Provider explains how children's medicines differ from adults'

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

Upstate Medical University and the Upstate Golisano Children's Hospital are full of different types of specialists.

And today I'll be speaking with someone who specializes in medications for children. Peter Aiello is an assistant professor of Pharmacy at Upstate.

Welcome to the informed patient, Dr. Aiello.

Peter Aiello, PharmD: Thank you Amber, for having me.

Host Amber Smith: Let me start by asking you, do kids have their own medications that have been approved just for use in kids, or is it generally the same medications as adults, just in smaller doses?

Peter Aiello, PharmD: Generally, most medications are originally formulated for adult patients, and they're usually approved by the Food and Drug Administration. That's the government body that regulates medications for use in patients, for adult patients. And a lot of the dosing that we use in pediatric patients is kind of extrapolated, or inferred, from adult doses based on a patient's weight.

Host Amber Smith: So, medications are tested in adults and then if they're safe for adults, they're assumed to be safe for children.

Is that right?

Peter Aiello, PharmD: They're not always assumed to be safe for children. Children will have their own studies where we look at the use of these medications in children, but generally they start out in adults, and then their use will get moved to children.

Host Amber Smith: Is dosing for children based only on their weight?

Peter Aiello, PharmD: Generally dosing for children is based on their weight, although sometimes there are different measurements that your doctor or pharmacist may look at, such as height and body surface area, which is a really complicated way of looking at the size of the body to dose medications.

Host Amber Smith: Are all medications for kids available as liquids?

Peter Aiello, PharmD: Most medication formulations that are given to children are available commercially as liquids. Sometimes though, we have to make tablets or capsules into a special formulation for children, and this is known as a process called compounding. And this is something that pharmacists specialize in while they're in pharmacy school.

So sometimes your doctor may prescribe a medication that's only for an adult patient and is in a tablet or a capsule, and then the pharmacist will have to break those capsules or tablets up and mix them with different liquids to create a liquid where none is available.

Host Amber Smith: What happens if a child chews a pill that's supposed to be swallowed? It's going to taste bad, right?

Peter Aiello, PharmD: Sometimes we have pills that are made to be chewed, and those are called chewable tablets and are meant for pediatric patients, for children, to consume.

In other instances, if that situation that you described has occurred, sometimes they'll taste bad, and other times they may be an overdose if they have a full adult dose of the medication. So in that case, you would have to call the poison center, and that number is available widely on the internet.

Host Amber Smith: This is going to sound very simplistic, but why do medications taste so bad?

Peter Aiello, PharmD: Medications are formulated in such a way that we don't really think about taste for the actual drug ingredient. And that's because if it's going to be in a liquid, we'll add other things to make it not bitter, we'll make it sweet, and the drug ingredients may be what we call an acid or a base. And that's just based off of the chemical structure of the drug. And those acids and bases just don't taste well, because in history, if someone were to have something that were too either acidic or basic, it could mean that it was a poison. So that's why they actually taste poor to us as human beings.

Host Amber Smith: But for children especially, you're able to add flavoring sometimes so that it doesn't taste so bad?

Peter Aiello, PharmD: Yeah. There's commercially available products, suspensions, chewable tablets, that already have flavorings in them, like amoxicillin or Tylenol, that everybody thinks of.

But sometimes if there is a liquid medication that still tastes bad, even though it is supposed to be formulated. There are ways that pharmacists can add flavorants and sweeteners to them to make them taste better.

Host Amber Smith: How do you tell if a new medication is causing an adverse reaction in a child that cannot speak, or a baby?

Peter Aiello, PharmD: This is a really good question that a lot of parents need to look out for when they give their child a new medication. So one of the things, the first telltale signs of a reaction, is either that you give the medication to the child and then a few minutes later, after they've swallowed it, they throw up, or they get a rash, or they start to have swelling in their face.

Any of those instances, you really need to call your doctor's office. But if it involves anything with breathing where their face swells, they sound like they're gasping for breath, they're coughing. you really should call 911 and get evaluated in the emergency department.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith.

I'm talking with assistant professor of pharmacy at Upstate Peter Aiello.

Can you tell us about what a typical day is like as a pharmacist in a children's hospital?

Peter Aiello, PharmD: Yes, and Amber, this is something I'm very passionate about. I think a lot of folks think of pharmacists as somebody who is behind the drugstore counter dispensing medications, and that's a really vital role for a lot of pharmacists.

But there's also a whole team of pharmacists that have gone on to specialize in various areas of medicine. I specialized in pediatrics, and we actually round with the medical team. We work in the emergency department alongside our nursing colleagues to help in emergency situations. We take medication histories if you're coming into the hospital.

It's something that's really important and that a lot of families get frustrated with. The nurse asks them what medications their child's on. The provider may ask the question, and then they have a pharmacist come in the room and ask the same question. It's really important, though, that you provide that information, even if it's a couple times, because that information will help us provide better care for your child.

So the next time you see a pharmacist in the hospital, please say hi to us. And it doesn't necessarily mean that your child's going to get medication. It just means that we're there to help ensure the safe delivery of medication to your child.

Host Amber Smith: So what is your educational training? What is it like to go to pharmacy school?

Peter Aiello, PharmD: I went to six years of pharmacy school. I did not get an undergraduate degree, so I actually went straight from high school, and in six years graduated with my doctorate in pharmacy.

