My mother pasted this poem on my cupboard the day I was enrolled into medical college:
“Celebrated authors across the land
Wield the pen like a magic wand
But the words of greatest admiration
Are written by the hands writing a prescription ”
I often look at it with a sigh and complain that medicine is a profession everyone practices and that there are a host of non-medical specialists who confidently volunteer to give their opinion. Initially I was intrigued as to why I received calls from parents asking if I was sure that they should give their child the medicine the way I have prescribed it. Friends call to double check on their pediatrician's prescription. I now realize that parents be in this way because children are so vulnerable to the effects of a medication error. Furthermore, children may not be able to recognize and communicate the initial signs and symptoms of a medication adverse effect.
After I received my degree, I pasted this along my mother's words:
God and the Doctor they alike adore
But only when in danger, not before;
The danger o'er, both are similarly requited,
God is forgotten, and the Doctor slighted.
I want to use this opportunity to explain what goes on in a good pediatrician's mind while he prescribes – it is not an effortless process that is not thought through!
First, we prescribe a specific dose depending on the weight of the child. It is there before possible for two kids of the same age to get slightly different doses. Drug dosage depends also on the formulation. For example, let us consider Paracetamol given for fever.Paracetamol drops come in a composition of 100mg per ml, a syrup of 125 mg per 5 ml, a double strength of 250 mg per 5ml and a tablet of 500 mg. So if a child of ten kilos needs a 10mg / kg dose of paracetamol she can be prescribed one ml of drops (or 12 drops), 5ml of syrup, 2.5 ml of a double strength syrup or one fourth of a tablet. It is always important to read the labels right (and be good at mathematics!).
Secondly, every drug is metabolized (broken down and acted upon by enzymes) by the body to an “active ingredient”. This amount has a specific range which in medical terms is called “the therapeutic window”. An excess diverts the ingredient to be acted upon by several body rescue systems producing undesired and sometimes toxic products, and a deficiency will produce no benefit. After that the compounds are predominately cleared away by the liver and kidneys along with all other body waste. That is how a drug's effect weans off and since we write a twice or thrice daily schedule aiming to make the active ingredient available for longer periods of time. Paracetamol is extensively metabolized by the liver and it will be almost two hours before the effects are noticeable. Over a period of four to six hours the effect wears out. This is why we insist that the drug be given no more than four times a day. There will be no additional benefit and it will become a toxic load for the immature liver to handle.
Genetic and environmental factors contribute to a wide inter-and intra-individual variability in drug metabolism. It is well known that smoking, charcoal broiled food or cruciferous vegetables (like broccoli and cage) induce the degradation of many drugs, whereas grapefruit juice increases the oral availability of some by inhibiting their elimination. Apiaceous vegetables (carrots, parley, celery, and fennel) lead to lower liver enzyme activity Energy deficiency, and especially a low intake of protein, will cause a decrease in clearance and elimination of some drugs, which can be accelerated by a protein-rich diet. Tea (normal-strength black and green tea) ups liver enzymes degraiding certain drugs. Protein deficiency is associated with greater susceptibility to toxic reaction of drugs, thanks to impaired detoxifying capacities. Body reserves of antioxidants such as vitamins A and E, beta-carotene and zinc which are protective also effect drug metabolism. So you need to be well nourished for your medicines to help you too.
Drug and drug interactions can involve prescription or nonprescription drugs and affect each other's efficacy. Types of drug-drug interactions include duplication (where both their effects are amplified), opposition (antagonism where one makes the other ineffective), and alteration of what the body does to one or both drugs. Since most drugs are broken down and inactivated (metabolized) by certain enzymes in the liver. Some drugs affect these liver enzymes, either increasing or decreasing their activity, and may cause another drug to be inactivated more quickly or more slowly than usual. So please check with your physician before taking any new medicine.
In addition, medication administration is typically dependent upon a parent or caregiver. The secret is in believing that the child needs the medicine. A child can sense any doubts in your mind and will resist no matter what you do, unless you really believe you're doing what is best. Be confident and determined. If you are not convinced the medicine is necessary, talk to your doctor first, rather than trying half-heartedly to get it into your child. Give liquid medicine along the side of the mouth, about halfway down. If it goes directly to the center of your child's palate, it will trigger a gag. Place tablets on the back of the tongue or they will be spit out. Never refer to medicine as candy because you're setting up a potentially dangerous confusion. Tell it like it is. Do not punish a child who refuses to take medicine. Just insist and plow ahead. And when the mission has been completed, do not forget the hug and congratulations on a job well done for both of you!
As for mom, she has not lost her enthusiasm for her job in spite of two decades of private practice. She holds on to the belief that medicine is an art more than a science and that one must always feel lucky to be chosen by the divine to act as a channel for Him to heal a disease. Like many things we discover to be true years after we ridiculed them I hope I discover that she is right!