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Pediatric Math
Children are more susceptible to medications than adults due to immature systems, metabolism
and physical composition that can alter the pharmacokinetics of drugs. Therefore it is essential that
everyone involved in the medication administration can accurately check the medications and ensure they
are safe for the child. Nurses must be attentive to the 8 rights (right patient, right medication, right route,
right time, right dose, right assessment, right education, right documentation). The nurse is also
responsible to know if the dose is safe and therapeutic for their patient! It is essential for nurses to learn
correct medication calculations in to ensure that each child receives a safe dose of medication within the
therapeutic range.
Review of formulas:
Ratio and proportion: Basic Formula:
𝐷𝑒𝑠𝑖𝑟𝑒𝑑
On hand: vehicle:: desired dose : x 𝑥 𝑣𝑒ℎ𝑖𝑐𝑙𝑒
𝐻𝑎𝑣𝑒
Most medications will be ordered in mg/kg for infants and children. Also due to size and
composition pediatric fluid requirements vary greatly than those of adults. Therefore it is necessary for
nurses to be able to convert pounds to Kilograms (kg).
Try not to round kg when doing drug calculations, if it is necessary round to the nearest
hundredth place (0.01)
Example 1)
2.2:1::12.5:x 2.2x=12.5
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Name: _____________________________
2.2x=12.5 x= 5.68
12.5
𝑥=
2.2
X= 5.68
Practice Questions:
1) 38 lb ______ kg
2) 16 lb ______ kg
3) 42 lb ______ kg
4) 60 lb ______ kg
5) 8 lb ______ kg
6) 12 lb ______ kg
Most medications for infants and children are ordered by kilograms of body weight. In order to
calculate the dosage you need:
a) A doctor’s order that includes the medications name, the dose, and the frequency of
administration.
b) The child’s weight.
c) The Pediatric safe dose as listed in the by the manufacturer or hospital formulary and
therapeutic range. (found in your drug book, or by calling the pharmacy)
d) How the drug is supplied (what we have on hand).
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Name: _____________________________
The pharmacy says that the dose for children 5< is 20-40mg/kg/day in 3- 4 divided doses.
ANSWER:
14
=x
2.2
X=6.36
Second we find out if the dose is safe. (I always do this second because if it is not then we stop
calculations here)
So here I figure out how many mg/kg/day of amoxicillin the doctor has ordered for the client.
So our patient is getting 225mg of amoxicillin a day we then need to divide 225mg by 6.36kg to
find mg/kg/day.
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225𝑚𝑔/𝑑𝑎𝑦
= 35.38mg/kg/day
6.36𝑘𝑔
IF A DOSE IS NOT SAFE WE DO NOT GIVE THE MEDICATION!!!! CALL THE DOCTOR and hold
the medication until you have clarification. If the dose is not therapeutic I call the doc and let
them know but still give the med.
Now we need to know how many milliliters (ml) of the amoxicillin we need to give:
Oral Meds:
Medications given orally can be supplied in many forms such as tablets, capsules, powders, and
liquids (including elixirs, syrups, and suspension).
Children under 5 are at risk for aspiration and normally have difficulty swallowing pills. If you
are caring for a child 5 or under you should try to get the medication in liquid form. If the
medication is only available in capsules or tabs than capsules can be opened, and tabs can be
crushed. Then the powder can be mixed with a pleasant tasting liquid, and administered to the
child.
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LIQUIDS:
Liquids may be less concentrated at the top and more concentrated at the bottom so should be
shaken prior to administration. Always use proper measuring equipment such as a medicine
cup, measuring spoon, plastic oral syringe, or dropper to administer medication. DO NOT USE
STANDARD HOUSEHOLD SPOONS FOR MEDICATION ADMINISTRATION!
When giving liquid medications to children with a dropper or oral syringe place the tip of the
dropper or syringe in posterior lateral section of the cheek. Give the medication slowly 0.2 to
0.5ml at a time and allow the child to swallow prior to giving more medication. Droppers and
oral syringes are best for infants. Toddlers may prefer a spoon or cup. Older children may use a
spoon, cup or syringe, whatever method they prefer.
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RECTAL SUPPOSITORIES:
Suppositories may be given to infants and young children when the oral route is unavailable.
Suppositories for children may sometimes be cut in half. If this is the case cut it Lengthwise.
Lubricant should be applied, use surgilube or water do NOT use Vaseline or other petroleum
based lubricant because it will interfere with absorption. The suppository should be inserted
above the internal anal sphincter and the buttocks should be held together for several minutes to
prevent expulsion. The fifth finger should be used for insertion in children three and under, the
index finger may be used in older children.
INJECTIONS:
Injections for pediatric patients differ than those in adults in that needle sizes must be smaller,
muscles are smaller so therefore they absorb less fluid volume, and sites differ on children due to
muscle development. Also the nurse may use EMLA crème to prevent pain during injections.
