition,althoughthesystolicblood
pressurecanbetransientlyelevatedifthechildisvigorouslycryingorscreaming.
Unlessachild'sbaselinebloodpressureisknown,valuesattheupperlimitofnormal
shouldbeassumedtobeelevated.Thedecisiontotreatelevatedbloodpressure
mustbemadeonanindividualbasis,basedontheclinicalscenarioandthetoxin
involved.

V.Neonatespresentspecificproblems,includinguniquepharmacokineticsandpotentiallysevere
withdrawalfromprenataldrugexposure.

A.Neonatalpharmacokinetics.Newborns(birth1month)andinfants(112months)are
uniquefromatoxicologicandpharmacologicperspective.Drugabsorption,distribution,
andeliminationaredifferentfromthoseofolderchildrenandadults.Incorrectdosing,
transplacentalpassageproximatetothetimeofbirth,breastfeeding,dermalabsorption,
andintentionalpoisoningarepotentialroutesoftoxicexposure.Ofparticularimportance
areenhancedskinabsorptionandreduceddrugelimination,whichmayleadtotoxicity
afterrelativelymildexposure.

1.Skinabsorption.Neonateshaveaveryhighratioofsurfaceareatobodyweight,
whichpredisposesthemtopoisoningviapercutaneousabsorption(eg,
hexachlorophene,boricacid,oralcohols).

2.Eliminationofmanydrugs(eg,acetaminophen,manyantibiotics,caffeine,lidocaine,
morphine,phenytoin,andtheophylline)isprolongedinneonates.Forexample,the
halflifeofcaffeineisapproximately3hoursinadultsbutmaybegreaterthan100
hoursinnewborns.

B.Neonataldrugwithdrawalmayoccurininfantswithchronicprenatalexposuretoillicitor
therapeuticdrugs.Theonsetisusuallywithin72hoursofbirth,butapostnatalonsetas
lateas14dayshasbeenreported.Signsusuallycommenceinthenursery,andinfantsare
notdischargeduntilclinicallystable.However,withearlydischargefromnurseries
becomingthenorm,aninfantinwithdrawalmayfirstpresenttoanemergencydepartment
oracutecareclinic.Thepresentationmaybeasmildascolicorassevereaswithdrawal
seizuresorprofounddiarrhea.

1.Opioids(especiallymethadoneandheroin)arethemostcommoncauseofserious
neonataldrugwithdrawalsymptoms.Otherdrugsforwhichawithdrawalsyndrome
hasbeenreportedincludephencyclidine(PCP),cocaine,amphetamines,tricyclic
antidepressants,phenothiazines,benzodiazepines,barbiturates,ethanol,clonidine,
diphenhydramine,lithium,meprobamate,andtheophylline.Acarefuldrughistory
 fromthemothershouldincludeillicitdrugs,alcohol,andprescriptionandoverthe
countermedicationsandwhethersheisbreastfeeding.

2.Themanifestationsofneonatalopioidwithdrawalincludeinabilitytosleep,
irritability,tremulousness,inconsolability,ahighpitchedincessantcry,hypertonia,
hyperreflexia,sneezingandyawning,lacrimation,disorganizedsuck,poorfeeding,
vomiting,diarrhea,tachypneaorrespiratorydistress,tachycardia,autonomic
dysfunction,sweating,fevers,andseizures.Morbidityandmortalityfromuntreated
opioidwithdrawalcanbesignificantandcommonlyresultfromweightloss,metabolic
acidosis,respiratoryalkalosis,dehydration,electrolyteimbalance,andseizures.
Withdrawalisadiagnosisofexclusionimmediatelyruleoutsepsis,hypoglycemia,
hypocalcemia,andhypoxia,andconsiderhyperbilirubinemia,hypomagnesemia,
hyperthyroidism,andintracranialhemorrhage.Seizuresdonotusuallyoccurasthe
onlyclinicalmanifestationofopioidwithdrawal.

3.Treatmentofneonatalopioidwithdrawalismainlysupportiveandincludes
swaddling,rocking,aquietroom,frequentsmallfeedingswithahighcalorieformula,
andIVfluidsifnecessary.Avarietyofdrugshavebeenused,includingmorphine,
paregoric,tinctureofopium,diazepam,lorazepam,chlorpromazine,and
phenobarbital.Numerousabstinencescoringsystemsexisttoevaluateopioid
withdrawalobjectivelyandtreatit.Thescoringandtreatmentofaneonatein
withdrawalshouldbesupervisedbyaneonatologistorpediatricianexperiencedwith
neonatalwithdrawal.

