BCPPS Study Plan: Mastering Neonatology and Pediatric Critical Care for the Pharmacy Specialist Certification

BCPPS Study Plan: Mastering Neonatology and Pediatric Critical Care for the Pharmacy Specialist Certification

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Preparing for the BCPPS exam can feel like managing a busy NICU service: many moving parts, high stakes, little time. The good news is that neonatology and pediatric critical care follow predictable logic once you anchor them to physiology, pharmacokinetics, and a few core guidelines. This plan shows you what to study, why it matters, and how to structure 12 focused weeks to master the material with confidence.

What the BCPPS exam emphasizes

The blueprint shifts slightly each year, but most points come from direct patient care. Expect many cases involving infectious diseases, NICU, and PICU. Why this focus? Dosing and decisions in neonates and children vary by age, weight, and organ maturity, so the exam tests your ability to individualize therapy, justify it, and monitor for harm.

Common themes:

  • Patient-specific dosing: Prematurity, postnatal vs postmenstrual age, organ support (ventilation, ECMO, CRRT).
  • Guideline-aligned care: Sepsis bundles, sedation/analgesia/delirium strategies, hyperbilirubinemia thresholds, bronchiolitis care, DKA protocols.
  • Medication safety: Calculations, concentration conversions, compounding, high-alert meds, and error prevention.
  • Primary literature: Read trials critically—especially if they guide first-line therapy or monitoring targets.

Neonatal physiology that drives dosing

Neonates are not small adults. Their bodies distribute, metabolize, and clear drugs differently. You will see questions that only make sense if you start with physiology.

  • Absorption: Higher gastric pH affects weak acids/bases; slower gastric emptying delays some oral absorption. Why it matters: acid-labile drugs may have higher bioavailability; some enteral meds have unpredictable onset.
  • Distribution: Higher total body water and lower fat increase volume of distribution for hydrophilic drugs (e.g., aminoglycosides), which supports higher mg/kg loading but longer intervals. Lower albumin raises free fraction of highly bound drugs.
  • Metabolism: CYPs and UGT pathways mature over months. Morphine (UGT2B7) clearance is slow; fentanyl can be more predictable. Why it matters: choose drugs with simpler metabolism and titratable effects early in life.
  • Elimination: GFR and tubular function are immature, especially in preterm infants. This prolongs half-lives. Dosing intervals must reflect PMA and serum creatinine trends.

Apply it:

  • Aminoglycosides: Larger Vd but slower renal clearance. Use higher mg/kg loading and longer intervals; monitor troughs before the second or third dose.
  • Caffeine citrate: Long half-life supports once-daily maintenance; monitor for tachycardia and feeding intolerance.
  • Opioids: Prefer fentanyl infusions over morphine in very preterm neonates to avoid histamine-mediated hypotension and slower clearance.

Pediatric critical care essentials

In PICU, pharmacotherapy revolves around stabilizing physiology, then fine-tuning. The exam wants to see you choose the right drug for the right shock state or ventilation challenge, then monitor the correct endpoints.

  • Shock and sepsis:
    • Crystalloid for initial resuscitation; vasopressor choice by shock type. Norepinephrine for vasoplegia, epinephrine for cold shock (low cardiac output), vasopressin as adjunct.
    • Early antibiotics with meningitic dosing when CNS involvement suspected; de-escalate with culture data.
    • Why: Matching hemodynamics to receptor effects restores perfusion faster and reduces drug exposure.
  • Respiratory failure and ARDS:
    • Low tidal volumes, adequate PEEP, permissive hypercapnia when appropriate.
    • Consider neuromuscular blockade in severe ARDS to improve synchrony; monitor depth of sedation to avoid awareness.
  • Sedation, analgesia, and delirium:
    • Analgesia first (e.g., fentanyl), then sedation (e.g., dexmedetomidine or midazolam). Daily sedation assessments and minimization reduce delirium.
    • Use age-appropriate delirium tools; avoid benzodiazepine accumulation in organ failure when possible.
  • Neurologic emergencies:
    • Status epilepticus: benzodiazepine first, then levetiracetam or fosphenytoin. Avoid oversedation and hypotension.
    • TBI: target intracranial pressure control; maintain euvolemia; avoid hyponatremia; consider hypertonic saline.
  • Endocrine/metabolic:
    • DKA: isotonic fluids, insulin infusion, careful correction to avoid cerebral edema. Avoid bolus insulin.

