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Department Policy
Code: D: PC-5645
Entity: Fairview Pharmacy Services
Department: Fairview Home Infusion
Manual: Policy and Procedure Manual
Category: Home Infusion
Subject: Pediatric Home Infusion Therapy
Purpose: To provide guidelines for the care of pediatric home infusion
patients.
Policy: All Fairview Home Infusion (FHI) pediatric patients will receive
consistent and appropriate care when receiving home infusion
therapy.
Points of I. Home Infusion therapy for the pediatric patient presents
clinicians with unique challenges. Each age group displays
Information:
various physical, physiological, developmental, cognitive and
emotional characteristics. The specific care issues include but are
not limited to:
A. Access devices and infusion equipment – Catheter type,
insertion site and infusion rates must all be considered to
assure safety. Considerations may include:
1. Emotional needs (thumb sucking); mobility (walking,
crawling) and other developmental considerations are
equally as important as size and condition of veins,
type of therapy, expected length of therapy, and rate
of infusion.
2. Catheter and connection securement and monitoring
are necessary to avoid accidental or intentional
removal/ disconnection.
3. Visualization of the site and catheter protection from
contaminants (diapers) is necessary so that the site
can be monitored for complications and to prevent
infection.
4. Equipment should be selected based on safety features
and medication administration requirements.
Promoting the child’s ability to maintain normal
activities should also be considered.
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Code: D: PC-5645
B. Medication Administration – the most commonly used
calculations for medication administration are those based on
body weight and body surface area. Dosing is usually
calculated as milligrams per kilogram or for chemotherapy
agents as milligrams per metered square.
C. Fluid and electrolyte imbalance – because the metabolic rate
in infants and children is higher than that in adults fluid
losses are also greater. Consideration in the determination of
replacement therapy include:
1. Pre-illness and current weight
2. Clinical signs of deficit
a. Poor skin turgor
b. Sunken eyes
c. Dry mucous membranes
d. Depressed fontanels
e. Low blood pressure
f. Altered neurological status (lethargic, irritable)
3. Reason for fluid loss (gastroenteritis)
4. Effects on metabolism (fever)
5. Sources of evaporative loss (increased respiratory
rate)
D. Growth and development stages - Each age group and
developmental stage express different characteristics that
require specific nursing interventions, refer to Attachment I.
Procedure: I. The assessment and reassessment of the pediatric patient may
include:
A. Weight, height, head circumference
B. Vital signs, refer to Attachment II
C. Condition of skin, mucous membranes, and fontanels
D. Nutritional status
E. Urine output
F. Neurological status
G. Growth and developmental level, emotional needs refer to
Attachment I
H. Special considerations that might affect IV access, such as
hand dominance or thumb sucking refer to Attachment III
I. Family or guardian expectations for involvement in patient
care and services.
II. Parents or caregivers must be responsible for constant
supervision, observing, and reporting signs and symptoms of
complications, since young children have a limited awareness of
what is happening to their bodies and the ability to express their
concerns (i.e., feeling hot or cold).
III. When placing a peripheral intravenous device, actual method of
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Code: D: PC-5645
venipuncture is the same for children as for adults, but certain
techniques enhance the successful placement and securement of
the device.
A. There is no recommended timeframe for rotation of pediatric
peripheral IV’s. Peripheral IV catheters should be removed
any time there are symptoms of phlebitis, infiltration,
extravasation, suspected contamination or; after therapy is
completed or access is not used for over 24 hours.
B. When establishing peripheral venous access in an infant or a
young child it is imperative to have at least one other person
present for the venipuncture. If the caregiver is unable or
unwilling to assist in the procedure, the patient must be taken
to the clinic or emergency room. The prescriber and
caregivers will be notified of this plan to maintain the
peripheral IV device.
C. The smallest gauge catheter, adequate to deliver the
prescribed therapy, should be used whenever possible.
D. Pad tongue blades for use as arm or foot boards. Secure
extremity with normal joint position maintained. Use caution
not to impair circulation with stabilization.
IV. Central venous access devices are recommended for home
infusion therapy that is to extend beyond a few days and/ or as
indicated by the ordered therapy (TPN, vesicants).
A. The most common complications of central venous
catheters in children include occlusion, migration, and
infection.
B. Securement of the device and any tubing connections is
important to prevent infection.
C. Lumens or extensions of the catheter should be secured
out of the child's reach to prevent accidental or
intentional catheter/ needle removal.
D. Pediatric patients should be assessed regularly for proper
central venous catheter tip placement due to growth and
development causing the tip to move out of the superior
vena cava.
V. Access Device Care:
A. Skin antisepsis with Chlorhexidine and use of Biopatch
are recommended for full term infants and premature
infants with a corrected age of > 37 weeks. Specific
orders will be obtained from the provider for any infant <
37 weeks corrected age.
B. Consider use of smaller dressing or Biopatch for infants
and toddlers.
C.
D.
VI. Pediatric patients may require agents to be administered for
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Code: D: PC-5645
catheter clearance or absence of a blood return. Refer to Policy
Alteplase (tPA) Central Vascular Access Device Clearance for
information related to catheter clearance in pediatrics.
