1
Q
What age is term neonate?
A
37-42 weeks gestational age (GA)
2
Q
What is preterm age?
A
Less than 37 weeks GA
3
Q
Know the following ages:
Extremely preterm
Very preterm
Moderate to late preterm
A
- Less than 28 weeks
- 28-32 weeks
- 32-37 weeks
4
Q
What is chronolocial age? (3)
A
- Also called “Post Natal Age (PNA)”
- The time elapsed after birth
- The response to “how old are you?” - Described in days, weeks and/or years
5
Q
How old is an infant?
A
1 month to 1 year of age
6
Q
How old is a ‘child’
What are the 3 developmental periods?
A
- 1 year through 12 years
- Developmental Periods:
- Toddler: 1 to 3 years of age
- Preschool: 3 to 5 years of age
- Gradeschooler: 5 to 12 years of age
7
Q
How old is an ‘adolescent’?
A
12 years to 18 years
8
Q
What are the Wellness programs in SK? (5)
A
- Newborn Screening
- Postpartum Visits
- Newborn Hearing Screens
- Specialized Clinics
- Immunization Programs
9
Q
Describe what newbron screening (NBS) is (4)
A
- Routine care for all neonates born in SK
- Tests for congenital disorders
- 32 metabolic and endocrine disorders - Completed after 24 hours of age
- Blood test
- Heel poke and dry blood spot card
10
Q
What % of babies screen negative and positive for the tests in NBS?
A
- Over 99% of babies tested “screen negative”
- Less than 1% “screen positive” for one of the conditions
11
Q
What are the key points to know about NBS? (3)
A
- A positive screen DOES NOT mean a baby has the disorder
- Further testing required
- “High” or “Low” risk
12
Q
What is the postpartum visiting program? (6)
A
- Support and follow-up care at home after the birth of a baby
- First 10-14 days of life
- Assess mother’s recovery, baby’s health and weight
- Support with feeding
- Answer questions
- Refer and connect to community services
13
Q
What is the Newborn Hearing Screen? (3)
A
- Hearing test about 12-16 hours after birth
- Usually performed in hospital before discharge
- Identify early hearing loss and how to address it
14
Q
What are the developmental skills/main development areas we look for in pediatrics? (10)
A
- Language
- Dressing
- Fine motor
- Grooming
- Physical
- Emotional
- Social
- Spiritual
- Intellectual
- Adaptive
15
Q
Between 2012-2017 use of medication was at least twice as common for children and youth specific chronic conditions. Such as: (4)
A
- Asthma
- ADD
- Learning disability
- Oral contraceptives
16
Q
What to know about meds in children? i.e., what makes them a special pop? (3)
A
- Medications can have different effects in this population:
- Brains are still developing
- Same disease states in adults can present differently in children and youth
- Different pharmacokinetics (ADME) in children - Drugs tend to be less studied for children
- Adult data is often extrapolated - Many drugs are used in children off-label
17
Q
What is Jordan’s Principle? (2)
A
- All First Nations children living in Canada can access the products, services and supports they need, when they need them.
- Health, social and educational needs, including the unique needs that First Nations Two-Spirit and LGBTQQIA children and youth and those with disabilities may have
18
Q
What are the most common DTPs seen in children? (4)
A
- Dose too low
- Adverse drug reaction
- Dose too high
- Adherence
19
Q
The DTP of dose too low impacts ______________
A
effectiveness
20
Q
The DTP of dose too high impacts ____ __ ____________ __ _______ ______
A
risk of experiencing an adverse effect
21
Q
There are some meds that should be avoided in children due to adverse effects. Such as? (5)
A
- Codeine
- Tetracyclines
- ?Fluoroquinolones
- Certain excipients (e.g., benzyl alcohol, propylene glycol)
- ASA - in most cases
22
Q
What are some issues that affect adherence to meds in pediatrics? (7)
A
Administration:
1. Drug product factors: tablets, taste, volume, spitting up
2. Caregiver: well-being, health literacy, ability to measure
Funding:
1. Private Insurance
2. SK Drug Plan, Special Support
3. NIHB, Jordan’s Principle
Supply:
1. Uncommon commercial liquids
2. Compounding availability
23
Q
How to deal with solid dosage form being an adherence issue in peds? (3)
A
- Try to change to a suitable liquid or dissolveable formulation
- Crush tablets (if able to) - Partial tablets, opening capsules and mixing into a vehicle
- Dissolve and dose
- A known amount of drug is mixed into water to make a solution and then dosed
(Remember: none of these methods have stability data)
24
Q
If taste is an issue with adherecnce, what can be done? (4)
A
- Mask with a stronger flavour (e.g., chocolate, raspberry)
- Compounded suspensions
- Give a popsicle/freezie before administration
- Can mix into food – but be careful!