High-yield NICU disease states and decisions

  • PDA: Conservative management vs pharmacologic closure (ibuprofen or indomethacin). Consider contraindications (renal dysfunction, NEC risk). Why: Closing a hemodynamically significant PDA can improve respiratory status.
  • PPHN: Optimize oxygenation/ventilation; inhaled nitric oxide as first-line; add sildenafil if refractory. Avoid hypoxemia, acidosis, hypothermia, which increase pulmonary vascular resistance.
  • BPD prevention and management: Non-invasive ventilation, caffeine, judicious oxygen; course steroids in select cases. Weigh benefits vs neurodevelopment risk.
  • HIE: Therapeutic hypothermia alters drug clearance (e.g., sedatives, opioids, antiepileptics). Reduce doses or extend intervals; monitor for accumulation.
  • NAS/NOWS: Prioritize non-pharm care; use morphine or methadone if needed; clonidine or phenobarbital as adjuncts. Titrate using standardized scoring.
  • NEC: Broad-spectrum coverage including anaerobes; bowel rest; surgical consult when indicated. Avoid enteral feeds during acute phase.
  • Hyperbilirubinemia: Phototherapy thresholds by age and risk factors; escalation to exchange transfusion if severe. Avoid ceftriaxone in neonates due to displacement of bilirubin and risk of kernicterus.
  • Apnea of prematurity: Caffeine as first-line; watch for infection or anemia as contributors.

Anti-infectives in children and neonates

  • Neonatal sepsis: Early-onset: ampicillin + gentamicin common; late-onset: tailor to nosocomial flora. Why: Coverage reflects maternal transmission vs hospital organisms.
  • Meningitis: Use meningitic dosing (higher mg/kg, more frequent intervals). Cefotaxime preferred over ceftriaxone in neonates. Add acyclovir if HSV risk (maternal lesions, seizures, temporal lobe findings).
  • Therapeutic drug monitoring: Vancomycin and aminoglycosides: set clear target exposures. Neonates often need extended intervals; ensure appropriate sampling.
  • Antimicrobial stewardship: Narrow therapy once cultures return; reassess every 24–48 hours; limit duration to evidence-based minimums to reduce resistance and toxicity.

Devices, extracorporeal support, and nutrition

  • ECMO: Drug sequestration by the circuit increases Vd and adsorption. Expect higher loading doses, cautious maintenance, and more monitoring for sedatives, antibiotics, and anticoagulants.
  • CRRT: Increased clearance for small molecules; adjust dosing by effluent rate and protein binding. For time-dependent antibiotics, consider continuous or extended infusions.
  • Parenteral nutrition (PN): Start low, advance macronutrients daily; ensure Ca/Phos solubility by temperature, pH, and sequence; track GIR to avoid hepatic steatosis and hyperglycemia.
  • Fluids and electrolytes: Maintenance fluid calculations, sodium correction rates, potassium replacement by route and renal function; hypertonic saline for severe hyponatremia with careful targets.
  • Blood products: Restrictive transfusion thresholds in stable infants; irradiated/CMV-negative products for high-risk groups.

Calculations you must be fast at

Calculation errors sink otherwise strong candidates. The exam expects speed and accuracy.

  • Weight-based dosing (mg/kg, mcg/kg/min), infusion rates (mL/hr), concentration conversions.
  • Renal dose adjustments by age, SCr, and support (CRRT, ECMO).
  • Maintenance fluids and deficit replacement; sodium correction limit per day.
  • Acid–base: anion gap, delta gap, expected CO2 in metabolic acidosis/alkalosis.
  • PN math: GIR, non-protein calories, protein g/kg/day, Ca/Phos ratios, osmolarity.
  • Vancomycin/aminoglycoside sampling times and interval adjustments.

Guidelines and statements to know cold

Do not memorize every detail. Focus on thresholds, first-line drugs, and monitoring endpoints.

