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Okay, Good evening, everyone on. Welcome to but I think it's just the full Senate. A pediatric Siris. My name is James Macintosh. I am an F Y one Stockman hospital on the savories Leading have been trying, organized, getting a little bit different, wonderful speakers that we had each week to tell you a bit more about pediatrics. This week, I will be delivering a talk about describing in pediatrics. Um, importantly, for this to do kind of Well, it's, um, research online. Also went down to the pediatric ward, Spoke to some of the pediatric pharmacists on, got them to take me through. Ah, the common things that they see is errors regularly from the junior doctors and other. I spoke with me some more senior doctors on with their patients who are course Children. So before we launch into it on, I've just got to do a quick plug who are sponsored. CPD me. So this is a website that provide you with hundreds and hundreds off different webinars a little bit like this one, uh, that you can use to get COPD certificates for your portfolio. Um, so kind of whatever you're interested in just ate pounds a year. Um, you can have access to all of this different content on build a really strong foundation portfolio. So because you're going through my mind that leap using this you are code over here, you get 50% off, so it will only be 8 lbs for the entire year. Okay, so now back to the session of pediatric describing. So what we're going to cover this evening the key differences in prescribing for Children compared to adults, Um, some common brand name medications. Because at least in my experience, kind of working in Children's emergency department. Um, um is actually a lot of parents will come in and they will tell you what medication their child's been taking. We're normally taking that they were used the brand name more than I've seen working with adult patients. We'll do some theoretical stuff on fluid prescribing, Um, which is a little bit more, a little bit more mathematical, that so that is with the adults on. We're gonna do a couple examples. They're on, as always. You guys always saying your feedback, we're gonna be doing some cases just so you can put this stuff in practice or just see how exactly it's going to affect you in your jobs in pediatrics. Um, normal is not just if you have a drop in pediatrics, actually, if you are on call in surgery or medicine, you may be asked to come down and see someone in the pediatric emergency department on often you end up prescribing them some painkillers, particularly if you're out of the edict ink or partly general surgery team. So it is. We'll work with any of one or two. They have some awareness of what differences to take into account with Children. Okay, so how is describing different and Children? Um, this might make a sound very obvious, but when you go to look up what you're gonna be prescribing, so the dose is the indications you need to use the Children's be in there. Um, So if you go into the regular being a sites, there might be some information that most Children you need to switch you from the beard after the Children's being there to get the up today accurate stuff on to be her medicine, A licensed in Children. One of the next thing is really that I've got my list is the weight and age based know sinks. This is really one of the biggest difference is in Children than with adults. So pretty much anything you described in pediatrics is gonna be either based on child weight on their age. So you need an accurate number for both of those things. And what's really important with the age is if you're prescribing anything at all to someone that is 12 years old or younger, it is a legal requirement in your documentation that you record what age they are and that that is so a pharmacist or someone else can come along and check that, actually, But your prescription is right. Um, we also have to consider the roots and formulation of the medicine that we're giving on it as a particularly big impact on the compliance in Children. Yeah, three year old child that they're not gonna be very good at swallowing tablets. They're gonna be very unhappy with you if you try and give them something with a sharp needle, whether that's IV or subcutaneously. So a lot of the time you'll be using the younger Children things like oral suspensions. And then when we get those are oral suspension. We also have the slightly strange consideration of how that medicine might taste. Um, and the only real way to kind of find this out and talk to patients. Talk to people who work in the pediatric ward. So but the seniors home, it's more experience with your pharmacist. Um, I do take into account, you know, if it tastes horrible. Particular again, those toddlers are much less likely to take the medication that you prescribed. It's hard to get get into them. Um, the reason that we're giving a talk actually, on the key differences in pediatric prescribing is how important it is for Children because they haven't increases susceptibility to drug reactions. Boasting errors partly because of just they are much smaller, have a fast metabolism s. So it's not going to because much of a wrong dose to give them a nobody dose, as we talked about before, with the weight and age based calculations and the fluids, it's a bit more math, so it's more likely that someone will make it error on again. It's not, you know, So you're paracetamol for