VI.Pregnancyanddrugsorchemicals.Estimatesofthepercentageofcongenitalabnormalities
andadversepregnancyoutcomesattributabletoprescriptionmedications,chemicals,
hyperthermia,andionizingradiationrangefromlessthan1%to5%,dependingontheauthor.

A.Theadverseeffectsofdrugsandchemicalsonpregnancyaredoseandtimedependent.
Pregnancyterminationshouldnotbeconsideredbecauseofexposuretoacontraindicated
drugwithoutcarefulconsiderationofthetruerisk.Evenwithexposuretowelldocumented
teratogens(eg,valproicacid),themajorityofexposedfetusesareunaffected.

B.Theadverseeffectsofthedrugorchemicalonpregnancyorthefetusmayinclude
preventionofimplantation(eg,nonsteroidalantiinflammatorydrugs[NSAIDs]),fetaldeath
(eg,intraamnioticmethyleneblue),malformations(eg,thalidomide),postnataladverse
physiologiceffects(eg,oralhypoglycemics),andadverseoutcomesapparentonlyyears
afterbirth(eg,diethylstilbestrol).Withsomedrugsthathaveaverylonghalflife(eg,
ribavirin,retinoids),cessationofexposureformonthsbeforeconceptionisrequired.

C.Forclinicalassistanceindeterminingtheriskposedtoapregnancybyaspecificexposure,
contactMotherisk(www.motherisk.org,14168136780).Motherisk,anevidencebased
informationandphoneconsultationservicebasedinToronto,Canada,isdevotedtothe
studyofthesafetyorriskofdrugs,chemicals,anddiseaseduringpregnancyandlactation.

D.TableI45liststheFDApregnancyratingsofdrugsandchemicals(seealsoTABLEIII
1).Somedrugshavemorethanonepregnancycategorybecausethecategorychanges
withthetrimesterorbecausedifferentmanufacturers/authoritiesarenotinagreement.The
bestsinglesourcefordataregardingtheeffectofdrugsonpregnancyandlactationis
BriggsGG,FreemanRK,YaffeSJ:DrugsinPregnancyandLactation:AReferenceGuide
toFetalandNeonatalRisk,7thed.LippincottWilliams&Wilkins,2005.Theauthorshave
assembleddataforindividualdrugsintomonographs.InadditiontotheFDApregnancy
categories,theauthorsmakerecommendationsregardingusebasedontheirreviewofthe
literature.DrugsthatareintheDorXcategoryorthathaveariskorcontraindication
recommendationbyBriggsetalareincludedinTableI45.DrugsthatarelabeledFDA
 categoryDorXmaystillbeconsideredcompatiblewithpregnancyifthebenefitstothe
motheroutweightheriskstothefetus(maternalbenefitfetalrisk).Selected
anticonvulsantsfallintothiscategory.