  • Pediatric sepsis management bundles and vasoactive guidance.
  • PALS and neonatal resuscitation priorities (medications, dosing, timing).
  • AAP hyperbilirubinemia thresholds and escalation of care.
  • Bronchiolitis management recommendations (supportive care; limited role for bronchodilators/steroids).
  • DKA treatment pathways and cerebral edema prevention.
  • Sedation/analgesia/delirium guidance for PICU; daily assessments and benzodiazepine-sparing strategies.
  • NICU PDA management consensus approaches; inhaled nitric oxide use in PPHN.

A 12-week study plan

This plan assumes 8–10 hours/week. If you have less time, compress by prioritizing starred items and daily calculations.

  • Week 1: Orientation and baseline
    • Skim the exam domains; set score goals by section.
    • Create formula sheets for dosing, fluids, PN, and TDM.
    • Do 50 mixed questions to find weak areas.
  • Week 2: Neonatal PK/PD and safety
    • Absorption, distribution, metabolism, renal maturation; case drills on aminoglycosides and vancomycin in preterm vs term neonates.
    • Compounding safety, concentration limits, smart pump basics.
  • Week 3: NICU respiratory and cardiovascular
    • RDS management, surfactant basics, BPD prevention.
    • PDA treatment decisions; PPHN and inhaled nitric oxide.
    • Calculations: mg/kg to mcg/kg/min conversions.
  • Week 4: NICU neurology and infectious diseases
    • HIE under hypothermia; NAS protocols.
    • Early vs late-onset sepsis; meningitis dosing; HSV coverage.
    • TDM workshop: setting vancomycin and gentamicin sampling/targets.
  • Week 5: PICU sepsis and shock
    • Fluid strategy, vasoactive selection by shock type, steroid use in refractory shock.
    • Antibiotic selection by source and local patterns; de-escalation logic.
  • Week 6: PICU respiratory and sedation
    • ARDS strategies, ventilator synchrony, neuromuscular blockade pros/cons.
    • Analgesia-first approach, dexmedetomidine vs midazolam; delirium prevention and assessment.
  • Week 7: Neurologic emergencies and endocrine
    • Status epilepticus sequence; TBI targets and osmotherapy.
    • DKA: fluids, insulin, electrolyte management; cerebral edema prevention.
  • Week 8: Renal, CRRT, ECMO
    • Dose adjustment on CRRT; extended/continuous infusion strategies.
    • ECMO drug sequestration; anticoagulation nuances.
  • Week 9: Nutrition and PN
    • GIR, amino acids, lipids, Ca/Phos compatibility; micronutrients.
    • Refeeding risk, cholestasis prevention.
  • Week 10: Hematology, oncology, and ID consolidation
    • Transfusion thresholds; VTE prophylaxis in children at risk.
    • Antifungals in neonates; stewardship cases.
  • Week 11: Full-length practice exam and gap-filling
    • Simulate test conditions; review every miss with a why-based note.
    • Create 20 one-page case summaries for rapid recall.
  • Week 12: High-yield review and polishing
    • Re-do weak topics; rapid-fire calculations daily.
    • Review guideline thresholds and first-line choices.

Daily and weekly habits that compound

  • Daily: 20 calculation problems, 10 flashcards on doses/targets, 10–15 mixed questions.
  • Weekly: One mini-OSCE: write out a plan for a NICU/PICU case including goals, doses, monitoring, and de-escalation.
  • Error log: Track every missed question by concept and write the “why” in one sentence. Review it twice weekly.
  • Anchor cases: Build 8–10 cases (e.g., 26-week preterm with sepsis; toddler with ARDS on CRRT). Rehearse dosing and monitoring aloud.

How to study primary literature fast

  • State the question in one line: population, intervention, comparator, outcome, and timing.
  • Identify the endpoint type (mortality, ventilator-free days, neurodevelopment scores) and whether it’s patient-centered.
  • Check size, randomization, and key exclusions that affect generalizability to NICU/PICU.
  • Decide if results change first-line therapy or just inform second-line or monitoring.