adults is you know, 1 g Q D s unless they weigh less than 50 kg. That's quite easy as just having your head on you see every day on drug charges. It's easy to describe that straight down, where is in Children, All the different drug will have different ages, different weights. So you're constantly seeing different doses written down so you can't really get a feel for that's what's right and what's wrong just by looking at it on the last point I've got my side is different licensing. So there are some medical medications that we use in adults. I'm just on the license, yet the Children on bit is, Ah, we were. You cannot then use them in Children, but it is a serious, significant issue if you do so, example might be, for example, in a teenager that's had a DVT or a year. They were an adult, so 18 and above we might use a dose or something like Picks about you cannot stress enough cannot, even if it even if they're 17 in the heart or their birthdays in a week. You cannot prescribe that for 17 year old and another thing that I wanted to highlight because, like I said, the city, if you're a surgical F one, you may be asked to come down to get some pain killers prescribed. Well, you know, the acute abdomen, the appendicitis ease on things like that coding. Well, not a good idea is there are many things were actually coding. You do not prescribe it. So any child under 12 does not get Cody. Um, if you have troubles come in but on select to me instructive sleep apnea if they have breathing difficulties, it'll there's strong evidence out there that coding and make that worse in Children. So you cannot prescribe. That is culture indicated any patient that is known to be a c Y p d 600 a rapid metabolizer. Obviously, you can't just ask, you know, come out and ask that straight away to a patient that they will give you a very funny look. Typically, if they're a child under 10. Um, but it is just kind of trying to your history that work out, you know, have they had severe drug reactions in the past, so they require higher doses and other people overdoses and other people you know, taking a bath or a history looking proven. It's It's very, very important. So just to illustrate some of the I guess the complications that can occur with prescribing. So this is kind of a case where you probably had it on the ward's. If you're working at the junior doctor or one of the nurses will come up to you with a drug chart now. So all the doctor, this looks a little bit funny. You sure I can give this? You know that the nurses, they probably know more than you do. They administer the medication. They see this stuff every day on, and they just want your sign up or realistically, often their hinting at the fact that it's wrong in your to correct it. So we look at the example I've given here, so we have a child age 13 months. We have a recent weight. We have more input. 5 kg. We ask the most to go away, then, before describing them so that we know that it's nice and accurate. And in the drug chart they've been prescribed 95 mg of IV paracetamol Q T s. For those underwear means four times each day. So I've taken the relevant part from the Children's being a fear for paracetamol. So we have a child here, body weight up to 10 kg. So that's, uh so and they can have 10 mg per kilo every 4 to 6 hours. So 10 mg book kilogram. We would do their weight nine point by kilos times by 10, which is going to give us a 95 mg. So so far, so good. That looks okay. They can have it every 4 to 6 hours. There's been prescribed four times a day, so four times in 24 hours, that's six hourly. So again, that looks okay. It says we want to administer this over 15 minutes, but it's an IV prescription, which is cough above by. Yeah, Trust me. Here is this is the IV meds, but the maximum is 30 mg per kilo per day. So we know that we've we've given a beach to use doses inappropriate on their own. But if we look at 30 mg per kilo, so 30 lots of mine 300.5, that is going to significantly exceed than 95 mg Q. D s. Does that make sense? Because you're you're definitely doing that finds 40. So if we were to give the 95 mg four times we would exceed 30 mg and be giving an overdose of paracetamol to about 13 month year old. So this prescription is not okay. It needs to be crossed out. Needs to be done. A text on a more appropriate prescription needs to be really. Um, actually, one of the things that one of the pediatric palms is recommended to me is when describing these things by but weight and age record the way to the age and kind of the, you know, you that you've done 10 mg per kilogram. But it's also really important that you document even when when you put, you know, Judy s or every four hours what the maximum dose is 24 hours and that just prevents drug levels like this from happening. Okay, so just a little bit of extra advice here, thinking about the different points that we really talked about, So use written guidance. I definitely know. When I started in F one, I looked up pretty much every prescription I wrote. I checked it in my be an f on. I still do that if it's drug, but I'm not familiar with or I think you know, I haven't done it for this particular reason. I'm just not 100% sure in Children, use the written gardens. Let us the Children's be NF, whether it's your trust guidelines, whatever it is, use the written guidance. Sit down, you know, don't do it off the cuff, but I still may work it out. Get something to check it, which I