TableI45DrugsandChemicalsthatPoseaRisktotheFetusorPregnancy
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TableI45DrugsandChemicalsthatPoseaRisktotheFetusorPregnancy
FDAa
DrugName RecommendationorCommentsb
Category
Amantadine C Contraindicated(firsttrimester)
Aminoglutethimide
D Nodata
(anticonvulsant)
Aminopterin X Contraindicated(anytrimester)
Amiodarone D Risk(thirdtrimester)
Amphetamine C Risk(thirdtrimester)
Androgenichormones X Contraindicated(anytrimester)
Angiotensinconvertingenzyme
C/D Risk(secondandthirdtrimesters)
(ACE)inhibitors
AngiotensinIIreceptor
C/D Risk(secondandthirdtrimesters)
antagonists
Antidepressants C Risk(thirdtrimester)
Lookupindividualdrugs.OnlycategoryXdrugs
Antineoplasticcytotoxicagents C/D/X
aregivenintable.Recommendationsvarywidely.
Azathioprine D Risk(thirdtrimester)
RecommendationbydrugvariesfromProbably
Barbiturates CorD
CompatibletoRisk(firstandthirdtrimesters)
RecommendationvariesbyagentfromLowRisk
Benzodiazepines D/X (animaldata)toContraindicated(anytrimester).
Lookupindividualagents.
Benzphetamine X Contraindicated(anytrimester)
Betaadrenergicblockers C/D Risk(secondandthirdtrimesters)
Bexarotene X Contraindicated(anytrimester)
Bluecohosh(herb) C Risk(thirdtrimester)usedtostimulatelabor
Bromides,anticonvulsant D Risk(thirdtrimester)
Carbamazepine D Compatible:benefits>>risks
Carbarsone,29%arsenic D Contraindicated(anytrimester)
Carbimazole D Risk(thirdtrimester)usepropylthiouracil(PTH).
Chenodiol X Contraindicated(anytrimester)
Ciguatoxin Contraindicated(anytrimester)
Clarithromycin C Highrisk(animaldata)
Clomiphene(fertilityagent) X Contraindicated(anytrimester)
Clonazepam,anticonvulsant D Lowrisk(animaldata)
Cocaine,systemicuse C/X Contraindicated(anytrimestertopicaluseokay)
Colchicine D Risk(animaldata)
Recommendationvariesfromcompatible,to
Corticosteroids C/D benefits>>risks,toriskinthirdtrimester.Lookup
individualagents.
Coumarinderivatives D/X Contraindicated(anytrimester)
Diazoxide C Risk(thirdtrimester)
Dihydroergotamine X Contraindicated(anytrimester)
Compatiblebutdonotuseforgestational
Diuretics BorC/D
hypertension(CategoryD)
 FDAa
DrugName RecommendationorCommentsb
Category
Ecstasy(methylenedioxy
C Contraindicated(anytrimester)
methamphetamine,MDMA)
Edrophonium C Risk(thirdtrimester)
Risk(thirdtrimester)stillbirthassociatedwith
Electricity D
relativelymildshocks
Epinephrine C Risk(thirdtrimester)
Ergotamine X Contraindicated(anytrimester)
Hepatictoxicityinpregnantwomen.Othersaltsare
Erythromycin(estolatesalt)
compatible.
Estrogenichormones X Contraindicated(anytrimester)
Ethanol D/X Contraindicated(anytrimester)
Ethotoin D Compatible(benefits>>risks)
Fenfluramine C Contraindicated(anytrimester)
Fluconazole400mg/d C Risk(thirdtrimester)
Flucytosine C Contraindicated(firsttrimester)
Fluorouracil D/X Contraindicated(firsttrimester)
Fluphenazine C Risk(thirdtrimester)
HMGCoAcreductaseinhibitors: X Contraindicated(anytrimester)
alldrugsinthisclass
Iodide125Iand131I X
Contraindicated(anytrimester)ablatesfetal
(radiopharmaceuticals) thyroid
Iodineandiodidecontaining
Variesfromcontraindicated(anytrimester)torisk
compounds,includingtopicals,
D/X (secondandthirdtrimesters).Fetalandneonatal
expectorants,anddiagnostic
goiterandhypothyroidism.
agents
Kanamycin D Risk(thirdtrimester)
Leflunomide X Contraindicated(anytrimester)
Lenalidomide(potentthalidomide
X Contraindicated(anytrimester)
analog)
Leuprolide X Contraindicated(anytrimester)
Lithium D Risk(thirdtrimester)
LSD(lysergicaciddiethylamide) C Contraindicated(anytrimester)
Marijuana X Contraindicated(anytrimester)
Measlesvaccine(live Contraindicated(anytrimester)avoidfrom12
C
attenuated) monthsbeforepregnancyuntilafterdelivery
Menadiol,menadione,vitaminK3 C Risk(thirdtrimester)
