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Children and Drug Dosing Variations When in Transit to the Hospital

July 10, 2023

Because children and adolescents comprise fewer than 10% of patients who are cared for by emergency medical services (EMS) personnel, these health care professionals are understandably not as comfortable taking care of pediatric patients – and they may not be used to calculating emergency drug doses for these patients. This means that children may be underdosed or overdosed with critical, lifesaving medications.

In an article entitled “Deviation from National Dosing Recommendations for Children Having Out-of-Hospital Emergencies,” being early released this week in Pediatrics (10.1542/peds.2023-061223), Dr. Sriram Ramgopal from Northwestern University and Dr. Christian Marin-Gill from the University of Pittsburgh use data from a large database of medical records from 2000 EMS agencies to describe dosing deviations from what is recommended.

They looked at the dosing for 10 different, commonly used emergency medicines:

  • Lorazepam, diazepam, and midazolam for the control of seizures
  • Diphenhydramine for the treatment of allergy or anaphylaxis
  • Epinephrine, both intravenously for resuscitation and intramuscularly for the treatment of allergy or anaphylaxis
  • Hydromorphone, morphine, and ketorolac for the treatment of pain
  • Methylprednisolone

There were nearly 1 million pediatric encounters included in the data analysis. Of these, 6.4% received a non-nebulized medicine and 3.4% received one of the medicines being studied.

For the 80% of the patients who had a documented weight, 42.6% of the medications were given at a dose consistent with national guidelines. Even when the authors estimated the dosages from weights that were estimated by the child’s age, results were similar.

Correct dosing was most common with methylprednisolone (75%) and intramuscular epinephrine (68%). Only 20% of medication doses given for seizure control (diazepam, lorazepam) were given in the correct dose. When the incorrect dose was given, it was usually an underdosing, and this was most frequently seen with lorazepam and morphine.

Given that incorrect dosing of medication contributes to poorer outcomes, what are the reasons for so much deviation from national guidelines? The authors speculate several reasons:

  • There is a lot of variation in EMS protocols, and some of these protocols are not consistent with national guidelines.
  • Dosing errors may be common in stressful situations among health care professionals who are not used to quickly calculating drug doses.
  • Hesitation to provide adequate dosing, particularly for benzodiazepines and opioids, because of concern for oversedation.

The data in this article will be of interest to all pediatricians, as we all at some point care for children who have had encounters with the EMS system. And for those who work in emergency departments or with EMS personnel, development of protocols, educational interventions, and quality improvement projects focused on correct dosing will be beneficial so we can assure that children and adolescents receive the appropriate doses of emergency medications.

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