IM INJECTIONS:
In infants and small children injection sites differ from adults in that if a child is not walking we
do not give injections in the ventrogluteal site. Also with infants and small children the deltoid is
too small to use for injections. The preferred site for infants under 3 year is the vastus
lateralis because it is the largest muscle in this age group. Also typically the Deltoid muscle
is too small to use for IM injections in children under 3 years of age.
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For children fewer than 3 years of age, pull For children over 3 years of age and adults,
the ear down and back. pull the ear up and back.
EXAMPLES:
1) You are caring for a 2 month old infant weighing 6.36 kg. The doctor has ordered
Tylenol 80mg PO q6hr PRN. We find that Tylenol is available in: infant suspension
80mg/0.8ml, in a liquid 160mg/5ml, chewable tabs 81mg/tab, tablets 250mg/tab,
suppositories 80mg, and 120mg. (We can find how medications are available in the drug
book or by calling the pharmacy).
a) Which form of medication would you give?
b) How would you administer it?
Answer: The best method would be the Tylenol Suspension, because it is an oral liquid which
would be the most appropriate for the age (and less invasive than a suppository), and the
suspension allows the nurse to administer less fluid therefore decreasing the risk for aspiration.
The best method for administration would be a dropper or an oral syringe to properly put the
liquid into the cheek pocket in the mouth.
2) You are caring for a 4 year old child requiring ear drops. Which way will you pull the
ear to administer the drops?
3) You are preparing to administer a DTaP vaccine to a 2month old infant. The nurse
knows that the DTaP is an IM injection of 0.5ml.
a. What muscle will you give the injection in?
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Answer: The nurse would expect to give the injection in the Vastus lateralis, using a
5/8inch 25G needle.
4) The nurse is preparing to give Acetaminophen to a 5year old girl weighing 20kg. The
doctor has ordered Acetaminophen 200mg PO q6hr PRN pain. Use the drug formulary in
the back to see how the drug is supplied.
a. What would be the best method to administer this medication?
Answer: This was a trick question at 5 years of age the child may take oral liquids
chewable pills. Either of these would be an appropriate answer. In the clinical setting the
nurse would want to check with the parent to see what method would be best.
PRACTICE QUESTIONS:
Use the drug formulary in the back of the packet to complete these problems
1) You are caring for a 10 year old child weighing 30kg. The doctor has ordered cephalexin
500mg po Q6 hrs. Use the drug formulary in the back to complete this problem.
2) You are caring for a 2 year old child weighing 12kg. The doctor has ordered
Prednisolone 12mg PO BID x 7 days.
a. Is the dose safe and therapeutic? ________
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c. How will you administer the medication? Please describe the steps:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
3) You are caring for a 1 year old child with otitis externa. The doctor has ordered
Ofloxacin 5gtts to the left ear BID.
______________________________________________________________________________
______________________________________________________________________________
Due to children’s immature organ systems, smaller size and larger body surface area
children’s fluid requirements differ greatly from adults. To calculate an infant or child’s
maintenance fluid requirements we use the formula below:
Always convert weight from pounds to kilograms for pediatric fluids as well as
medications!
100ml/kg for the first 10kg of body weight
We use this formula to calculate the hourly rate of IV fluid the child should receive in
order to prevent fluid volume imbalances.
Now remember when calculating maintenance fluid is just the fluids required to maintain
a normal fluid balance if a child is not drinking. In cases of dehydration the child may be
receiving more fluids, and with cardiac or renal problems the requirements may be less.
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1) If the child weighs 23 kg what would the daily fluid volume be?
2) If the child weighs 8 kg what would the daily fluid volume be?
3) If the child weighs 12 kg what would the daily fluid volume be?
100ml/kg for the first 10kg = 1000ml
50ml/kg for the next 2kg = 100ml
TOTALS 12kg = 1100ml/day
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Due to children’s small size and immature systems children are at higher risk for fluid
volume imbalances than adults. Therefore it is extremely important for the nurse to be able to
identify if the child is getting appropriate fluid maintenance for their size. If the child is not
receiving normal maintenance fluids the nurse should be asking why!
1) If the child weighs 23kg and we already calculated the daily requirements of
1560ml/day. You simply divide 1560ml by 24 because there are 24 hours in a day:
65ml/hr
1) If the child weighs 8kg we have calculated that the child need 800ml/day:
800𝑚𝑙/𝑑𝑎𝑦
= 33.33𝑚𝑙/ℎ𝑟, so we round to 33ml/hr
24ℎ𝑟/𝑑𝑎𝑦
2) If the child weighs 12kg and we have calculated the child needs 1100ml/day:
1100𝑚𝑙/𝑑𝑎𝑦
= 45.83, so we round to 46ml/hr
24ℎ𝑟/𝑑𝑎𝑦
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#1 RECONSTITUTION:
Reconstitution is adding liquid to a powder to make a new solution. Most antibiotics are
received in a powder form and the nurse must add a liquid (normally sterile water or saline) in
order to prepare the medication for administration.
