129  Therapeutics

Published

June 28, 2025

129.1 Introduction

Pediatric therapeutics involves the art and science of prescribing medications and other treatments to children for disease management and prevention. Children are not just small adults; they possess unique physiological, metabolic, and developmental traits that affect how drugs are absorbed, distributed, metabolized, and excreted. Consequently, pediatric therapeutics demands a thorough understanding of child growth stages, dosing principles, safety issues, and the specific disease burden in the Ghanaian context.

129.2 Principles of Pediatric Therapeutics

a. Age-related Pharmacokinetics and Pharmacodynamics

  • Absorption: Gastric pH is higher (less acidic) in neonates, which affects drug solubility and absorption. Gastric emptying is also slower.
  • Distribution: Neonates have higher body water content, which affects water-soluble drugs (e.g., gentamicin) and lower fat content, affecting lipophilic drugs.
  • Metabolism: Liver enzyme activity is immature at birth and develops over time, altering drug metabolism.
  • Excretion: Renal clearance is reduced in neonates due to immature kidneys, necessitating dose adjustments for renally-excreted drugs (e.g., aminoglycosides).

b. Dosing Principles

  • Pediatric dosing is usually weight-based (mg/kg) or surface-area-based (mg/m²). For example:

    • Paracetamol: 10–15 mg/kg per dose every 4–6 hours

    • Amoxicillin: 20–40 mg/kg/day in divided doses

  • Always confirm doses with a pediatric formulary or guidelines.

129.3 Drug Formulations and Administration

Children, especially infants and young kids, might not tolerate adult formulas (e.g., tablets, capsules). Pediatric options include:

  • Syrups and suspensions: Easier to swallow; dose flexibility
  • Suppositories: Useful for vomiting or unconscious children
  • Inhalers/spacers: For respiratory conditions like asthma
  • Injectables: Used in emergencies or when oral route is unsuitable

Tip: Always ensure accurate dosing with oral syringes or calibrated spoons.

129.4 Commonly Used Drugs in Ghanaian Pediatric Practice

a. Antipyretics and Analgesics

  • Paracetamol: First-line for fever and mild-to-moderate pain
  • Ibuprofen: Useful for inflammatory pain, but caution in dehydrated children due to renal risks

b. Antibiotics

  • Used empirically or based on culture results. Indications include pneumonia, otitis media, and sepsis.
  • First-line antibiotics:
    • Amoxicillin
    • Cloxacillin (for skin/soft tissue infections)
    • Cefuroxime or Ceftriaxone for severe infections
  • Rational use is essential to prevent resistance.

c. Antimalarials

  • Malaria is a leading cause of morbidity and mortality in children.

  • First-line treatment (per Ghana NMCP):

    • Artesunate-amodiaquine (ASAQ)
    • Artemether-lumefantrine (AL)
    • Injectable artesunate for severe malaria

d. Anthelmintics

  • Albendazole and mebendazole are used in deworming programs.
  • Dosing is age-based and used regularly in public health programs.

e. Anticonvulsants

  • Diazepam (rectal or IV) for acute seizures
  • Phenobarbital and Carbamazepine for chronic seizure management

f. Asthma Medications

  • Salbutamol: Short-acting beta-agonist (inhaler or nebulizer)
  • Beclomethasone: Inhaled corticosteroid for maintenance
  • Use of a spacer device improves drug delivery in children.

129.5 Rational Drug Use and Safety

a. Preventing Medication Errors

  • Double-check drug names, doses, and units (mg vs mL)
  • Use weight-based dosing and avoid “teaspoon” measurements
  • Monitor for adverse drug reactions (e.g., rashes, GI upset)

b. Drug Interactions

  • Be mindful of drugs that enhance or reduce each other’s effects (e.g., enzyme inducers/inhibitors)
  • Check compatibility, especially when using multiple IV medications

c. Avoid Contraindicated Medications

  • Aspirin: Avoid in febrile children due to risk of Reye’s syndrome
  • Tetracyclines: Not recommended in children <8 years due to dental staining
  • Chloramphenicol: Risk of “gray baby syndrome” in neonates

129.6 Therapeutics for Common Pediatric Conditions

a. Pneumonia

  • First-line: Amoxicillin
  • Severe cases: Ceftriaxone or Benzylpenicillin + Gentamicin
  • Supportive care: Oxygen, fluids, antipyretics

b. Acute Diarrhea

  • Oral Rehydration Salts (ORS): Cornerstone of therapy
  • Zinc supplementation: 10–20 mg/day for 10–14 days
  • Avoid anti-diarrheal medications in children

c. Severe Acute Malnutrition (SAM)

  • Therapeutic feeds: F-75 and F-100
  • Antibiotics: Empirical (e.g., amoxicillin) due to immune suppression
  • Micronutrients: Vitamin A, iron (after stabilization), folate

d. HIV in Children

  • ART regimens are weight- and age-specific
  • Use pediatric fixed-dose combinations (FDCs)
  • Co-trimoxazole prophylaxis is essential

129.7 Immunization and Preventive Therapeutics

Vaccination is one of the most cost-effective therapeutic interventions in pediatrics.

Ghana EPI (Expanded Programme on Immunization) Schedule includes:

  • BCG
  • Pentavalent vaccine (DPT-HepB-Hib)
  • OPV, IPV
  • PCV (Pneumococcal vaccine)
  • Rotavirus
  • Measles-Rubella
  • Yellow fever

Vitamin A Supplementation

  • Prevents blindness and improves immunity
  • Given every 6 months starting at 6 months of age

129.8 Monitoring and Follow-up

a. Therapeutic Drug Monitoring (TDM)

  • Important for drugs with narrow therapeutic index (e.g., aminoglycosides, phenobarbital)
  • Monitor renal and liver function where necessary

b. Adherence and Education

  • Educate caregivers on correct drug use
  • Emphasize completing antibiotic courses
  • Address barriers to adherence (e.g., taste, cost)

129.10 Conclusion

Therapeutics in pediatrics involves more than simply prescribing medications. It requires an understanding of developmental physiology, rational drug use, dosing accuracy, and the sociocultural context of care. For medical students in Ghana, mastery of local treatment guidelines, National Standard Treatment Guidelines, and EPI protocols is essential for safe and effective pediatric practice.

129.11 Further Reading and Resources

  • Ghana Standard Treatment Guidelines (2021)
  • IMCI (Integrated Management of Childhood Illness) Guidelines
  • BNF for Children
  • WHO Pocket Book of Hospital Care for Children