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Course: Pediatric Nursing

Topic: Pediatric Drug Administration- Part II

The Nurses International Community

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Module Goals

Learners will be able to

Describe proper technique for administering medications in children via oral, sublingual, rectal, intramuscular, intravenous and subcutaneous route.
Discuss the role of nurses in the administering/ managing medication to children.

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Medication Administration Routes in Children

Enteral Routes

Oral
Sublingual
Rectal

Parenteral Routes

Intravenous
Intramuscular
Subcutaneous

Other Routes

Otic
Ophthalmic
Intranasal
Inhalation
Intraosseous
Intrathecal
Intravaginal

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Medication Administration: Oral Route

Least invasive, most preferred route for children who can swallow
Formulations.

Dissolved or suspended in liquid preparation.
Solid dosage forms include tablets, capsules, granules/sprinkles, chewable tablets, orodispersible tablets and controlled release tablets.

Not recommended for young children due to risk of aspiration.

Medication preparation

Use plastic oral syringes to draw accurate dose for liquid formulations.

Do not use kitchen household measuring devices.

Ernstmeyer & Christman, 2021

Batchelor & Marriot, 2015

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Medication Administration: Oral Route

Medication preparation

Determine if tablets can be crushed

Crushing make some tablets lose their therapeutic effect

Read patient information leaflet tablets, powders, granules, pellets or sprinkles

Exact amount of water to be mixed with
If they can be mixed with food

Avoid mixing medication with the foods the child must have

Risk of child beginning to dislike food he/she needs

Batchelor & Marriot, 2015

Nationwide Children’s Hospital, 2019

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Administering Oral Medication

Dosage age appropriate
Assess swallowing ability, also ask parents
Newborn and infants

Administer right before feeding
Infant in upright position
Let infant suck medicine out of the syringe, or administer small amounts at side of the tongue
Let wallow all medicine before giving more

Remain until the child swallows medicine

Nationwide Children’s Hospital, 2019

European Medicines Agency, 2013

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Tips for Child Adherence with Oral Medication

Provide accurate information on medicine to the child

Call medicine ‘medicine’, not ‘candy’
Explain why medicine helps

Do not threaten with a ‘shot’ when the child refuses to take medicine
Ask parents what has worked before
Give choices

Method: Syringe, cup, spoon
Flavor (where medicine can be mixed): icecream, applesauce, juice, etc

Praise the child for taking the medication

Nationwide Children’s Hospital, 2019

European Medicines Agency, 2013

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Medication Administration: Sublingual and Buccal

Sublingual: Place the medication under the tongue
Buccal: Place medication between the cheek and the gum

Older children:

Dry area around cheek and gum with tissue, if possible, to remove extra saliva
Rub outside of the cheek at medicine spot to facilitate absorption

Younger children:

Position child’s head such that one cheek is facing down
Place the medicine in the cheek lying flat

SickKids, 2010a

Nationwide Children’s Hospital, 2017

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What Would the Nurse Do?

A nurse is administering a dose of liquid acetaminophen to a 3-month-old with a fever.

The nurse draws the medication up in a syringe and squirts 1 mL onto the infant’s tongue.

The infant immediately spits the medication out and begins to cry. What should the nurse do next?

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Medication Administration: Rectal

Forms: creams, ointments, suppositories, foams, sprays and enemas
Useful in infants and children who have

Difficulty swallowing oral medicines
Nausea, vomiting
Upper intestinal disorders

Rapid absorption and higher concentrations of medication in blood
Medication preparation

Age-appropriate dose and size
If soft inside wrapper, chill in refrigerator or run under cold water
Cut to smaller doses only if directed by manufacturer

Batchelor & Marriot, 2015

SickKids, 2010b

European Medicines Agency, 2013

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Rectal Suppository Administration

Inform child and family about the procedure
Empty bowels first
Position: left side-lying with upper leg bent forward
Incontinence pad underneath child’s buttocks
Lubricate suppository tip water/water-soluble lubricant
With tip first, insert suppository 2cm (1 inch) deep into rectum
After insertion, hold buttocks together for 5-10 minutes if possible
If child needs second suppository, first wait for the first one to dissolve completely