Mephobarbital,anticonvulsant D Compatible:benefits>>risks
Meprobamate D Contraindicated(firsttrimester)
Metaraminol C Risk(secondandthirdtrimesters)
Methaqualone D Nodata
Methimazole D Risk(thirdtrimester)usepropylthiouracil(PTH).
Methotrexate X Contraindicated(anytrimester)
Methyleneblue,intraamniotic C/D Contraindicated(secondandthirdtrimesters)
 FDAa
DrugName RecommendationorCommentsb
Category
Methylergonovinemaleate,ergot
C Contraindicated(anytrimester)
derivative
Mifepristone,RU486 X Contraindicated(anytrimester)
Misoprostol(oral) X Contraindicated(anytrimester)
Misoprostol:lowdoseforcervical
X Lowrisk(humandata)
ripening
Mumpsvaccine(liveattenuated) C Contraindicated(anytrimester)
Naloxone B Compatible
Risk(thirdtrimester):CategoryDriskassociated
Narcoticagonistanalgesics BorC/D
withprolongeduseorhighdosesatterm
Narcoticagonistantagonist
BorC/D Risk(thirdtrimester)
analgesics
Narcoticantagonists(except
D Risk(thirdtrimester)ornodatausenaloxone.
naloxone)
Nonsteroidalantiinflammatory
BorC/D Risk(firstandthirdtrimesters)
drugs(NSAIDs,fulldoseaspirin)
Norepinephrine D Risk(thirdtrimester)
Insulinisthepreferredagentformanagementof
diabetesduringpregnancy.Oralantidiabetic
Oralantidiabeticagents C
agentscrossplacentariskforsevere
hypoglycemiainnewborn.
pAminosalicylicacid C Risk(thirdtrimester)
Paramethadione D Contraindicated(firsttrimester)
Penicillamine D Risk(thirdtrimester)
Phencyclidine X Contraindicated(anytrimester)
Phensuximide D Risk(thirdtrimester)
Phentermine C Contraindicated(anytrimester)
Phenylephrine C Risk(thirdtrimester)
Phenytoin D Compatible:benefits>>risks
Plicamycin,mithramycin X Contraindicated(firsttrimester)
Podofilox,podophyllum C Contraindicated(anytrimester)
Primidone D Risk(thirdtrimester)
Progestogenichormones DorX Contraindicated(anytrimester)
Quinine,antimalarial D/X Risk(thirdtrimester)
Quinoloneantibiotics C Arthropathyinimmatureanimals
Retinoidagents X Contraindicated(anytrimester)
Ribavirin,antiviral X Contraindicated(anytrimester)
Contraindicated(anytrimester)avoidfrom12
Rubellavaccine(liveattenuated) C/D
monthsbeforepregnancyuntilafterdelivery.
Smallpoxvaccine(live Epidemic:compatible(benefits>>risks)otherwise
X
attenuated) risk(thirdtrimester)
Streptomycin D Risk(thirdtrimester)
Sulfonamides C/D Risk(thirdtrimester)
Tacrolimus C Risk(thirdtrimester)
 FDAa
DrugName RecommendationorCommentsb
Category
Tamoxifen D Contraindicated(anytrimester)
Contraindicated(anytrimester)owingtoethanol
Terpinhydrate D
content
Tetracyclines,all D Contraindicated(secondandthirdtrimesters)
Thalidomideandanalogs X Contraindicated(anytrimester)
Tramadol C Risk(thirdtrimester)
Tretinoin:topicaldoses C Lowrisk(humandata)
Risk(anytrimester)weakfolicacidantagonist,
Triamterene C/D
andCategoryDforgestationalhypertensionuse
Trimethadione D Contraindicated(firsttrimester)
Trimethaphan C Contraindicated(anytrimester)
Trimethoprim C Risk(thirdtrimester)
Valproicacid D Risk(thirdtrimester)
Varicellavaccine(live Contraindicated(anytrimester)avoidfrom12
C
attenuated) monthsbeforepregnancyuntilafterdelivery.
Venezuelanequineencephalitis
Contraindicated(anytrimester)avoidfrom12
vaccine,VEETC84(live X
monthsbeforepregnancyuntilafterdelivery.
attenuated)
Vidarabine,antiviral C Teratogenicinanimals
Contraindicated(anytrimester)indosesgreater
VitaminA A/X
thanFDARDAc
CompatibleexceptfordosesgreaterthanFDA
VitaminD A/D
RDAc
VitaminK3,menadiol,
C Risk(thirdtrimester)
menadione
Voriconazole D Teratogenicinanimals
Warfarin D/X Contraindicated(anytrimester)
Epidemic:compatible(benefits>>risks).
Yellowfevervaccine(live
D Otherwiseavoidfrom12monthsbefore
attenuated)
pregnancyuntilafterdelivery.
Zonisamide,anticonvulsant C Teratogenicinanimals

