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Pharmaceutical Services DivisionMinistry of Health Malaysia

Pharmaceutical Services DivisionMinistry of Health Malaysia

Lot 36, Jalan University,46350 Petaling Jaya,Selangor Darul Ehsan.

Tel : +603 7841 3200 Fax : +603 7968 2222Website : www.pharmacy.gov.my

Paediatric Pharmacy Services Guideline2

First Edition 2015Pharmaceutical Services DivisionMinistry of Health, Malaysia

ALL RIGHTS RESERVED

This is a publication of the Pharmaceutical Services Division, Ministry of Health Malaysia. Enquiries are to be directed to the address below. Permission is hereby granted to reproduce information contained herein provided that such reproduction be given due acknowledgement and shall not modify the text.

Pharmaceutical Services DivisionMinistry of Health Malaysia

Lot 36, Jalan Universiti, 46350 Petaling Jaya, Selangor, Malaysia

Tel: 603 - 7841 3200 | Fax: 603 - 7968 2222Website: www.pharmacy.gov.my

Paediatric Pharmacy Services Guideline 3

Mes

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MESSAGE

Paediatric pharmacists are in prime position to maximize the safe and effective use of medicines and influence the management of medicines for children and adolescents. Children are a special population which require detailed attention on the management and medications as their physiological function is still developing and yet to mature.

Paediatric pharmacy is a specialized clinical pharmacy service that is currently increasing in significance in Malaysia. We aim to have paediatric pharmacy service in all major hospitals and at least one paediatric pharmacist in secondary hospitals.

Therefore Clinical Pharmacy Working Committee ( Paediatric subspecialty ) Pharmaceutical Services Division, Ministry of Health has initiated to produce this guideline. I am optimistic that this guideline will assist paediatric pharmacist in their practices especially for those who will set up paediatric pharmacy services in their setting.

I would like to commend the Clinical Pharmacy Working Committee (Paediatric subspecialty) Pharmaceutical Services Division, Ministry of Health for their contribution and commitment to the development of this guideline.

Thank you.

Puan Abida Haq bt Syed M. HaqDirector of Pharmacy Practice and Development Division

Paediatric Pharmacy Services Guideline4

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ADVISORS

Main Editorial Committees

Madam Abida Haq Syed M.HaqDirector of Pharmacy Practice & Development DivisionPharmaceutical Services Division, Ministry of Health, Malaysia

Madam Rosminah Mohd DinDeputy Director (Clinical Pharmacy & Technical)Pharmaceutical Services Division, Ministry of Health, Malaysia

Madam Noraini MohamadSenior Principal Assistant Director PharmacyPharmaceutical Services Division, Ministry of Health, Malaysia

Noor Haslina OthmanSenior Clinical PharmacistHospital Raja Perempuan Zainab II

Subasyini SivasupramaniamSenior Clinical PharmacistHospital Kuala Lumpur

Khoo Sze NiSenior Clinical PharmacistHospital Raja Permaisuri Bainun

Ng Boon YahSenior PharmacistHospital Pulau Pinang

Ng See YeeSenior Clinical PharmacistHospital Sultanah Bahiyah

Stella Chuo Sing HongSenior PharmacistHospital Sibu

Won Zi YunPharmacistHospital Putrajaya

Wong Pui MunSenior PharmacistHospital Serdang

Nurul Hidayah SallehPharmacistHospital Tengku Ampuan Afzan

Khairunnisa Mohamad PharmacistHospital Kemaman

Paediatric Pharmacy Services Guideline 5

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Wong Shien WoanPharmacistHospital Melaka

Sharini ShaariSenior PharmacistHospital Tuanku Jaafar

Tea Ming HuiPharmacistHospital Sultanah Nora Ismail

Irwinder Kaur ChhabraPharmacistHospital Wanita dan Kanak - kanak Likas

Low Yong ChiaPharmacistHospital Wanita dan Kanak-kanak Likas

Tan Jing WenPharmacistHospital Kuala Lumpur

Angeline Tan Meng Wah Principal Assistant Director Pharmaceutical Services Division, MOH

