MacPeds

PEDIATRIC FORMULARY

For drugs prescribed in the NICU please refer to the handbooks available in unit at both McMaster and St Joseph’s Healthcare.

There is a separate PICU handbook with a drug formulary specific to the PICU.

This document is intended for use at McMaster Children’s Hospital (MCH) only and may not be applicable elsewhere. While this document is intended to reflect the practice at MCH at

the time of writing, new information may become available. Every attempt has been made to ensure accuracy but these recommendations should be used in conjunction with good

clinical judgment, and in consultation with a Pharmacist as needed.

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Unapproved Abbreviations, Symbols and Dose Designations and Acceptable Corrections

Unapproved Abbreviation

Intended Meaning

Problem Acceptable Correction

U Unit Mistaken for “0” (zero), “4” (four), or cc. Use 'unit'.

IU International unit

Mistaken for “IV” (intravenous) or “10” (ten). Use 'unit'.

Abbreviations for Drug Names

Misinterpreted because of similar abbreviations for multiple drugs; e.g., MS, MSO4 (morphine sulphate), MgSO4

(magnesium sulphate) may be confused for one another.

Do not abbreviate drug names.

(exceptions: ASA, KCl, Humulin R)

QD QOD

Every day Every other day

QD and QOD have been mistaken for each other, or as ‘qid’. The Q has also been misinterpreted as “2” (two).

Write “daily” and “every other day”

in full

OD Every day Mistaken for “right eye” (OD = oculus dexter) Write “daily”

OS, OD, OU Left eye, right eye, both eyes

May be confused with one another. Use “left eye”, “right eye” or

“both eyes”.

AS, AD, AU Left ear, right ear, both ears

May be confused with one another. Use “left ear”, “right ear” or “both ears”

D/C Discharge or discontinue

Premature discontinuation of medications if D/C (intended to mean “discharge”) has been misinterpreted as

“discontinued” when followed by a list of discharge medications

Use “discharge” and "discontinue".

SC, SQ, or sub q Subcutaneous SC mistaken as SL (sublingual); SQ mistaken as “5 every;” the “q” in “sub q” has been mistaken as “every” (e.g., a heparin dose ordered “sub q 2 hours before surgery”

misunderstood as every 2 hours before surgery)

Use "subcut" or "subcutaneous"

cc Cubic centimetre Mistaken for “u” (units). Use “mL” or “millilitre”.

μg Microgram Mistaken for “mg” (milligram) resulting in one thousand-fold overdose.

Use “mcg or microgram”.

Unapproved Symbol

Intended Meaning

Potential Problem Acceptable Correction

@ at Mistaken for “2” (two) or “5” (five). Use “at”. Write out “at” in full

>

<

Greater than

Less than

Mistaken for “7”(seven) or the letter “L” .

Confused with each other.

Write out “greater than” in full

Write out “less than” in full

Unapproved Dose

Designation

Intended Meaning

Potential Problem Acceptable Correction

Trailing zero X.0 mg Or 10.0 mg

Decimal point is overlooked resulting in 10-fold dose error. Never use a zero by itself after

a decimal point. Use “X mg or 10

mg”

Lack of leading zero

. X mg Decimal point is overlooked resulting in 10-fold dose error. Always use a zero before a

decimal point. Use “0.X mg”

Adapted from ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations (2010) and ISMP Canada’s Do Not Use – Dangerous Abbreviations, Symbols and Dose Designations (2006)

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Legend: GAS GP

Group A Streptococcus Gram Positive

GPC Gram Positive Cocci GN Gram Negative GNB Gram Negative Bacilli MAX Maximum MIN Minimum NF Non-Formulary At HHS

Adjust dosing interval for patients with renal impairment.

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Safer Order Writing To reduce the potential for medication errors:

Write orders clearly and concisely.

Write medication orders using generic drug names only.

Be careful with mg/kg/DAY vs mg/kg/DOSE.

Include the intended dose per kilogram on each order.

Write the patients weight on each order sheet.

Never place a decimal and a zero after a whole number (4.0 mg should be 4 mg) and always place a zero in front of a decimal point (.2mg should be 0.2 mg). The decimal point has been missed and tenfold overdoses have been given.

Never abbreviate the word unit. The letter U has been misinterpreted as a 0, resulting in a 10 fold overdose.

Always order medications as mg, not mL as different concentrations may exist of a given medication. There are a few exceptions such as co-trimoxazole (Septra®).

QD is not an appropriate abbreviation for once daily, it has been misinterpreted as QID. It is best to write out “once daily” or “q24h.”

Do not abbreviate drug names (levo, 6MP, MSO4, MgSO4, HCTZ).

Do not abbreviate microgram to g, use mcg, or even safer, write out microgram or use milligrams if possible (0.25 mg instead of 250 micrograms)

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ANTIBACTERIALS CELL WALL SYNTHESIS INHIBITORS (BACTERICIDAL)

-LACTAMS PENICILLINS

benzyl penicillin: narrow spectrum; NOT Penicillinase resistant

Penicillin G (IV or IM)

Penicillin V Potassium (PO)

Suspension: 60mg/mL Tablet: 300mg

Penicillin V 500 000 units is equivalent to 300 mg.

Moderate to Severe Infections: IV: 100 000 - 400 000 Units/kg/DAY ÷ q4-6h (MAX: 24 million Units/DAY) Meningitis: IV: 400 000 Units/kg/DAY ÷ q4h (MAX: 24 million Units/DAY) Penicillin V Potassium (oral):

1. Mild to moderate Group A Strep infections: 25-50mg/kg/day PO ÷ q8-12h x 10 days IDSA (GAS pharyngitis)– Children: 300mg bid-tid; Adolescents & adults: 600mg po BID x 10

days

2. Rheumatic fever (treatment): < 27kg: 300mg PO bid x 10 days; > 27kg: 600mg PO BID x 10 days 3. Rheumatic fever (prophylaxis AND > 5 yrs): 300mg PO bid 4. Prophylaxis in asplenics:

6 months – 5 yrs: 150mg PO bid >5 yrs: 300mg PO bid

isoxazoyl penicillin: narrow spectrum; Penicillinase resistant

Cloxacillin (IV or PO)

Oral: Suspension 25mg/mL

Capsule: 250mg, 500mg

Primarily used in methicillin-sensitive Staphylococcus aureus (MSSA) infections:

IV: 100-200 mg/kg/DAY q4-6h (MAX: 12 g/DAY); up to 300mg/kg/DAY may be used in select cases (please consult Infectious Diseases) PO: Suggest to use cephalexin (1st generation cephalosporin) in place as cloxacillin has low oral bioavailability, poorly tolerated (GI side effects) and need to be taken on an empty stomach

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Aminopenicillin: Penicillinase sensitive

Ampicillin (IV) Meningitis: IV: 300-400 mg/kg/DAY q4-6h (MAX: 12 g/day)

Other infections: IV: 100-200 mg/kg/DAY q6h (MAX: 2 g/DOSE)

Amoxicillin (PO)

Suspension: 50mg/mL (supplied at HHS);

25mg/mL

For coverage against Streptococcus pneumoniae (including empiric therapy for community-

acquired pneumonia or otitis media): PO 80-90mg/kg/DAY q8h (MAX: 1 g/DOSE)

Standard dose: PO: 40-50 mg/kg/DAY q8h GAS pharyngitis: PO: 50mg/kg ONCE daily (MAX: 1000mg/DOSE) OR 25mg/kg (MAX: 500mg/DOSE) BID

Clavulanic Acid: Enhances spectrum; beta-lactamase inhibitor

Amoxicillin + Clavulanic Acid (Clavulin) (PO)

Tablets (amoxicillin/clavulanic acid):

500/125mg(4:1); 875/125mg(7:1)

Beginning in fall 2014: Suspension (supplied as HHS): 1 mL

= 80mg amoxicillin and 11.4mg clavulanic acid (7:1)

For coverage against Streptococcus pneumoniae (i.e. sequential oral therapy in complicated CAP, AOM, sinusitis): 80-90mg/kg/DAYof amoxicillin component

q8h **BID dosing may be adequate for AOM, but TID dosing is recommended for pneumonia** Standard dosing for other gram positive, gram negative, anaerobic infections:

PO: 30-50 mg/kg/DAY of amoxicillin component q8-12h (MAX: 500 mg/DOSE) *One major side effect with clavulanic acid (particularly at high doses) is GI intolerance **When writing discharge prescription and if suspension is required, please indicate (particularly if high dose amoxicillin is used) the formulation of the amoxicillin-clavulanic acid is specified. Example of prescription: Amoxicillin clavulanic acid suspension Please dispense as 7:1 formulation (80mg/mL amoxicillin + 11.4mg/mL clavulanic acid) 480mg (of amoxicillin component) po TID x 10 days

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ANTIBACTERIALS (CONTINUED) PENICILLINS (CONTINUED)

Ureidopenicillin: broad spectrum; Penicillinase sensitive Tazobactam: Enhances spectrum; β-lactamase inhibitor

Piperacillin (IV)

For documented Pseudomonas aeruginosa infections IV: 200-300 mg/kg/DAY ÷ q6h (MAX: 16 g/DAY)

Piperacillin + Tazobactam (IV)

Broad coverage against many pathogens. First line for febrile neutropaenia. IV: 200-300 mg/kg/day (of Piperacillin component) ÷ q6-8h (Adult dose is 4.5g IV q8h) **Order antibiotic as x mg (or g) of piperacillin component IV q6-8h**

CEPHALOSPORINS – do NOT cover MRSA, Enterococcus species, Listeria, or extended spectrum beta-lactamase producing organisms (ESBL)

1st Generation Excellent coverage against S. aureus, group A Streptococcus, E. coli, Klebsiella. Empiric therapy for cellulitis, osteomyelitis, bacterial adenitis.

Cefazolin (Ancef) (IV or IM)

IV: 75-150 mg/kg/DAY ÷ q8h (MAX: 6 g/DAY) Higher doses are needed for infections such as osteomyelitis

Cephalexin (Keflex) (PO)

Tablet: 250mg, 500mg Suspension: 50mg/mL

PO: 25-100 mg/kg/DAY ÷ qid Osteomyelitis following IV therapy: 100-150mg/kg/DAY (MAX: 4 g/DAY)

2nd Generation NO LONGER INDICATED FOR EMPIRIC TREATMENT OF PNEUMONIA. These agents offer no benefit compared to ampicillin/amoxicillin for treatment of S. pneumoniae. Main benefit is coverage against (nontypeable) H. influenzae and Moraxella, which cause sinusitis and otitis.

Cefuroxime (IV or IM)

IV: 100-150 mg/kg/DAY ÷ q8h (MAX: 2g/DOSE)

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Cefuroxime Axetil (Ceftin) (PO)

Poor oral bioavailability; unlikely to achieve optimal concentrations in severe infections

Cefprozil (Cefzil) (PO)

Tablet: 250mg, 500mg Suspension: 50mg/mL

(eg. for otitis media unresponsive to high-dose amoxicillin or for acute sinusitis) PO: 15-30 mg/kg/DAY ÷ q12h (MAX: 1 g/DAY).

