Drug prescription in children

Drug prescription in children has many specific features which

are inherent, on the one hand, to the physiological and pathological particularities of the child and, on the other hand, to regulatory singularities of pediatric therapies.

From these two points, it is fundamental to remember that the prescription of medication for children must imperatively respect the child’s weight and thus take into account the galenic forms adapted to the child’s age and cognitive development.

For example, dry forms (capsules, tablets) are contraindicated in

children under six years of age. Particular attention should also be paid to the different sugar or alcohol contents of the various formulations.

Finally, we know that the success of drug treatment is closely linked to

treatment compliance. This concept becomes more complicated in the pediatric population where the prescriber must obtain compliance from both the child and the parents.

If one of the two does not adhere to the treatment and this for various reasons (not

does not understand the point, cannot reconstitute the medicine, bad taste…) it will fail. It is therefore essential that the prescriber takes a significant amount of time to explain the substance and form of the treatment to both the child and the patient.

the accompanying adult.

Prevention and pharmacological treatment of pain

The proper use of painkillers in pediatrics

Here we will only deal with drugs for nociceptive pain and/or

inflammatory, keeping in mind that pain is certainly a sensory experience but also an emotional one . Thus, the prevention or treatment of pain cannot be solely pharmacological.

The rational use of analgesic medications first requires a rigorous diagnosis of the pathophysiology of the pain, followed by an assessment of the pain itself. This last step is essential. Non-opioid, weak morphine analgesics will be used.

The choice of painkiller will therefore be based on the patient’s state of health (contraindication, drug interaction, etc.) and the intensity of the pain.

Depending on this, non-morphine analgesics (WHO level 1:

paracetamol, NSAIDs) will be prescribed to prevent or treat mild to moderate pain, for more severe pain or pain resistant to analgesics

Figure 1 Classification of acute pain relievers according to their chemical nature. NSAIDs: nonsteroidal anti-inflammatory drugs.

Non-morphine analgesics

Paracetamol is the first-line analgesic treatment of choice for

prevent or treat mild to moderate pain. Its benefit/risk ratio is excellent. Its side effects are exceptional in short courses and it does not present

drug interaction.

The only danger with paracetamol is the risk of acute (150 mg/kg in a single dose) or chronic poisoning. It is therefore important to respect a dose of 15 mg/kg every six hours without exceeding 80 to 90 mg/kg per day.

It will also be important to pay particular attention to the different dosages which must be adapted according to the child’s weight. Suppositories and oral forms

are available from 5 kg. From 3 kg, there is an oral suspension with a syringe graduated in kg of body weight (Doliprane® 2.4%).

Efferalgan® 3% oral solution contains a sugar content of 0.17 g/dose-kg, Doliprane® 2.4% oral solution is sugar-free but contains 71.5 mg of sorbitol per 1 kg graduation.

Nonsteroidal anti-inflammatory drugs (NSAIDs)

Are a pharmacological class that includes many molecules. Table I lists the active ingredients with pediatric marketing authorization with their dosage per dose and for 24 hours. Of all these, ibuprofen is the most studied and best known. The risks incurred with NSAIDs in short courses, less than five days, and at the recommended doses are very similar to those of paracetamol, whether in terms of renal or gastrointestinal toxicity.

The only uncertainty concerns the risk of infection, especially during chickenpox. For this reason, it is recommended not to use NSAIDs before the child has had chickenpox. The most suitable dosage forms for children are still oral suspensions containing 20 mg/ml for ibuprofen and 1 mg/ml for ketoprofen.

Morphine analgesics

In pediatric dentistry, the use of strong opioid analgesics such as morphine remains exceptional. In cases of pain that does not respond to paracetamol or in children for whom NSAIDs are contraindicated, it is recommended to prescribe weak opioids, with codeine as a first-line treatment.

Codeine is the leading weak opioid. However, there are few truly satisfactory studies in children. Codeine should always be combined with a non-morphine analgesic (paracetamol or NSAID).

In children, the dosage of codeine is 0.5 mg/kg per dose, without exceeding 6 mg/kg per day. Practically speaking, the starting dose in milligrams corresponds to the child’s weight divided by two. Few dosage forms are well adapted except for the syrup form (Codenfan®) dosed at 1 mg/ml (Table III).

The main side effects of codeine are relatively moderate in short-term doses, mainly nausea, dizziness and sometimes skin reactions such as pruritus. Codeine is contraindicated in patients with asthma or respiratory failure. The toxic dose of codeine in a single dose is 2 mg/kg.

To be effective, codeine must be metabolized into morphine. Four to ten percent of the Caucasian population are said to be “poor metabolizers” and cannot perform this transformation. Codeine will then be ineffective. A possible alternative is then

the use of tramadol.

Tramadol is a weak opioid analgesic with serotonin and norepinephrine reuptake inhibitory properties. It is indicated for children from three years of age and can be used alone without a non-morphine analgesic.

