kupdf.net_drugs-in-pediatrics.pdf - Drugs in Pediatrics NMT11 Respiratory TB Treatment Treatment Combined drug therapy for Long time 2 to 3 first line

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Unformatted text preview: Drugs in Pediatrics NMT11 Respiratory TB Treatment: Treatment: Combined drug therapy for Long time: 2 to 3 first line drugs for at least 6-9 months. months 1- First line drugs are: are: Dose 10-20 mg/kg/day 10-20 mg/kg/day 2020-40 mg/kg/day Route orally orally orally Side effect Hepatotoxicity Hepatotoxicity Hepatotoxicity 2- Second line drugs are: Dose 10-20 mg/kg/day • Ethambutol 10-20 mg/kg/day • Ethionamide 2020-40 mg/kg/day • Streptomycin • Kanamycin Route orally orally IM Side effect • • • Isoniazid Rifampicin Pyrazinamide Ototoxicity, Nephrotoxicity Bronchial asthma TTT of acute attack: A-Acute mild to moderate attack: attack: 1-Bronchodilators: Bronchodilators Dose 0.1-0.2 mg/kg/d • B-agonist: Salbutamol, Terbutaline, Fenoterol 15-20 mg/kg/d • Theophylline (methylxanthine derivatives) • Anticholinergic: Ipratropium 250 microgram/dose, 4times daily Route - Orally in mild attack - Nebulizer for infants and young children - Inhalers for older children orally or rectally Inhalation Action Selective B agonist direct relaxation of bronchial Sm.Ms Reduce the intrinsic vagal tone 2-Corticosteriods: Corticosteriods In moderate or severe cases orally or parenterally (anti-inflammatory and interfere with synthesis of LKs& PGs) N.B: Mild cases>>one or 2 bronchodilators are given, inhaled bronchodilator are the best Moderate cases>>inhaled bronchodilator and oral corticosteroids can be used 1 Drugs in Pediatrics NMT11 B-Acute severe attack (status asthmatics): asthmatics): -Drugs: Dose Intermittent B2 0.25-0.5 ml added to 2-3 ml saline every 1-2 h B2 agonist nebulized Salbutamol theophylline 5 mg/k/6 hr hydrocortisone 5-10mg/kg/6 hr Route inhalation IV slowly IV Preventive TTT in between attacks: attacks AntiAnti-inflammatory drugs: drugs it is indicated in persistant asthma 1-Corticosteriods: beclomethazone Budesinide Fluticasone Prednisone Dose 200-800 microgram/d (4 doses/d) 200-800 microgram/d (2 doses) 100-500 microgram/d (2 doses) 2mg/kg/d divided doses for 3-10 days Route inhaled Dose 5-10mg (once daily) Route orally Dose 0.06mg/kg/d 5-20mg/dose (3-4 doses/d) Route orally inhalation oral 2-Antileukotrines: Antileukotrines Montelukast (Singulair) 3-Mast cell stabilizers: stabilizers Ketotifen Na cromoglycate Cardiology Rheumatic fever 1-Prevention: Prevention (very imp.) - Prevention of streptococcal infection e.g. proper ventilation - Early diagnosis of strept. Pharyngitis , then, - Adequate TTT by: Benzathine penicillin 1,200,000 IM OR Benzathine penicillin 1,200,000 oral In Allergic Pt. Erythromycine 50mg/kg/d single injection at least 10 d - Prevention of rheumatic activity in pts with history if R.F.: 2 Drugs in Pediatrics Benzathine penicillin NMT11 1,200,000 IM every 2-3 weeks for life 2-Supportive TTT: TTT - Rest: pts with carditis should have absolute bed rest for at least 4 weeks, Daily examination is important to detect carditis that usually present within 2w of onset 3-Specific TTT: TTT A-Arthritis only (or carditis without cardiomgaly): Salicylates 100mg/kg for 2w then 74mg/kg for 4-6 w B-Carditis with cardiomegaly or failure: failure Prednisone 2mg/kg/d for 2-3w Salicylates 75mg/kg/d during tapering then taper 1m after stopping Prednisone C-Chorea: Chorea Phenobarbitone Haloperidol 3-5 mg/kg/d 0.02-0.1 mg/kg/d (in pts over 12 years) 4-TTT of complications: complications H.F - Mild cases: complete bed rest, o2, fluid restrictions and steroids - Sever cases: Dose Action furosemide 2mg/kg/d Preload reducing agents (diuretics) digoxin Digitalizing dose : 0.02-0.05 mg/kg Inotropes maintenance dose: 0.01 mg/kg/d captopril may be given After load reducing agents Infective endocarditis  Prevention • Dental procedures and surgery: Dose Amoxicillin 50mg/kg (single large dose) Route oral  Specific: Specific immediate parenteral antibiotic