3rd Generation Broad spectrum activity against gram negatives. Ceftriaxone/cefotaxime offer excellent coverage against Streptococcus pneumoniae and good coverage of methicillin sensitive S. aureus. Only ceftazidime is active against Pseudomonas aeruginosa. Useful for CNS infections.

Cefotaxime (IV or IM)

**reserved for neonates** Meningitis: IV: 200-225mg/kg/DAY ÷ q6h; up to 300mg/kg/DAY ÷ q6h may be used in infants and older children for this indication (MAX: 12 g/DAY) Other infections: IV: 100-200 mg/kg/DAY ÷ q6-8h (MAX: 6 g/DAY) Neonates greater than 2kg (if less than 2kg, please refer to neonatal dosing handbook): 0 – 7 days: 100-150mg/kg/DAY IV ÷ q8-12h > 7 days: 150-200mg/kg/DAY IV ÷ q6-8h

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ANTIBACTERIALS (CONTINUED) CEPHALOSPORINS

Ceftriaxone (IV or IM)

Meningitis: IV/IM: 100mg/kg/DAY divided q12h or q24h (Max: 2g/DOSE) Other infections: IV/IM: 50-75 mg/kg q24h (MAX: 2 g/DAY) STI (gonococcal infection): >45kg: 250mg IM x 1

Ceftazidime (IV or IM)

Active against Pseudomonas aeruginosa: IV: 75-150 mg/kg/DAY ÷ q8h (MAX: 6 g/DAY)

Cefixime (Suprax) (PO)

Tablet: 400mg

Suspension: 20mg/mL

Increasing MIC (minimum inhibitory concentration) against Neisseria gonorrhea; avoid use if possible due to increased risk of treatment failure. IM ceftriaxone is preferable. Other infections (Not active against Pseudomonas and poor GP activity): PO: 8 mg/kg/DAY ÷ q12-24h (MAX: 400 mg/DAY)

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CARBAPENEMS – Very broad spectrum antibiotics (coverage against GP, GN and anaerobes including extended beta-lactamase producing strains of GN); no coverage against MRSA ** Requires ID endorsement **

Meropenem (IV)

Meningitis: 40mg/kg/DOSE IV q8h (MAX: 2g/DOSE) Other infections: 20mg/kg/DOSE IV q8h (usual MAX: 1g/DOSE)

Ertapenem (IV)

3 months - 12 years : 15mg/kg/DOSE IV q12h (max: 1 gram/DAY) >13 years: 1 g IV once daily (max: 1 gram/DAY)

GLYCOPEPTIDES Only active against GP (including MRSA). Use as an alternative for GP coverage in patients with severe penicillin allergy (i.e. anaphylaxis, angioedema)

Vancomycin (IV or PO)

The IV formulation will

be provided when prescribed orally while

in hospital

Meningitis: IV: 60 mg/kg/DAY ÷ q6h (MAX: 4 g/DAY) Other infections (MRSA or Coagulase Negative Staphylococci): IV: 40-60 mg/kg/DAY ÷ q6-12h (usual MAX: 2 g/DAY) Higher doses may be required in patients with suspected/confirmed MRSA infections, or individuals who are in clinically severe sepsis Infuse over a minimum of 1 hour to avoid Red Man Syndrome; If reaction occurs, increase infusion time. In patients with known history of Red Man Syndrome, write on order to infuse over at least 2 hours. Monitor trough levels in patients with septic shock, proven MRSA infections, concurrent nephrotoxins, fluctuating renal function or extended treatment courses Clostridium difficile infection (usually reserved for severe infection or failed metronidazole): PO: 12.5 mg/kg/DOSE q6h (MAX: 125 mg/DOSE)

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ANTIBACTERIALS (CONTINUED) Protein Synthesis Inhibitors

VIA 50S Ribosome (Bacteriostatic)

MACROLIDES Atypicals: Mycoplasma, Legionella, Chlamydia, H. pylori GAS and S. pneumoniae infections in patients with severe penicillin allergy (although substantial macrolide resistance has been observed with these pathogens).

Clarithromycin

Tablet: 250mg, 500mg Suspension:

25mg/mL, (50mg/mL not available at HHS)

Useful for mild bacterial pneumonia in adolescents. Also commonly used for atypical mycobacterial infections. PO: 7.5 mg/kg/DOSE BID (Max: 500mg/DOSE) Rx Interactions: theophylline, carbamazepine, cisapride, digoxin, cyclosporine, tacrolimus.

Azithromycin

Tablet: 250mg Suspension:

40mg/mL

Useful for known atypical respiratory infections and bacterial enteritis. AVOID USING TO TREAT INFECTIONS PRESUMED TO BE CAUSED BY GROUP A STREPTOCOCCUS OR PNEUMOCOCCUS. PO/IV: 10 mg/kg (MAX: 500 mg) once, then 5 mg/kg (MAX: 250 mg) q24h for 4 days Pertussis: 10 mg/kg PO/IV q24h for 5 days Chlamydia trachomatis urethritis or cervicitis: PO: (> 1 month) 12 – 15mg/kg once (MAX: 1g)

LINCOSAMIDES Useful for toxic shock syndromes, anaerobic infections of the head and neck, and for susceptible S. aureus (including some MRSA) and group A streptococcus infections. Be careful – resistance in S. aureus is not particularly uncommon!

Clindamycin

Capsule: 150mg, 300mg

Suspension 15mg/mL

IV: 30-40 mg/kg/DAY ÷ q8h (usual MAX: 600 mg/DOSE; 900mg IV q8h is usually prescribed in the setting as adjunct therapy in gram positive toxic shock or necrotizing fascitis) PO: 10-30 mg/kg/DAY ÷ q6-8h (MAX: 450 mg/DOSE) May potentiate muscle weakness with neuromuscular blockers. Oral suspension is very poorly tolerated, avoid if possible, use 150 mg capsules or an alternative antibiotic

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VIA 30S and 50S Ribosome (Bacteriocidal)

AMINOGLYCOSIDES GN Aerobes (including Pseudomonas aeruginosa)

Gentamicin

OR

Tobramycin

IV: 5-6 mg/kg/dose q24h (extended frequency dosing is preferred in patients without renal impairment to maximize pharmacokinetics and dynamics of drug) Synergy with beta-lactams for severe S. aureus and Enterococcus infections: 3mg/kg/day IV ÷ q8h Tobramycin: doses as high as 10mg/kg/DAY IV q24h is recommended in patients with cystic fibrosis. (Inhaled tobramycin for CF patients): 80mg bid to tid via inhalation Once daily dosing should be used for all patients > 1 month of age, except in the treatment of endocarditis and in patients with extensive burns. Ototoxicity and nephrotoxicity may occur, consider monitoring trough levels (target <1 mg/L) in patients at risk for nephrotoxicity (e.g. septic shock, concurrent nephrotoxins, fluctuating renal function or extended treatment courses). Prolonged therapy (i.e. >/= 2 weeks) generally not warranted. May potentiate muscle weakness with neuromuscular blockers.

DNA Complex Damaging Agents (Bactericidal)

METRONIDAZOLE (IV or PO) Tablets: 250mg; Suspension: 15mg/mL

Anaerobic infections: IV/PO: 20-30 mg/kg/DAY ÷ q8-12h (MAX: 1 g/DAY) C. difficile (For Colitis): (Enteral administration preferred but IV can be used) IV/PO: 30-50 mg/kg/DAY ÷ q6-8h (MAX: 1.5 g/DAY) Excellent oral absorption, use IV only if PO contraindicated or not tolerated

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ANTIBACTERIALS (CONTINUED) Folic Acid Metabolism Inhibitors (Bacteriostatic)

TRIMETHOPRIM-SULFAMETHOXAZOLE (TMP-SMX) (Septra, Co-trimoxazole) Useful for: Pneumocystis carinii, Toxoplasma, Shigella, Salmonella, MRSA (in settings of cellulitis after appropriate incision and drainage), Nocardia

Order in mg of trimethoprim component and mL of suspension (or number of tablets) Bacterial infections (UTI): PO/IV: 8-12 mg/kg/DAY (of Trimethoprim component) ÷ q12h Pneumocystis jiroveci pneumonia (PCP): PO/IV: 15-20 mg/kg/DAY (of Trimethoprim component) ÷ q6-8h If PCP is severe (i.e. hypoxia), consider adding IV Methylprednisolone 1 mg/kg q24h PCP prophylaxis (Hematology/Oncology, HIV): PO/IV: 3-5mg/kg/day (of Trimethoprim component) ÷ bid on Monday, Wednesday, Friday Urinary tract infection prophylaxis: 2 – 5mg /kg/DAY trimethoprim once daily Formulation:

Trimethoprim Sulfamethoxazole

Suspension 8 mg/ml 40 mg/ml

Injectable 16 mg/ml 80 mg/ml

SS (single strength) Tablet

80 mg 400 mg

DS (double strength) Tablet

160 mg 800 mg

Excellent oral absorption, use IV only if PO contraindicated. Maintain good fluid intake and urine output. Monitor CBC and LFTs. Do not use in patients with G-6-PD deficiency.

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DNA Gyrase Inhibitors (Bactericidal)

QUINOLONES Enteric GNB, including most ESBL and Pseudomonas. Levofloxacin also has excellent coverage against S. pneumoniae. Theoretical risk of development of arthropathy in children is based primarily on animal studies. The use of quinolones in situations of antibiotic resistance where no other agent is available is reasonable, weighing the benefits of treatment against the low risk of toxicity of this class of antibiotics. Another situation would be where there are no other orally administered antibiotics available.

Ciprofloxacin (IV or PO)

Tablet: 250mg, 500mg, 750mg

Suspension: 100mg/mL

(tablets are preferable if dose is given via NG tubes)

** REQUIRES ID ENDORSEMENT** Ciprofloxacin usually reserved for infections caused by Pseudomonas aeruginosa or other resistant gram negative bacilli IV/PO: 20-30 mg/kg/DAY ÷ q12h (MAX: 400 mg/DOSE IV or 750 mg/DOSE PO) Excellent oral absorption, use IV only if PO contraindicated. Feeds, formula, calcium, magnesium, iron, antacids and sucralfate reduce absorption, hold feeds for 1 hour before and 2 hours after dose.

Levofloxacin Tablet: 250mg, 500mg,

750mg

Suspension not available commercially; use dissolve

and dose

** REQUIRES ID ENDORSEMENT** Levofloxacin usually reserved for infections caused by Pseudomonas aeruginosa, other resistant gram negative bacilli or penicillin-resistant Streptococcus pneumoniae.