Paediatric Pharmacy Services Guideline6

Table of Content

1.0 Introduction To The Guideline 8

2.0 Job Description Of A Paediatric Pharmacist 9

3.0 General Pediatrics 11

Respiratory Illness 12

Viral Bronchiolitis 12

Asthma 14

Neurology 24

Status Epilepticus 24

Epilepsy 28

Infantile Spasm 37

Nephrology 43

Acute Glomerulonephritis 43

Nephrotic Syndrome 45

Acute Renal Failure 49

Infectious diseases 52

Tuberculosis 52

Malaria 60

Meningitis 71

Urinary Tract Infection 77

Viral Croup 80

Pneumonia 84

Cardiovascular 92

Kawasaki Disease 92

Rheumatic Heart Disease 95

Paediatric Pharmacy Services Guideline 7

4.0 Paediatric ICU 98

Fluid & Electrolyte Management 99

Nutrition In Critically Ill Patients 107

Shock Management 113

Neuromuscular Blockade 119

Stress Ulcer Prophylaxis 127

Sedation & Pain Management 131

5.0 Neonatal ICU 141

Neonatal Jaundice (NNJ) 142

Sedation & Pain Management 147

Total Parenteral Nutrition In Neonates 161

Fluid & Electrolyte Management 168

Necrotizing Enterocolitis 170

6.0 Dosing Considerations in Special Populations 181

7.0 Appendix 189

Corticosteroid Equipotency Chart 189

Nutrition Reference 190

Immediate-release Opioid Analgesics Comparison Chart 191

TDM Sampling Time 192

Growth Charts 193

Stability and Storage of Oral Medications 203

Drugs To Avoid In G6PD Deficiency 211

Paediatric Pharmacy Services Guideline8

1.0 Introduction To The Guideline

Neonates and paediatrics are vulnerable groups who require extra careful handling, and hence the role of paediatric pharmacists is crucial to ensure medication safety. With this insight, paediatric pharmacy service was introduced under the pharmacy program of Ministry of Health (MOH), Malaysia in 2006, and subsequently the first paediatric pharmacists working group committee was formed in 2009.

The role of paediatric pharmacists has gained recognition throughout the years. Despite the increasing demand for paediatric pharmacists, this remains as one of the most challenging clinical pharmacy field to venture in. The lack of evidence and standardized dosing in paediatrics and neonates can be a hurdle to practice evidence based medicine in this field. Also, the lack of standardized guidelines on the conduct of paediatric pharmacy services under facilities of MOH, Malaysia may lead to great differences in the expected roles and responsibilities as a paediatric pharmacist. The aim of this service guideline is to serve as a baseline reference and information for paediatric pharmacists who are new to this field on the conduct and practice of paediatric pharmacy. It can also be a basic reference for provisionally registered pharmacists (PRP) who will be doing paediatric clinical clerkship during clinical attachment. It is of great hope that with the introduction of this service guideline, paediatric pharmacy services under MOH, Malaysia can be further expanded and established.

Paediatric Pharmacy Services Guideline 9

2.0 Job Description of a Paediatric Pharmacist

Paediatric pharmacy consists of general paediatric, paediatric intensive care and neonatal intensive care. The ultimate goal of paediatric pharmacy service is to assist in the best possible way to achieve safe and effective treatment. Hence, evidence-based practice should be the mainstay in the management of all patients at all time.

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2.0 Job Description Of A Paediatric Pharmacist Paediatric pharmacy consists of general paediatric, paediatric intensive care and neonatal intensive care. The ultimate goal of paediatric pharmacy service is to assist in the best possible way to achieve safe and effective treatment. Hence, evidence-based practice should be the mainstay in the management of all patients at all time.

Table 2.1: Job Description of Paediatric Pharmacist Job Scope Description

Admission clerking

Medication history clerking, which includes non-prescription

drugs e.g. herbal remedies and over the counter drugs (OTC) Compliance assessment (CP1 form) if applicable Medication reconciliation

Pharmacotherapy Rounds

Active participation in ward rounds with doctors Collaborate with other healthcare providers in developing

pharmaceutical care plans for the patients Provide medication therapy evaluations and

recommendations to healthcare providers supported by evidence-based medicines

Monitor and review patients medication

Case clerking and review (CP2 form) Checking patients medication chart Ensure medications are served Ensure prescription is completely filled Ensure safe and rational drug use Ensure approppriate dilution and administration of injectable

drugs Ascertain proper extemporaneous preparation Therapeutic Drug Monitoring (TDM) / Total Parenteral

Nutrition (TPN) services

Identify Pharmaceutical Care Issues

Dosing adjustment based on patients body weight, age

group, body surface area, renal and liver function. Medication errors e.g. drug, dose, frequency, duration,

administration, etc Drug- drug interactions Drug incompatibilities and contraindications Polypharmacy

Paediatric Pharmacy Services Guideline103

Adverse Drug Reaction Report

Identifies and r