Information on how to reconstitute can be found either on the drug label, on formularies
provided by your facility, or the nurse can call the pharmacy. The nurse knows how much
medication to draw up after s/he reconstitutes the medication.
The doctor has ordered Ampicillin 500 mg IV TID for a child weighing 28kg.
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So if the daily dose ordered for the child is over 1,400 it is therapeutic and if it is under
5600mg it is safe. Our child’s daily dose is 1,500mg so it is safe and therapeutic.
So from the label above we can reconstitute the medication with 1.8 ml of diluent and the
resulting concentration will be 250mg/ml
Note that the bottle says for IM use to reconstitute with 1.8ml of solution, but we can reconstitute
medications the same for IV or IM use, but often the medication must be further diluted for IV
use.
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PRACTICE RECONSTITUTION:
The doctor has ordered Cefzil 150mg PO BID for a 10kg toddler.
Is it therapeutic? ________
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1) The doctor has ordered cefazolin 120mg a day for a 4kg neonate.
The normal neonatal dose is 60mg/kg/ day
Using the label above how much diluent would you add to the bottle?
________
________
________
After we have figured out if the medication is safe for the patient, reconstituted the med
and drawn the medication up for delivery often we need to dilute the medication further for
delivery. There will be safe administration concentrations that you can find in the drug book, by
calling the pharmacy and on facility drug formularies. Also the nurse must know the length of
time the medication is to be given over. This information can be found in your drug book.
For all practice problems in this packet the information is provided under Drug formularies in the
back.
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#1) The doctor has ordered Ampicillin 500 mg IV TID for a child weighing 28kg.
The normal pediatric dose is 50-200mg/kg/day in divided doses
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#2) The doctor has ordered Cefazolin Sodium 700mg Q6hr. You are caring for a child
weighing 45 kg. Available is a 1gm vial.
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So the minimum amount of fluid you can put it in is 35ml for administration. We can
dilute it further!!
= 420ml/hr
So the fastest rate we can give the med is 420ml/hr. We can give it slower!!!
b. How much fluid will you use to reconstitute the medication? ________
c. How many milligrams per milliliter will there be after reconstitution? ________
g. What will the fastest rate you could give it at? (in ml/hr) ________
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2) You are caring for an infant weighing 5kg. The doctor has ordered Ceftazidime 140mg
Q8hr. Available is Ceftazidime 500mg.
b. How much fluid will you use to reconstitute the medication? ________
g. What will the fastest rate you could give it at? (in ml/hr) ________
3) The doctor has ordered Cefazolin 350mg Q6hr. You are caring for a 33lb child.
Available is:
b. How much fluid will you use to reconstitute the medication? ________
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g. What will the fastest rate you could give it at? (in ml/hr) _________
4) You are caring for the infant below, who weighs 12 kg. The doctor has ordered the Hib
vaccine for this infant.
___________________
In which direction should the nurse pull the ear to straighten the
canal?
___________________
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Acetaminophen (Tylenol)
Analgesic/ antipyretic
Available-
Caplet: 500mg
Pediatric Dosage:
Ampicillin
Antibiotic
Available-
Pediatric dosage:
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Reconstitution-
Dilute-
Available-
Pediatric Dosage:
Reconstitution-
Dilute-
Further dilute with NS, D5W, D5/NS, to a final concentration of 20mg/ml for
administration.
CEFTAZIDIME (Fortaz)
Antibiotic
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Available-
Pediatric Dosage:
Reconstitution-
Dilute-
CEPHALEXIN (Keflex)
Antibiotic first generation cephalosporin
Available-
Pediatric Dosage:
NAFCILLIN (Nallpen)
Antibiotic
Available-
Reconstitution-
Dilute-
Further dilute with NS, D5W, D5/NS, to a final concentration of 30mg/ml or less for
administration.
Available-
Pediatric Dose:
Otitis Externa: 1yr-12yr 5gtts to affected ear(s) BID. >12yrs 10gtts to affected
ear(s) BID.
PREDNISOLONE (Prelone)
Corticosteroid
Available-
Tab: 5mg
Pediatric Dosage:
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CEFPROZIL (Cefzil)
Antibiotic
Available-
Pediatric Dosage:
20-100mg/kg/day
Reconstitution-
Dilute-
Further dilute with NS, D5W, D5/NS, to a final concentration of 15mg/ml for
administration.
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References
Robertson, J. & Shilkofski, N., (2005) The Harriet Lane Handbook: Seventh Edition.
Wilson, Shannon, Shields, & Stang (2007) Nurses Drug Guide. Upper Saddle River,
Kee, J. L., Marshall, S. M., (2004) Clinical Calculation: Fifth Edition. St. Louis, MO;
Saunders.
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