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ANTIFUNGALS

Fluconazole (IV or PO)

Oropharyngeal candidiasis: IV/PO: 3 mg/kg q24h Esophageal candidiasis: IV/PO: 6 mg/kg q24h (MAX: 400 mg/DAY) Candidemia: IV/PO: 12 mg/kg once (MAX: 800 mg) Then 6 mg/kg/DAY (MAX: 400 mg/DAY, doses used) Excellent oral absorption, use IV only if PO contraindicated. May increase serum levels of cyclosporine, midazolam, cisapride, phenytoin. Aspergillus species and Candida krusei are intrinsically resistant, Candida glabrata may respond to higher doses. Dosage adjustment is required in patients with impaired renal function

Voriconazole (IV or PO) Tablet: 50mg, 200mg

Suspension: 40mg/mL

** Requires ID endorsement ** Coverage against many Candida species and Aspergillus Loading dose:6mg/kg Q12h x 2 doses then Maintenance dose: 4mg/kg q12h (higher doses may be used in specific clinical scenarios) Only IV formulation needs to be used with caution in patients with renal impairment (use oral formulation in this scenario)

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ANTIFUNGALS (continued)

Liposomal Amphotericin B (IV)

(Ambisome)

** Requires ID endorsement ** Coverage against many Candida species, Aspergillus and most Mucor 3 – 5 mg/kg IV once daily Monitor renal function and electrolytes (particularly potassium and magnesium). Infusion-related adverse effects (e.g. fever, rigors etc) may require pre-treatment with acetaminophen, diphenhydramine

Caspofungin (IV) ** Requires ID endorsement ** Loading dose: 70mg/m2/DAY IV x 1 dose (MAX: 70mg) then Maintenance dose: 50mg/m2/DAY IV once daily (MAX: 50mg)

Nystatin

Oral candidiasis: PO: infants: 100 000 Units swish and swallow QID children: 250 000 Units swish and swallow QID

adolescents: 500 000 Units swish and swallow QID

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ANTI-VIRALS

Acyclovir

Tablets: 200mg, 400mg and 800mg

Suspension: 40mg/mL

Need to monitor kidney function and ensure adequate hydration (especially on high dose of intravenous therapy). Dosing adjustment is necessary in patients with impaired renal function Infants 1-3 months: 60mg/kg/DAY IV ÷ q8h (duration will be dependent on organ involvement – 21 days for CNS and disseminated disease; 14 days for skin and mucous membrane involvement) HSV encephalitis (> 3 months to 12 years): 60mg/kg/DAY IV ÷ q8h (MAX: 1g/DOSE) HSV encephalitis (> 12 years): 30mg/kg/DAY IV ÷ q8h (MAX: 1g/DOSE) Mild – moderate mucocutaneous HSV infection in immunocompetent hosts: 30-50mg/kg/DAY PO ÷ 3 TO 5 TIMES DAILY HSV infection in immunocompromised hosts or severe infection (eg. eczema herpeticum): 15-30mg/kg/DAY IV ÷ q8h PO dosing (following IV therapy): 60-80mg/kg/DAY PO ÷ 3 TO 5 TIMES DAILY Varicella or zoster in immunocompromised hosts: 30mg/kg/DAY IV q8h PO dosing (following IV therapy): 80mg/kg/DAY PO ÷ 3 TO 5 TIMES DAILY Varicella or zoster in immunocompetent host (note that therapy not always indicated): 80mg/kg/DAY PO ÷ 3 TO 5 TIMES DAILY

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Oseltamivir

Available as 75 mg capsules

OR 6mg/mL suspension

Usual treatment duration is for 5 days only **dosage adjustment is necessary in renal impairment** Children > 12 months:

Weight Treatment dose

< 15 kg 30 mg/dose PO BID

> 15 kg to 23 kg 45 mg/dose PO BID

> 23 kg to 40 kg 60 mg/dose PO BID

> 40 kg 75 mg / dose PO BID

< 12 months (does not apply to premature infants): 3 mg/kg/dose PO BID (if possible, please round to nearest multiple of 3mg)

References: Bradley JS and Nelson JD. Nelson’s Pocket Book of Pediatric Antimicrobial Therapy. 18th edition. 2010.

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PEDIATRIC FORMULARY Acetaminophen Analgesic and antipyretic.

PO/PR: Refer to table for weight based dosing standardization Can be dosed q4-6h prn

Weight (kg)

Single Dose (mg)

2.5 - 3.9 40

4.0 - 5.4 60

5.5 - 7.9 80

8.0 - 10.9 120

11.0 - 15.9 160

16.0 - 21.9 240

22.0 - 26.9 320

27.0 - 31.9 400

32.0 - 43.9 480

44 – over 650

Acetylsalicylic Acid

Antiplatelet: PO: 5 mg/kg/DOSE q24h. Minimum 20 mg, usual maximum 325 mg. Kawasaki disease:

PO: 80-100 mg/kg/DAY q6h, reduce dose to 3-5 mg/kg q24h once fever resolves. Supplied as 80 mg chewable tablets and 325 and 650 mg tablets.

Amlodipine Calcium channel blocker: PO: 0.1-0.3 mg/kg/DAY (max 15mg/kg/day

Due to long half life of drug, dose adjustments should be made

every 3-5 days only)

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Captopril Angiotensin converting enzyme inhibitor (ACE-I).

PO: 0.1-0.3 mg/kg/DOSE q8h initially (usual maximum 6 mg/kg/DAY or 200 mg/DAY).

Monitor blood pressure closely after first dose, may cause profound hypotension. Cough is a common side effect of ACE-I. Carbamazepine Anticonvulsant.

PO: 10-20 mg/kg/DAY initially, usual maintenance dose is

20-30 mg/kg/DAY. Divide daily doseq8-12h. Serum trough concentration target is 17-50 micromol/L (4-11 microgram/mL). Charcoal Adsorbent used in toxic ingestions.

PO: 1-2 g/kg once. PO: Multiple dose therapy 0.5 g/kg q4-6h.

Give via NG if necessary, consider antiemetics.

Chloral Hydrate Sedative and hypnotic.

Procedural Sedation: PO/PR: 80 mg/kg 20-45 mins before procedure may repeat

half dose if no effect in 30 minutes (maximum 2 g/dose).

Sedation: PO/PR: 25-50 mg/kg/DOSE q6-8h (maximum 500 mg q6h or 1 g hs).

Avoid in liver dysfunction. Tolerance develops and withdrawal may occur after long-term use. For PR use dilute syrup with water.

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Codeine: Codeine has now been replaced with Morphine as the preferred oral narcotic analgesic for acute pain at HHSC due to better safety profile. Please refer to morphine dosing

Dexamethasone Corticosteroid.

Acute Asthma: IV/PO: 0.3 mg/kg/DOSE (usual max 8 mg/DOSE) Croup: IV/PO: 0.6 mg/kg ONCE (usual max 12 mg) Cerebral Edema::

IV/PO: 1-2 mg/kg then 1-1.5 mg/kg/DAY divided Q6H (usual maximum 16 mg/DAY) Antiemetic for antineoplastic regimens: IV/PO: 0.25mg/kg/DAY divided q8h

Discontinuation of therapy greater than 14 days requires gradual tapering. Consider supplemental steroids at times of stress if patient has received long-term or frequent bursts of steroid therapy. Dextrose Treatment of hypoglycemia: IV: 0.5-1 g/kg/DOSE: 1-2 mL/kg of 50% dextrose 5-10 mL/kg of 10% dextrose 1 mmol of dextrose (0.2 g of dextrose) provides 2.8 kJ (0.67 kcal).

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Diazepam Benzodiazepine sedative, anxiolytic and amnestic.

Status epilepticus: IV: 0.1-0.5 mg/kg/DOSE (usual maximum 5 mg for <5 yrs, 10 mg for >5yrs) PR: 0.5 mg/kg/DOSE (maximum 20 mg/DOSE). Skeletal muscle spasms: PO: 1-2.5mg /DOSE q3-4h prn (May increase gradually as needed)

Fast onset and short duration of action with single doses, duration of action prolonged with continued use. Withdrawal may occur if discontinued abruptly after prolonged use. Not recommended for continuous infusion due to poor solubility. Can give parenteral preparation rectally, diluted with water. Dimenhydrinate (Gravol) Antihistamine used to treat nausea and vomiting.

IV/IM/PO: 0.5 -1 mg/kg/DOSEq4-6h prn (max 50 mg/DOSE).

Available as 3mg/mL liquid. Please round to nearest 2.5mg dose.

Diphenhydramine (Benadryl) Antihistamine used primarily to treat urticaria.

IV/IM/PO: 0.5-1 mg/kg/DOSE q6h prn (maximum 50 mg/DOSE).

Available as 2.5mg/ml elixir. Please round to nearest 2.5mg dose.

Docusate (Colace) Laxative

PO: 5 mg/kg/DAY once daily or in divided doses BID-QID (maximum 200 mg/DAY)

Available as 10 mg/mL suspension or 100 mg capsule Suspension is bitter tasting. Mask taste by diluting with juice or milk/formula. Please round to nearest multiple of 5mg.

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Domperidone Prokinetic agent.

PO: 1.2-2.4 mg/kg/DAY q6h (maximum 80 mg/DAY). Give 15- 30 mins prior to feed/meals and at bedtime Enoxaparin Anticoagulant, low-molecular weight heparin. Treatment: Subcutaneous: <2 months of age: 1.5 mg/kg/DOSE q12h. >2 months of age: 1 mg/kg/DOSE q12h. Prophylaxis: Subcutaneous: <2 months of age: 0.75 mg/kg/DOSE q12h. or 1.5 mg/kg q24h >2 months of age: 0.5 mg/kg/DOSE q12h or 1mg/kg q24h Monitor platelets and hemoglobin. Avoid in severe renal dysfunction. Anti-factor Xa level drawn 4 hours post Subcutaneous injection should be 0.5-1 unit/mL for treatment and 0.2-0.4 unit/mL for prophylaxis. Epinephrine (1:1000)

NEB: If less than 10kg: 2.5mg/DOSE inhaled q8h prn 10kg or greater: 5mg/DOSE inhaled q8h prn

Bronchiolitis: NEB: 1.5 mg in 4 mls of 3% Hypertonic saline q8h

10/14 23

Fentanyl Narcotic analgesic Continuous infusion: Initial bolus dose: IV: 0.5-1 mcg/kg then Continuous infusion: 0.5-2 microgram/kg/hr

Breakthrough: 0.5-1 mcg/kg q1-2h prn (refer to continuous infusion preprinted order set)

Please note: Fentanyl is 100 x more potent than morphine To prevent withdrawal, avoid abrupt cessation following high doses or long duration of therapy (> 5 days). Common adverse effects are pruritis, nausea and constipation Ferrous Sulfate : See iron. Fluticasone (Flovent) Inhaled corticosteroid.

INH: 50-500 microgram q12h. Available as 50mcg, 125mcg , 250 mcg /inhalation metered dose inhaler Furosemide

Loop diuretic. PO: 1-2 mg/kg/DOSE q6h-q24h (usual max 80 mg/DOSE) IV: 0.5-2 mg/kg/DOSE q6h-q24h (usual max 80mg/DOSE)

or begin at 0.1 mg/kg/hour and titrate to clinical effect (maximum 0.5 mg/kg/h).

Available as 10mg/mL oral solution. Please round to nearest 1mg dose. Hydrochlorothiazide Thiazide diuretic.

PO: 1-4 mg/kg/DAY q12h Available as 5mg/mL suspension. Please round to nearest 0.5mg or 1mg.

10/14 24

Hydrocortisone Corticosteroid.