25
If spitting up is an issue with adherence in children what can be done?
Re-dose if within 30-60 minutes
26
What to know about bloodwork in peds? (2)
1. Health care professionals try to avoid poking children with a needle
- Needle pain and fear
- Anemia: maximum blood draw limits
2. Some bloodwork is unavoidable, but consider which tests are required
- In hospital: pairing bloodwork with other tests
27
How long are infants typically breastfed? (2)
1. Exclusively for the first 6 months
2. Sustained for up to two years or longer with appropriate complementary feeding
28
Breastfeeding is rarely contraindicated, but when is it? (3)
1. HIV
2. Infectious tuberculosis
3. Infant has galactosemia
29
If breastfeeding is not possible, appropriate milk substitutes should be offered. Such as? (3)
1. Expressed breastmilk from the mother
2. Pasteurized donor milk – from appropriate sources
- Currently limited to hospitalized infants who will benefit the most
- Do not share or use unprocessed or unscreened human milk
3. Commercial infant formula
30
What to know about infant formula (tips from a dietitian)? (6)
1. Formula is complete infant nutrition for the first 6 months of life
2. Cow’s milk- based formula is recommended
3. Avoid low-iron formula
- Marketed as easier to digest, but can lead to deficiencies
4. Lactose intolerance is EXTREMELY rare
5. Cow’s milk protein allergy is possible – refer
6. Probiotics
- Are not likely harmful but can increase the cost of formula
- Weak evidence and non-essential at this time
31
What are some important considerations to know for infant formula? (4)
1. Refer infants with medical conditions affecting formula choice.
2. Discourage the use of homemade formula or other
milks (cow or other animal)
3. Ensure caregivers can properly prepare and administer formula.
4. Never leave infants unattended during feeding due to choking hazards.
32
Vitamin D supplementation in infants. Yay or nay/
Yay
All breastfed infants (exclusive and partial), living anywhere in Canada, should receive 400 units daily up to 1 year of life.
- Low stores of vitamin D can lead to rickets
33
Iron in infant diet. What to know? (3)
1. Deficiencies in iron may have serious and irreversible adverse effects
2. Most infants have sufficient stores until about 6 months of life, then they need to be supplemented for development
3. Meat, meat alternatives, iron-fortified cereals
34
What are the different nutrition administration routes commonly used in peds? (3)
1. Oral
2. Enteral
3. IV
35
What is the pharmacist's role in tube feeding? (3)
1. Assess for interactions
- Drug-formula/food interactions
2. Assess absorption
- Most drugs are absorbed in the small GI tract. Does the tube reach there
3. Assess for drug-tube compatibility
- Can the drug and/or formulation be given via tube?
36
How to solve the problem of drug absorption via tubes? (2)
1. Alternate routes of administration: suppository, transdermal, IV**, small amounts orally?
2. Therapeutic alternatives: would a different drug be better absorbed?
37
How to solve the problem of drug occlusion in tubes? (2)
1. Solutions or soluble tablets are the formulation of choice
- Crushing a soluble tablet and mixing into a small amount of water is generally preferred
- Easier transport and cheaper for patients
2. Families should have instructions on how to flush an occluded tube and when to seek care.
- Do not use Cola to unclog tubes (old myth)!
38
How to solve the problem of drug adhesion to tube? (1)
Alternate routes of therapy or other meds that could be used
39
What is the 4-2-1 rule of fluids?
1. Used to calculate maintenance fluid regimens (IV and enteral) in children
- Maintenance fluid: amount of fluid needed to be replace normal daily losses
- Respiratory, urinary, GI tract, skin losses
40
How would you apply the 4-2-1 rule to a 32kg patient?