aFDAcategories(seealsoWarfareAgentsChemical):A=controlledstudyhasshownnorisk
B=noevidenceofriskinhumansC=riskcannotberuledoutD=positiveevidenceofriskX
=contraindicatedinpregnancy.

bDatafromBriggsGG,FreemanRK,YaffeSJ:DrugsinPregnancyandLactation:AReference
GuidetoFetalandNeonatalRisk,8thed.LippincottWilliams&Wilkins,2008.All
recommendationsarebasedonhumandata.Animaldataarecitedonlyifhumandataare
unavailableandanimaldatashowserioustoxicityinmultiplespecies.Risk:Humandata
suggestriskexposureduringpregnancyshouldbeavoidedunlessthebenefitsofthedrug
outweightherisks.Contraindicated:Humanexposuredataindicatethatthedrugshouldnotbe
usedinpregnancy.Numbersinparenthesesindicatetimesduringpregnancywhenthedrugis
contraindicatedorposesrisk:All:anytimeduringpregnancy.
 cAbbreviations:HMGCoA=hepatichydroxymethylglutarylcoenzymeARDA=recommended
dailyallowance.

TableI44PediatricVitalSignsa
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TableI44PediatricVitalSignsa
BloodPressure(mmHg)
RespiratoryRate HeartRate Lower Upper
Age Average Severe
(breaths/min) (beats/min) Limit Limit
Newborn 3080 110190 52/25 5055b 95/72 110/85
1mo 3050 100170 64/30 85/50 105/68 120/85
6mo 3050 100170 60/40 90/55 110/72 125/85
1y 2040 100160 66/40 90/55 110/72 125/88
2y 2030 100160 74/40 90/55 110/72 125/88
4y 2025 80130 79/45 95/55 112/75 128/88
8y 1525 70110 85/48 100/60 118/75 135/92
12y 1520 60100 95/50 108/65 125/84 142/95

aReferences:DieckmannRA,CoulterK:Pediatricemergencies.In:SaundersCE,HoMT(editors):
CurrentEmergencyDiagnosis&Treatment,4thed,p811.Appleton&Lange,1992GundyJH:The
pediatricphysicalexam.In:HoekelmanRAetal(editors):PrimaryPediatricCare,p68.Mosby,1987
HoffmanJIE:Systemicarterialhypertension.In:RudolphAMetal(editors):Rudolph'sPediatrics,
19thed,p1438.Appleton&Lange,1991LiebmanJ,FreedMD:Cardiovascularsystem.In:
BehrmanRE,KleigmanR(editors):Nelson'sEssentialsofPediatrics,p447.WBSaunders,1990
LumGM:Kidneyandurinarytract.In:HathawayWEetal(editors):CurrentPediatricDiagnosis&
Treatment,10thed,p624.Appleton&Lange,1991.

bMeanarterialpressurerangeonthefirstdayoflife.

