Paeds · clinical-pharmacology-and-therapeutics
Developmental pharmacology and age-related pharmacokinetics
Also known as Paediatric pharmacokinetics · ADME ontogeny · Neonatal drug handling · Developmental clinical pharmacology
Fellowship guide to how absorption, distribution, metabolism and excretion of medicines change across paediatric development, and the dosing and monitoring consequences from preterm neonate to adolescent.
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Red flags
- Unexpected toxicity in a neonate on a 'standard' weight-based dose
- Apnoea in a preterm infant after an opiate or sedative
- Grey discolouration and cardiovascular collapse in a neonate on chloramphenicol
- Worsening jaundice after starting a sulfonamide or ceftriaxone
- Subtherapeutic anti-epileptic or antibiotic level in a school-age child on mg/kg dosing
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- General and Community Paediatrics
- Current 2026 PREP curriculum — Learning Objective 1.2.3: Apply principles of clinical pharmacology, including developmental pharmacology, to safe prescribing in infants, children and young people
- Current 2026 PREP curriculum — Learning Objective 1.4.1: Use evidence-based guidelines and paediatric formularies to prescribe safely
- Renewed curriculum for first-year trainees from 2027 — Learning goal 6: Pharmacology and safe prescribing in children
- Medical Sciences
- Clinical Applications
- Long Cases
- Short Cases
- 7. Patient safety, including safe prescribing
- 4. Professional skills and knowledge: Patient management
- 1. Knowledge base: Clinical pharmacology and safe prescribing
- Foundation of Practice (FOP)
- Theory and Science (TAS)
- Applied Knowledge in Practice (AKP)
- Clinical
- History
- Communication
- General Pediatrics Content Outline — Domain 23: Pharmacology
- General Pediatrics Content Outline — Universal Task 1: Physiology and Pathophysiology
- General Pediatrics Content Outline — Universal Task 5: Pharmacology
- Patient Care 5: Patient Management
- Systems-Based Practice 1: Patient Safety
- Systems-Based Practice 2: Systems-Based Quality Improvement
- Medical Expert
- Pediatrics: Foundations EPA #3 — Prescribing medications accurately and safely in children
Two ways children differ from adults
Pharmacokinetics (what the body does to the drug)
Pharmacodynamics (what the drug does to the body)
Quote the developmental stage before you argue the dose. Postmenstrual age, postnatal age, weight in kilograms and the maturational trajectory of the relevant organ together set the safe exposure window. [1] [5]
Overview & Definition
Developmental pharmacology is the study of how drug handling and drug action change across the developmental continuum — from fetal life, through preterm and term neonate, infancy, childhood, adolescence and into adult transition. [1] The reason it deserves its own topic is that pharmacokinetics in children is not a scaled-down version of adult pharmacokinetics. The same dose per kilogram that is curative in a teenager can be lethal in a preterm neonate, because the gut, the body water compartments, the hepatic enzymes and the kidney all mature at different rates over the first months and years of life. [1] [5]
The working definition a fellowship candidate should hold is operational. Pharmacokinetics (PK) describes what the body does to the drug — absorption, distribution, metabolism and excretion, summarised by the apparent volume of distribution (Vd), clearance (CL) and half-life (t½). Pharmacodynamics (PD) describes what the drug does to the body. In paediatrics, PK is the dominant variable that changes with age, and the change is steepest in the first month of life. [1] [4]
The age variables that matter for prescribing are gestational age at birth, postmenstrual age (gestational plus postnatal, used as the covariate for renal maturation), postnatal age, corrected age, and weight in kilograms. [5] [7] The next sections walk through how each ADME phase matures, and how that should change what you write on the chart.
References12ShowHide
- [1]Kearns GL Developmental pharmacology--drug disposition, action, and therapy in infants and children. N Engl J Med, 2003.PMID 13679531
- [2]Hines RN The ontogeny of drug metabolism enzymes and implications for adverse drug events. Pharmacol Ther, 2008.PMID 18406467
- [3]Hines RN Developmental expression of drug metabolizing enzymes: impact on disposition in neonates and young children. Int J Pharm, 2013.PMID 22766445
- [4]de Wildt SN Drug metabolism for the paediatrician. Arch Dis Child, 2014.PMID 25187498
- [5]van den Anker J Considerations for Drug Dosing in Premature Infants. J Clin Pharmacol, 2021.PMID 34185893
- [6]van Groen BD Ontogeny of Hepatic Transporters and Drug-Metabolizing Enzymes in Humans and in Nonclinical Species. Pharmacol Rev, 2021.PMID 33608409
- [7]Anderson BJ Mechanistic basis of using body size and maturation to predict clearance in humans. Drug Metab Pharmacokinet, 2009.PMID 19252334
- [8]Chapron BD Recent advances in the ontogeny of drug disposition. Br J Clin Pharmacol, 2022.PMID 33733546
- [9]Smits A Current knowledge, challenges and innovations in developmental pharmacology: A combined conect4children Expert Group and European Society for Developmental, Perinatal and Paediatric Pharmacology White Paper. Br J Clin Pharmacol, 2022.PMID 34180088
- [10]Leeder JS Ontogeny of Pediatric Pharmacogenetics: Celebrating the Past and Vision for the Future. J Pediatr Pharmacol Ther, 2022.PMID 35002553
- [11]Morse JD Pharmacokinetic Pharmacodynamic Modelling Contributions to Improve Paediatric Anaesthesia Practice. J Clin Med, 2022.PMID 35683399
- [12]Thakur A Ontogeny of Drug-Metabolizing Enzymes. Methods Mol Biol, 2021.PMID 34272706