SickKids, 2010b

Great Ormond Street Hospital for Children, 2020

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Medication Administration: Intramuscular (IM)

Never give injection in buttocks
Use muscle mass area able accommodate medication volume
Use needle of appropriate length and gauge
Perform Z-track method for medicine that irritates skin, ‘bunching’ for little muscle tissue
Inject needle at 90^o angle to the skin
*Aspirate before injecting medication (if blood, remove needle and discard, draw new dose and inject in different site)
Apply pressure at injection site with gauze, do not massage, after removing syringe from skin

Children’s Health Queensland Hospital and Health Service, 2020.

Elsevier, 2021

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Medication Administration: Vastus Lateralis

Alberta Health Services, 2020

Preferred site for IM injection in children, especially infants under 12 months of age
Dose: up to 2mL
Landmarking

Draw an imaginary line from the greater trochanter to the lateral femoral condyle of the knee
Middle third portion is a safe area for injection

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Figure 1: Anatomical markers used to identify the vastus lateralis injection site (X) on the anterolateral thigh

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Medication Administration: Ventrogluteal

Safe site, free from penetrating nerves/blood vessels
Landmark

Place heel of the hand over the greater trochanter of the femur with thumb pointing to the child’s front
Palpate superior iliac spine with index finger
Move middle finger across iliac crest to make ‘V’ with index finger
Center of the formed ‘V’ is the injection site

Alberta Health Services, 2020

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Medication Administration: Deltoid

Alberta Health Services, 2020

Injection site preferred only for children above 3 years
Dose: Below 1 mL
Landmark:

Locate lower edge of the acromion process and insertion site of the deltoid muscle
Injection site is the centre of the upside down triangle between these two points

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Figure: ‘Vaccine Administration: Needle Gauge and Length’ by Advisory Committee on Immunization Practices General Best Practice Guidelines for Immunization, from www.cdc.gov/vaccines/hcp/acip-recs/general-recs/administration.html

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What Would the Nurse Do?

A nurse is preparing to give an intramuscular injection to a 6-month-old.

What site, needle length, and gauge of needle should the nurse use?

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Medication Administration: Subcutaneous

Important consideration:

Pinch fatty tissues between thumb and index finger for injection
Angle of injection to skin

90^o in larger or older children
45^o in smaller, younger, or thin children

Change sites with each injection
Separate injection site by at least one inch
Avoid areas that are bruised, scarred, swollen, tender
Clean injection site with soap and clean water, do not need alcohol swab

SickKids, 2010c

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Subcutaneous (Continued)

National Center for Immunization and Respiratory Diseases, 2022

ConnectedCare, 2021

Preferred sites based on age

Newborns and infants: Middle of the thigh, front outer top part
Child older than 1 year: Middle of the thigh and back part of upper arm

A ⅝-inch, 23- to 25-gauge needle is used

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Medication Administration: Intravenous (IV)

Peripheral IV sites

Cephalic, basilic or median cubital veins
Veins on the dorsum (back) of the hand
Tributaries of the cephalic and basilic veins, dorsal venous arch
Saphenous vein, just anterior to medial malleolus
Median marginal vein
Dorsal venous arch on the foot
Scalp

Less used sites: External jugular, abdominal, axillary veins
Central venous access: Internal jugular vein, subclavian vein, or femoral vein

Government of Canada, 2013

Scott-Warren & Morley, 2015

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Sites for IV access in infants and young children

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IV Access in Pediatrics

Follow agency protocol regarding

Skin cleansing products

Chlorhexidine gluconate 2% in isopropyl alcohol 70% not recommended in children <2 months of age

Local anaesthetics for specific age group

Choice of IV site

Avoid placing catheter at the bend of the arm or lower extremities

Increased risk of infiltration, erythema, pain, inability to administer medications, no or poor flow due to gravity, and kinked catheter

