Pediatricians left guessing at drug doses

It was one of many bad days I had as an intern at a busy city hospital: One of my fellow interns had tattled to our supervisor that I had written a prescription for amoxicillin that was twice as strong as it should have been.

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It was a rookie error - despite carefully calculating the correct dose based on the child's weight after consulting my trusty Harriet Lane Handbook, I had forgotten that amoxicillin came in different strengths. And as it turns out, the dose I had erroneously prescribed then would actually be the correct dose for treating an ear infection today.

Welcome to the world of pediatric drug dosing, a moving target of sometimes unknown or hard-to-find recommendations that can change frequently. Sometimes the lack of information puts doctors in the position of simply making an educated guess.

For years parents would come into my exam room anxiously clutching over-the-counter medications such as Triaminic with queries about proper dosing: "Dr. McEvoy, it says for children under 2 years, to consult their doctor." Many times I would slink off to another room and consult the Physician Desk Reference, the Bible for all drug questions. There I would be met by the same show stopper - "consult your physician for ages under 2" or "studies have not been completed for children under 2," or there would be a chart of dosages based on weight. . . . for all children over the age of 3 months.

But what if a baby under 3 months needed a medication? How should I know what the dose should be?

Now it's clear that many of the pediatric cold formulas are not effective - and worse, may be harmful. They weren't, it seems, tested on children under 6 years old.

Although we'd all like to avoid medicating children entirely, there are times when pediatricians really do need to know the proper, safe dose of a drug to give a child. For example, infants often get a condition known as thrush, which is characterized by a thick, white coating on the tongue and inside lining of the mouth, and can interfere with feeding. It is caused by yeast, Candida Albicans, and it used to respond to a drug called Nystatin, but it often doesn't anymore.

Many pediatricians have turned to Diflucan, another anti-fungal agent. However, using Diflucan to treat fungus in infants is considered an "off label" use, meaning studies have not been done for this condition. And finding the proper dose to use sets physicians on a frustrating search. Many times, the discovery of such "off label" uses as well as the proper dose comes by happenstance - perhaps you hear a certain speaker at an educational seminar or just happen to read an article; maybe one of your colleagues shares a "trade secret." But, of course, by using such a drug for "off-label" use, the prescribing doctor assumes more responsibility ...continued

 

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