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After completing this case study, the reader should be able to:


  • Determine the role that the rate and extent of organ development plays in the variation of absorption, distribution, metabolism, and elimination of medications in the pediatric population.

  • Compare and contrast the pharmacokinetic and pharmacodynamic differences between pediatric and adult patients, as well as among various pediatric age groups.

  • Identify and manage challenges in pediatric pain management.

  • Identify and manage challenges in pediatric drug formulation and administration.




Chief Complaint


Nursing reports of new-onset fever and hypotension, increased number of apnea episodes, and “infant acting different.”




Alexander Halstrom is a premature 730-g male infant born at 25 4/7 weeks, now day of life 22, who is currently intubated, sedated, on vasopressors and parenteral nutrition with new-onset fever, increased number of apnea episodes, and a 1-day history of “acting different” according to nursing reports.




  • Prematurity: born at 25 4/7 weeks with APGARs of 1, 4, and 6

  • Extremely low birth weight (ELBW) = 760 g

  • Respiratory distress syndrome (RDS)

  • Anemia

  • Apnea of prematurity

  • At risk for retinopathy of prematurity

  • Cholestasis

  • Diaper dermatitis

  • Grade II intraventricular hemorrhage (IVH)

  • Hypotension

  • Microcephaly, head circumference below 10th percentile

  • Newborn sepsis

  • NPO, receiving nutritional support

  • Patent ductus arteriosus (PDA)—small with left-to-right shunt

  • Pulmonary hemorrhage

  • Immunizations up-to-date




Infant born to a 24-year-old Gravida 2 Para 0 Abortion 1 (G2 P0 AB1) mother secondary to polyhydramnios, nonreassuring fetal status, and premature onset of labor


Maternal labs: HBsAg (–), rubella (–), VDRL (–), and HIV (–) with unknown GBS status who received partial penicillin prophylaxis prior to delivery and indomethacin for tocolysis.


Mother denies drug and alcohol use during pregnancy.




  • Noncontributory


Current Meds


  • Ampicillin 73 mg IV every 12 hours (200 mg/kg per day)

  • Gentamicin 1.8 mg IV every 8 hours (7.5 mg/kg per day)

  • Caffeine 3.7 mg IV every 24 hours (5 mg/kg per day)

  • Phenobarbital 3.7 mg IV every 24 hours (5 mg/kg per day; off-label use for cholestasis)

  • Morphine continuous infusion 10 mcg/kg/hour

  • Midazolam continuous infusion 0.05 mg/kg/hour

  • Dopamine continuous IV infusion 10 mcg/kg/min

  • TPN at total fluid volume of 150 mL/kg per day

  • Nystatin 100,000 U/g cream one application to affected area PRN

  • Aquaphor, one application to affected area PRN

  • Glycerin suppository, one PR every 24 hours PRN constipation

  • Acetaminophen 7.3 mg PO/PR every 6 hours PRN pain/fever (10 mg/kg/dose)




  • NKDA


Physical Examination


Intubated, sedated, premature ...

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