Foot, ankle, or scalp- Increased risk of occlusion

Paterson et al., 2020

Scott-Warren & Morley, 2015

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IV Access in Pediatric

Choice of IV catheters

Peripheral catheter preferred for peripheral IV access requiring less than 7 days treatment
Peripherally inserted central catheters (PICCs) and Central venous access devices (CVADs) preferred for treatment requiring more than 14 days

22- to 24-gauge peripheral catheters considered appropriate for children
Flashback may not be visible in 24-gauge IV catheter

Paterson et al., 2020

Scott-Warren & Morley, 2015

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IV Access in Pediatrics

Ideal vein site

Runs straight
Stands up a little
Fills and empties
Is easy to splint

Successfully inserted cannula should be secured carefully with splint

Immobilize the joint above insertion site
Pad with gauze between skin and cannula

hub to avoid skin friction, injury

Distal fingers or toes and insertion site should be visible

Resite promptly with signs of phlebitis, induration or swelling
Resite after 48-72 hours to minimise infection

Safer Care Victoria, 2021

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Roles of Nurses in Medication Administration

Through Different Routes

Ensure prescribed medication match route to be administered
Inform child and parents about the procedure

Obtain their consent and cooperation

Get help from the parents, where possible, to

Stabilize/immobilize medication administration site in the children
Distract the child, or calm the child during the procedure

Use aseptic technique to administer the medication
Use site that is free of redness, swelling, scar, bruises

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Role of Nurses in Medication Administration Using Various Routes

Use appropriate size of syringe needle for IM administration
IV administration

Choose cannula size appropriate to size of visible vein
Let other nurse try IV access after three failed attempts

Document medication, route, time, and child’s response to it
Monitor and manage adverse reactions to medication administration

Medications for pain, infection, allergic reaction
Cold ice pack for inflammation

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What Would the Nurse Do?

While assessing a 2-year-old admitted for malaria, the nurse notices that no drops are falling from the IV bag into the drip chamber. All the clamps on the IV tubing are open.

The IV is located in the median cubital vein (inside of the elbow) and is secured with a gauze wrap and tape.

What should the nurse do next?

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IVs located in the antecubital veins on the inside of the elbow are very prone to occlusion from kinking of the catheter any time the arm is bent. As such, these veins are not ideal for IVs in infants and small children who find it very difficult to keep their arms straight. In this situation, the most likely explanation for the IV stopping running is that the child has their arm bent. The nurse should inspect the site for signs of infiltration (can make IV stop running as well) and if there is none, they should straighten out the child’s arm and watch to see if the IV starts running again (if using a pump must restart the pump). If the bent arm appears to be the problem, the nurse needs to splint the arm in a straight position so that the IV can flow freely. This can be done using an armboard made for pediatric IVs or by wrapping padding around something like stiff cardboard that the child’s arm can be secured to, to keep it in a straight position. If the nurse finds that there are no signs of infiltration but straightening the arm does not fix the problem, the nurse should manually flush the IV with a syringe to better assess whether it is infiltrated or whether a small blood clot occluded the end of the catheter while the IV was not running (this is common).

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Red Flags

Redness, swelling, tenderness at the IV or injection site
Allergic reaction to medication
Blood on aspiration in IM injection
Infiltration during IV medication

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Health beliefs: In some cultures talking about a possible poor health outcome will cause that outcome to occur
Health customs: In some cultures family members play a large role in health care decision-making
Ethnic customs: Differing gender roles may determine who makes decisions about accepting & following treatment recommendations

(AHRQ, 2020)

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Cultural Considerations (Continued)

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may effect health seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family
Interpersonal customs: Eye contact or physical touch may be ok in some cultures but inappropriate or offensive in others.

