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
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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
10/14 45
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