Adult nursing teaches five rights of medication administration. Pediatrics expands the list to ten rights, because a child cannot check a dose, speak up about an allergy, or understand what a medication is for — the nurse carries all of that responsibility for them. The ten are: right medication, right patient, right time, right route (the path the drug takes into the body — by mouth, IV, injection, and so on), right dose, right approach, right documentation, right to be educated, right to refuse, and right form.
Three of these are distinctly pediatric. Right approach means the technique fits the child's developmental level — how you give a medication to a toddler is completely different from how you give it to a teen. Right form means the physical version of the drug is one the child can actually take, such as a liquid instead of a tablet. The right to be educated and the right to refuse acknowledge that children and their caregivers deserve an explanation in words they understand, and a genuine voice in care.
These two words organize everything else in this chapter, so learn the contrast cold. Pharmacodynamics is what a medication does to the body — its effects at the cellular level. A child's response can vary because the body systems themselves are still maturing, and because of genetics. Pharmacokinetics is the reverse direction: what the body does to a medication. It has four steps — absorption (getting into the bloodstream), distribution (traveling through the body), metabolism (being chemically broken down), and excretion (being removed from the body).
Absorption differs by route. Oral (by mouth) absorption is affected by gastric pH (how acidic the stomach is), gastric emptying (how quickly the stomach empties into the intestine), and intestinal motility (how fast the gut moves contents along) — all of which differ in young children. Intramuscular injections (into a muscle) absorb less predictably because infants have smaller muscle mass and variable perfusion, meaning blood flow to the tissue varies. Subcutaneous injections (just under the skin) likewise depend on tissue perfusion.
The one that surprises people is topical medication — creams and ointments applied to the skin. Infant skin is more permeable (things pass through it more easily), and an infant has a much larger body surface area relative to weight than an adult. So a cream that barely registers in an adult can absorb in drug amounts that matter in a baby. The overall result: absorption is less predictable in infants and young children.
Once absorbed, the drug distributes through the body, and a child's body proportions change the math. Children carry a higher percentage of total body water and a greater extracellular fluid volume (the fluid outside the cells), so water-soluble medications get diluted into a bigger fluid space. They also carry a lower percentage of body fat, which changes how fat-soluble medications behave.
Two safety-critical differences: young infants have reduced plasma protein binding. Many drugs normally ride through the bloodstream attached to proteins, and only the unattached ("free") portion is active. Less binding means more free, active drug circulating — stronger effects and more toxicity risk from the same dose. And the blood-brain barrier — the protective filter that keeps many substances out of the brain — is immature, especially in neonates (newborns in the first 28 days of life), so medications can reach the brain more easily. Remember: drug distribution changes with growth and development, so it must be reconsidered as the child grows.
Metabolism occurs primarily in the liver, where enzyme systems break medications down. Hepatic (liver) enzyme activity changes with age, so a child's medication clearance — the rate at which the body removes the drug — may be slower or faster than an adult's depending on age and the drug involved.
Excretion occurs primarily through the kidneys, and renal (kidney) function is immature in newborns. Reduced clearance prolongs the medication's half-life — the time it takes for half of the drug to be eliminated — so the drug stays in the body longer and the risk of toxicity increases. This is why newborn dosing intervals are often longer and doses are double-checked so carefully.
Because children's bodies vary so much, pediatric doses are calculated for the individual child: most often by body weight, expressed as milligrams per kilogram (mg/kg), and sometimes by body surface area, expressed as mg/m² (milligrams per square meter of body surface).
Technique matters as much as the dose. Explain why the medication is needed, describe what the child will experience, and explain what is expected of the child — honest, simple, and matched to developmental level, exactly as with any procedure. Encourage parent or caregiver participation, offer age-appropriate choices where real choices exist, and use atraumatic care strategies — the approaches that minimize physical and psychological distress.
For oral medications specifically: use age-appropriate formulations (liquids for young children), and measure liquids with an oral syringe — never a kitchen spoon, which can be off by a dangerous amount. Give the liquid slowly along the inside of the cheek so the child can swallow safely, and position the infant or child appropriately. Never force medication into a crying child — a crying, struggling child can inhale the medication into the lungs. Verify compatibility before mixing medication with food or liquids, and encourage the child's participation whenever developmentally appropriate.
For ophthalmic (eye) medications, instill drops into the lower conjunctival sac — the pocket formed by gently pulling the lower eyelid down — and never touch the eye with the dropper, which would injure the eye and contaminate the medication. Rectal medications are absorbed unpredictably, so use that route only when specifically indicated.
Injections are chosen by age, muscle development, and medication volume. The vastus lateralis — the large muscle on the outer thigh — is the preferred intramuscular site in infants, because it is their best-developed muscle and is away from major nerves and blood vessels. The deltoid (upper arm muscle) works for older children with adequate muscle mass. The ventrogluteal site (on the hip) is used in selected situations. Subcutaneous injections (into the fatty layer under the skin) are used for insulin and certain other medications, and intradermal injections (into the top layers of the skin itself) are used for selected diagnostic testing. Whatever the site, use atraumatic techniques to reduce pain and anxiety.
Giving medication through a feeding tube adds steps. Verify tube placement before administration — medication delivered into a misplaced tube can reach the lungs. Confirm the medication is appropriate for the tube and route, and use suitable liquid formulations when available.
Stepping back, preventing medication errors in children is a system: verify weight and medication concentration, check the prescribed dose against pediatric references, use standardized measuring devices, confirm allergies and monitor for adverse reactions, avoid unsafe abbreviations and dosing units, and educate caregivers about administration and safe storage at home. The teaching check is teach-back or return demonstration — the caregiver explains the steps back or physically shows them, which proves the teaching actually landed.