Its usual dosage is 1 to 2 mg/kg and taken every six hours without exceeding 8 mg/kg and per day. The dosage form reserved for children is an oral solution in drops (Contramal® or Topalgic®) dosed at 100 mg/ml.

Adverse effects, particularly gastrointestinal (nausea, vomiting), are very common. Furthermore, tramadol is contraindicated in patients prone to seizures.

Antibiotic drugs

The use of antibiotics in oral medicine is regulated by

national recommendations from the French Agency for the Safety of Health Products (Afssaps). These recommendations, which now date back to 2001, are currently being updated and mainly concern adult patients. For

pediatric populations few data exist to confirm the interest of these therapies in all indications.

Two main therapeutic modalities are possible: taking antibiotics for

prevent the onset of an infectious phenomenon, also called antibiotic prophylaxis, and the prescription of antibiotics to treat a proven infection, also called antibiotic therapy. It is obvious that the latter can only be considered in our discipline if it is accompanied by a surgical procedure.

Antibiotic prophylaxis

It will be considered primarily to prevent the risk of infective endocarditis in at-risk patients. It will involve prescribing a single dose one hour before the risky procedure (Table IV).

Antibiotic therapy

In the face of a proven bacterial infection, the first treatment will be surgical (endodontic, surgical). This may be combined with an antibiotic prescription. Regardless of the molecule chosen, it is imperative that the treatment be continued for the necessary time, most often seven days, and that the number of doses per dose be respected. For school-age children, it is important to consider that they will generally not be able to bring their treatment to school.

The choice of antibiotic molecule is based first on the medical examination and in particular the existence of drug hypersensitivity. In the absence of any allergy,

Amoxicillin is the first-line antibiotic in the treatment of oral infections. The other families of interest in our discipline, macrolides and related antibiotics, are only of interest in cases of allergy to beta-lactams.

• Beta-lactam
• Amoxicillin It is, across all disciplines, the most prescribed antibiotic. Its broad spectrum, its bactericidal properties and its high safety make it a drug that is both effective and safe. In children, the usual dosage is 25 mg/kg/day to 50 mg/kg/day in two or better three doses, without exceeding the dosage of 3 g/day for children over thirty months, and 50 mg/kg/day to 100 mg/kg/day in three doses spaced eight hours apart for children under thirty months. (Table V).

The only two contraindications for amoxicillin are documented beta-lactam allergy and infectious mononucleosis. The most common adverse effects are gastrointestinal in nature.

• Amoxicillin/clavulanic acid combination: Augmentin

Like any antibiotic combination, Augmentin should be prescribed as a second-line treatment after failure of monotherapy properly followed for 48 hours. The dosage is 80 mg/kg per day in three doses, without exceeding 3 g per day.

Contraindications are the same as for amoxicillin. Digestive problems will generally be more common.

• Macrolides and related compounds

These antibiotics form a relatively large class in terms of molecules. Their properties are relatively similar; they are all bacteriostatic antibiotics which have a less broad antimicrobial spectrum, particularly with regard to anaerobic bacteria ( bacteroides, peptostreptococcus, Clostridium perfringens, fusobacterium ) .

• Josamycin : Among all the macrolides that can be prescribed for

In children, josamycin has interesting dosages and galenic forms (Table VII). The only real contraindication is allergy to macrolides and the side effects are limited to digestive disorders.

• Clindamycin : Clindamycin is a lincosamide antibiotic. It has an antibacterial spectrum that is relatively well-adapted to the pathogenic flora of oral infections. However, there is no form specifically adapted for children. All dosages (75, 150, and 300 mg) are in capsule form, which contraindicates their use in children under six years of age.

The dosage of clindamycin is 8 to 25 mg/kg per 24 hours in three or four doses. The only contraindication is allergy.

• Metronidazole

This is a very special antibiotic since it is active only on strict anaerobic bacteria. It can be prescribed as monotherapy, particularly in

periodontology. Its combination with another antibiotic (amoxicillin, clindamycin, etc.) is useful in cases of severe infection or as a second-line treatment after failure of monotherapy.

In children, the dosage is 20 to 30 mg/kg per 24 hours divided into two or three doses. In pediatric dentistry, the most appropriate dosage form is a 4% oral suspension (Flagyl® 4%) with a 5 ml measuring spoon or 200 mg of metronidazole. It should be noted that Flagyl 4%® contains 3 g of sucrose per measuring spoon and 40 mg of alcohol per measuring spoon.

Oral sedation drugs

Sedation is classically defined as the set of means

pharmacological or not intended on the one hand to ensure the physical and psychological comfort of the patient and on the other hand to facilitate care techniques.

The use of oral drug treatments must remain

exceptional and should only be considered after the failure of non-drug therapies.

In an out-of-hospital setting, only ASA1 or 2 patients can be sedated. In all cases, the practitioner must be proficient in first aid procedures and have the necessary equipment.

adequate. Currently, no therapy for extra-hospital use is truly satisfactory.