(AHRQ, 2020)

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References:

Alberta Health Services. (2020, January 1). Standard for the administration of immunization. https://www.albertahealthservices.ca/info/page10802.aspx

Atay, S., Yilmaz Kurt, F., Akkaya, G., Karatağ, G., İlhan Demir, Ş., Çalidağ, U. (2017). Investigation of suitability of ventrogluteal site for intramuscular injections in children aged 36 months and under. J Spec Pediatr Nurs., 22(4),e12187. https://doi.org/10.1111/jspn.12187

Batchelor, H. K., & Marriott, J. F. (2015). Formulations for children: problems and solutions. British journal of clinical pharmacology, 79(3), 405–418. https://doi.org/10.1111/bcp.12268

Contact info: info@nursesinternational.org

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References:

Children’s Health Queensland Hospital and Health Service. (2020). Queensland Paediatric Emergency Care Nursing Skill Sheets : Medication Administration -Intramuscular Injection. Queensland Government. https://www.childrens.health.qld.gov.au/qpec-nursing-skill-sheets/

Connected Care. (2021, September 21). What is the best practice for administering subcutaneous injections in children with 'slim limbs'?. SickKids. https://www.connectedcare.sickkids.ca/quick-hits/subcutaneous

Elsevier. (2021, March 25). Medication administration: Intramuscular Injection (Pediatric)- CE. https://elsevier.health/en-US/preview/intramuscular-injection-pediatrics

Contact info: info@nursesinternational.org

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References:

Ernstmeyer, K., & Christman, E. (Eds.). (2021). Open RN Nursing Skills. Chippewa Valley Technical College. , licensed under CC BY 4.0. https://www.xanedu.com/higher-education/solutions/open-rn

European Medicines Agency. (2013). Guideline on pharmaceutical development of medicines for paediatric use. https://www.ema.europa.eu/en/pharmaceutical-development-medicines-paediatric-use#current-effective-version-section

Great Ormond Street Hospital for Children. (2020, January 22). How to give your child suppositories. https://www.gosh.nhs.uk/conditions-and-treatments/medicines-information/how-give-your-child-suppositories/

Contact info: info@nursesinternational.org

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References:

National Center for Immunization and Respiratory Diseases. (2022, March 15). Vaccine administration. Centers for Disease Control and Prevention. https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/administration.html#fig_4

Nationwide Children’s Hospital. (2017, November). Buccal medicines: Giving buccal medicines.https://www.nationwidechildrens.org/family-resources-education/health-wellness-and-safety-resources/helping-hands/buccal-medicines-giving-buccal-medicines

Nationwide Children’s Hospital. (2019, June). Medicine: How to give by mouth. https://www.nationwidechildrens.org/family-resources-education/health-wellness-and-safety-resources/helping-hands/medicine-how-to-give-by-mouth

Contact info: info@nursesinternational.org

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References:

Paterson, R.S., Chopra, V., Brown, E., Kleidon, T.M, Cooke, M., Rickard, C.M., Bernstein, S.J., & Ullman, A.J. (2020). Pediatrics, 145 (3): S243–S268. https://doi.org/10.1542/peds.2019-3474H

Safer Care Victoria. (2021, February 17). Peripheral intravenous (IV) catheter insertion for neonates. Victoria State Government. https://www.bettersafercare.vic.gov.au/clinical-guidance/neonatal/peripheral-intravenous-iv-catheter-insertion-for-neonates

Scott-Warren, V.L., & Morley, R.B. (2015). Paediatric vascular access. BJA Education, 15(4): 199–206. https://www.bjaed.org/article/S2058-5349(17)30147-6/fulltext#relatedArticles

Contact info: info@nursesinternational.org

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References:

SickKids. (2010a, March 21). Lorazepam buccal sublingual tablets. The Hospital for Sick Children. https://www.aboutkidshealth.ca/Article?contentid=177&language=English#:~:text=This%20medicine%20should%20only%20be,cheek%20and%20gums%20(buccally).

SickKids. (2010b, March 17). Suppository instructions. The Hospital for Sick Children. https://www.aboutkidshealth.ca/Article?contentid=992&language=English

SickKids. (2010c, November 25). Subcutaneous injections: Injecting at home. The Hospital for Sick Children. https://www.aboutkidshealth.ca/Article?contentid=998&language=English

Yapucu Güneş, Ü., Ceylan, B. & Bayındır, P. (2016). Is the ventrogluteal site suitable for intramuscular injections in children under the age of three?. Journal of Advanced Nursing, 72( 1), 127– 134. doi: 10.1111/jan.12813

Contact info: info@nursesinternational.org

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