Exam strategy and test-day tactics

  • Time: Move. If you cannot decide in 60 seconds, mark and advance. Many questions are straightforward if you know the dose/threshold.
  • Math: Write units first; convert weights/volumes before plugging in numbers. Sanity-check final answers.
  • Elimination choices: Remove options that violate physiology (e.g., ceftriaxone for a neonate), exceed safe dosing, or ignore organ support.
  • Revisit marked items last: Often another question jogs a memory that unlocks a tricky one.

Quick reference: must-know doses and targets

These values are common starting points. Always consider institutional standards, organ function, and support devices.

  • Resuscitation and shock
    • Epinephrine infusion: 0.05–1 mcg/kg/min; push dose in arrest per resuscitation guidance.
    • Norepinephrine infusion: 0.05–1 mcg/kg/min for vasoplegia.
    • Vasopressin infusion: 0.0003–0.002 units/kg/min as adjunct.
    • Hydrocortisone stress dosing: 1–2 mg/kg/dose q6–8h for refractory shock.
  • Analgesia and sedation
    • Fentanyl infusion: 0.5–2 mcg/kg/hr; bolus 1–2 mcg/kg carefully to avoid chest wall rigidity.
    • Dexmedetomidine infusion: 0.2–1 mcg/kg/hr; avoid loading in unstable patients.
    • Midazolam infusion: 0.05–0.2 mg/kg/hr; monitor for accumulation in organ dysfunction.
  • Seizures
    • Lorazepam: 0.1 mg/kg IV for status epilepticus.
    • Levetiracetam loading: 40–60 mg/kg IV; maintenance 20–30 mg/kg/day divided.
  • DKA
    • Insulin infusion: 0.05–0.1 units/kg/hr; start after initial fluids; avoid bolus insulin.
    • Fluids: isotonic crystalloid; correct sodium for hyperglycemia when interpreting labs.
  • Neonatal essentials
    • Caffeine citrate: load 20 mg/kg; maintenance 5–10 mg/kg/day.
    • Ibuprofen for PDA: step-down dosing (e.g., 10 mg/kg then 5 mg/kg x2 doses 24 hours apart) if no contraindications.
    • Acyclovir in suspected HSV: 20 mg/kg IV q8h; monitor SCr and adjust for renal function.
    • Aminoglycosides: higher mg/kg with extended intervals; monitor troughs and adjust by PMA and renal function.
  • Antibiotics
    • Ceftriaxone: avoid in neonates; in older children, 50 mg/kg/day for many indications (verify by source and severity).
    • Vancomycin: target exposure per institutional practice; in neonates use extended intervals with TDM.

Practice case frameworks

  • Preterm neonate with late-onset sepsis: Choose empiric coverage for hospital flora, set dosing intervals by PMA/SCr, plan TDM, and draft a 48-hour de-escalation note.
  • PPHN with refractory hypoxemia: Confirm ventilator optimization, start inhaled nitric oxide, consider sildenafil, and outline weaning and rebound prevention.
  • PICU cold shock on CRRT: Pick epinephrine first, adjust beta-lactam dosing to effluent rate, and justify continuous infusion for time-dependent antibiotics.
  • Severe ARDS needing paralysis: Set analgesia and sedation targets, choose neuromuscular blocker, and define daily wake-up and delirium checks.

Final week plan

  • Re-read your one-page summaries and error log.
  • Do one 75–100 question block daily; review only what you missed.
  • Drill calculations for 20 minutes twice a day.
  • Memorize thresholds: bilirubin phototherapy/exchange cues, DKA steps, sepsis timing, bronchiolitis do/don’t list.

Last 24 hours checklist

  • Skim your formula sheet and “must-know doses.”
  • Review five anchor cases aloud, including monitoring and de-escalation.
  • Pack a timing plan: minutes per question, when to mark and move.
  • Sleep. Memory consolidation beats last-minute cramming for complex cases.

Mastery here is about clarity, not cleverness. Tie every dosing choice to physiology, match every drug to a measurable goal, and write down the “why” behind each decision while you study. Do that for 12 weeks, and the NICU and PICU vignettes on exam day will feel like familiar consults—not surprises.

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