TableI45DrugsandChemicalsthatPoseaRisktotheFetusorPregnancy
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TableI45DrugsandChemicalsthatPoseaRisktotheFetusorPregnancy
FDAa
DrugName RecommendationorCommentsb
Category
Amantadine C Contraindicated(firsttrimester)
Aminoglutethimide(anticonvulsant) D Nodata
Aminopterin X Contraindicated(anytrimester)
Amiodarone D Risk(thirdtrimester)
Amphetamine C Risk(thirdtrimester)
Androgenichormones X Contraindicated(anytrimester)
Angiotensinconvertingenzyme
C/D Risk(secondandthirdtrimesters)
(ACE)inhibitors
AngiotensinIIreceptorantagonists C/D Risk(secondandthirdtrimesters)
Antidepressants C Risk(thirdtrimester)
Lookupindividualdrugs.OnlycategoryXdrugsare
Antineoplasticcytotoxicagents C/D/X
givenintable.Recommendationsvarywidely.
Azathioprine D Risk(thirdtrimester)
RecommendationbydrugvariesfromProbably
Barbiturates CorD
CompatibletoRisk(firstandthirdtrimesters)
RecommendationvariesbyagentfromLowRisk
Benzodiazepines D/X (animaldata)toContraindicated(anytrimester).Look
upindividualagents.
Benzphetamine X Contraindicated(anytrimester)
Betaadrenergicblockers C/D Risk(secondandthirdtrimesters)
Bexarotene X Contraindicated(anytrimester)
Bluecohosh(herb) C Risk(thirdtrimester)usedtostimulatelabor
Bromides,anticonvulsant D Risk(thirdtrimester)
Carbamazepine D Compatible:benefits>>risks
Carbarsone,29%arsenic D Contraindicated(anytrimester)
Carbimazole D Risk(thirdtrimester)usepropylthiouracil(PTH).
Chenodiol X Contraindicated(anytrimester)
Ciguatoxin Contraindicated(anytrimester)
Clarithromycin C Highrisk(animaldata)
Clomiphene(fertilityagent) X Contraindicated(anytrimester)
Clonazepam,anticonvulsant D Lowrisk(animaldata)
Cocaine,systemicuse C/X Contraindicated(anytrimestertopicaluseokay)
Colchicine D Risk(animaldata)
Recommendationvariesfromcompatible,tobenefits
Corticosteroids C/D >>risks,toriskinthirdtrimester.Lookupindividual
agents.
Coumarinderivatives D/X Contraindicated(anytrimester)
Diazoxide C Risk(thirdtrimester)
Dihydroergotamine X Contraindicated(anytrimester)
Compatiblebutdonotuseforgestational
Diuretics BorC/D
hypertension(CategoryD)
Ecstasy(methylenedioxy
C Contraindicated(anytrimester)
methamphetamine,MDMA)
 FDAa
DrugName RecommendationorCommentsb
Category
Edrophonium C Risk(thirdtrimester)
Risk(thirdtrimester)stillbirthassociatedwith
Electricity D
relativelymildshocks
Epinephrine C Risk(thirdtrimester)
Ergotamine X Contraindicated(anytrimester)
Hepatictoxicityinpregnantwomen.Othersaltsare
Erythromycin(estolatesalt)
compatible.
Estrogenichormones X Contraindicated(anytrimester)
Ethanol D/X Contraindicated(anytrimester)
Ethotoin D Compatible(benefits>>risks)
Fenfluramine C Contraindicated(anytrimester)
Fluconazole400mg/d C Risk(thirdtrimester)
Flucytosine C Contraindicated(firsttrimester)
Fluorouracil D/X Contraindicated(firsttrimester)
Fluphenazine C Risk(thirdtrimester)
HMGCoAcreductaseinhibitors: X Contraindicated(anytrimester)
alldrugsinthisclass
Iodide125Iand131I X Contraindicated(anytrimester)ablatesfetalthyroid
(radiopharmaceuticals)
Iodineandiodidecontaining
Variesfromcontraindicated(anytrimester)torisk
compounds,includingtopicals,
D/X (secondandthirdtrimesters).Fetalandneonatal
expectorants,anddiagnostic
goiterandhypothyroidism.
agents
Kanamycin D Risk(thirdtrimester)
Leflunomide X Contraindicated(anytrimester)
Lenalidomide(potentthalidomide
X Contraindicated(anytrimester)
analog)
Leuprolide X Contraindicated(anytrimester)
Lithium D Risk(thirdtrimester)
LSD(lysergicaciddiethylamide) C Contraindicated(anytrimester)
Marijuana X Contraindicated(anytrimester)
Contraindicated(anytrimester)avoidfrom12
Measlesvaccine(liveattenuated) C
monthsbeforepregnancyuntilafterdelivery
Menadiol,menadione,vitaminK3 C Risk(thirdtrimester)
Mephobarbital,anticonvulsant D Compatible:benefits>>risks
Meprobamate D Contraindicated(firsttrimester)
Metaraminol C Risk(secondandthirdtrimesters)
Methaqualone D Nodata
Methimazole D Risk(thirdtrimester)usepropylthiouracil(PTH).
Methotrexate X Contraindicated(anytrimester)
Methyleneblue,intraamniotic C/D Contraindicated(secondandthirdtrimesters)
Methylergonovinemaleate,ergot
C Contraindicated(anytrimester)
derivative
 FDAa