VII. Lab Specimen Collection:
A. Discard volume for patients ≤ 10kg is 3ml.
B. Discard volume for patients > 10kg is 5ml.
C. Utilize Push/Pull method to minimize blood loss in at risk
patients.
VIII. Since a child may not be able to communicate symptoms of
an allergic reaction, all requests for First Doses in the home will
be reviewed for safety. In most cases it is preferred that the first
dose be administered in a controlled setting.
IX. Benzyl Alcohol Toxicity – It has been documented that neonates
receiving greater than or equal to 99mg/kg/day of Benzyl alcohol
developed Gasping Syndrome. This toxicity is potentially fatal;
the syndrome is exhibited as metabolic acidosis, respiratory
distress, gasping respirations, seizures, intracranial hemorrhage,
hypotension and/ or cardiac collapse. Pediatric patients receiving
medications that contain benzyl alcohol must be monitored for
symptoms of toxicity. Utilize preservative free medications
whenever possible.
X. Infusion pumps may be used in the pediatric population to avoid
fluid overload and enhance concise administration of the IV
therapy over the prescribed period of time. Use of a pump is
recommended when infusing vancomycin, amphotericin,
aminoglycosides, TPN and hydration or electrolytes. The
medication ordered as well as the patient's weight and age should
be considered when determining appropriate volumes and when
choosing an infusion method or device.
XI. Intramuscular injections:
A. The sites for intramuscular injection vary with age group.
1.
Up to one year old – anterolateral thigh
2.
1 year or older - anterolateral thigh, deltoid,
ventrogluteal The ventrogluteal site is located by
placing the palm of the hand over the greater
trochanter, index finger over anterior iliac
tubercle and middle finger over the crest of ileum
posteriorly, spreading fingers as far as possible.
Inject into the center of the V formed by fingers.
B. Needle gauge and length should be determined based on the
patient's weight and actual muscle mass. The length of the
needle must be sufficient to assure the medication is
administered within the muscle tissue. In general; Infants – 1
inch; Toddlers – 1 to 1 ¼ inch; Older children – 1 ½ to 2
inch.
C. Site rotation for intramuscular injections is strongly
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Code: D: PC-5645
recommended to avoid damage to the muscle and
surrounding tissue.
D. Volume to be administered should be determined based on
patient age, muscle mass and medication to be administered.
In general, infants less than 12 months volume should be 1
ml or less per site.
XII. Subcutaneous injections:
A. Subcutaneous injections can be given anywhere there is
subcutaneous tissue; common sites include:
1.
Center/ lateral aspect of the upper arm
2.
Abdomen
3.
Center/anterior aspect of the thigh
B. Needle gauge and length should be determined based on the
patient's weight and amount of subcutaneous tissue. In
general; ½ inch needle, 23-25 gauge or smaller.
C. Site rotation is generally recommended however in some
cases use of a subcutaneous catheter device may be
appropriate (i.e. Insuflon). Consult with prescriber and obtain
order for use as indicated.
D. Volume to be administered is generally 1 ml or less per site.
XIII. Nursing documentation at the SOC, ROC or recertification
visit will be completed using pediatric assessments to facilitate
complete and age appropriate assessments of the pediatric
patient.
XIV. The pediatric patient will be case managed using an
interdisciplinary team as appropriate, and may include a
pharmacist, nurse, dietitian, social worker, TLC team, school
nurse, and public health programs as needed.
External Ref: Joint Commission applicable standards
Policies and Procedures for Infusion Nursing; 4th Edition, 2011
Infusion Nurses Society Infusion Nursing An Evidence-Based
Approach, 3rd Edition, 2010
Wong’s Nursing Care of Infants and Children, 9th Edition, 2011
Pediatric Dosage Handbook, 13th Edition, 2006-2007
Internal Ref: Fairview Pharmacy Services Resource Center; on line access:
http://formweb.com/fps/
Refer to Policy: Subcutaneous Catheters: Insertion, Use and Care
Fairview Laboratory Policies
Source: FHI Clinical Managers, , Compliance Manager
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Code: D: PC-5645
Approved by: Director of Operations, Medical Director
Date Effective:
Date Revised: 09/09/2000, 1/1/2002, 4/04, 6/08, 12/2011, 4/2012, 12/2012, 4/2015
Date Reviewed: 12/2011, 4/2012, 12/2012, 4/2015
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Code: D: PC-5645
Attachment I
Developmental Stages of Childhood and Nursing Implications for Painful Procedures
Age group
Infant (birth to 1 yr)
Developmental Stage – Concept of Pain
Infants younger than 6 months seem to have no
memory of previous painful experiences. After 6
months of age a child’s pain response is felt to be
influenced by prior experience. Older infants may
use whatever motor activity they are capable of to
attempt to escape the procedure.