4 mL/kg/hr x first 10kg = 40mL/hr
2 mL/kg/hr x second 10kg = 20mL/hr
1 mL/kg/hr x remaining kg (12) = 12 mL/hr
Rate = 40+20+12 mL/hr = 72 mL/hr, or approximately 1.7L per day
41
What is the pharmacist's role in IV fluids? (3)
1. Electrolyte Imbalance
- Electrolyte dosage
- Administration safety
2. IV Compatibility
- Children usually have limited IV access
- Need to understand chemistry and how to use references to provide advice.
3. TPN Compounding
- Some pharmacists are responsible for writing TPN orders
- TPN integrity
42
Why are preschoolers challenging to diagnose with asthma? (2)
1. Asthma diagnosis relies on spirometry
2. Preschool aged children (< 6 years of age) are not able to reliably complete pulmonary function tests
43
Most children with asthma experience onset of symptoms as preschoolers. How does it present? (3)
1. Wheeze: associated with decreased lung function
2. Increased emergency department visits and hospital admissions
3. Airway remodelling leading to altered lung function trajectory into adulthood
44
What are 4 symptoms of airflow obstruction?
1. Wheezing is the most specific sign
2. Other breath sounds may be heard (decreased to the bases)
3. Tachypnea, prolonged expiration, accessory muscle use (chest indrawing), hypoxemia, altered level of consciousness
4. Cough (non-specific): chronic cough that occurs while sleep or trigged by allergens, exertion, laughing or crying
45
Children <6 require a therapeutic trial of a medication for asthma. What meds? (3)
1. ICS
2. SABA
3. Oral steroids (prednisone, prednisolone, dexamethaone)
46
What to know about ICSs? (3)
1. MOA
2. Types and dosing
3. Proper technique
1. Mechanism of Action
- Inhaled corticosteroids reduce airway inflammation and prevent asthma symptoms.
2. Types and Dosing
- Commonly used options include fluticasone, budesonide, and beclomethasone, with dosages tailored to asthma severity.
3. Proper Technique
- Ensuring correct inhaler technique is crucial for the medications to be effective and minimize adverse effects.
47
What to know about SABAs? (3)
1. MOA
2. Common examples
3. Appropriate use
1. Mechanism of Action
- These medications rapidly relax and open the airways, providing quick relief of symptoms.
2. Common Examples
Salbutamol is the most widely used SABA.
3. Appropriate Use
They should be used as needed for symptom relief, not as a replacement for daily controller medications.
48
What are the steps of a therapeutic trial with signs of airway obstruction? (3)
1. Patients presenting with symptoms
- First step: identify signs of obstruction (active or parental report)
2. Start on SABA ± oral corticosteroid
- Physician will start medications.
3. Assess patient response
- Pharmacist follow-up: reassess at appropriate intervals, check adherence and provide plan for caregivers.
49
What are the steps of a therapeutic trial with no signs of airflow obstruction? (3)
1. Patients not presenting with obstruction, but report 2 or more episodes of asthma-like symptoms
2. Depending on severity and frequency of symptoms:
- PRN SABA x 3 months and reassess
- Trial of medium dose ICS and PRN SABA x 3 months
3. Reassess in 3 months
- Can a dechallenge be initiated?
- Communicate guideline-based plan to caregivers.
50
What is the pharmacist's role in peds asthma treatment? (3)
1. Our role is not to diagnose, but to give context about what patients can expect when starting therapy at a young age
2. Ensure the patient is using the medication appropriately (important for efficacy and adverse effects)
3. Efficacy is very important to assess; need to figure out if this will be a long-term medication
51
For a successful therapeutic trial of an asthma med, we should ensure: (4)
1. Adherence
2. Adequate inhalation technique
3. Diligent documentation of signs/symptoms
4. Timely medical reassessment
52
When assessing a new Rx for an inhaler for young children (1-5 years old), how can we assess if the meds are indicated? (3)
1. Confirm the patient's asthma symptom history
- Airway obstruction
- Symptom frequency
2. Confirm therapeutic trial plan
- Make sure caregivers understand what they need to do in the next 3 months
- Manage their expectations
3. The goal is to ensure that there is a clear indication for therapy
53
How can we assess if asthma med trial is effective? (2)
1. Check the dose: SABA PRN is acceptable
- Ensure the child is prescribed medium-dose ICS
2. Counsel caregivers on what they need to document —> suggest a diary
- Change in frequency and severity of symptoms
- Daytime and nighttime symptoms
- Rescue SABA use
- Effort limitation
- Absenteeism from usual activities
- Exacerbations that require medical visits, oral corticosteroids and/or hospital admission
54
Pharmacists can only administer vaccines over the age of _
5
55
What are 3 non-pharm ways to help with needle pain in children?