think is point number three. So check and double check, particularly if you've done a few different calculations. It's really good to get someone else. Even if they're the same grade is you just have a look at it. Make sure we're not making errors. Um, last year, seniors. I think that's kind of Ah, definitely a theme that we've had across all of our pediatrics talks. If you're unsure, ask ask, the doctors are about that really knows. We're really friendly and they want to help you. They want you to come to them with the issues that you're having. The only time they will get upset. Doctor, in front of the only central be upset with you is if you don't ask for help, okay? And then award pharmacists the whole reason they were on the walls and they try and be around it so you can ask these questions and get help with that stuff because we don't want to be taking drug. There is for anyone, adults or Children. But it's extra important in Children on because if the lucky could have been having a more significant reaction, Um, I also got a couple of extra bits here, so we really talked about the legal requirement to include age on prescriptions. But they don't advise. And this is when you tell parents that they mix or ulcer pensions with feeds her babies. So I got this from some other prescribing guidelines on the Children's. Being on. This is really important because if you mix in the medication with a feed, they may not finish it, you know, 100% sure exactly the around they had so far. You know, if you if you take this much milk in this much medicine and they had half of half of their feet, and you need to know whether, uh, you can give him another dose of something else in another way, you don't know how well that's mixed in. You actually just don't know exactly the amount of medicine they had when they had it. If it takes, you know, a few different foods to get your uh so that is not a good idea. It's much better to get one of the tiny little syringes. And you kind of just squirt employed now, but generally the best way to do it. Okay. And then we have another case. So this one is kind of getting at the brand name medications. Which emergency? Stop. So we have a seven year old girl coming in this my little pain and fever Onda mother tells you that she hasn't had any paracetamol at home, just a teaspoon of kalpoe a couple of hours ago, and she has no allergies. You know, the seven year old there in a lot of pain there, you know, they know that in a bit of quite distressing mother asked. You know, can can you prescribe something for the pain and you need to work out. How much paracetamol can they have now? A lot of parents do know that how cold complains paracetamol on for those you that you didn't have calculus. A child or didn't grow up in the UK, particularly Kalpoe, is delicious and makes you feel so much better just cause it's a little strawberry and sweet. It was full of Paris eating, Um, so when you get old, they haven't had paracetamol, but they've had some cow call. This is what they are likely to have had. So you need to take into account the amounts paracetamol. What is in that elbow on? Just so you know, a teaspoon you can take to be roughly 5 mL, but they get slightly more complicated than just having a look at the picture over on that side of the screen. So there are two different types of cowboys, but you can buy here in the U case. You get couch in front suspension, which has 120 mg of paracetamol per 5 mg, and you get a couple six plus distention, which contains over twice a much paracetamol her 5 mL. It was really important you go back to that mother back to that parent and try and clarify which of the two they've had, because it will affect how much receipts when we're having that behind that you can give if they don't know you're unsure always around the side of caution and assume that they had the higher those already. So when you prescribed further pain relief, you're not gonna be giving them too much paracetamol. Um, another couple ones that I'd come across quite regularly in my care background, Um, would be parrots on, um, people on people generally referred to as parents on which is a hay fever relief kind of, uh, liquidy syrup Equant. Sweet thing. But it contains chlorphen A Me. So again, if you're prescribing something that perhaps interacts with court chlorpheniramine or you want to give him or chlorpheniramine that again needs to be taken into account on diffuse do take a drug history from where parents and they're giving you all these brand names, it's really important you go up and you look these things up on. We'll see or see. You know they can find a packet for you, Um, and then with my epilepsy background. Epling in his sodium valproate keppra is liver terrorists, a town which I can never say properly again. These are commonly referred to you by patient Children, and their parents is definitely keppra, but these are the actual medications. The only to look up in the Children's being there to check interactions. Check closing. Okay, So if we go back to that case, we have gone back to the mother would clarify, and she's Oh, yes, we used to use the in from one. But now you know about the sixth plus one of my daughter's seven. So if we look at the Children took in the camper, five mills of one teaspoon will be 250 mg. And we go to our Children's being a look up how much paracetamol they can have orally, which will be 240 to 200 mg every 4 to 6 hours. So they