Two classes of molecules can be prescribed: benzodiazepines and H1 antihistamines. Whichever molecule is chosen, its effect appears forty-five minutes to one hour after taking it and can last well afterward. It is therefore

It is essential that the child, regardless of age, be escorted and monitored until the effects of the medication have worn off.

• Benzodiazepines

Among all benzodiazepines, diazepam (Valium®) remains the most widely used molecule. Its dosage is 0.5 mg/kg. The most suitable form for children is a 1% oral solution, available in a 20 ml dropper bottle.

Contraindications to benzodiazepines include severe respiratory failure and myasthenia gravis. Interactions with all other central nervous system and/or respiratory depressant medications should be avoided.

• H1 antihistamines

In this class, only one molecule is of real interest: hydroxyzine (Atarax®) which has anxiolytic and sedative properties.

Its usual dosage in the prevention of anxiety and conscious sedation is

1 mg/kg. One milliliter of syrup corresponds to 2 mg of hydroxyzine dihydrochloride and the amount of syrup will be measured using the oral administration syringe, graduated in 0.25 ml increments. The sucrose content of the syrup is approximately 700 mg/ml, its ethanol content is 1 mg/1 ml.

Conclusion

Prescribing medication should never be “trivial”; it is a medical procedure in its own right. The specific nature of pediatrics requires the prescriber to be particularly vigilant and to carefully assess the benefit-risk ratio of the therapies used. In particular, the prescriber must pay particular attention to the choice of dosage forms and their proper adaptation to the doses per dose and daily doses, which will most often be guided by the child’s weight and the progress of their cognitive development.

Table I – NSAIDs indicated in children for analgesic indications.
Active substance	Tmax	½ life	AMM Age	Shapes	Dosage per dose per day
Ibuprofen	1.5	2	3 months	Susp buv, Cp, suppo.	7.5 mg/kg 30 mg/kg/day
Ketoprofen	1-1.5	3.6	6 months	Syrup	0.5 mg/kg2 mg/kg/day
A. Tiaprofenic	1.5	2	4 years	CP	3 mg/kg 10 mg/kg/day
Niflumic acid	2	4 to 6 hours	6 months	Suppo.	40 mg/kg/day

Table II – Sugar content of different children’s oral suspensions containing ibuprofen
Speciality	Sugar content
Advil 20 mg/ml oral suspension	0.5 g/ml
Antarene 20 mg/ml oral suspension	1.5 mg/ml
Ibuprofen Mylan 20 mg/ml susp buv	Sugar-free
Nurofenpro 20 mg/ml suspension	Sugar-free

It is essential to correctly complete the child’s health record, particularly regarding the prescription prescribed for the child in order to ensure multidisciplinary monitoring.

Table III – Pediatric codeine specialties
	Codeine alone	Codeine combined with paracetamol
Speciality	Codenfan®	Efferalgan codeine®	Codoliprane®	Dafalgan codeine®
AMM	1 year	3 years (15 kg)	6 years old	15 years old
Dosage	1 mg/ml	30 mg/500 mg	20 mg/400 mg	30 mg/500 mg
Shape	Syrup Sucrose content: 0.6 g/ml.	Cp effer	CP sec	CP

The main side effects of codeine are relatively moderate in short-term use.

Table IV – Modalities of antibiotic prophylaxis (Afssaps, 2001)
ANTIBIOTIC	DOSAGE
Absence of allergy to ß-lactams	Amoxicillin 50 mg/kg
β-lactam allergy	Clindamycin 15 mg/Kg or Pristinamycin 25 mg/Kg

Table V – Amoxicillin-based specialties for children
Specialties	Agram®, Amodex®, Clamoxyl®, Amoxicillin125 mg/5 ml	Agram®, Amodex®, Clamoxyl®, Amoxicillin250 mg/5 ml
Dosage	125 mg/5 ml125 mg per measuring spoon	250 mg/5 ml250 mg per measuring spoon
Dosage form	Powder for oral suspension	Powder for oral suspension

Table VI – Amoxicillin/clavulanic acid combination
Speciality	Augmentin 100/12.5	Augmentin 100/12.5	Augmentin 250/31.25	Augmentin 500/62.5
AMM	Infant	>30 months	Infant	> 30 months
	Graduations / Kg 112 doses	Graduations / Kg 224 doses	–
Syringe				–
Number of shots/day	3	3	3	3
Shape	Powder for oral suspension. Solution	Powder for oral suspension. Solution	Powder for oral suspension. Sachet	Powder for oral suspension. Sachet

Table VII – Pediatric forms of josamycin
Speciality	Josacine® 125 mg/5 ml	Josacine® 250 mg/5 ml	Josacine® 500 mg/5 ml
AMM	< 5 kg	5-20 kg	10-40 kg
Dosage	1 dose weight (syringe)/shot	1 dose (weight syringe)/intake	1 dose (weight syringe)/take
Shape	Granules for oral suspension	Granules for oral suspension	Granules for oral suspension

The only real contraindication is an allergy to macrolides and the side effects are limited to digestive disorders.

Drug prescription in children

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Drug prescription in children