Acute asthma:

IV: 1-2 mg/kg/DOSEq6h for 24-48 hours then reassess. (usual max is 5mg/kg/DOSE) Anaphylaxis: IV: 5-10 mg/kg/DOSE. Acute adrenal crisis: IV: 1-2 mg/kg then:

Infants: 25-150 mg/DAY q6h.

Older children: 150-250 mg/DAY q6h. Discontinuation of therapy >14 days requires gradual tapering. Consider supplemental steroids at times of stress if patient has received long-term or frequent bursts of steroid therapy. Hydromorphone Narcotic analgesic Intermittent Analgesia : PO: 0.03-0.08 mg/kg/DOSE q4-6h prn

(usual initial max 3mg/DOSE) IV: 0.01-0.02 mg/kg/DOSE q2-4h prn Continuous infusion: Initial bolus dose: IV: 0.01-0.02 mg/kg then Continuous infusion: 2-8 microgram/kg/hr

Breakthrough: 0.01-0.02 mg/kg q2-4h prn (refer to continuous infusion preprinted order set) To prevent withdrawal, avoid abrupt cessation following high doses or long duration of therapy (> 5 days). Common adverse effects are pruritis, nausea and constipation Hydroxyzine Anti-pruritic: PO: 2 mg/kg/DAY ÷ TID or QID Available as a 2mg/mL suspension or 10mg, 25mg capsules

10/14 25

Hypertonic Saline 3%: Bronchiolitis NEB: 4 mls of 3% saline q8h

Ibuprofen Analgesic and anti-inflammatory (NSAID). Can be dosed q6-8h prn. PO:

Weight (kg) Single Dose (mg)

2.5 - 3.9 20

4.0 - 5.4 30

5.5 - 7.9 40

8.0 - 10.9 60

11.0 - 15.9 100

16.0 - 21.9 150

22.0 - 26.9 200

27.0 - 31.9 250

32.0 - 43.9 300

44 – over 400

Avoid in patients with renal impairment or increased risk of bleeding

Insulin (regular) Recombinant human insulin.

Diabetic ketoacidosis: IV: 0.05-0.1 units/kg/h initially. (add 25 units of regular insulin to 250 ml/NS) then titrate to patients response

For IV administration MUST use regular insulin. Hyperkalemia: IV: 0.1 units/kg AND dextrose 0.5 g/kg.

Ipratropium (Atrovent) Inhaled anticholinergic bronchodilator.

Severe asthma: NEB: 125-250 microgram (0.5-1 mL) q4-6h. INH: 2-4 puffs q4-6h (1 puff = 20 mcg)

10/14 26

Iron

Treatment of iron deficiency anemia:

PO: 4-6 mg/kg/DAY (of elemental iron)q8-24h. Prevention of iron deficiency anemia: PO: 2-3 mg/kg/DAY (of elemental iron) ÷ q8-24h.

Give with food if GI upset occurs. Does stain teeth, rinse mouth well after administration. Available as ferrous sulfate 75mg/mL solution (15mg/mL elemental iron). Please round to nearest 12.5mg dose (2.5mg elemental iron) Kayexelate® (Sodium Polystyrene Sulfonate) Cation exchange resin.

Treatment of hyperkalemia: PO/PR: 1 g/kg/DOSE may be repeated q4-6h prn

(usual maximum 30-60 g/DOSE). Give in water or juice, do not mix with fruit juices with high potassium content such as orange juice.

Ketorolac (Toradol) Analgesic and anti-inflammatory (NSAID).

IV/IM: 1-2 mg/kg/DAY (maximum 120 mg/DAY) q6h. Adverse effects include renal dysfunction, GI irritation and ulceration. Lactulose Osmotic laxative.

PO: infants: 2.5-5 mL q8-24h. children: 5-10 mL q8-24h. adolescents: 15-30 mL q8-24h.

10/14 27

Levetiracetam Anticonvulsant PO: 5-10 mg/kg/DAY (Daily or BID) May titrate dose to effect (max 3000mg/DAY), may require

dosage adjustment in renal impairment Lorazepam

Benzodiazepine sedative, anxiolytic and amnestic. Status epilepticus: IV: 0.1 mg/kg/DOSE, (usual maximum 4 mg/DOSE). May repeat 0.1mg/kg in 5 mins if needed PR: 0.2 mg/kg/DOSE (usual maximum 8 mg/DOSE) Pre-op/procedural sedation: PO/SL: 0.05 mg/kg/dose (max 4mg/DOSE) IV: 0.03-0.05 mg/kg/dose (max 4 mg/DOSE).

Intermediate duration of action and no active metabolites. Withdrawal may occur if discontinued abruptly after prolonged use. Not recommended for continuous infusion due to poor solubility. May give parenteral preparation rectally, diluted with water. Magnesium salts Electrolyte. Treatment of hypomagnesemia: PO: 20-40mg/kg/day elemental magnesium ÷ TID-QID IV: 25-50 mg/kg (maximum 5g) over 4-5 hours

Severe acute asthma: IV: 25-75 mg/kg/DOSE once (usual maximum 2g/DOSE) IV available as magnesium sulfate. PO available as magnesium glucoheptonate oral liquid 100mg/mL (5mg/mL elemental Mg) or magnesium oxide 420mg tablet (252mg elemental Mg)

10/14 28

Methylprednisolone Corticosteroid.

Severe acute asthma: IV: 0.5-1 mg/kg/ DOSE q12h (usual max 40 mg/DOSE) Or 1-2 mg/kg/DOSE q6h can be used until improvement

seen (usually 24-48 hours) then q24h or switch to oral prednisone.

Anti-inflammatory: IV: 1-2 mg/kg/DOSE q24h. High dose/pulse therapy: IV: 10-30 mg/kg/DOSE q24h

Discontinuation of therapy >14 days requires gradual tapering. Consider supplemental steroids at times of stress if patient has received long-term or frequent bursts of steroid therapy. Metoclopramide Antiemetic, gastrointestinal prokinetic agent.

IV/PO: 0.4-0.8 mg/kg/DAY q6h (usual maximum 40 mg/DAY).

Extrapyramidal reactions occur more commonly in children and may be treated with diphenhydramine.

10/14 29

Morphine Narcotic analgesic.

Intermittent Analgesia : PO: 0.2-0.5 mg /kg/DOSE q4-6h prn

(usual max is 10-15 mg/ DOSE) IV: 0.05-0.1 mg/kg/DOSE q2-4h prn and increase as required Continuous infusion:

Initial bolus dose: IV: 0.05-0.1 mg/kg then Continuous infusion: 10-40 microgram/kg/hr

Breakthrough: 0.05-0.08 mg/kg q2-4h prn (refer to continuous infusion preprinted order set)

Please note: Morphine has now replaced codeine as the preferred oral narcotic analgesic for acute pain at HHSC due to better safety profile. Reduced doses may be required if used in combination with benzodiazepines. To prevent withdrawal, avoid abrupt cessation following high doses or long duration of therapy (> 5 days). Common adverse effects are pruritis, nausea and constipation Naproxen Analgesic and anti-inflammatory (NSAID).

PO: 10-20 mg/kg/DAY q8-12h (maximum 1 g/DAY). Adverse effects include renal dysfunction, GI irritation and ulceration. Nifedipine Anti-hypertensive PO/SL: 0.125-0.25 mg/kg/DOSE (max 10mg/dose)

(use immediate release capsules) Nurse to use needle to withdraw liquid from 10 mg capsule. Each 1mg = 0.03mL.

10/14 30

Omeprazole Inhibitor of gastric acid secretion (proton pump inhibitor).

PO: 1-2 mg/kg/DAY q12-24h (maximum 40 mg/DAY). A 2mg/mL oral suspension is available. Please round to nearest 1mg dose. Ondansetron Antiemetic.

IV/PO: 0.1-0.15 mg/kg/DOSE q8h prn (maximum 8 mg/DOSE).

Oxybutynin Urinary antispasmotic agent. PO: 1-5 years: 0.2 mg/kg/dose BID-QID

>5 years: 5mg/DOSE BID-QID Available as 1mg/mL syrup or 5mg tablets Pantoprazole Inhibitor of gastric acid secretion (proton pump inhibitor).

PO/IV: 1-1.5 mg/kg/DAY ÷ q12-24h (usual max 40 mg/DOSE) GI bleed: IV: 5 – 15 kg: 2 mg/kg/DOSE x 1 DOSE, then 0.2 mg/kg/h

16 – 40 kg: 1.8 mg/kg/DOSE x 1 DOSE, then 0.18 mg/kg/h

> 40 kg: 80 mg x 1 DOSE, then 4 - 8 mg/h

There is no liquid formulation available. Intravenous and oral pantoprazole provide equivalent acid suppression. Do not crush tablets. IV infusion is available as 40 mg in 50 mls of NS

10/14 31

PEG-3350 (Polyethylene Glycol) Osmotic Laxative Constipation: PO: 0.5-1 g/kg/DAY

( titrated to effect up to a usual max of 17 g/day)

Available as 17 gram /sachet in hospital. Mix in 125-250 mL of water or juice. Onset 2-4 days. May titrate to effect up to a usual max of 17 g/DAY . Is odorless and tasteless. Phenobarbital Barbiturate anticonvulsant.

Status epilepticus: IV: 20 mg/kg over 20-30 minutes. Maintenance:

IV/PO: 3-5 mg/kg/DAY q12-24h. Usual serum level for seizure control: 65-172 micromol/L (15-40 mg/L) Phenytoin Anticonvulsant

Status epilepticus: IV: 20 mg/kg over 20 minutes. Maintenance:

IV/PO: 5 mg/kg/DAY (range 3-10 mg/kg/DAY) q8-12h. May require higher doses for patients with head injuries. Must be diluted in saline only and requires in-line filter (0.22 micron). Hold feeds before and after enteral administration as continuous feeds and formula may decrease bioavailability of oral products. Significantly increased free fraction in patients with hypoalbuminemia may result in underestimation of effective drug concentration and difficulty in interpretation of drug levels and toxicity may occur at “therapeutic” serum levels. Therapeutic level: 40-80 micromol/L (10-20 microgram/mL).

10/14 32

Phosphate salts: Electrolyte Treatment of hypophosphatemia: PO: 1-2 mmol/kg/day ÷ BID-QID IV: 0.15-0.64 mmol/kg (maximum 30mmol) over 4-6 hours IV available as sodium phosphate (3mmol phosphate + 4 mmol sodium/mL) and potassium phosphate (3mmol phosphate + 4.4 mmol potassium/mL). PO available as IV formulation of potassium phosphate (see above), given PO and Phosphate Novartis 500mg effervescent tablet (16 mmol phosphate/3mmol potassium per tablet). Order in mmol phosphate component. Dose recommendations assume normal renal function. Please refer to Pediatric IV monograph for further prescribing details and limitations Pico-Salax® (picosulfate sodium/magnesium oxide/citric acid) Stimulant and Osmotic Laxative PO: 1-6 yrs administer ¼ sachet 6-12 yrs administer ½ sachet Over 12 yrs: 1 sachet Dose can be repeated after 6-8hours if no effect Used for refractory constipation, fecal impaction and for cleaning out bowels. Contents of 1 sachet are mixed with 160mL water.