DrugName RecommendationorCommentsb
Category
Mifepristone,RU486 X Contraindicated(anytrimester)
Misoprostol(oral) X Contraindicated(anytrimester)
Misoprostol:lowdoseforcervical
X Lowrisk(humandata)
ripening
Mumpsvaccine(liveattenuated) C Contraindicated(anytrimester)
Naloxone B Compatible
Risk(thirdtrimester):CategoryDriskassociated
Narcoticagonistanalgesics BorC/D
withprolongeduseorhighdosesatterm
Narcoticagonistantagonist
BorC/D Risk(thirdtrimester)
analgesics
Narcoticantagonists(except
D Risk(thirdtrimester)ornodatausenaloxone.
naloxone)
Nonsteroidalantiinflammatory
BorC/D Risk(firstandthirdtrimesters)
drugs(NSAIDs,fulldoseaspirin)
Norepinephrine D Risk(thirdtrimester)
Insulinisthepreferredagentformanagementof
diabetesduringpregnancy.Oralantidiabeticagents
Oralantidiabeticagents C
crossplacentariskforseverehypoglycemiain
newborn.
pAminosalicylicacid C Risk(thirdtrimester)
Paramethadione D Contraindicated(firsttrimester)
Penicillamine D Risk(thirdtrimester)
Phencyclidine X Contraindicated(anytrimester)
Phensuximide D Risk(thirdtrimester)
Phentermine C Contraindicated(anytrimester)
Phenylephrine C Risk(thirdtrimester)
Phenytoin D Compatible:benefits>>risks
Plicamycin,mithramycin X Contraindicated(firsttrimester)
Podofilox,podophyllum C Contraindicated(anytrimester)
Primidone D Risk(thirdtrimester)
Progestogenichormones DorX Contraindicated(anytrimester)
Quinine,antimalarial D/X Risk(thirdtrimester)
Quinoloneantibiotics C Arthropathyinimmatureanimals
Retinoidagents X Contraindicated(anytrimester)
Ribavirin,antiviral X Contraindicated(anytrimester)
Contraindicated(anytrimester)avoidfrom12
Rubellavaccine(liveattenuated) C/D
monthsbeforepregnancyuntilafterdelivery.
Epidemic:compatible(benefits>>risks)otherwise
Smallpoxvaccine(liveattenuated) X
risk(thirdtrimester)
Streptomycin D Risk(thirdtrimester)
Sulfonamides C/D Risk(thirdtrimester)
Tacrolimus C Risk(thirdtrimester)
Tamoxifen D Contraindicated(anytrimester)
 FDAa
DrugName RecommendationorCommentsb
Category
Contraindicated(anytrimester)owingtoethanol
Terpinhydrate D
content
Tetracyclines,all D Contraindicated(secondandthirdtrimesters)
Thalidomideandanalogs X Contraindicated(anytrimester)
Tramadol C Risk(thirdtrimester)
Tretinoin:topicaldoses C Lowrisk(humandata)
Risk(anytrimester)weakfolicacidantagonist,and
Triamterene C/D
CategoryDforgestationalhypertensionuse
Trimethadione D Contraindicated(firsttrimester)
Trimethaphan C Contraindicated(anytrimester)
Trimethoprim C Risk(thirdtrimester)
Valproicacid D Risk(thirdtrimester)
Contraindicated(anytrimester)avoidfrom12
Varicellavaccine(liveattenuated) C
monthsbeforepregnancyuntilafterdelivery.
Venezuelanequineencephalitis
Contraindicated(anytrimester)avoidfrom12
vaccine,VEETC84(live X
monthsbeforepregnancyuntilafterdelivery.
attenuated)
Vidarabine,antiviral C Teratogenicinanimals
Contraindicated(anytrimester)indosesgreaterthan
VitaminA A/X
FDARDAc
VitaminD A/D CompatibleexceptfordosesgreaterthanFDARDAc
VitaminK3,menadiol,menadione C Risk(thirdtrimester)
Voriconazole D Teratogenicinanimals
Warfarin D/X Contraindicated(anytrimester)
Epidemic:compatible(benefits>>risks).Otherwise
Yellowfevervaccine(live
D avoidfrom12monthsbeforepregnancyuntilafter
attenuated)
delivery.
Zonisamide,anticonvulsant C Teratogenicinanimals

aFDAcategories(seealsoWarfareAgentsChemical):A=controlledstudyhasshownnoriskB=
noevidenceofriskinhumansC=riskcannotberuledoutD=positiveevidenceofriskX=
contraindicatedinpregnancy.

bDatafromBriggsGG,FreemanRK,YaffeSJ:DrugsinPregnancyandLactation:AReference
GuidetoFetalandNeonatalRisk,8thed.LippincottWilliams&Wilkins,2008.Allrecommendations
arebasedonhumandata.Animaldataarecitedonlyifhumandataareunavailableandanimaldata
showserioustoxicityinmultiplespecies.Risk:Humandatasuggestriskexposureduringpregnancy
shouldbeavoidedunlessthebenefitsofthedrugoutweightherisks.Contraindicated:Human
exposuredataindicatethatthedrugshouldnotbeusedinpregnancy.Numbersinparentheses
indicatetimesduringpregnancywhenthedrugiscontraindicatedorposesrisk:All:anytimeduring
pregnancy.

cAbbreviations:HMGCoA=hepatichydroxymethylglutarylcoenzymeARDA=recommendeddaily
allowance.
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