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Don’t Be Victim To Medication Mistakes

Everyone makes mistakes. The problem with medicine is that the mistakes can be potentially really harmful. As a parent, you just expect that your doctor never makes a mistake when prescribing medications for your child. But the truth is, it happens. The problem is that you’re stuck trusting that your doctor did it right. So here’s some insider’s tips into helping you double check your doctor. (If you think something may be off, don’t be afraid to speak up. Doctors aren’t trying to make mistakes, but it’s easy to get distracted and dosing medications for kids can be tricky).

Most pediatric medications are weight-based

Almost all oral (and IV) medications are weight-based in kids. After all, some 2 year olds are the size of 5 year olds and some teens are adult sized.

  1. Make sure your child was weighed during the check in. Unless the medication is topically applied, chances are the doctor will need your child’s weight.
  2. Medications are based on kilograms (kg), not pounds (lb). In our office, the electronic medical record system automatically converts lbs. to kgs. FYI, there are 2.2 lbs. in 1 kg. (e.g., a 22 lb. child weighs 10 kg.). If the doctor is doing the calculation manually, it is easy to skip the conversion step and your child can be way over dosed.

Frequency of the medication

As a general rule, most doctors opt for medications that can be given less frequently (we know it will increase the chances of people remembering to take the medications). With this in mind:

  1. Most medications are prescribed once or twice a day. There are some exceptions, like eye drops, medications for skin infections, etc.
  2. Clarify/double check with the doctor anytime the medication is given 3+ times a day.
  3. Most medications for acute problems are prescribed for 5-10 days (with most antibiotics being 10 days). Occasionally medications will be for a shorter period (like a 3-day course of steroids) or longer (like a 14-day course for a serious bacterial infection or a continuous medication for a chronic problem). These situations are the exception rather than the rule and warrant clarification with the doctor.
  4. If the medication is a long term medication, clarify if the medication is supposed to go beyond a month and should you utilize refills to continue the medication uninterrupted. All the medications used for chronic conditions fall into this category (e.g., asthma medications, heart medications, psychiatric medications).

Liquid medications come in different concentrations

A common place to make a mistake is in prescribing the “right amount”(volume) of a liquid medication, but choosing the wrong concentration. In our office, all prescriptions are done electronically. This reduces the chance for errors and allows quick reference to see what has been previously prescribed. The problem is that in many liquid medications, I have to click the concentration I want. For example, amoxicillin comes as 125 mg/5 mL, 250 mg/5 mL, 200 mg/5 mL and 400 mg/5 mL. It’s easy to see that 5 mL (which is a teaspoon) could mean 4 different doses of medication. As a general rule, use more concentrated medications in older children so they don’t have to take as much volume of the medication.

Same medication with different doses for different conditions

If I do come across a mistake (e.g., a patient of mine was prescribed a medication at an Urgent Care over the weekend), the mistake often falls under this category. Sometimes, the very same medication is used at different doses for different problems. There are lots of subtle nuisances to dosing medications in children. If the doctor doesn’t work with kids often, it’s easy to see how this happens.

A common example of this is with amoxicillin (one of the most prescribed antibiotics in the world of pediatrics). Amoxicillin is used for Strep throat, ear infections, and pneumonia (among other things). When prescribed for strep throat, amoxicillin is dosed at 50 mg/kg. When prescribed for an ear infection it is dosed at 80mg-90mg/kg (significantly higher due to bug resistance and difficultly penetrating the affected area). For example, take a 35 lb. (16 kg.) 3 year old. If the child has a strep throat, the dose will be 5 mL twice a day of amoxicillin (using the 400 mg/5 mL suspension). The same child would get 8-9 mL twice a day for an ear infection (using the same amoxicillin 400 mg/5 mL).

Max out at adult dosing

As mentioned previously, most medications in pediatrics are weight-based. If, however, the child tends to be on the heavy side, it is quite possible that the dose per kg (weight) may exceed the standard adult dose. As a general rule (again, there are exceptions with certain medications/circumstances), don’t give a child more than you would give an adult. I know this seems very basic, but you’d be surprised how often I see this happen.

Example:  You and your child get strep throat. Your doctor prescribes amoxicillin 875 mg tablets twice a day for 10 days for the parent. Your 100 lb. (45.5 kg) 11 year-old also gets strep. Strep is dosed 50 mg/kg, so a total daily dose of 2,275 mg. If you divide that in two, because it’s dosed twice a day, you get 1,137.5 mg which exceeds the adult dose. So in this case, I would prescribe the adult dose.


Know your child’s allergies. Don’t assume your doctor will remember your particular child’s medication allergies. Be vocal. Anytime a prescription is going to be written for your child, reiterate allergies (especially if the nature of the reaction was anaphylaxis). Doctors should ask/review, but sometimes they forget to ask. So speak up-even if the medication seems different (sometimes, they are in the same drug class or cross react which is equally risky as the original offending medication).