1. Breastfeeding during vaccine injections
- Strongly recommended in children two years and younger
- Reduce stress through multiple mechanisms
- Cost-neutral, could also bottle-feed
2. Position during vaccination (not lying supine on a table)
- Skin to skin with neonates
- Holding infants with patting and/or rocking
- Children sitting up
3. Distractions
56
What is a pharmacological option for dealing with needle pain in children?
1. Lidocaine/Prilocaine and lidocaine only
2. Children 12 years and younger
3. Apply at home before going to the clinic
57
Touch on sucrose solution for helping with needle pain in kids
1. Children 2 years and younger
2. Mechanism of action is unknown, but thought to involve release of endogenous opioids
58
What are the consequences of acute pediatric pain? (4)
1. Avoidance of medical care later in life
2. Associated with chronic pain: mental illness, opioid use, socioeconomic disparities into adulthood
- Potential for interruptions in daily activities like schooling
3. Increased health system costs
4. Infants and children have been identified to be a population at greatest risk of inequitable and poor-
quality pain management
- First Nations Children in Canada: more likely to have a pain-related condition but less likely to seek care or
get a referral
59
What is the pathophysiology of acute pain in children? (5)
1. Nociceptive system has increased excitability and sensitization when compared to adults
2. Greater degree of plasticity
3. Descending inhibition is delayed
- Important endogenous analgesics are not present as they are in adults
4. Exaggerated reflex responses which can cause sensitivity
5. Perception of pain may be more influenced by developmental, social, and psychological factors
60
What are some signs and symptoms of pain in children? (6)
1. Vocal - crying, yelling etc.
2. Social - quietness, irritability, etc.
3. Facial - furrowed brow, grimace, etc.
4. Activity - less movement, agitated, etc.
5. Physical - pallor, sweat, etc.
6. Other - changes in sleep, etc.
61
What is the 3 P approach to pain management?
Psychological - parent is prepared and offers distraction
Physical - positioning
Pharmacological
62
What are the first-line therapies (pharmacological) in children for pain? (2)
OTC ibuprofen or acetaminophen
- Ibu more effective than acet for children's pain
63
Can codeine be used in children?
NO - not under 18
64
What is chronic pain and what are the most prevalent forms in pediatrics?
1. Persistent or recurrent pain for greater than 3 months
2. Most prevalent forms of paediatric chronic pain:
- Headache, abdominal and MSK pain
65
How might chronic pain be treated in children? (2)
1. Interdisciplinary chronic pain clinic, when available
- Often includes a combination of treatment modalities
- Involvement of caregivers is key to success
2. Pharmacological therapy:
- Antidepressants (e.g., amitriptyline)
- Antiepileptics (e.g., gabapentin, pregabalin)
Very little quality evidence for pharmacological treatment for non-cancer pain in children
66
What is the dosing for acetaminophen in children?
10-15 mg/kg/dose q4-6h. No more than 5 doses (75mg/kg/day)
67
What is the dosing for ibuprofen in children?
5-10mg/kg/dose q6-8h up to a maximum of 40mg/kg/day
68
What are febrile seizures? (3)
1. Seizures occurring in children aged 6 months to 5 years with a temperature greater than or equal to 38C
- No signs of CNS infection or metabolic disturbance (e.g., hyponatremia)
- No history of a prior afebrile seizure
2. Precise mechanism is unknown
3. Febrile seizure recurrence is common after a first febrile seizure
- Risk of future epilepsy is not increased after a first simple febrile seizure
69
What are some potential risk factors for febrile seizures? (3)
1. Family history of febrile seizure
2. Developmental delay
3. Viral illness (e.g., influenza, adenovirus, parainfluenza, etc.)
70
How to manage febrile seizures? (3)
1. Most simple febrile seizures will have stopped before
presentation to a health care professional
- Do not require antiseizure medication
2. If seizure is occurring, stabilization and monitoring
- Keep child safe, do not put anything into their mouths
- Try to roll them onto their side or roll their head to one side
- If lasts longer than 3 minutes – call an ambulance
3. Children should be reviewed by a physician after a febrile
seizure
71
Antiseizure meds for febrile seizure prevention. Yay or nay?