And then I went on to complete two years of additional postgraduate training known as a residency. So pharmacists do, and can do, residencies, and those were both completed here at Upstate. And there was that second year of residency that I specialized in pediatric pharmacy.

Host Amber Smith: Well, let's talk about some of the most common medications that kids may take.

You already mentioned amoxicillin. That's that pink liquid. That's got to be one of the most popular, and I doubt there's any child who makes it through childhood without taking that. Are there special concerns about antibiotic use in children compared with those used in adults?

Peter Aiello, PharmD: Antibiotics used in children are some of them, amoxicillin is one of the most common, and like you said, most children are exposed to it at some point in their early childhood. It's used to treat a lot of common conditions, like ear infections and strep throat. Amoxicillin is also used in our adult patients as well, and there's a lot of common antibiotics between the two populations.

We use very similar drugs. I think the most important thing is, is that if you are prescribed an antibiotic, just like as if an adult were, you should take the full course as directed by your doctor and make sure that if you have any questions about what medications can be given with the antibiotic that you ask your pharmacist or your doctor.

But in terms of specialty antibiotics versus adults? In pediatric patients, I think it's more the formulation that we all talk about, like the liquid amoxicillin.

Host Amber Smith: Steroids are another type of medication kids may be prescribed. Are there side effects to be aware of with steroids?

Peter Aiello, PharmD: Steroids are generally very well tolerated in children.

Sometimes it can make them have a little bit more energy; it may make them anxious, but that usually very quickly goes away once you stop them. We usually give children steroids for shorter periods of time. If for some reason there are any side effects that just don't make sense, that would be a question to please ask your pharmacist.

They serve a really important role. When you go to the pharmacy counter and pick up any prescription, to make sure that you have that conversation with your pharmacist and develop a relationship with them because they have great information, and it's not always good to just walk away if you haven't had those questions answered.

Host Amber Smith: What are the best pain relief options for babies, toddlers, preschoolers, teens? There's a lot on the market over the counter. What would you recommend?

Peter Aiello, PharmD: There is a lot of over-the-counter options. I think the most important thing is, if there's any type of pain or fever, to make sure that your child, especially if they're less than 6 months old, that they get evaluated by their pediatrician right away and that you don't delay going to your pediatrician or calling your pediatrician's office.

I think Tylenol is probably the cornerstone of pain and fever relief in children, and liquid Tylenol is what we recommend for pretty much everything, fever- or pain relief-wise.

I think with Tylenol though, it's important to remember that many products, liquid cough medicines and things, can contain Tylenol.

So it's important to just give plain Tylenol and not use any cough or cold liquid medications with your child, unless you've been specifically pointed to those by a doctor and have gone over that dosing with a doctor or a pharmacist.

Host Amber Smith: So some of those over-the-counter cough and cold remedies already have Tylenol in them.

Is that what you're saying?

Peter Aiello, PharmD: That is correct, yes.

Host Amber Smith: Do you ever encounter children who are taking herbal supplements, and I wonder if that complicates what medications they can be prescribed?

Peter Aiello, PharmD: Herbal supplements are becoming more common these days.

I think before starting your child on any herbal supplement or dietary supplement, that should be a conversation between the parent and the doctor.

I also think that you should, if you do decide to start an herbal supplement, it's very, very important that you tell your pharmacist that you're on those medications, so they can check for drug interactions. So if you are filling your prescriptions at any chain drugstore or independent drugstore to let the pharmacist know. They're not going to have that information, and there's not going to be a prescription for that herbal supplement, so it's really important that it's put on the patient's profile so that they can do interaction checking to make sure that the medications that have been prescribed are safe and are not going to interact.

Host Amber Smith: I'd like to get your advice for parents or caregivers who are trying to get a child to take a medicine they don't want to take.

What strategies can you suggest?

Peter Aiello, PharmD: I think we've touched on one of the most important ones, is that pharmacists can add flavoring and sweeteners to certain medications and formulate them so that they're more palatable to infants, toddlers and children.

I think some of the other strategies that are really important are maybe offering something with a glass of cold water to help the medication go down easier.

And if the child's in the hospital and is started on a new medication, and there's issues with taking it, certainly asking the medical team to involve pharmacy, the inpatient pharmacy. We can help counsel families on how to start that medication.

And then there's also another group of professionals that I always like to work side by side with, and those are our child life specialists. So they are a wonderful addition to our children's hospital and provide a wonderful service of helping children cope with their hospitalizations. And they also have some techniques to help our children take medication easier, so definitely making it an interdisciplinary approach if you're in the hospital.

But if you're not, and your pediatrician's just prescribed something that's new, let your pharmacist know at the counter when you pick it up that you're concerned, and they can offer some techniques tailored to that medication.

Host Amber Smith: What age do you think you can start coaching a child to swallow a pill?

Peter Aiello, PharmD: It's really dependent on their developmental status and things like that. And I've seen a wide range of ages when children can start taking pills. Again, that's a conversation best suited for that specific child, between the doctor and the family and the pharmacist and the family.

Host Amber Smith: Good to know. Well, thank you so much for making time for this interview.

Peter Aiello, PharmD: Thank you Amber, for having me.

Host Amber Smith: My guest has been Peter Aiello. He's an assistant professor of pharmacy at Upstate specializing in pediatrics.

"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe.

Find our archive of previous episodes at upstate.edu/informed.

This is your host, Amber Smith, thanking you for listening.