10/14 33

Potassium Salts Electrolyte. 1mmol of potassium chloride = 1 mEq of potassium chloride

Treatment of hypokalemia:

PO: 1-2 mmol/kg/DAY q6h-24h. IV: 0.25-0.5 mmol/kg/DOSE.

For PO administration potassium chloride is available as oral solution 1.33 mmol/mL, and slow release tablets (Slow K) 600 mg (= 8 mmol). Potassium citrate is also available as effervescent tablet (25 mEq/tablet). Give po with food. Dilute oral solution in water or juice and give over 5-10 mins. Slow-release tablets should not be crushed or chewed. Usual adult maximum = 80 mmol/DAY

Risk of arrhythmias and cardiac arrest with rapid IV administration. Dose recommendations assume normal renal function. Please refer to Pediatric IV monograph for further prescribing details and limitations

Prednisone or Prednisolone Corticosteroid.

Acute asthma: PO: 1-2 mg/kg/DOSE q24h. Anti-inflammatory or immunosuppressive: PO: 0.5-2 mg/kg q24h (usual max is 60mg/DAY)

1 mg Prednisone = 1 mg Prednisolone. Discontinuation of therapy greater than 14 days requires gradual tapering. Consider supplemental steroids at times of stress if patient has received long-term or frequent bursts of steroid therapy.

10/14 34

Ranitidine H2 receptor antagonist.

Reduction of gastric acid secretion:

IV: 2-4 mg/kg/DAY q8-12h (usual max 50 mg q8h).

PO: 4-10 mg/kg/DAY q8-12h (usual max 300 mg/DAY). IV dose is approximately 50% of oral dose. Modify dosage interval for patients with renal impairment. May add IV daily dose to TPN. Available as a 15mg/ml oral solution. Salbutamol (Ventolin)

Bronchodilator, 2 agonist. Acute asthma: MDI: 4-8 puffs q ½-q4h prn. NEB: Less than 10 kg: 2.5 mg q ½-q4h prn 10 kg or greater: 5 mg q½-q4h prn Administered in 3 mL of NS. Available as 5 mg/mL solution for nebulization.

Maintenance therapy: MDI: 1-2 puffs q4h prn.

Titrate dose to effect and/or adverse effects (tachycardia, tremor and hypokalemia). For most patients metered dose inhalers with a spacer device are the preferred method of drug delivery. Senna Stimulant laxative.

PO: infants: 1 or 2.5 mL (1.7 or 4.25 mg) q24h. children: 2.5 or 5 mL (4.25 or 8.5 mg) q24h. adolescents: 5 or 10 mL (8.5 or 17 mg) q24h.

Some patients, particularly those receiving opiates may require higher doses and/or more frequent administration. Also supplied as 8.6 mg tablets.

10/14 35

Spironolactone Potassium sparing diuretic.

PO: 1-3 mg/kg/DAY q12-24h. Available as a 5mg/mL suspension. Please round doses to the nearest 0.5mg or 1mg. Topiramate Anticonvulsant

For greater than 2 yrs and less than 16 yrs: PO: 1-3 mg/kg/DAY as a single dose

(initial max 25 mg/DAY) then can increase dose at 1-2 week interval by 1-3 mg/kg/DAY divided q12h. Usual maintenance PO: 5-9 mg/kg/DAY divided q12h 17 years and older : PO: 25 to 50 mg/DAY as a single dose , may increase dosage by 25 to 50 mg/DAY at 1-week intervals, give q12h. . Titrate dose to response to a usual maintenance dose of 200 to 400 mg/DAY divided q12h

Ursodiol TPN Cholestasis: PO: 30mg/kg/DAY divided q8h Biliary Atresia: PO: 10-15 mg/kg/DAY once daily

10/14 36

Valproic Acid and Derivatives Anticonvulsant.

Maintenance PO: 15-20 mg/kg/DAY increased to a maximum of

30-60 mg/kg/DAY q6-12h. Desired therapeutic range: 350-700 micromol/L (50-100 microgram/mL). Dosing is equivalent for valproic acid, divalproex and sodium valproate. Valproic acid IV is special access only and reserved for specific indications. Please consult pharmacist. Vitamin K Reversal of prolonged clotting times or warfarin induced anticoagulation.

IV/PO: 0.5-10 mg/DOSE. Use lower doses if there is no significant bleeding and patient will require warfarin in the future. May repeat in 6-8 hours. Injection may be given by mouth, undiluted or in juice or water.

Zinc Sulphate Supplement PO: 0.5-1 mg elemental zinc/kg/DAY divided q8-12h (usual max 15mg elemental zinc/DAY) Available as 10mg/mL elemental zinc suspension, 10mg or 50mg elemental zinc tablets (as zinc gluconate)

10/14 37

Suggested dose equivalency applies to stable analgesic states. Patients with acute

postoperative pain may have variations to suggested conversions.

OPIOID Parenteral Dose

(mg)a

Oral Dose

(mg) FentaNYL 0.1 N/A

HYDROmorphone 2 6

Methadone N/Ab 2.5-10b

Morphine 10 30

OxyCODONE N/A 15

These approximate analgesic equivalences should be used only as a guide for estimating equivalent

doses when switching from one opioid to another in chronic pain patients.

If the patient was on high dose opioid therapy (100 mg/day or greater of morphine), initial doses of

the new opioid should be 50% of the calculated dose of the new opioid.

If patient was on moderate dose of opioid therapy ( 60 – 90 mg/day morphine) start with 75% of

calculated dose of new opioid.

Additional references & patient response should be consulted to verify appropriate dosing of individual

agents. Additional resources for dose conversion can be found at: http://nationalpaincentre.mcmaster.ca/ a Parenteral route includes intravenous, intramuscular and subcutaneous route, but does not include

intraspinal route. b. Methadone equivalency is highly variable – this ratio is taken from Micromedex as suggested

equivalency ratio in patients on chronic oral methadone.

Approximate Opioid Analgesic Equivalence

at HHS –April 2014

HHS- March 2010

10/14 38

Drug Equivalent Dose

(mg)a Relative Mineralocorticoid

Potency

Glucocorticoids:

Short-acting (biologic half-life 8–12 h)

Cortisone 25 2

Hydrocortisone 20 2

Intermediate-acting (biologic half-life 12–36 h)

Methylprednisolone 4 0

Prednisolone 5 1

Prednisone 5 1

Long-acting (biologic half-life 36–54 h)

Dexamethasone 0.75 0

a Equivalent doses are approximations and may not apply to all diseases or routes of

administration. Duration of hypothalamic-pituitary-adrenal (HPA) axis suppression and

degree of mineralocorticoid activity must be considered separately.

Approximate Systemic Corticosteroid Equivalence

at HHS - May 2010

10/14 39

Antibiotics  Guide  for  Common  Pediatric  Infections  (>3  months)  

Infection   Major  Organisms   Antibiotic   Duration   Notes  

Otitis  Media   S.  pneumoniae,  H.  influenzae  (non-­‐typable),  M.  catarrhalis  (2-­‐20%)  Group  A  Streptococcus  (5%)  

First  line:  High-­‐dose  Amoxicillin  PO  Second  line:  if  type  1  allergy  à  Clarithromycin  PO  if  non-­‐type  1  à  Cefprozil  PO    OR  Ceftriaxone  IM  x  1  dose  If  initial  therapy  fails:  Amoxicillin-­‐Clavulanate  (Clavulin)  PO  if  type  1  allergy  à  call  ID  

5  days  OR  10  days  if:    <  2yo,  frequent  recurrent  AOM,  perforated  TM,  failed  initial  Abx  

watchful  waiting  appropriate  when:    -­‐ >  6mo  -­‐ healthy  child  (NO  immunodeficiency  or  chronic  disease  or  anatomical  abnormality  of  head  and  neck,  NO  Down’s  syndrome,  NO  history  of  complicated  otitis  media)  

-­‐ illness  not  severe  -­‐ reliable  parents  

CPS  statement  2009  Community-­‐acquired  pneumonia  

3  mo  –  4  yrs  Viral  >  Bacterial  (S.  pneumoniae,  group  A  Streptococcus)  >>  Atypicals  (Mycoplasma,  Chlamydophila,  Legionella)    5  –  18  yrs  Bacterial,  Atypicals,  Viral  

Outpatient  or  admitted  to  ward:  High  dose  Amoxicillin  PO  or  Ampicillin  IV  Atypical  pneumonia:    Clarithromycin  PO  Pleural  effusion/Admitted  to  PCCU/Necrotizing:  Ceftriaxone  IM/IV  +  Vancomycin  IV    

7-­‐10  days,  depending  on  clinical  status    (treatment  duration  will  be  longer  in  the  presence  of  complications  such  as  empyema)    

Features  of  atypical  pneumonia:  subacute  onset,  non-­‐lobar  infiltrate,  minimal  leukocytosis,  school-­‐age    

-­‐ Macrolides  are  useful  in  pen-­‐allergic  patients  -­‐ If  you  are  sure  it  is  not  a  type-­‐1  reaction,  can  try  cephalosporins  (2nd  or  3rd  gen.)  

-­‐ Consider  risk  factors  for  MRSA  CPS  statement  2011  

Meningitis     Bacterial  (S.  pneumoniae,  H.  influenza,  N.  meningitidis),  Viral  (HSV,  Enterovirus)    Special  considerations  in:  

-­‐ <  3mo  -­‐ immunocompromised  -­‐ known  CNS  disease,  

trauma  

Cefotaxime  IV  OR  Ceftriaxone  IV/IM    PLUS  Vancomycin  IV      ADD  acyclovir  if:  

-­‐ CSF  pleocytosis  <2000  WBC/hpf    

Depends  on  organism:  S.  pneumonia  10-­‐14  days  N.  meningitidis  5-­‐7  days  If  CSF  culture  negative  but  strong  clinical  suspicion  then  continue  empiric  antibiotics  for  7-­‐10  days  

Mandatory  ID  consult  

consider  DEXAMETHASONE  if  bacterial  pathogen  suspected  0.6  mg/kg/day  divided  q6h  before  or  within  30  minutes  of  the  first  dose  of  antibiotics  (only  continue  for  2  days  if  S.  pneumonia  or  H.  influenza  isolated,  any  other  pathogen  discontinue)  

-­‐  Target  vancomycin  trough  levels  10-­‐15  CPS  statement  2014  

Urinary  Tract  Infection  

E.Coli,  Klebsiella,  Enterococcus,  Proteus,  Serratia,  Pseudomonas,  S.  Saprophyticus    Acronym:  KEEPPSS    

Uncomplicated  (cystitis):  Cephalexin  Sulfamethoxazole/Trimethoprim  

No  clear  consensus  7-­‐14  days    considerations:  age,  anatomy,  complicated  vs.  uncomplicated  

-­‐ Diagnosis:  urine  R+M  and  culture  (will  only  send  culture  if  mid-­‐stream,  catheter  or  suprapubic  aspiration  ie.  NO  BAG  SAMPLES  for  culture)  

