Pediatrics

Pediatrics

December 1, 2018

We work together with prescribers, children, and their families to customize medications and meet specific needs.

Children pose many challenges when it comes to medication: they may resist having to take a medication, dislike the taste or texture, have difficulty swallowing solid dosage forms, and are fearful of injections.

The limited pediatric market for most drugs may be the leading reason for the lack of investment in drug development for this population by the pharmaceutical industry. Most medications are not labeled for pediatric populations, and when a medication is not approved for use in infants and children, it usually is not available in a suitable pediatric dosage form. Fortunately, our compounding pharmacy is able to help. We can compound oral medications into pleasantly flavored suspensions, solutions, concentrates, freezerpops, “gummy bears” or lozenges, in colors that entice the child to take the medication. A palatable formulation is more likely to improve compliance and minimize spillage or waste during administration. Lollipops are an ideal alternative to “swish and swallow” medications that need to be retained in the mouth for a prolonged period of time. Most drugs can be compounded into transdermal gels that can easily be applied to an appropriate site, such as the child’s wrist, for absorption through the skin.

Professional compounding is not just diluting existing medications, or mixing powders with bases. We must consider physical and chemical properties of each active and inactive ingredient in order to prepare an effective and safe customized medication with the desired taste, color, fragrance, viscosity, uniformity, texture, and stability. The efficacy of any compounded medication is influenced by the technique and equipment used in preparing the formulation, the purity and quality of the ingredients, choice of vehicle (base), and proper use of additives such as penetration enhancers.

Attention Deficit Hyperactivity Disorder (ADHD)

The use of medications to treat ADHD has greatly increased, yet the dosage requirements for many children differ from strengths that are commercially available. This often necessitates a midday dose at school, which can be embarrassing to a child. Slow-release dosage forms can be compounded to contain the precise dose of medication needed.

Autism

Autism is a neurodevelopmental disorder. It is characterized by impairments in social relatedness and communication, repetitive behaviors, abnormal movements, and sensory dysfunction. A review of some of the current biomedical therapies-such as nutritional supplementation, chelation, and secretin suggests that these therapies may benefit autistic children.

The Autism Research Institute has asked parents to rate the effectiveness of numerous biomedical treatments. Over 23,000 parents have responded, and of 77 interventions, Mercury detoxification was rated helpful by 73% of parents, with the gluten/casein-free diet coming in second with 63%.

Transderml Medications: We can compound medications in transdermal gels that can easily be applied to an appropriate site, such as child’s wrist or back, for absorption through the skin.

Flavoring: We can compound oral medications into pleasantly flavored suspensions, solutions, concentrates, lozenges. A palatable formulation is more likely to improve compliance and minimize waste.

Gluten-Free and Casein-Free Medications: Children with Autism may benefit from gluten-free and casein-free diet.

Gluten is a mixture of wheat proteins, and proteins from other grains such as rye, oats and barley. many commonly used medications-antibiotics, decongestants, and pain relievers including acetaminophen and ibuprofen-may contain gluten. Even flavors can contain gluten.

Casein is a milk protein commonly found in dairy products. we can compound medications that are free of gluten, casein, lactose, sugar, dyes and alcohol to solve problems for sensitive individuals.

Diaper Rash

Customized formulations containing protectants, absorbents, and bile acid sequestrant can provide relief for baby’s irritated skin. We can also compound medications, such as cholestyramine ointment, to prevent site irritation in ostomy patients/ babies.

Some examples for the compounded combination for diaper rash or baby’s irritated skin are:

  • Combination of Cholestyramine, Zinc oxide, and Nystatin ointment
  • Combination of Sucralfate, Zinc oxide, and Nystatin ointment

Nipple healing Ointment

Nipple soreness while breast feeding can be caused by different reasons:

fungus, yeast, Bactria,…

There are some medications that are typically prescribed in different strengths for treatment:

  • Mupirocin: an antibiotic, used to treat infections caused by bacteria
  • Clotrimazole/Nystatin: antifungals, used to treat some types of fungal or yeast infections
  • Betamethasone: a corticosteroid used to treat irritation, swelling, redness, itching, and allergic reactions

Resistant warts and molluscum contagiosum have been treated successfully with compounded topical medications, avoiding discomfort associated with freezing, scraping, electrocautery and laser therapy.

The following study found that 5% KOH aqueous solution proved to be as effective and less irritating when compared to the 10% KOH solution. This trial also emphasizes the effectiveness of topical KOH in the treatment of molluscum contagiosum, sparing affected children from more aggressive physical modalities of treatment.