Considerations
Keep infants warm and swaddled
Consider use of a pacifier
A topical anesthetic like EMLA may be applied prior to a
needle stick, consider application to more than one site at
the same time in case the first attempt is unsuccessful
Administration of oral sucrose before, during and after
procedures has been shown to decrease procedural pain Avoid feeding just prior to a procedure to avoid the risk of
vomiting/ aspiration
Infants may be soothed by a parents touch or voice –
encourage parents to interact with child during and after the
procedure
Toddler (1 – 3 yr)
Toddlers tend to react to intrusive procedures with
intense emotional upset and physical resistance.
Pain may be exhibited as restless or overactive
behavior.
Prepare needed supplies and equipment out of view of the
child
Use simple and honest explanations
Positioning during the procedure may increase comfort, if
willing parents may hold the child
Use transitional objects to provide comfort (blanket, toy).
Use rewards (stickers)
Preschool (4 – 6 yr)
Reactions to pain in this age group are similar to
that of toddlers. Preschoolers are more responsive
to pre- procedural preparation than younger
children.
Prepare needed supplies and equipment out of view of the
child
Use play to prepare the child, allowing the child to handle
equipment or to practice the procedure on a doll helps
familiarize the child with the frightening aspects of the
procedure
Explain that it is okay to cry and that holding still is a big
help, praise cooperation
School age (6 – 12 yr)
School age children like to have a sense of control
and participation during procedures. In addition to
concerns of pain this age group is concerned with
the benefits and effects of the procedure. By the
age of 9 or 10 most children show less fright and
resistance to painful procedures
Explaining the procedure will generally decrease the child’s
anxiety
Discuss what distractions the child would like during the
procedure
If interested, allow the child to help and give tasks, such as
ripping tape, holding still, slow breathing
Offering choices increases the child’s sense of control.
Reassure that crying is okay
Adolescence (13 – 19 yr)
Adolescents typically react to pain with much selfcontrol. They may be reluctant to disclose their
pain making observation of physical indications of
pain necessary.
Explaining the procedure will generally decrease the child’s
anxiety
Show equipment, explain function and allow time for
questions – explain therapy as to an adult patient
Offer choices such as site location, if peers or family can be
present
Sources: Wong’s Nursing Care of Infants and Children Ninth Edition 2011; Infusion Nursing An Evidence-Based Approach Third Edition 2010
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Code: D: PC-5645
Attachment II
Pediatric Vital Signs (Normal Values)
Temperature
Age
36.5-37 (axillary)
Pulse rate
(Beats/min)
120-140
Respiratory Rate
(Breaths/min)
30-60
36.4-37 (axillary)
80-150
25-30
Fahrenheit
Celsius
Newborn
97.7-98 (axillary)
3 months to 3
years
97.5-98.6
(axillary)
3 to 10 years
97.5-98.6 (oral)
36.4-37 (oral)
70-110
16-22
10 years to adult
97.5-98.6 (oral)
36.4-37 (oral)
55-90
16-20
Blood Pressure (mmHg)
Systolic: 60-90 (Doppler)
Diastolic: 30-60
Girls
Systolic: 89-114
Diastolic: 49-74
Boys
Systolic: 93-107
Diastolic: 50-65
Girls
Systolic: 104-115
Diastolic: 66-74
Boys
Systolic: 102-115
Diastolic: 61-75
Girls
Systolic: 103-125
Diastolic: 65-80
Boys
Systolic: 112-125
Diastolic: 65-80
Adapted with permission from Wong’s Nursing Care of Infants and Children Ninth Edition 2011
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Code: D: PC-5645
Attachment III
Intravenous Sites in Children
Site
Patient Age
Veins Used
Considerations
Scalp
Infant, < 9 months
of age; used only if
other sites are not
accessible
Superficial temporal,
frontal, posterior
auricular
Foot
Infant, toddler
Great saphenous, median
marginal, dorsal venous
arch
Hand
All ages
Dorsal venous arch,
network with tributaries
Forearm
All ages
Cephalic, Basilic,
Antecubital
All ages
Cephalic, Basilic, Median
cubital
Average of 4-8 sites on the scalp
Hands kept free, sites in temporal/forehead area do not interfere with
side-to-side head movement
Hair may need to be removed, do not shave
Difficult to secure device
Greater family anxiety
Must have assistance for successful insertion
Average of 1-2 sites on the foot
Hands kept free
Can be more visible in chubby infants
Decreases mobility with walking
Risk of phlebitis in older patients
Catheter must be placed in the direction of the blood flow
In younger children vein location can be difficult because of
subcutaneous fat and small vein size
In older children hand veins are generally easily accessible and
readily visible
Catheters placed in the hand of an infant can be difficult to anchor
Potentially interferes with child’s activity
Keeps hands free
In younger children vein location can be difficult because of
subcutaneous fat and small vein size
Larger veins visible and palpable
Elbow joint must be maintained in extended position which limits
activity
Limits sites for drawing lab specimens
May interfere with peripherally inserted central catheter placement
General Considerations:



Utilize the most distal available site first to preserve proximal sites
Avoid sites over a joint whenever possible
Choose a site that restricts movement as little as possible
Sources: Wong’s Nursing Care of Infants and Children Ninth Edition 2011; Infusion Nursing An Evidence-Based Approach Third Edition 2010
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Code: D: PC-5645