-­‐ First  febrile  UTI  in  an  infant  warrants  investigation  with  an  abdominal  ultrasound  

AAP  Clinical  Practice  Guideline  2011  

Complicated  (<2-­‐3  months  pyelonephritis  systemically  ill  vomiting,  immunocompromised):  Ampicillin  IV  PLUS  Gentamicin  IV  OR  Ceftriaxone  IV/IM  

Cellulitis   Group  A  Streptococcus,    S.  aureus  (MSSA/MRSA),  Group  C/G  streptococcus  If  pus  present  –  very  likely  S.  aureus  

If  pus  not  present  –  very  likely  streptococcal  

First  line:  1st  generation  Cephalosporin  such  as  Cephalexin/Cefazolin    If  allergic  to  beta-­‐lactam:  Clindamycin  PO/IV  If  suspect  MRSA:  Outpatient  à  Trimethoprim/Sulfamethoxazole  Inpatient  à  Vancomycin    

7-­‐10  days  (usually  1-­‐2  days  after  the  rash  resolves)    Varies  depending  on  presence  of  abscess  and  degree  of  drainage  

-­‐ Consider  I&D  as  first  line  if  abscess  or  furuncle  -­‐ Consider  MRSA  risk  factors  -­‐ avoid  oral  cloxacillin  if  possible  as  it  has  poor  bioavailability  and  has  GI  side  effects  

 

Osteomyelitis   S.  aureus,  Group  A  Streptococcus,  pneumococcus,  kingella  

First  line:  Cefazolin  (high  dose)  If  suspect  MRSA:  Vancomycin  

Prolonged  treatment  course:  4-­‐6  wks  (combination  of  IV/PO  as  per  ID)  

-­‐ mandatory  ID  consult  for  management  and  F/U  -­‐ consider  special  groups:  eg.  Salmonella  in  sickle  cell  disease,  MRSA  colonized,  infected  hardare  

Pharyngitis   Viral  >  bacterial  (Group  A  Strep)   If  suspect  GAS:  penicillin  V  or  amoxicillin  If  True  beta-­‐lactam  allergy:  Macrolide  or  Clindamycin  

10  days   -­‐ useful  to  confirm  dx  with  throat  culture  -­‐ bacterial  >  viral  if:  cough  absent,  tender  lymphadenopathy,  high  fevers,  ++  tonsillar  exudates    

10/14 40

Antibiotics  Guide  for  Common  Pediatric  Infections  (>3  months)    

CLNICAL  PEARLS  

 Other  Clinical  Scenarios:    

Challenging  Organisms:    

Antibiotics  of  note:    

Septic  Shock:    ceftriaxone  +  vancomycin  can  consider  pip-­‐tazo  if  require  coverage  for  anaerobes  (eg.  GI  infection)  or  pseudomonas    Febrile  Neutropenia:    -­‐ Piperacillin-­‐tazobactam  -­‐ Refine  Abx  if  blood  Cx  +ve  -­‐ Consider  previous  microbiology  history  (e.g.  antibiotic-­‐resistant  organisms)  

 

Pseudomonas  covered  by:    -­‐ ceftazidime  -­‐ piperacillin  +/-­‐  tazobactam  

-­‐ ciprofloxacin  /  levofloxacin  

-­‐ meropenem  -­‐ aminoglycosides    (gentamicin/tobramycin/  amikacin)  

 

MRSA  covered  by:    -­‐ Vancomycin  -­‐ Clindamycin  -­‐ Septra  -­‐ Linezolid  (needs  ID  endorsement)  

 Risk  Factors:    -­‐ Previous  MRSA  infection  or  household  contact  

-­‐ Healthcare  exposure/recent  hospitalization  

-­‐ TRAVEL  (including  to  USA)  

 

Organisms  resistant  to  penicillins  and  cephalosporins:    -­‐ MRSA  -­‐ ESBL  -­‐ CONS    -­‐ C  diff  -­‐ SPICE  (AmpC  producers):  Serratia,  providencia,  Indole  +ve  Proteus  (Proteus  vulgaris),  Citrobacter,  Enterobacter  cloacae  

-­‐ Atypicals    

Vancomycin  (only  covers  gram  +ve),  indications:    -­‐ MRSA  -­‐ Severe  C  diff  infection  (PO  only)  -­‐ CONS  -­‐ Enterococcus    

Carbapenem  indications:    -­‐ ESBL  -­‐ SPICE  -­‐ Polymicrobial  infection    REQUIRES  ID  CONSULT  

10/14 41

PPI  (Proton  Pump  Inhibitors)  in  Pediatrics  –  Reflux  Disease  –  Best  Evidence  in  Peds  with  Omeprazole,  Lansoprazole  and  Pantoprazole.  

Drug  Generic  Name  

Brand  Name  

Pediatric  Dose1,  6  (BID  dosing  is  thought  to  provide  better  control  of  breakthrough  acid)  

Max  Dose1  (faster  clearance  in  peds  than  adults  –  may  need  higher  than  standard  adult  dose)  

Usual  Adult  Dose  GERD2  

 Administration  (See  note  below)  Note:  Pharmacy  Prepared  Suspension5(  

(Compounding  dependent  on  pharmacy)  

Available  Formats4  and  Cost  

LU  Code  3  

Omeprazole   Losec   1-­‐1.5  mg/kg/day  PO  once  daily  or  divided  BID  NEONATAL:  0.5-­‐1.5  mg/kg/dose  

3.5  mg/kg/day     10-­‐20  mg  PO  OD  

1.Capsule  –  can  be  opened  &  sprinkled  on  yogurt  and  given  2.  Pharmacy  prepared  suspension    can  be    used    

10mg    capsules–  not  ODB  covered  20  mg    cap  ($0.6/cap)    

293  –  GERD  or  non  erosive  GERD  when  H2Antags  have  failed    297-­‐PUD  or  prevention  of  NSAID  induced  ulcers    401-­‐  treatment  of  GI  disorders:  Crohns,  short  Gut  etc.    402-­‐severe  esophagitis,  Zollinger-­‐Ellison  etc.  

Lansoprazole   Prevacid   <10  kg:  7.5  mg  PO  OD  10-­‐30  kg:  15  mg  PO  OD  >30  kg:  30  mg  PO  OD      

1.6  mg/kg/day  or    30  mg/day  

15-­‐30  mg  PO  OD  

1.Capsules  may  be  opened  and  sprinkled  into  applesauce    2.FasTabs  can  be  placed  on  tongue  for  doses  15mg  or  greater  3.  FasTabs  can  be  mixed  with  water  (10mL)  to  provide  part  doses  only  if  no  other  options  exist  4.  Pharmacy  Prepared  suspension  may  be  used  if  available  

15mg  ($0.5/cap)  30mg  ($0.5/cap)    with  Enteric  coated  microgranules    

293  –  GERD  or  non  erosive  GERD  when  H2Antags  have  failed    295  –  for  HPylori  Peptic  Ulcer    297-­‐PUD  or  prevention  of  NSAID  induced  ulcers    401-­‐  treatment  of  GI  disorders:  Crohns,  short  Gut  etc.    402-­‐severe  esophagitis,  Zollinger-­‐Ellison  etc.  

15,  30  mg  FasTabs  (not  ODB  covered)  

Esomeprazole   Nexium   1mo-­‐11  yrs:      <5kg:2.5-­‐  5mg  PO  OD  >5kg:  10  mg  PO  OD  12-­‐17yrs:  20  mg  PO  OD  

40  mg/day   20-­‐40  mg  PO  OD  

1.Tabs  can  be  dispersed  for  PO  admin.  Mix  with  25-­‐50mL  mL  of  water  2.  Sachet  can  be  dissolved  &  administered  via  G  tube    

20  mg,  40  mg  tablet  10  mg  sachet  for  oral  suspension  (Not  ODB  covered)  

NO  –  Not  covered  under  ODB  

Pantoprazole   Pantoloc   1-­‐1.5  mg/kg/day   40  mg/dose   20-­‐40  mg  PO  OD  

Cannot  be  crushed    

20mg-­‐  not  a  benefit    40  mg    ($0.5/tablet)  

293  –  GERD  or  non  erosive  GERD  when  H2Antags  have  failed  295  –  for  HPylori  Peptic  Ulcer  297-­‐PUD  or  prevention  of  NSAID  induced  ulcers  401-­‐  treatment  of  GI  disorders:  Crohn’s,,  short  Gut  etc.  402-­‐severe  esophagitis,  Zollinger-­‐Ellisons  etc.  

Rabeprazole   Pariet   Greater    than  10  years:  10  mg  PO  OD    

  20  mg  PO  OD  

Cannot  be  crushed    

10  mg  ($0.17  tablet)),  20  mg  ($0.3/tablet)    

NO-­‐  Not  Covered  under  ODB  

Note:  Directions  for  opening  capsules  and  dissolving  tablets  with    dispersed    microgranules  into  food  or  water  requires  that  the  granules  must  NOT    be  crushed  or  chewed  for  effect.  

1. Hospital  for  Sick  Children.  Drug  Handbook  and  Formulary.  2009.  2. RX  Files  Drug  Comparison  Charts.  8th  Edition  3. ODB  Drug  Formulary  4. eCPS,  2012  5. Jew,  RK  et.  Al.  Extemporaneous  Formulations  for  Pediatric,  Geriatric,  and  Special  Needs  Patients.  ASHP.  2nd  Edition.  6. Micromedex  .  Accessed  December  2012.  

Prepared  by  N  Fernandes  RPh,  Drug  Information  Centre,  HHS.  Reviewed  by  S  Yousaf  RPh,  Pediatrics  MCH.  

10/14 42

3

FEED

Kcal Protein gram

Protein source

Fat gram

Fat source

CHO gram

CHO source

Na mg

K mg

Cl mg

Ca mg

PO4

mg Fe mg

Vit A (IU)

Vit D (IU)

mOsm/ kg H20

Indications for use

INFANT (0-1 YR) HUMAN MILK * (mature) 70 1.1 Lactalbumin casein

70:30 -whey:casein 4.2 Human milk fat 7.2 Lactose 18 1.4 1.1 0.7 0.5 0.05 61 - 290 Preferred feeding for term and preterm infants 70:30 whey:casein

SIMILAC ADVANCE Abbott

68 1.4 Evaporated /dry skim milk, whey protein

3.7 Safflower/sunflower coconut, soy

7.3 Lactose, monoglycerides

16 71 44 53 29 1.2 203 41 300 Iron fortified term infant formula with added DHA (5 mg) and ARA (13 mg)

ENFAMIL A+ Mead Johnson

68 1.4 Modified milk ingredients

3.6 Palm olein, soy, coconut, sunflower

7.6 Lactose, corn syrup GOS maltodextrin polydextrose

18 73 43 53 29 1.22 200 41 300 Iron fortified term infant formula with added DHA (11.5 mg) and ARA (23 mg). Prebiotics added (GOS, polydextrose)

GOODSTART Nestle

67 1.5 Whey hydrolysate (100% whey)

3.4 Palm olein, soy, coconut, safflower

7.5 Lactose, corn maltodextrins

18 72 44 44 24 1.0 200 40 260 Hydrolyzed 100% whey-for infants at risk for milk protein allergy or mild reflux. ↓ PO4, DHA (10 mg) and ARA (20mg)

ENFAMIL A+ THICKENED Mead Johnson

68 1.7 Nonfat milk 3.4 Palm olein, soy, coconut, sunflower

7.4 Rice starch lactose maltodextrin corn syrup

27 73 51 53 36 1.2 200 41 230 Thickens when combines w/stomach acids- for reflux. Do not concentrate beyond 24 kcal/oz. DHA (11.5mg) ARA (23mg)

ENFAMIL LACTOSE FREE Mead Johnson

68 1.4 Milk protein isolates 3.6 Coconut, sunflower soy, palm olein

7.4 Corn syrup solids maltodextrin

20 74 45 55 31 1.2 200 41 200 Milk-based, lactose free formula. NOT suitable for galactosemia. RTF only in hospital – concentrate n/a.

