NR 566 Week 4 Pediatric Amoxicillin Dosing Write-Up Example

Pediatric Dosing Write-Up: High-Dose Amoxicillin Suspension for Acute Otitis Media in a 4-Year-Old Weighing 35.2 Pounds, Converted Once and Carried Through to a Syringe

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College of Nursing, Chamberlain University

NR 566: Advanced Pharmacology for Care of the Family

Instructor Name

Month Day, Year

Pediatric Dosing Write-Up: High-Dose Amoxicillin Suspension for Acute Otitis Media in a 4-Year-Old Weighing 35.2 Pounds, Converted Once and Carried Through to a Syringe

The Child and the Diagnosis

The patient is the composite household's grandchild, a 4-year-old who attends a daycare center five days a week, with two days of right ear pain and fever to 39.0 degrees Celsius. On examination the right tympanic membrane is red and bulging with no perforation; the left is normal. There has been no antibiotic in the past 30 days, there are no drug allergies, and the child is drinking well. Weight at today's visit is 35.2 pounds. The diagnosis is acute otitis media with severe symptoms (fever of 39 degrees Celsius or higher), for which guidance recommends antibiotic treatment rather than observation (Lieberthal et al., 2013).

Convert Once, Visibly

35.2 pounds, divided by 2.2, gives 16.0 kg.

Every calculation that follows uses 16.0 kg. Pounds do not appear again in this write-up.

The Range and the Choice Inside It

The reference is the American Academy of Pediatrics guideline on acute otitis media, which sets high-dose amoxicillin for a child with no amoxicillin in the previous month at between 80 and 90 mg per kilogram each day, split into morning and evening doses (Lieberthal et al., 2013). I choose the top of the range, 90 mg/kg/day, because of daycare attendance, which increases exposure to pneumococcal strains with reduced penicillin susceptibility, and high-dose amoxicillin is chosen to overcome that resistance.

Daily Amount to Per Dose

90 mg/kg/day multiplied by 16.0 kg equals 1,440 mg/day.

Divided into two doses: 1,440 mg divided by 2 equals 720 mg per dose, every 12 hours.

Milligrams Into Milliliters

The pharmacy stocks amoxicillin suspension at 400 mg per 5 mL, which is 80 mg per mL.

720 mg divided by 80 mg per mL equals 9 mL per dose.

Nine milliliters is a volume a 10 mL oral syringe measures exactly, so no rounding is needed. If the pharmacy had only 250 mg per 5 mL (50 mg per mL), the dose would be 14.4 mL, which is awkward to measure and would round to 14.5 mL using a syringe with 0.5 mL markings; the stronger concentration is requested on the prescription to keep the volume manageable.

Two Ceilings Checked

Weight-based ceiling. 90 mg/kg/day is the top of the recommended range for this indication, so the dose does not exceed it.

Adult ceiling. High-dose amoxicillin in adults and adolescents is generally capped at about 2 g per dose and 4 g per day. This child's 720 mg per dose and 1,440 mg per day are well below that, so the adult ceiling does not limit the order. This check matters more for large adolescents, in whom weight-based calculations can exceed adult doses.

Why Ten Days and Not Five or Seven

Duration is part of the dose. Shorter courses reduce side effects and resistance, and the guideline allows 7 days for children aged 2 to 5 with mild or moderate illness (Lieberthal et al., 2013). Among children under two, a randomized trial stopped early because the shorter 5-day arm failed more often than the 10-day arm (Hoberman et al., 2016). That trial does not settle the question for a 4-year-old, but together with the severe symptoms in this case it supports the full 10 days. If the child had mild symptoms and no fever, 7 days would have been the choice, and the quantity would fall to 126 mL.

Common Errors This Write-Up Avoids

Three errors are checked against the working above. First, the daily amount is never given as a single dose; 1,440 mg once daily would be both the wrong schedule and a dose a parent might later double. Second, the conversion from pounds is done once, so the weight cannot be accidentally halved or doubled. Third, the volume is checked against the bottle concentration actually dispensed, because the same 720 mg is 9 mL of one concentration and 14.4 mL of another. Each of these errors produces a confident number that is wrong, and a reader can verify every step here.

Duration and Quantity

For children aged 2 to 5 years with acute otitis media, a 7-day course is an option (Lieberthal et al., 2013); because the symptoms are severe, I choose 10 days, which the guideline recommends for children with severe symptoms.

9 mL per dose multiplied by 2 doses per day multiplied by 10 days equals 180 mL.

Dispense 200 mL (for example, two 100 mL bottles) to allow for spillage and the dose drawn up in the clinic. No refills.

The Prescription as Written

Amoxicillin oral suspension 400 mg/5 mL. Give 9 mL (720 mg) by mouth every 12 hours for 10 days. Dispense 200 mL. Refills: 0. Weight 16.0 kg; dose 90 mg/kg/day.

Pain and Fever

Pain relief is part of the treatment (Lieberthal et al., 2013). For ibuprofen, 10 mg per kilogram comes to 160 mg; using the 100 mg per 5 mL liquid that is 8 mL, no more often than every 6 hours and only while the child keeps drinking. Acetaminophen 160 mg per 5 mL at 15 mg/kg is 240 mg, which is 7.5 mL, every four to six hours as needed, with no more than five doses in 24 hours.

What Goes Home

The parent goes home with a 10 mL oral syringe, not a kitchen spoon, and the dose written in milliliters only: "9 mL in the morning and 9 mL in the evening." Labels and instructions that use milliliters alone, paired with a syringe, reduce parent dosing errors compared with teaspoon or mixed units (Yin et al., 2014). The suspension is shaken before each dose and kept in the refrigerator, where it tastes better, and any left after the course is discarded. The parent is told to call if the fever persists after 48 to 72 hours, if doses are vomited, or if a rash, hives or swelling appear, and to return in three days if the child is not improving, since treatment failure would call for amoxicillin-clavulanate.

Follow-Up

A recheck of the ear is not needed for a child who recovers fully, unless symptoms return. If episodes repeat this year, growth and hearing will be reviewed.

The weight used today is recorded on the prescription so that any later dose change can be checked against it.

References

Hoberman, A., Paradise, J. L., Rockette, H. E., Kearney, D. H., Bhatnagar, S., Shope, T. R., Martin, J. M., Kurs-Lasky, M., Copelli, S. J., Colborn, D. K., Block, S. L., Labella, J. J., Lynch, T. G., Cohen, N. L., Haralam, M., Pope, M. A., Nagg, J. P., Green, M. D., & Shaikh, N. (2016). Shortened antimicrobial treatment for acute otitis media in young children. New England Journal of Medicine, 375(25), 2446-2456. https://doi.org/10.1056/NEJMoa1606043

Lieberthal, A. S., Carroll, A. E., Chonmaitree, T., Ganiats, T. G., Hoberman, A., Jackson, M. A., Joffe, M. D., Miller, D. T., Rosenfeld, R. M., Sevilla, X. D., Schwartz, R. H., Thomas, P. A., & Tunkel, D. E. (2013). The diagnosis and management of acute otitis media. Pediatrics, 131(3), e964-e999. https://doi.org/10.1542/peds.2012-3488

Yin, H. S., Dreyer, B. P., Ugboaja, D. C., Sanchez, D. C., Paul, I. M., Moreira, H. A., Rodriguez, L., & Mendelsohn, A. L. (2014). Unit of measurement used and parent medication dosing errors. Pediatrics, 134(2), e354-e361. https://doi.org/10.1542/peds.2014-0395