for 6 weeks Dose Route Penicillin G 300000 IU/kg/day parenteral Oxacillin 200mg/kg/day Gentamicin 2 mg/kg/day This treatment is modified according to the results of blood culture Timing 1 h. before the procedure Duration for 6 weeks 3 Drugs in Pediatrics NMT11 Hepatology • • • • Chronic hepatitis Antiviral drugs in chronic HBV, HCV have limited response (25%) Immunosuppressive (e.g. corticosteroidscorticosteroids-azathioprine) azathioprine in autoimmune hepatitis D-penicillamine (copper chelating agent) in Wilson disease. It is the only curable chronic liver disease and it should be excluded in every case of chronic hepatitis Liver implantation in end stage liver disease Cholestasis 1- Treatment of correctable conditions • Antibiotics for septicemia. • Elimination of lactose from diet in galactosemia • Surgical treatment of Choledochal cyst 2- Extrahepatic biliary atresia • Correctable lesion (rare): direct drainage. • No correctable lesion: kasia (hepatoportoenterostomy).it should be done before 60 days to obtain best results. • Liver transplantation for end stage liver disease ( biliary atresia is the commonest indication ) 3- Supportive Supportive treatment  Nutritional support • Fat soluble vitamins defeciency is replaced by synthetic water soluble preparations (e.g. for vit A and K) active vit D and vit E is given by injection . • Medium chain triglycerides containing formulas. • Calcium, zinc and Phosphorus.  Pruritus • Phenobarbitone • Cholestramine ( bile acid binder ) Portal hypertension 1- Management of variceal hemorrhage: hemorrhage:  Emergency therapy for bleeding varices: varices: . Anti shock measures: blood transfusion, intravenous fluids. . Correction of coagulopathy: vitamin k, fresh plasma, platelets transfusion . Nasogastric tube placement . Vasopressin infusion if bleeding persist  Emergency endoscopy and either injection sclerotherapy or band ligation  Emergency shunt: shunt: protosystemic shunt 2- Prevention of bleeding from varices: varices:  Prevention of the first attack of bleeding . Avoid aspirin and non steroid anti inflammatory drugs . B adrenergic blockers (propranolol) to lower the pressure in portal area . Prophylactic sclerotherapy or band ligation 4 Drugs in Pediatrics NMT11  prevention of rere- bleeding: bleeding: in addition to above measures, the following may needed: . Surgical protosystemic shunt. .Liver transplantation. Nephrology Minimal change nephrotic syndrome  Home management: management: for most cases  Hospitalization: Hospitalization: indicated for the first attack or relapses with marked edema 1- Supportive treatment: treatment: . Diet: Diet: rich in protein to compensate for protein loss & salt free Fluid restriction is indicated only in moderate or severe cases of edema . Bed rest: rest: is not indicated & children with mild edema can attend school 2- Specific treatment: treatment:  Control of edema: edema: > Mild edema: salt free diet is sufficient > Moderate edema: diuretics (Furosemide) 1-2 mg/kg/day Furosemide 1-2 2 mg/kg/day diuretics > Marked edema: intravenous salt free albumin followed by Furosemide  Steroids: Steroids:  Induction or remission: remission: Daily therapy Prednisone 2 mg/kg/day (60 mg/m2/day) divided into 3-4 doses Respose: urine becomes free of albumin usually occurs after 2 weeks. Therapy is continued for 1 week after that  No respose after 1 month: Steroid resistant (renal biopsy is indicated) Minimal lesion type usually gives excellent respose to corticosteroids  Maintenance of remission: remission: Alternate day therapy For those who responded to prednisone Prednisone 2 mg/kg/day single morning dose after breakfast every other day for 3-6 ms  Relapses: Relapses: Relapse is the recurrence of edema. It is treated as the initial attack but alternate day therapy is continued for longer period (6-12 months) Cyclophosphamide 2-3 mg/kg/day single dose for 8 weeks - in steroid resistant and in cases with frequent relapses - alternate day therapy with low prednisone is continued during therapy - Total leucocytic count is monitored every week (stop therapy if count drops below 3000/mm3 3- Treatment of complications: treatment of infections . Antibiotics: Penicillin for urgent treatment of any suspected infections (peritonitis & skin infections) Acute poststreptococcal glomerulonephritis  Home management: management: for most cases. More than 95 5 of cases will recover completely within few weeks & even without therapy 5 Drugs in Pediatrics NMT11  Hospitalization: Hospitalization: for cases complicated with severe hypertension, marked congestion or severe renal failure  Supporative treatment: - Rest: Rest indicated only during the oliguria phase of illness (first week) - Diet: Diet  High carbohydrate diet  Salt & protein restriction during the oliguria phase and in the presence of complications e.g: hypertension & marked congestion  Fluid balance: amount of fluids/day = urine output of the previous day + insensible water loss (400cc/m2)  Specific treatment: - Control of edema: edema . In most cases edema subsides spontaneously by the end of the first week. Fluid restriction & salt restriction during the first week are usually sufficient . Diuretics e.g: Frusemide, in some cases - Control of hypertension (when diastolic pressure exceeds 95 mmHg- usually one oral antihypertensive drugs is sufficient) Captopril 0.5-1 mg/kg/day divided into 3-4 doses) ACE Inhibitor B blockers - For eradication of any streptococcal infection Penicillin oral 10 days course  Treatment of complications: Renal failure diuretics, fluid restriction, treatment of acidosis, dialysis) Heart failure Dopamine not digitalis Hypertensive I.V. Diazoxide encephalopathy Chronic renal failure  Periodic clinical evaluation: evaluation nutritional status, growth, blood pressure, cariac function & skeletal examination for rachitic changes  Laboratory evaluation: evaluation blood urea, creatinine, acid base status-serum electrolytes (Na,K,Ca,P) hemoglobin level & radiological examination of bones for evidence of rachitic changes  Measurement of glomerular filtration rate: rate is important to determine the degree of renal insufficiency: . Values between 20-30 ml/min/m2: manifestations of renal failure appear . Values below 10 ml/min/m2 denote severe renal insufficiency 1- Conservative measures: measures mild to moderate cases of renal insufficieny with GFR above 10 2 ml/min/m - Diet: Diet . Carbohydrate & fat: allowed freely to provide sufficient calories . Protein restriction to dercearse the nitrogenous waste products . Salt restriction in cases with hypertension - Drugs: Drugs 6 Drugs in Pediatrics NMT11 Rickets Growth failure Hypertension Hyperphsphatemia & hypocalcemia active form of Vitamin D feeding regimen-growth hormone therapy salt restriction, oral furosemide & anti-hypertensive drugs > Oral calcium supplementation > Vit D therapy > Oral aluminium hydroxide Anaemia erythropoietin & packed RBCs Acidosis oral NaHco3 Antibiotics for severe urinary tract infection or severe systemic infections as it may precipitate an episode of acute renal failure 2- Dialysis: Dialysis severe renal insufficiency with GFR below 10 ml/min/m2 or when conservation measures are no longer effective - Peritoneal (continous ambulatory or chronic cycling) - Hemodialysis 3- Renal transplantation: transplantation - It is the ideal therapy for children with severe renal insufficiency - It can be carried out in children above the age of 5 years - Problems limiting its application include: graft rejection, finding suitable donor Urinary tract infection Proper antibiotics according to culture and sensitivity 1. Acute cases: cases  Pyelonephritis: Pyelonephritis Drugs Dose Route Gentamicxin 4 mg/kg/day IV initially then shift to oral therapy ampicillin 100 mg/kg/day after 5 days if the patient is improving Duration of therapy 10-14 days Urine should be sterile within 48 hours of adequate therapy  Cystitis: Cystitis Drugs Dose Route Amoxicillin or co50 mg/kg/day oral co-trimoxazol For 7-10 days Treatment can be adjusted