ENFAMIL SOY A+ Mead Johnson

68 1.7 Soy protein isolates 3.6 Coconut, sunflower soy, palm olein

7.2 Corn syrup solids Mono/diglycerides

24 81 54 71 47 1.22 200 41 170 Soy based formula. Suitable for vegans. DHA (11.5 mg) & ARA (23mg) Use powdered form only for galactosemia.

ALIMENTUM Abbott

68 1.9 Hydrolyzed casein 3.8 MCT, safflower, soy 6.9 Sucrose, mod tapioca starch

30 80 54 71 51 1.2 203

30 370 Hydrolyzed casein for milk protein allergy (60 % amino acids), 33% MCT. Lactose-free. Not kosher. √ ODB

NUTRAMIGEN A+ Mead Johnson

68 1.9 Hydrolyzed casein (100% casein)

3.6 Palm olein, soy, coconut, sunflower

7.0 Corn syrup solids, mod. corn starch

32 74 58 64 35 1.22 200 34 320 rtf 300 pdr

Hydrolyzed casein for milk protein allergy. Lactose/sucrose free. Not kosher. DHA (11.5 mg) & ARA (23mg) √ ODB

PREGESTIMIL A+ Mead Johnson

68 1.9 Hydrolyzed casein (100% casein)

3.8 MCT, corn, soy, sunflower/safflower

6.9 Corn syrup solids, mod. Cornstarch

32 74 58 64 35 1.22 240 34 330 Hydrolyzed casein for milk protein allergy/fat malabsorption. 55% MCT. DHA(11.5 mg) & ARA(23mg) NO ODB

NEOCATE INFANT Nutricia

67 2.1 Free amino acids 3 Safflower, coconut, soy

7.8 Corn syrup solids 25 104 52 83 62 1 212 35 375 Amino acid-based for milk protein allergy, malabsorption. 5% MCT ,95% LCT √ ODB

NUTRAMIGEN AA Mead Johnson

68 1.9 Free amino acids 3.6 Palm olein, soy, coconut, sunflower

7.0 Corn syrup solids, tapioca starch

32 74 58 64 35 1.22 200 34 350 Amino acid based for severe cow milk protein/ multiple allergies. 2.8% MCT DHA (11.5 mg) & ARA (23mg) √ ODB

ENFAMIL ENFACARE A+ Mead Johnson

74 2.1 Nonfat milk, whey protein

3.9 High oleic vegetable, soy, coconut, MCT

7.7 Lactose cornu syrup solids

28 78 58 89 49 1.34 330 52 310 Preterm discharge formula with more kcal, protein, vitamins, minerals. DHA (12.6 mg) ARA (25 mg) 20% MCT √ ODB

ENFAMIL PREMATURE A+ With iron 24 kcal Mead Johnson

81 2.4 Non-fat milk Whey protein

4.1 MCT, soy, high oleic sunflower/safflower

8.9 Corn syrup solids, lactose

47 80 73 134 67 1.46 1010 195 300 For preterm Infants when human milk not available. 40% MCT. DHA (13.8 mg) ARA (28mg)

ENFAMIL HMF Mead Johnson (per 4 pkg HMF )

14 1.1 Milk protein isolate, whey hydrolysate

1.0 MCT, soy <0.4 Corn syrup solids, lactose

16 29 13 90 50 1.44 950

150

35 To fortify human milk fed to premature/low birthweight infants MCT 70%

PEDIATRICS (1-10 YR) PEDIASURE

Abbott 100 3.0 Na caseinate (82%),

whey protein (18%) 5 Safflower, soy MCT,

sunflower 11 Maltodextrin, sucrose 37 130 101 97 80 1.4 259 32 310 Sole source of nutrition or supplement, oral/tube feed. Gluten and

lactose free . 20% MCT. √ ODB PEDIASURE PLUS with fibre

Abbott 150 4.2 Na/ca caseinate (82%)

whey protein (18%) 7.5 Safflower, soy, MCT,

sunflower 18 Maltodextrin, soy, FOS

sucrose, oat hulls, 65 180 122 90 80 1.4 330 45 345 High calorie Oral/tube feed. Not gluten free. 20% MCT, 0.75g

fiber/100mL FOS = 0.35g/100 ml) √ ODB NUTREN JR

Nestle 100 3 Casein (50%), whey

protein (50%) 5 Soy, canola, MCT 11 Maltodextrin, sucrose 46 132 108 120 84 1.4 332 60 350 Sole source nutrition or supplement. Oral/tube feed.

21% MCT Lactose & gluten free √ ODB NUTREN JR + Fiber

Nestle 100 3 Isolated casein (50%)

whey protein (50%) 5 Soy, canola, MCT 11 Maltodextrin, sucrose,

FOS/ inulin, pea fibre 46 132 108 120 84 1.4 332 60 350 Supplement/tube feed. 21% MCT Lactose and gluten free. 0.36g

pea fiber and 0.2g FOS/inulin per 100 mL. √ ODB PEPTAMEN JR

Nestle 100 3 Hydrolyzed whey 3.8 MCT, soy, canola 14 Maltodextrin, sugar,

corn starch 48 132 108 112 84 1.4 332 60 380 Partially hydrolyzed protein. 60% MCT, 100% whey peptides

√ ODB PEPTAMEN JR 1.5 (prebio)

Nestle 150 4.5 Hydrolyzed whey 6.8 MCT, soy, canola,

refined tuna oil 18 Maltodextrin, corn

starch, oligofructose 73 198 162 165 135 2.1 48 80 450 Partially hydrolyzed protein, hypercaloric, Per 100mL- 14mg EPA

+58mg DHA, 0.56 g Prebio Contains inulin 60% MCT NO ODB

NEOCATE JR (unflavoured) Nutricia

100 3.3 Free amino acids 5 Coconut, canola,safflower

10.4 Corn syrup solids 41 137 63 113 70 1.5 250 44 590

Amino acid formula for allergy, protein intolerance, malabsorption. Fruit/choc flavours avail. 35% MCT √ ODB

COMPLEAT PEDIATRIC Nestle

100 3.8 Chicken/peas/gr bean Na caseinate

3.9 Canola, MCT 13 Cranberry juice corn syrup solids peaches

80 164 56 144 100 1.4 332 60 380 Made with pureed food/juice for1-13 yrs. 20% MCT per 100 mL - 0.68 fibre from veg/fruit + guar gum fibre √ ODB

PEDIATRIC FORMULARY NUTRIENTS PER 100 mL unless otherwise noted

May, 2012

10/14 43

May 2012 FEED

Kcal Protein

gram Protein source

Fat gram

Fat source

CHO gram

CHO source

Na mg

K mg

Cl mg

Ca mg

PO4

mg Fe mg

Vit A (IU)

Vit D (IU)

mOsm/ kg H20

Indications for use

PEDIATRICS (10+ yr) HOMOGENIZED MILK 62 3.3 Casein, whey 3.4 Cow milk fat 4.7 Lactose 50 156 105 123 96 0.05 128 43 For children >1 yr if consuming balanced, varied diet with

adequate source of iron. JEVITY 1 CAL

Abbott 106 4.4 Na/Ca caseinate, soy 3.6 Safflower/sunflower

canola MCT 15.2 Maltodextrin, corn

syrup solids soy fibre 74 124 115 91 76 1.4 381 31 310 Isotonic, high protein for tube feeding 1.4 g/100 mL fibre. √ ODB.

19% MCT JEVITY 1.2 CAL

Abbott 120 5.55 Na/ ca caseinate

Soy protein 3.9 Safflower, canola,

MCT 17.3 Maltodextrin FOS soy +

oat fibre, corn syrup solids 135 185 150 120 120 1.8 400 30 450 High kcal, high protein fiber containing tube feed. 1.2 g fiber /100

mL-soluble & insoluble.FOS = 1.0 g/100 mL. 19% MCT √ ODB JEVITY 1.5 CAL

Abbott 150 6.4 Na , ca caseinate, soy 5.0 MCT, canola, corn 21.6 Maltodextrin FOS soy +

oat fibre, corn syrup solids 140 215 136 120 120 1.8 375 40 525 High pro& kcal for fluid restriction/elevated energy needs 19%

MCT. 0.89g fiber/1g FOS/100 mL. √ ODB 1 & 1.5L size only RESOURCE 2.0

Nestle 200 8.0 Na + ca caseinate 9.0 Canola 22 Corn syrup, sugar,

maltodextrin 80 150

120 106 106 2.0 529 42 790 High nitrogen, calorically dense.for fluid restriction. Oral

supplement / tube feed. √ ODB ENSURE

Abbott 106 4.0 Milk & soy protein

concentrates 2.9 Soy, canola, corn

oils. Soy lecithin 16 Sugar, corn

maltodextrin 106 160 106 128 117 1.6 532 26 642 Oral supplement/ tube feed. Lactose & gluten free. Vanilla,

strawb, choc. NOT ODB covered (Ensure w fiber IS √ ODB) ENSURE PLUS

Abbott 151 5.7 Milk/ soy/ whey

protein concentrates 4.7 Canola, corn oil. Soy

lecithin 21.5 Corn maltodextrin,

sucrose 106 170 115 128 117 1.6 532 26 633

vanilla Oral supp. Calorically dense, high pro for fluid restrictions. Lactose/gluten free. Strawb/van/butter pecan. No fiber √ ODB

ENSURE HP Abbott

96 5.0 Na/ ca caseinate, soy protein

2.6 Safflower, canola, corn oils

13.2 Sugar, corn maltodextrin

123 182 107 117 117 1.5 496 21 546 High protein supplement/ tube feed. Lactose and gluten free. NOT ODB covered. Van/choc/straw. No fiber

ISOSOURCE VHN Nestle

100 6.2 Na , ca caseinate 2.9 Canola, MCT, soy 12.8 Maltodextrin, guar gum soy polysaccharides

128 160 136 80 80 1.4 288 27 300 High protein, fibre containing tube feed. 50% of fat as MCT. 0.45g fiber/100 mL. Lactose and gluten free √ ODB

OXEPA Abbott

150 6.3 Na, ca caseinates 9.4 Canola, MCT, marine + borage oils

10.5 Sucrose, maltodextrin

131 196 169 106 106 2 1191 42.5 535 Low CHO, calorically dense - for critically ill/Sepsis/ARDS. EPA&GLA oil, 25% MCT. Lactose/gluten free. NOT kosher

OPTIMENTAL Ross

100 5.1 Whey /na caseinate hydrolysates, arginine

2.8 Marine oils, MCT, canola, soy oils

14 Maltodextrin, sucrose, FOS

112 171 120 106 106 1.3 823 28 585 Elemental for malabsorption EPA(2.3 g/L) DHA(1g/L) Arginine 3.6g/L. FOS 5g/L 60% fat as marine/MCT √ ODB NOT kosher

PERATIVE ** Abbott

130 6.7 Na caseinate, arginine lactalbumin

3.74 Canola, MCT, corn 17.7 Maltodexrtrin 104 173 165 87 87 1.6 868 35 385 Peptide based for metabolically stressed. 8.05g/L arginine, Oral and tube feed. For those > 4yrs.