Intravenous (IV) therapy delivers fluids, medications, and nutritional support directly into a vein. Peripheral IV access — a catheter in a vein of the hand, arm, or foot — is most commonly used; central access (a catheter ending in a large central vein near the heart) is reserved for prolonged or specialized treatment.
Four pediatric considerations drive the whole section. Children's veins are smaller and more fragile. Their circulating blood and fluid volume is limited, so a volume of fluid that would be trivial for an adult can produce an increased risk of fluid overload in a small child. And the child's developmental and emotional needs are part of the procedure, not an afterthought. Common peripheral sites are the hands and forearms, the feet in selected infants and young children, and scalp veins in neonates and young infants, whose scalp veins are visible and accessible. Choose the site by age, mobility, and treatment needs, avoid areas of excessive movement when possible, preserve future venous access (don't burn through every good vein), and select an appropriate catheter size.
Insertion follows atraumatic care: prepare all equipment before approaching the child (so the frightening part isn't prolonged), explain the procedure honestly and simply, use appropriate pain-reduction strategies, encourage comfort positioning and caregiver participation, and minimize unsuccessful attempts — repeated sticks traumatize the child and destroy trust. Secure the catheter while protecting fragile skin.
Once fluid is running, safety means machinery and vigilance. Use programmable infusion or syringe pumps, verify the prescribed rate and total volume, and use pediatric drug libraries and safety limits (built-in pump software with preset dose and rate limits for children) when available. Monitor the infused volume closely and assess the IV site and fluid status frequently.
Maintenance fluids are the baseline fluids a child needs each day just to stay even. Requirements are calculated by weight in tiers, because smaller children burn through fluid faster relative to their size:
Monitoring is continuous comparison: prescribed versus actual infusion volume, intake and output, weighing diapers when necessary (a gram of diaper weight equals a milliliter of urine), urine output measured in mL/kg/hr, and daily weight and hydration status — daily weight is one of the most sensitive indicators of a child's fluid balance. Watch throughout for fluid overload and electrolyte imbalance (electrolytes are the dissolved minerals, like sodium and potassium, that must stay in balance).
Know the complications by their findings. Infiltration is leakage of IV fluid into surrounding tissue: cool skin, swelling, blanching, and leakage at the site. Extravasation is the dangerous cousin — leakage of a vesicant, a medication or solution that damages tissue on contact, causing tissue injury. Phlebitis is inflammation of the vein: redness, warmth, and tenderness along it. Infection shows redness, drainage, and fever. Fluid overload shows edema (swelling from excess fluid), respiratory changes, and weight gain.
Adequate nutrition is essential for growth and development, so when oral intake is insufficient, support is added by one of two routes. Enteral nutrition is delivered through the gastrointestinal tract — the digestive system — usually through a feeding tube. Parenteral nutrition delivers nutrients intravenously, bypassing the gut entirely.
Indications for enteral feeding include inadequate oral intake or poor weight gain, difficulty sucking, chewing, or swallowing, increased aspiration risk with oral feeding (aspiration means food or liquid entering the airway and lungs), neurologic or developmental conditions, structural abnormalities affecting feeding, and increased nutritional needs related to illness or injury.
Tubes are named for where they start and where they end. Nasogastric (NG) — through the nose into the stomach — for short-term feeding. Orogastric (OG) — through the mouth into the stomach — short-term, particularly in neonates. Nasojejunal (NJ) ends in the small intestine; nasoduodenal (ND) ends in the duodenum, the first section of the small intestine. For long-term feeding, tubes go through the abdominal wall: a gastrostomy (G-tube) into the stomach, and a jejunostomy (J-tube) into the small intestine.
For every feeding: verify tube placement, confirm the formula, volume, and prescribed rate, and position the child appropriately to reduce aspiration risk (head elevated). Feedings run as intermittent/bolus feedings — a set amount given over a short period, like a meal — or as a continuous infusion. Flush the tube according to orders and policy, and monitor feeding tolerance.
Complications of enteral feeding include aspiration, vomiting and feeding intolerance, abdominal distention (a swollen, tight belly), diarrhea or constipation, tube obstruction or dislodgment, and skin irritation or infection at the insertion site. For a G-tube, daily care means: assess the insertion site and surrounding skin, clean and dry the site as directed, watch for redness, leakage, drainage, and pain, maintain tube stabilization, monitor tube position and external length, prevent accidental dislodgment, and follow device-specific instructions for rotation.
Families going home with enteral feeding must be taught the purpose and expected duration, shown feeding administration and tube care by demonstration, taught placement checks and flushing, formula preparation and storage, the signs of complications, and emergency actions for dislodgment or respiratory distress — with return demonstration to verify understanding before discharge.
When adequate nutrition cannot be provided through the gastrointestinal tract, nutrition goes intravenous. Peripheral parenteral nutrition (PPN) runs through a peripheral vein, provides short-term supplementation, and uses lower nutrient concentrations — because small peripheral veins cannot tolerate concentrated solutions. Total parenteral nutrition (TPN) provides complete nutritional support and generally requires central venous access, since a large central vein can handle the concentration. And the principle from earlier still governs: enteral nutrition is preferred when the GI tract is functional and usable.
Nursing care of the child receiving TPN: administer it using an infusion pump at the prescribed rate, maintain strict aseptic technique and central-line precautions, and monitor blood glucose, electrolytes and laboratory results, intake and output, daily weight and hydration, and the central-line site for infection.