PORTSMOUTH – With the recent Food and Drug Administration restriction of two medications that they say should not be given to children, a reminder that children and adults metabolize medications very differently, and the importance of accuracy and care with the younger population is warranted.

The FDA is restricting the use of codeine and tramadol medicines in children. Codeine is approved to treat pain and cough, and tramadol is approved to treat pain. These medicines carry serious risks, including slowed or difficult breathing and death, which appear to be a greater risk in children younger than 12 years, and should not be prescribed for children.

An FDA bulletin, issued last week, indicates these medicines should also be limited in some older children. Single-ingredient codeine and all tramadol-containing products are FDA-approved only for use in adults. The FDA is also recommending against the use of codeine and tramadol medicines in breastfeeding mothers due to possible harm to their infants.

The FDA’s strongest warning, called a contraindication, will be added to the drug labels of codeine and tramadol alerting that the drugs should not be used in children younger than 12 years.

“The first thing to remember is that kids are not just small adults,” said Jeffrey Low, lead pediatric pharmacist at Dartmouth Hitchcock Medical Center. “There is a real difference in the way they process (metabolize) medications. They can have different rates of elimination and there can be significantly more profound results. In the case of children, particularly infants and very young toddlers, they are unable to communicate the side effects they may be experiencing.”

Regarding the latest FDA warning, Low said codeine and tramadol can transform into a more potent form in a child’s liver, so he feels the warning is a good one.

“Some people, kids included, have a genetic disposition to rapidly metabolize medications,” said Low. “As a result, they can get too much of the drug, too fast and have adverse results. There is no way to know this ahead of time, so it is unpredictable as to who may have a reaction.”

Since Dartmouth Hitchcock is a teaching hospital, Low said the alerts on drugs like codeine are built into their electronic dispensing system to make sure everyone is aware.

Dosing medications correctly for children is important. And Low says there is a lot of misconception surrounding that.

“A lot of parents think that dosing is about volume, but really it is not,” said Low. When we think of prescribing, we are thinking in terms of milligrams and such, not teaspoons. There is a wide variation in common household teaspoons and they are not an accurate way to measure the child’s dose.”

A prescription order will give dosing information and the frequency of when the medicine should be administered. Low said it is important to follow both.

“Pharmacies can give out oral syringes for liquid medications that will measure the exact dose,” said Low. “They rely on the metric system, which is how the medications are prescribed in most cases.”

Dr. Scott Murcin of the Women’s and Children’s unit at Portsmouth Regional Hospital said there is a big push, medically, to find better ways to measure children’s medications.

“The teaspoon you eat with is not an accurate measure,” said Murcin. “At the pharmacies, if they do not give it automatically, parents should ask for an oral syringe or a special measuring spoon. Most prescribers are moving to metric measurements, based on body weight, rather than teaspoons because of safety. Medicines like codeine are really risky because they can suppress the respiratory system and result in breathing problems, which is an emergency.”

Also, Low said different medications which purport to be the same, especially in over-the-counter drugs, can have varying formulas, with varying concentrations of the active ingredient.

“Tylenol, in liquid form used to have this problem, but they have corrected it,” said Low. “There are still a number of prescription medications that may have different concentrations.”

Amanda C. Chuk, pharmacist and manager of medication use and standards at Dartmouth Hitchcock Medical Center, said if anything, this highlights the need for parents to be informed, and to be engaged in knowing what they are giving to their children.

“If they have a clear understanding, they can avoid a medication error,” said Chuk. “We, as pharmacists, welcome questions about the medications prescribed.”

Chuk said the Board of Pharmacy recognizes in its rules that pediatric medicines require counseling. She said they are committed, as a profession, to assuring the best, safe practices.

Allergic reactions can be mild to severe, and parents should know the signs. Low said the first sign is usually a skin rash, or hives.

“Some children with repeated exposure to a medication can have a reaction that is severe, even life-threatening,” said Low. “If there is facial swelling, or difficulty breathing, that is a medical emergency and requires immediate medical care.”

Antibiotics require care, too. Murcin said giving too much of an antibiotic can not only kill the bad bacteria, but also the useful bacteria in the stomach, which will result in gastric issues. He said doctors are more careful about prescribing antibiotics for children, and they are moving away from prescribing for viral illnesses.

“The antibiotics are not really intended for viral conditions, which will usually resolve on their own in a few days,” said Murcin.

“Over-the-counter medicines like liquid Motrin can cause liver problems or gastritis,” said Murcin. “When I get calls from parents in the middle of the night, they ask about what they have in the house. I ask them to read me the concentration, which is listed on all over-the-counter medications. Then I can, if appropriate, tell them the dose they can safely use, based on the weight of the child.”

Never give a child a medication that was prescribed for another person, especially an adult. Low said it is not enough to estimate a lower dose for safety. It is not safe.

“Also, unless prescribed for a specific condition, avoid aspirin for children because of the risk of Reye’s Syndrome which can be life-threatening,” said Low. “Avoid over-the-counter cough preparations for small children under 2. They can pose risks and the FDA has found them to be ineffective. For congestion, use a bulb syringe.”

Chuk said knowledge is the key. If the parent has a complete understanding of the medications prescribed for their child, they will greatly reduce the risk to them.