PEPTAMEN Nestle

100 4.0 Hydrolyzed whey 3.9 soybean, MCT 13 Maltodextrin, sugar corn starch

56 150 100 80 70 1.8 324 27 380 Elemental diet for impaired GI function/malabsorption. Oral & tube. 100% whey protein. 70% MCT. Vanilla flavour √ ODB

PEPTAMEN 1.5 Nestle

150 6.8 Whey 5.6 soybean, MCT 19 Maltodextrin, corn starch

102 186 174 100 100 2.7 486 41 550 Elemental high calorie diet for malabsorption. 100% whey protein. Vanilla flavour 70% MCT. √ ODB

VITAL HN ** Abbott

100 4.2 Partially hydrolyzed protein blend, whey

1.1 Safflower, MCT 18.5 Maltodextrin, sucrose 57 140 103 67 67 1.2 333 27 500 Peptide based, VERY low fat formula for limited digestion + absorption. Contains peptides and free aa. 43% MCT NOT kosher

VIVONEX PEDIATRIC (Per 100 g powder) Nestle

411 12.3 Free amino acids 12.1 Coconut, soybean palm/coconut

64.7 Maltodextrin, corn starch

205 616 534 493 411 5.34 127 164 360 Elemental formula for fat malabsorption-68% MCT - 1 pkg powder (48.7g) + 220 mL water = 250 mL (0.8 kcal/mL) √ ODB

NEPRO CARB STEADY Abbott

180 8.1 Milk protein, Ca, mg, na caseinates

9.6 Safflower, soy lecithin, canola

16 Corn syrup solid FOS maltodextrin sucrose

106 106 84 106 72 1.9 318 8.5 745 Acute or chronic renal failure requiring dialysis. Oral/tube feed. 0.84g FOS + 0.42g fiber per 100 mL NOT ODB Vanilla

SUPLENA Abbott

200 3.0 Na + ca caseinate 9.6 Safflower, soy 25 Maltodextrin, sucrose 78 112 93 139 74 1.9 106 8.5 600 Low protein for chronic/acute renal failure patient not on dialysis. Oral/ tube feed. √ ODB

MODULEN IBD ** Nestle

99 3.5 Casein 4.8 Milk fat, MCT, corn 10.8 Corn syrup, sugar 35 126 80 83 54 0.96 284 38 340 Polymeric formula for Crohn’s disease. Oral/tube feed. Can be concentrated to 1.5 kcal/mL. 25% MCT √ ODB

* Jensen, RD (ed) Handbook of Milk Composition. San Diego, Academic Press, 1995. ** HMF = Human Milk Fortifier CONVERSION FACTORS: Ca - 40mg per mmol PO4 – 31mg per mmol Na – 23mg per mmol Cl – 35.5 mg per mmol K – 39 mg per mmol √ ODB indicates product covered by Ontario Drug Benefits Vitamin A – 3.33 IU = 1 mcg Vitamin D – 40 IU = 1 mcg ** Available as non-formulary request

PEDIATRIC FORMULARY NUTRIENTS PER 100 mL unless otherwise noted

10/14 44

May, 2012

FEED

Kcal Protein grams

Protein source

Fat grams

Fat source

CHO gram

CHO source

Na mg

K mg

Cl mg

Ca mg

PO4

mg Fe mg

Vit A (IU)

Vit D (IU)

mOsm/ kg H20

Indications for use

METABOLICS/SPECIALTY PORTAGEN

(per 100g powder) Mead Johnson 470 17 Na caseinates

(100%) 22 MCT, corn, coconut 54 Corn syrup solids

Sugar 235 590 404 440 330 8.8 1560 130 n/a Fat malabsorption, chylothorax, defective lymphatic transport.

87% MCT Consult RD for recipe √ ODB RCF (per 100mL concentrate)

Abbott 81 4 Soy protein

isolates 7.2 soy, coconut,

safflower .008 - 59 146 83 140 100 2.4 405 81 - Carbohydrate-free soy formula for carbohydrate intolerance -

water and CHO source required. √ ODB PROPHREE

(per 100g powder) Abbott 510 0 28 Safflower, coconut,

soy 65 Corn syrup solids

250 874 350 750 525 11.9 2000 300 - For reduced protein diet, specific amino acid disorders, or

increased energy, minerals, vitamins. 1 cup powder = 120 g KETOCAL

(per 100g powder) Nutricia 720 15 Dry whole milk 72 Soy oils, soy

lecithin 3 Corn syrup solids 300 1080 500 800 650 11 1500 208 Used in treatment of intractable epilepsy with ketogenic diet

Contains aspartame. √ ODB TYREX 1

(per 100 g powder) Abbott 480 15 L-amino acids 21.7

Safflower, coconut, soy

53 Corn syrup solids 190 675 325 575 400 9 1400 300 For infants with tyrosinemia. No PHE or TYR–must be from diet.1 cup powder = 120 grams; 2.73 mosm/g powder.

PHENEX 1 (per 100 g powder) Abbott

480 15 L-amino acids 21.7 Safflower, coconut, soy

53 Corn syrup solids 190 675 325 575 400 9 1400 300 For infants with phenylketonuria. No PHE – must be obtained from diet 1 cup powder = 120 grams; 2.72 mosm/g powder.

PROPIMEX 1 (per 100 g powder) Abbott

480 15 L-amino acids 21.7 Safflower, coconut, soy

53 Corn syrup solids 190 675 410 575 400 9 1400 300 For propionic academia/methylmalonic academia. No VAL, MET, low THR, ILE 1 cup powder =120 grams; 2.76 mosm/g

CYCLINEX 1 (per 100 g powder) Abbott

510 7.5 L-amino acids 24.6 Safflower, coconut, soy

57 Corn syrup solids 215 760 390 650 455 10 1600 300 For urea cycle disorders. Additional protein obtained from diet. 1 cup powder = 120 grams; 2.20 mosm/g powder.

GLUTAREX 1 (per 100 g powder) Abbott

480 15 L-amino acids 21.7 Safflower, coconut sou

53 Corn syrup solids 190 675 325 575 400 9 1400 300 For infants/children with glutaric aciduria Type 1or 2-Ketoadipic Aciduria. 1 cup powder = 120g 2.73 mosm/g pwdr.

CALCILO XD (per 100 g powder) Abbott

513 11.4 Whey, sodium caseinate

28.7 Coconut, corn oil 52.3 Corn syrup 125 420 292 <50 128 9.2 1540 0 202 Low calcium, low phosphorus NO vit D formula with iron for hypercalcemia. Order via Specialty Food Shop. 1 cup = 105 g

MODULARS/SUPPLEMENTS PEDIASURE COMPLETE (Per 235 mL bottle) Abbott

235 9.3 Milk protein, whey, soy

7.7 Soy,canola, MCT, coconut/palm

33 Sucrose, FOS (1g), maltodextrin

90 450 204 250 250 2.4 782 24 600 Supplement-not for tube feeds. Chocolate/vanilla (only choc in hospital) DHA(10 mg) ARA(3.3) 15% MCT NO ODB

POLYCOSE POWDER (per 100 gram) Abbott

380 - - 0 - 94 Glucose polymers 130 10 223 30 15 0.09 - - - Carbohydrate module, lactose free 1 Cup = 100g √ ODB

MICROLIPID (per mL) Nestle

4.5 - - 0.5 Safflower, soy lecithin - - - - - - - - - - - Fat module 1 TBSP = 67.5 kcal NOT ODB covered

MCT OIL (per mL) Nestle

7.7 - - MCT - - - - - - - - - - - Fat module for fat malabsorption, cholestasis. 1 TBSP = 14 g = 115 kcal √ ODB

RESOURCE BENEPROTEIN (per gram) Nestle

3.6 0.86 Whey (100%) 0 - 0 - 1.4 5 - 4.3 2.1 - - - Protein module lactose/gluten free. 1 pkg = 7g = 6g pro/25kcal Mix 1 pkg in 60-120 ml water for tube feed, 30 mosm/pkg

BREAKFAST ANYTIME Nestle (per 315 mL box)

300 15 Skim milk, milk protein

9 Corn oil, milk fat 41 Maltodextrin, sugar lactose, inulin

250 370 - 420 370 7 1998 - - Oral supplement, 315 mL tetra pack, chocolate, vanilla, strawberry. 4 g FOS/inulin per 315 mL serving NO ODB

BOOST FRUIT BEVERAGE Nestle

77 3.7 Whey (100%) 0.2 soy 15 Sugar, corn syrup solids

1.3 0.1 2.6 1.4 2.2 1.0 80 0.5 700 Low fat supplement. Lactose, gluten free. Orange, peach, wildberry. √ ODB

DUOCAL (per 100 gram) Nutricia

492 0 - 22.3 Corn, coconut, palm kernel

73 Mono/diglycerides hydrolyzed cornstarch

<20 <5 <20 <5 <5 - - - 310 Soluble fat and CHO module. Lactose, gluten, sucrose fructose free. 35% of fat as MCT. Oral/tube 1tbsp = 42kcal NO ODB

OTHER PRODUCTS GLUTAMINE powder

Per 10g container 40 ?? L-glutamine 0 ?? - - - - - - - - - Dosage = 0.5 g/kg divided TID. Mix 10g in liquid (not

pop)/add to 60mL for tube feed. Not with renal/liver disease RESOURCE THICKEN UP Nestle (per 1 Tbsp or 4.5g)

15 4 Modified food starch (corn)

10 Instant food thickener for dysphagia management.

ENFAMIL ENFALYTE Mead Johnson

12.6 3.2 Corn syrup solids, citrates

115 98 160 170 Oral electrolyte maintenance solution. Light cherry flavour,

PEDIALYTE (per 100 mL) Abbott

10 - - - - 2.5 Dextrose 104 78 124 - - - - - 250 Oral electrolyte maintenance solution

PEDIALYTE POPSICLES per 62.5 mL popsicle - Abbott

6.3

- - - - 1.6 Dextrose 64 51 78 - - - - - 250 Oral electrolyte maintenance. Popsicles contain flavour + colouring. Melt and add to regular pedialyte for flavour.

PEDIATRIC FORMULARY NUTRIENTS PER 100 mL unless otherwise noted

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