Safe guards

Maybe I’m an optimist, but I don’t think medication mistakes happen a lot. There are a number of safeguards to help prevent erros.

  1. New electronic medical record/prescribing programs have all sorts of safe guards and dosing calculators built into them to help catch/prevent errors.
  2. Pharmacists (although it technically isn’t their responsibility) will often catch mistakes when a prescribed medication or dose seems out of the ordinary for a child.
  3. Parents. I think parents are savvy. They remember how much they took of a medication for a particular problem or what another child of theirs took. So keep up the good work. You can help keep your doctor on his/her “A-game.”

Motrin (Ibuprofen) Dosing

I get a lot of questions about what are appropriate doses for Tylenol (see Tylenol dosing article) and Motrin in kids. Here’s the info. Feel free to bookmark this page, print it (and hang in your medicine cabinet) or pass it along.

Medication: The medication is in the drug class called NSAIDS (non-steroidal anti-inflammatory drugs). Motrin is the trade name. Ibuprofen is the generic name. Both work equally well. Generally, the trade name medication (Motrin) is more expensive.

Age Limit: Do NOT give to infants less than 6 months of age unless specifically directed by your pediatrician to do so. Ibuprofen is not FDA approved in children under the age of 6 months.

Use: Treat fever, pain, or inflammation.

Interval: Every 6 hours.

Dose: Based on your child’s weight (age dosing is based on averages and not as accurate as weight dosing). For the mathematically minded, the dose is 5-10 mg/kg/dose (which I’ve calculated out below).

Forms: The concentrations are different. Infant Motrin is more concentrated than Children’s Motrin. Read labeling carefully to avoid a dosing error.

Infant Motrin (ibuprofen: 50 mg in each 1.25 mL)

Weight | estimated age | Dose

6-11 lbs | 0-5 months | Do Not Dose

12-17 lbs. | 6-11 months | 1.25 mL

18-23 lbs. | 12-23 months | 1.875 mL

Children’s Motrin (ibuprofen: 100 mg in each 5 mL)

Weight | estimated age | Dose

24-35 lbs. | 2-3 years | 5 mL

36-47 lbs. | 4-5 years | 7.5 mL

48-59 lbs. | 6-8 years | 10 mL

60-71 lbs. | 9-10 years | 12.5 mL



How To Reduce Medication Mistakes

I don’t give my children medication very often. In general, I think medications are over prescribed and kids are often over medicated. Ironically enough, two of my children ended up getting medication tonight before bed. My oldest got an over-the-counter medication where I just used the measuring/dosing cup that came with the product. My baby, got an antibiotic that I used a syringe to dose.

After putting them to bed, I pulled out my copy of the September 2016 Pediatrics journal. Wouldn’t you know it, there’s an article about medication dosing errors: “Liquid Medication Errors and Dosing Tools: A Randomized Controlled Experiment.” Naturally, I was intrigued. In short, we’re all blowing it when it comes to giving medication to our kids.

The study found that 84.4% of parents made one or more dosing errors (as defined by being off by 20% or more) when giving medications. (Parents were measured giving 9 different doses). I was blown away; almost everyone made mistakes. Furthermore, more errors were made with cups than syringes.

Over time, lots have studies have shown how bad it is to use kitchen spoons, teaspoons, and such to measure and give liquid medications. They are all different sizes, so it makes sense that many dosing errors would happen using those methods. I just never imagined so many mistakes would happen with the devices designed to measure medications.

So how do I get the most accurate measurements?

  1. Use a syringe to measure. Use the smallest syringe possible for the amount of medication needed (e.g., if the medication dose is 0.7 mL, use a 1 mL syringe rather than a 10 mL syringe). The closer the medication dose to the syringe size, the more precisely it can be measured.
  2. Choose a syringe that has markings for individual numbers (e.g., 1 mL, 2mL, 3 mL, etc., through 10 mL instead of 5 mL, and 10 mL only).
  3. When drawing up the medication, make sure the syringe is completely depressed and the end is completely covered with the liquid before drawing up the syringe. Draw up more than needed and then push out the excess back into the bottle “down to the desired dose.” This will ensure air bubbles are not drawn up in the dose.
  4. If the medication arcs slightly in the syringe (where the liquid comes up slightly on the sides), use the bottom of the arc to line up the measurement.
  5. Avoid spoons, cups, teaspoons, etc.


Doctors should write liquid prescriptions in “mL” (milliliter) doses. However, sometimes doctors inadvertently write them in teaspoons (a bad, old habit). In case they do, it’s worth knowing what doses are equal.

  1. 5 mL = 1 teaspoon (tsp)
  2. 3 teaspoon (tsp) = 1 tablespoon (tbsp)
  3. 1 tablespoon = 15 mL

I hope this helps you dose liquid medications more accurately to your little ones. I know I’m going to ditch the medicine cups that come with the medications and stick with syringes.