had that two hours ago, which means they need to wait at least another two hours before I can have a similar dose. But that that scalpel six plus a tablet of Paris eat more whatever. But you need to wait. So you have to be thinking about some other sort of pain relief. Okay. And here we have another case. So, um, I am monitoring the chats on the site of the video. So if anyone is able to just have a think on stick from suggestions in the chart or second act up there and tell me what could go wrong in this scenario. So we have a 15 year old with suspected acute appendicitis is once again, it's it's painful that quite happy. Um, and the nurses said, Well, you know, German prescribing some and algesia on the patient's already had paracetamol and you give him something stronger. The Paris eat hasn't really worked. You are the surgical f Y one. Um, and you can see they're really well, actually, you decide for one reason or another, right? Fine. That's good. It seems reasonable. You know, You look at the down here, you got the Children's be in effect. So this is you know, initially, for some of this age, we can give them large 10 mg every four hours, and then you can adjust it, just like in adults on to their response. So what's wrong with this prescription here? Is you know, Orel is a liquid. You can certainly have 5 mg of a milliliter sort of a liquid. Um, why might not be a sensible way to describe a little more. I'm just gonna give you that time ago, think and the issue, and it's, um, it's again. It's the same in adults, but it seems to happen more in Children whose according to the front, But when we prescribe things in milliliters of the volume, Yeah, the medicine comes in different strengths, which actually or um or does on the ward. Maybe, you know, they may finish one strength to move on to a different strength. 5 mL of a different sort of normal is going to contain a different amount of medicine. It was really important. But when we prescribe anything, Children again or adults that we do it in mass units, So that's grands micrograms milligrams. But ideally, we shouldn't ever really be prescribing because, like I said, a different strength. The same volume will mean a different amount of medicine is given a young person. Okay, so slightly more theoretical. You may remember this from medical school. You may be at medical school and be desperately trying to memorize this before finals. Fluid describing and Children. It is different. They have different violence. You kind of have to take into account different factors and has a few more calculations. The bones. Um, and it's important that you understand how to prescribe fluids and Children. And just because of the last point I've got here on the power point on, Children have a really large physiological reserve, which is excellent because it means actually, when they're kind of quite unwell, they can. They can kind of deal with it. They kind of keep going, keep going, keep going. And then all of a suddenly con compensate anymore, and they just deteriorate incredibly rapidly on go. A pediatrician have to work very quickly on to resuscitate them, to get the right care too quickly as possible. I'm I'm making sure that they're fluid. Balance is correct. Whether that's resuscitation maintenance, a replacement is a really big part of it. So let's start with through a resuscitation so similar to adults were used Blue Coast free crystalloids, on which I'm sure most of you will know crystalloids are either sodium chloride know by 9% or normal saline. I know many people say, you know, there's nothing normal about normal saline, but either that or Hartmann's both about crystal light fluids on the standard amount that we were using 20 mL per kilo I'm given. Um, basically within 10 minutes. Um, so you get nice and quickly to try and resuscitate someone again. We need a nice, accurate wait to work this out on. So ideally, we would have waited before. We may have to go on record in the emergency on scenario, or, you know, why don't they estimate? But I think sometimes you can have the best guess they're gonna be conservative if you have to pay. Um, and in adults were prescribing our 500 mL bonus of fluid. We have exceptions where we only prescribe half about 250 a time because we want to be more cautious. And patients with heart failure patients are very elderly on do similarly intruding. There are exceptions where we actually have this when you give 10 mills kilo on by, just drop them down here. So, in the neonatal buried if they're in a diabetic ketoacidosis, this one is really important if you give fluids too quickly. So a child in DKA they are really high risk of cerebral edema. And it is a very significant core outcome on something will be very much one of avoid always in DKA follow the guidelines. But it is somewhere that we do need to get a small about this of fluid now just to be where that if they are in septic shock, just set in septic struck a significant trauma and again heart failure, cardiac apology. But we might want to go up smaller boats of 10 Mills Kilo. If you're unsure, Air on the side of caution Go to the lower 1 10 mills Peculiar. Up from 20 and again. Run it past your senior and it's very unlikely a junior. You're gonna be resuscitating Children on your own. But please, really Part of senior, you're gonna find someone order. It will be a help you out. In the meantime, go the what? Slightly more fortune you can always give