Pediatr Dermatol 2000 Nov-Dec;17(6):495
Evaluation of the effectiveness of 5% potassium hydroxide for the treatment of molluscum contagiosum.

Romiti R, Ribeiro AP, Romiti N.
Department of Dermatology, University of Sao Paulo, Sao Paulo, Brazil.

Click here to access the PubMed abstract of this article.

Orally administered anti-emetics can be difficult for a nauseated child to “keep down”, and rectal suppositories may not be well accepted by children. Even persistent nausea can often be effectively controlled by using a combination of medications tailored to meet an individual’s specific needs. Dosage forms include transdermal gels, suppositories, lollipops, and more.

Promethazine is commonly compounded for topical or transdermal application to treat nausea, vomiting, and vertigo, but this preparation may be used as an antiemetic for cases ranging from chemotherapy to motion sickness. The dose is typically 25mg for adults, and the dose is decreased for children. The gel is applied to an area of soft skin, such as the inside of the wrist or arm, the side of the torso, or the inside of the thigh. For children, doses are often applied to the inside of one wrist, and then the wrists are rubbed together.

US Pharmacist, August 1999; 74-5

Topical anesthesia is needed for common pediatric procedures such as suturing, wound cleaning, and injection administration. The ideal topical anesthetic would provide complete anesthesia following a simple pain-free application, not contain narcotics or controlled substances, and have an excellent safety profile. The combination of topical anesthetics lidocaine and tetracaine and the vasoconstrictor epinephrine has been used successfully for anesthesia prior to suturing linear scalp and facial lacerations in children. A triple-anesthetic gel containing benzocaine, lidocaine, and tetracaine (“BLT”) has also been reported to be effective when applied prior to laser and cosmetic procedures. Convenience of application without need for occlusion is an advantage of these topical anesthetics.

The following article concludes: “LAT gel (4% lidocaine, 1:2000 adrenaline, 0.5% tetracaine) worked as well as TAC gel (0.5% tetracaine, 1:2000 adrenaline, 11.8% cocaine) for topical anesthesia in facial and scalp lacerations. Considering the advantages of a noncontrolled substance and less expense, LAT gel appears to be better suited than TAC gel for topical anesthesia in laceration repair in children.”

Pediatrics 1995 Feb;95(2):255-8
Lidocaine adrenaline tetracaine gel versus tetracaine adrenaline cocaine gel for topical anesthesia in linear scalp and facial lacerations in children aged 5 to 17 years.

Ernst AA, Marvez E, Nick TG, Chin E, Wood E, Gonzaba WT
Department of Medicine, Louisiana State University, New Orleans.

Click here to access the PubMed abstract of this article.

The following article reported that a triple-anesthetic gel containing benzocaine, lidocaine, and tetracaine (“BLT”) applied prior to treatment with a 532-nm KTP laser resulted in significantly lower pain scores than with 3 other topical anesthetics at 15, 30, 45, and 60 minutes after application.

Cosmetic Dermatology 2003 Apr;16(4):35-7
Topical Triple-Anesthetic Gel Compared With 3 Topical Anesthetics

Lee MWC
Department of Dermatologic Surgery, University of California, San Francisco

Acne

Emergence of resistant pathogens emphasizes the need for alternatives to antimicrobial agents for acne therapy. We can compound cosmetically-appealing customized formulations which can contain numerous medications to provide a synergistic effect for treatment of resistant acne.

Int J Dermatol 1995 Jun;34(6):434-7
Topical nicotinamide compared with clindamycin gel in the treatment of inflammatory acne vulgaris.

Shalita AR, Smith JG, Parish LC, Sofman MS, Chalker DK
Department of Dermatology, State University of New York, College of Medicine, Brooklyn, USA.

Click here to access the PubMed abstract of this article.

J Dermatol 1996 Apr;23(4):243-6
Topical spironolactone reduces sebum secretion rates in young adults.

Yamamoto A, Ito M
Department of Dermatology, Niigata University School of Medicine, Japan.

Click here to access the PubMed abstract of this article.

Pediatrics: Examples of compounded medications

  • BLT or LAT topical gel or spray
  • Cholestyramine ointment
  • Clotrimazole in DMSO solution
  • Fluconazole/Ibuprofen topical
  • Ivermectin topical
  • KOH solution – 5% and 10%
  • Nicotinamide/Spironolactone topical
  • Promethazine transdermal gel
  • Urea 40% plasters

The above list is just a few of the preparations that we can compound for pediatric use. We work together with prescriber and patient to solve problems, and all formulations are customized per prescription to meet the unique needs of each child.

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