according to the results of urine culture and sensitivity 2. Recurrent cases: cases After eradication of infection the following should be done: - Suppressive therapy with co-trimoxazol (Trimethoprim-sulfamethoxazole) given in lower dose (one third of usual therapeutic dose) - Adequate fluid intake - Frequent voiding - Avoid constipation Nocturnal enuresis  - Identification & treatment of organic causes e.g. urinary tract infection & polyuria Simple measures in children above 4 years: years 7 Drugs in Pediatrics NMT11 - Fluid restriction after dinner - Let the child urinate before sleep - Wake the child up by night to urinate - Rewarding for dry night - Punishment should be avoided  Drug therapy in children above 6 years: years Oxybutyrin Anticholinergic drugs increase bladder capacity Desmopressin vasopressin analog single night dose 0.1-0.2 mg Alarm device it gives a ring immediately at the beginning of wetting so the child can wake up for urination Neurology Epilepsy I- epilepticus. Treatment of the ongoing seizures or treatment of status epilepticus • First aid measures - Patent airway - O2 - IV line • Immediate anticonvulsant drugs Diazepam 0.3-0.5 mg/kg IV or rectal Phenobarbitone 10-15 mg/kg (loading dose) that can be repeated 5 mg/kg (maintenance dose) after seizure control If phenobarbitone failed to control the seizures shift to other drugs Phenytoin 15-20 mg/kg (loading dose) 5 mg/kg/day (maintenance) Na valproate 20-40 mg rectally IIII- Prevention of recurrence by antiepileptic drugs - Drugs: Drugs Drug Seizure type Dose(mg/kg/day) - Generalized seizures: 1- Sodium valproate Tonic clonic, Absence and myoclonic 10-40 - Partial seizures - Partial seizures: the best in partial seizures 2- Carbamazepine 10-30 - Generalized tonic clonic - Generalized tonic clonic 3- Phenobarbitone 3-5 - Partial seizures 4- Phenytoin As phenobarbitone 5-8 - Myoclonic 5- Clonazepam 0.05-0.1 - Infantile spasms - absence 6- Ethosuximide 20-40 - Myoclonic 8 Drugs in Pediatrics 7- Vigabatrin NMT11 - Partial - Infantile spasms 40-80 8- Lamotrigine - Atypical absence seizures 5-10 9- Topiramate - Partial seizures 5-10 10- Infantile spasms, myoclonic seizures 10- Corticosterioids and ACTH - Symptomatic intractable seizures Important rules for long term drug therapy 1- Initiation of therapy only after accurate diagnosis. 2- Choice of drugs according to clinical and EEG findings. 3- Number of drugs: start with one drug in small dose (to avoid toxicity and improve compliance) then increases gradually until seizure control or maximum dose is reached . Failure of the first drug is an indication to add the second drug. 4- Duration and termination of therapy At least 2 years after the child is being seizure free – termination should be gradually. 5- Patent counseling  Avoid watching TV except in lighted room and far enough from the screen.  Computer games should be done under supervision Meningitis 1- Prevention - Vaccination · Infants in the first year of life:- HIB vaccine 3 doses (against Hemophilus influenza) · Children:- Meningococcal polysaccharide vaccine (A and C) at 3 years - Chemoprophylaxis · Rifampicin used to eradicate meningococci from the nasopharynx of carriers and minimize the risk of contact infection. 2- Supportive treatment - I.V fluid if meningitis is complicated by shock (otherwise it should be restricted to minimize cerebral edema) - Blood transfusion for cases with DIC - Anticonvulsants: diazepam and phenoparbitone 3- Specific treatment: antibiotics Neonates 3 weeks Initial antibiotics should be active against IV for at least haemophilus influenzae type b, streptococci meningococci and menin gococci, then modified according 10-- 14 days 10 to the result of culture and sensitivity tests Neonates and infants younger than 2 months Cefotriaxone Chloramphenicol Ampicillin 100 mg kg/day, 100 mg kg/day, 100 mg kg/day, Infants and children older than Third generation cephalosporin and 2 months chloramphenicol  N.B Corticosteroids for H influenza improve CSF findings and decrease