1. Common Problems in Infants and Toddlers(teething, colic and fever) PHM 456 Angela Trope MSc The Hospital for Sick Children

2. Common Problems in Infants and Toddlers • PJ 271 2003 Survey to determine the extent and use of OTCs in children and to examine how OTCs are handled at home. Study population < 12y old • N = 424 questionnaires completed by parents/caregivers (61% RR) • Acetaminophen and cough/cold remedies- most frequently purchased • 16% of purchases were from non-pharmacy outlets • Storage at home: 50% respondents were “sure” that medicines were safely stored

3. Common Problems in Infants and Toddlers • 30% requested medicines with no sugar • Dosing info: most followed instructions on container; insert; own knowledge/friends. 17% used a health care professional  tended to be parents of younger children (median 4 vs 6yr) i.e. parents learn from experience • Most used a medicine spoon • Frequency of dosing was generally appropriate • Disposal:Most respondents saved medicines for future use

4. Role of the pharmacist • Provide advice wrt choice of medicine, brand vs generic • Dosing and administration/measuring device • Safe storage • Ensure the safe and effective use of medications in children

5. Teething: You are asked by a mother to recommend something for infant whom she thinks is teething. She says that her baby is feeling miserable, is drooling a lot and has diarrhea. • Teething occurs from about 6-36 months of age (refers to the process by which teeth move from their site of development within the jaws to their final functional position in the mouth) • 20 primary (baby) teeth come in by about 3 years of age • The first permanent teeth come in at 6-7 years of age. Children lose primary teeth until about 12 years of age

6. Teething : Signs and SymptomsBeliefs versus Academic Publications • Many symptoms have been attributed to teething in infancy • Biting • Drooling • Gum rubbing • Irritability • Sucking • Change in appetite • Changes in sleep patterns • Cough • Rash on face / in diaper area • Diarrhea • Fever

7. Teething: Fever and Diarrhea • There is no good evidence to support an association between teething and fever or diarrhea • cultural beliefs in an association between teething and diarrhea /loose stools may exist *Don’t ignore diarrhea * • mild increase in temperature (<102F) may be seen on the day of a tooth eruption • Other causes of high or prolonged fevers must be ruled out

8. Teething: Pharmacist’s Dialogue • General aspects of dental hygiene for infants/toddlers (< 4yr) • Avoid going to bed with bottle of milk, formula or juice • Children < 6 years old use less than a pea-sized amount of fluoridated toothpaste • <2- 3years old use a non fluoridated toothpaste as it is difficult for young children to avoid swallowing.

9. Teething: Pharmacist’s dialogueManagement • ? Acetaminophen – not more than 65mg/kg/day • Topical agents • Local anaesthetic agents- AVOID

10. Infantile Colic: Unexplained infant irritabilityYou are asked by a parent to recommend a remedy for her 2 month old colicky baby. You note that the baby is sleeping peacefully and looks well nourished. • Excessive crying in healthy, thriving infants • The infants may be inconsolable, may draw up their legs, pass gas and have difficulty stooling • Crying typically occurs at the same time each day e.g evenings • Onset: first weeks of life up to 4-5 months • Incidence: highly variable

11. Infantile Colic: Etiology remains unclear • ? Painful gut contractions secondary to excess gas, cow’s milk allergy or lactose intolerance • ? Behavioural problem: difficult temperament and parent - infant interaction may be less than optimal • ? Extreme end of normal crying

12. Infantile Colic: Pharmacist’s DialogueManagement • Reassure caregiver/parent: • Colic is not a disease • It is self limiting • Formula switching: caution is required! Trial new feed for one week • Do not discourage breast feeding • Avoid over stimulation of infant

14. Infantile Colic: Pharmacist’s DialogueManagement • Medications • Simethicone, surface active agent • Not beneficial • Dicyclomine, anticholinergic agent • Beneficial but not recommended because of serious side effects • See CPS monograph

15. Fever:It is midwinter and you are working the evening shift. You received aphone call from a mother who lives in Alliston. She’s very concernedbecause her baby has a fever and she cannot take her to the local hospital because the area is “snowed in”. The mother says that she has some ASA in the house and thinks that there may be some adult Tylenol in the car.

16. Fever: General principles • Febrile illness 10-20% of pediatric visits to Emerg Depts • Fever is a symptom not a disease • physical sign or symptom that often accompanies an illness • Fever: rectal temperature >38°C (100.4°F) mouth/armpit or ear >37.8 °C/ > 37.5 °C respectively • Use rectal or axillary temperatures in children <5years • Most fevers in children are due to viral infections • Need to carefully assess fever in children <3 years without a focus for infection in order to rule out serious bacterial infection

17. Fever: General principlesConsider physical signs and symptoms • How sick does the infant/child look • Is it difficult to wake the infant/child • Is the child delirious/confused LOC – poor or absent eye contact or failure of a child to recognize parents or interact with objects in the environment • Is the infant/child inconsolable • Does the infant’s/child’s skin colour look pale/grey • Are there small purple spots on the skin

18. Fever: with no source of infection in children < 3yrDifferent age groups have been assigned different risk categoriesBabies < 3months are most vulnerable!! • All febrile babies/neonates <1 month must be hospitalized to rule out serious bacterial infection e.g sepsis, meningitis or UTI • Febrile infants 1-3 months must be seen by a physician  assign risk  treat accordingly • Infants/toddlers 3-36 months If temperature >39°C,  investigated If temperature is <39°C, may manage at home. Reevaluate if temperature persists for 2-3 days

19. Acetaminophen 10-15mg/kg po q4-6 prn (max 65mg/kg/day) Measuring device Availability: drops,syrup, chew tablets, tablets/caplets Ibuprofen *< 6mos: 5mg/kg po q8h prn **> 6mos: T< 39°C 5mg/kg po q6-8h prn T  39°C 10mg/kg po q6-8h prn **But 10mg/kg is optimal suspension, tablets, drops, tablets/caplets Fever: Antipyretics*Must give clear instructions in order to avoid misadventures in dosing*

20. Fever: Antipyretics*Must give clear instructions in order to avoid misadventures in dosing* • Alternating doses • no evidence to support this strategy • potential for confusion/dosing errors • Interventions • Avoid insufficient dose e.g. for acetaminophen:< 10mg/kg/dose or dosing intervals >6h • Avoid prn dosing, if necessary, BUT limit duration • Use ibuprofen when fever unresponsive to maximal doses of acetaminophen. Ibuprofen has a longer duration of action • ?Taste

21. Resources • Canadian Society of Paediatrics • American Academy of Pediatrics • Canadian Dental Association