them. You know, once more, bolus and then repeat that again. It'll go through nice equipment. Okay, so no, the case. So this time you have a little thing about what you need to know in this case. So two year old girls come in, she's got fever. Uh, they go into the triage room nurse, that's an option as a heart road. 1 40. Respiratory eight no crashes, 70/38 SATs and 98 on the rumor. And the temperature is 38.1. You better NATO reassessment on and you decide to prescribes and fluids. Now, what do we need to know about this? About this girl about this case? Medicine in general. What do we need to know to address this properly. So first thing I think I would like to know is probably what the normal values are. Vital signs. Because if we had an adult with these probably would be very, very worried about them. I'm definitely getting a lot of fluid very quickly amongst other things. But, you know, the source of this guy was 12 years old, so all right, that's actually a normal heart rate free someone that you know, around two years old, um, respirator again. Abnormal model on a two year old about about normal, But their systolic should be up kind of in the 80 to 95 range. This little girl's sister look secretary. So that is why we're prescribing some fluids that one cm it even less accurate weight. Um, little girl with ways, Tropea lows, which is kind of an averageish number of the age for girls her age, I should say we checked. They have no past medical history of cardiac follow. Gee, there were no other things on this list that we're particularly worried about. So we do. Our calculations will give us 20 mils per kilos and 20 times 12, which is her weight, gives us 240 mills, and we're going to give that of the less than 10 minutes. And then, as always, we'll reassess doing a very T and see what affect that had a systolic BP on basically will be escalating to see him gangs and hope we are worried. Okay, so next part of routine maintenance. So if someone is nobody, mouth, um, if they can't swallow of the God poor intake because it's just feeling very well on we prescribe him some routine maintenance just that people go. So in the Unites, there are some very specific, Um, you know, each day this is what you would be giving them the amount you know, this number of mils per kilo her day given after you know, that certain number of days after birth and look this up, look it up. Get some help you with that as well to make sure you are doing it right because he's a tiny, tiny baby. So it is important that we get this right. I'm not going to read your values on you guys can read it and again look it up if you are working with me and it's for a child. Were you something called the holiday cigar formula on you will have heard about at medical school that you're at medical school. This is something that you asked both of opiate finals. Um, so we give 100 mils particular particular 1st 10 kg for the next 10 kg of weights. We give 50 miles per kilo per day and then any weight over 10 2 kg is 20 miles per kilo per day. Now that's a lot of words. What numbers? Let's do an example just to illustrate what we mean by the first thing. Kilo the next 10 kg. Okay, so 10 year old girl, New Obama, pre surgery. She weighs 33 kg. So 1st 10 kg off her weight's because she weighed more than 10 kg. We will be doing 100 mils per kilo per day So 100 mils time. 10 kg gives us one liter or found milliliters. So we can take kind of 10 kg from the 33 with accounted for that. So they're still 23 kg left. So the next 10 kg of weights, we're going to get 50 miles per kilo per day. So we do 50 primes. 10 because we've got another 10 within within that range of about 23 which is going to give us 500 mils and we can take off the next 10. Let's have you take off that were left with 13 kg left. So 20 minutes per kilo per the weight is over 20 kg. For some reason, I've written 12 here when I clearly I should've rented a team. But let's just go with it. So 13 time for 20 mils would give us 260 mills, so total daily fluid requirement would be the total of those three values, which again I seem to have added them up wrong down here. Very embarrassing for me. But anyway, so we would do the one liter plus the half a liter less 260. You give us 1760 mills off fluid. And if we look here, the fluid that we will be using is no 0.1% sodium to roll over 5% extras. We should also do the other. She's more click me and any calories mouth way had a different patient. The only way. Streaky lows. Let's cover up that three. So 3 kg patient on the within the 1st 10 kg of weight, we're giving 100 mils per kilo. Now there are only 3 kg. That would mean we would be giving just 300. Miralax is hopefully that makes sense to you. If you do have any questions, any issues do just stick them in the chart. And I was trying keeping on it while I'm talking. But the best way to get better with this So it's like it's just a practice practice. Get some structure over. But this is something I would expect, you know, final year medical student to be able to do on the kind of have the values in your head, um, for your exams as an F one again, Just look it up. Don't try and remember stuff. If you haven't done it for a while. It's not worth it. Just look it up. Make sure you do it right. Okay. Okay. And then the last part of fluid on theory I wanted to go into was replacement fluids. This is if someone is dehydrated, if they've lost fluids through burns or, um, you