the incidence of hearing loss 9 Drugs in Pediatrics NMT11 4- Treatment of complications · Assisted ventilation if respiratory failure occurs. · Subdural taps to evacuate extensive subdural effusions 5- Follow up after treatment .Children who have meningitis should have a complete neurological evaluation at the time of discharge (vision, hearing and developmental assessment). . Periodic follow up for at least 2 years is recommended. Nutritional disorders Protein energy malnutrition  Prevention of protein energy malnutrition 1- Breast feeding promotion (it is the most important) Enumerate factors important for successful breast feeding 2-Health education of the mother about infant feeding 3-Assessment of nutritional status during infancy in every visit for earlier diagnosis of nutritional deficiency disorders  Management of protein energy malnutrition 1-Hospital management • Indication . 3rd degree marasmus . Kwashiorkor or marasmic kwashiorkor (edema) . Infections e.g. pneumonia, diarrhea • Treatment of life threatening conditions is the initial line of management:. Control of infections by proper antibiotics according to culture & sensitivity . Correction of shock, dehydration & electrolyte imbalance by proper I.V. fluids . Correction of anemia by blood or packed red cells 10-15cc/kg . Prevention of hypothermia (adequate clothing & external heat) 2-Home or hospital: nutritional management: Type Amount Marasmus . Milk: in young non-weaned infants . Other food (balanced diet): in older weaned infants . 150-200 Kcal. / kg / day Kwashiorkor . Milk: start with soy based lactose free formula (lactose intolerance), then gradually shift to standard formulas . Other food: Animal protein (high biological value): eggs, chicken, meat & yogurt Plant protein: lentils, beans Fresh vegetables & fruits are added . High protein diet: 4-6 gram protein/kg/day 10 Drugs in Pediatrics NMT11 N.B: calculation according to actual body weight & gradually increase (5-10 Kcal/kg/day) every day or every other day according to the infant tolerance Route . Nasogastric tube may be required if there is marked anorexia . Parentral feeding may be required in severe cases Orally N.B N.B: N.B Kwashiorkor (more difficult to manage because of anorexia) Marasmus Marasmus & kwashiorkor - Treatment of vitamin & mineral deficiency Vit.. A Single dose Vit 50 000 IU (age up to 6 months) 100 000 IU (from 6 months to one year) 200 000 IU (more than one year) (4-6 mg/kg/day) in 3 doses Folic acid – iron vitamin D, C & B complex – minerals as (potassium & zinc) Others - Treatment of parasitic infestations if present Rickets  Preventive treatment: treatment Vitamin D orally  daily from Full Full term: term 400-800 IU the second month of life Preterm Preterm: Preterm 1000-1500 IU from the age of one month Exposure to sun Diet rich in vitamin D e.g. egg yolk, liver, oily fish  Specific treatment: treatment: 1-Vitamin D therapy  Vitamin D deficiency rickets is sensitive to vitamin D in ordinary doses Oral treatment Daily for 2-4 weeks Vitamin D3 :2000-5000 IU/day OR 1.25 dihydroxycholecalciferol 0.5-2 Mg/day I.M injection Single injection without further therapy 600.000 IU N.B N.B: If no healing occurs the rickets is probably resistant to vitamin D 11 Drugs in Pediatrics NMT11 of: N.B: Injection treatment may be better than oral treatment because of More rapid healing Less dependence on parents for daily administration Earlier differential diagnosis from vitamin D resistant rickets 2-Instructions to the parents: parents Diet rich in vitamin D Proper sun exposure  Treatment of complications: complications - Tetany Tetany:: 1ml/kg calcium gluconate 10% I.V slowly to be accompanied by oral calcium - Treatment of iron deficiency anemia by oral iron therapy 6 mg/kg/day - Deformities Deformities: surgical treatment if sever and persistent Infections Rashes Prevention Measles • Active : measles vaccine (MMR) • Passive: immune Scarlet fever Prevention of droplet infec...
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