Nay
Continuous or intermittent antiseizure medication for single or recurrent simple febrile seizures not recommended
72
Antipyretics for febrile seizure prevention. Yay or nay?
Nay
No evidence that antipyretic treatment affects illness course or neurologic complications
73
What are 3 of the common heart defects in children?
1. Atrial Septal Defect (ASD)
2. Coarctation of the Aorta (CoA)
3. Hypoplastic Left Heart Syndrome (HLHS)
74
How are congenital heart malformations treated? (2+5)
1. Surgery
2. Pharmacological therapy:
- Diuretics: furosemide, spironolactone/hydrochlorothiazide
- Aspirin therapy
- Anticoagulation: enoxaparin, warfarin (older children)
- Blood pressure medications
--Double check the indication for propranolol prescriptions
- Pulmonary hypertension medications: sildenafil, tadalafil, bosentan
75
What is the potential pathophysiology of GERD in infants? (3)
1. Spend a lot of time lying down
2. Frequent, liquid meals
3. Short esophagus and lower-esophageal sphincter (LES)
76
What are 3 non-pharm therapies to help with GERD?
1. Thickened feeds
2. Cow's Milk Protein
3. Infant Positioning
- Keep head elevated after feeding
- Left-side down positioning when sleeping
77
What is a minor burn defined as?
Necrosis to the epidermis and dermis only
78
What are key physiological differences in children to be aware of when thinking about burns? (4)
1. Children have relatively thinner skin
- Can result in deeper burn wounds at any temperature
2. Children have larger skin surface area to body mass ratio
- Greater fluid and heat loss
3. Children have larger heads – different calculations for total body surface area
4. Maltreatment concerns: if suspected, contact Ministry of Social Services (SK)
79
Distinguishing between a major burn and a minor burn will dictate the treatment. Major burns include any of the following: (5)
1. >10% of Total Body Surface Area (TBSA)
2. Involving face, hands, feet, genitalia, perineum, or major joints
3. Full-thickness burns
4. Electrical or chemical burn
5. Concomitant trauma
80
What is the non-pharm treatment for burns? (2)
1. Cooling: for up to 20 minutes with cool-to-touch tap water or cool water compresses
2. First aid for minor burns:
- Remove the causative agent
- Cool tap water; ice is not recommended
- Mild soap (like baby soap) for gentle cleansing
- Appropriate dressings (sterile, non-adherent gauze)
- Antiseptics and disinfectants not recommended
81
What are 3 pharmacological therapies for burn treatment?
1. Topical Antimicrobials
- Use for small superficial burn wounds but discontinue within 1 week (avoid sensitivity reactions)
- Caution with products that contain topical anesthetics e.g., lidocaine
2. Pain Control
- OTC Analgesics (acetaminophen, ibuprofen)
3. Tetanus Booster
- If immunization was more than 5 years prior or unknown
82
How to deal with itching after a burn? (2)
1. Moisturizing Lotions
- Colloidal oatmeal products
2. Systemic Antihistamines
- Diphenhydramine, cetirizine, loratadine, desloratadine
83
What are 2 complications of burns?
1. Cellulitis, colonized with gram-positive and gram-negative bacteria
2. Scarring
84
What is the most common cause of poisoning events in preschool-aged children?
1. Accidental ingestion
2. Medications, toys, common household products
85
How to prevent accidental ingestion of cannabis for children? (2)
Prevention is key:
1. Use legal cannabis products – contain no more than 10 mg THC and must be plain, child-resistant packaging
2. Other products may try to mimic popular brands of candies, snacks, etc that appeal to children
86
How to manage accidental ingestion in children? (4)
1. If the substance is present, ensure the parent takes it with them (to the hospital presumably)
2. Do not make the child vomit unless instructed to do so
3. Call 911
4. Call the Poison Information Centre
(Bottom-line = REFERRAL)
350 again
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