know, so you can sweat out there. Really febrile third space loss is etcetera, etcetera. So you can assess this clinically on, which is very much a school. You kind of have. You kind of have to, um, develop over sometime in clinical practice. I would try and do it long. Sort of seen you get them, too. So you know, what do you think I need about that much fluid? What? Why? That's like that. It's kind of more of an art and science, but the month supplies. But I'm going to quickly go through with you in tackling the loss in fluid, using a weight when they were well on now. So particularly the younger Children, we actually do wear them quite frequently on their growth charts. They get weight at school, and parents were quite often have a good a good idea of how much their child ways. And actually, if it's something you have not been quite frequently you They know what they're weight is when they are well, so you take that as their baseline and then we use the weight that they are now to work out how much fluid loss there has been. So we take their well, wait with subtract the current weight. So how much weight loss has there being? So we have a 10 kg Ah, toddler, I suppose, on they've lost 1 kg Wait, so we would have their well, wait they currently weighing nine. So that gives us our one. We then divide that by their well, wait to come to my 100 together as a percentage. So that toddler that has lost a kilo from their normal 10 kg has lost 10% off their body weight. So now we want to convert that into the fluid that except we know that one liter of fluid ways 1 kg we can take off a sentence. Dehydration. So our example was 10%. We times that by that weight on, then we multiply that by 10 to get how many millions of fluid we need Okay, so on this Ms and it would be 10 time nine times. So 900. Now, the total fluid requirements is gonna be there. Maintenance fluids. Plus this fluid deficits. So we would take the fluid that were previously, but we would do off. We would we would do the calculation we did before to work out what they just need daily. And then we want to add in what they've already lost. Okay, I hope that makes sense. I know this was a slightly slightly shorter weather. Now, some of the other ones, and that was before we finish. I just want to highlight some useful resources. So the Children's be enough. We've already mentioned um, there is a really good actually prescribing and Children medicine guy guidance on which is from nice. It is published on the beer Will work read when we're not quite the information to this presentation. Um, there is also from nice, really good IV fluid therapy in Children, young people, Guidance. If you are actually doing this in practice, this is where I would go to look it up. Where was the most examples? They're that similarly with pediatric IV fluid prescribing geeky medics on again. Check it out. They got practice questions down the bottom. You can have a girl that it get confident on. And it's good practice either for your exams or your own clinical practice. Um, pediatric describing there is already an article in mind. The bleak, um, if you want to write other articles on pediatric pediatrics, remind the week. Do you go to our website on? There is a form you can fill out little pinker an email to me that says you requested to write an article about something I will get. It comes out of you. Okay, full. The junior doctors, we have scrip modules. There are some on ah pediatric describing and similarly using local guidelines asking are seen our pharmacist. It's kind of you have the same same sort of things we do a little time, but equally important. Okay, um so hopefully that has been informative. Um, please do take five minutes to give us a feedback. Once you filled out the flu. Once you filled out the feedback form, there's a link on the Facebook event. There's this QR code here on in a second. I will cop thing. Actually, in shots so you guys will get access done. Uh, she got sick, but I didn't read all the feedback positive and negative. And we try and take it into account when we're planning subsequent sessions. And so if it's not myself leading the session, I do actually take the previous feedback summarize and send it to who is giving our next talk. Just that they know what is working well on what you go the benefiting from. So if I have a look on you she did get then posted to the shop. But we find it really selection because life stuck war be back on again. It's unusual. Get a difficult. So if your medical student and you just want to show Yes, I have some interval. I have a lot of interest in pediatrics. Look of attended of the sessions on that looks really nice in the book. Polio. If you're a foundation doctor and you have the foundation court earlier and you need some evidence of your long called teaching, um, again, you can submit by a Horace your certificate showing. Look, I ended the session. It was about an hour long on. You could put it down for you on Encore Teaching walls. Okay, if you do have any questions and boil means, um, you can pop them on the Facebook group or I think there is away to pop it in on the back for my don't know if there was a fruit textbooks or not, but do by all means, let me know if you have any issues with it. If I make any mistakes other than those type of that, hopefully I highlighted as we went through on Thank you very much for joining us one currently working out how to stop this lot of street.