1. Palliative Care For Children
General Overview
Mike Harlos MD, CCFP, FCFP
Professor, Faculty of Medicine, University of Manitoba
Medical Director, Winnipeg Regional Health Authority Palliative Care Program
Co-Chair, Canadian Network of Palliative Care for Children
Physician Consultant, Canadian Virtual Hospice

2. Objectives To consider the definition of pediatric palliative care
To consider where pediatric palliative care may fit in the care of seriously ill children
To consider similarities/differences with palliative care for adults
To review the prevalence and management of symptoms in children living with life-threatening illness

3. Prognostic Uncertainty
Pediatric Palliative Care services providers must acknowledge the uncertainty involved in determining if a specific circumstance or condition is life-limiting / life-threatening

4. Common Trajectory Of Decline In Progressive Life-Limiting Illness In Children
From presentation by Joanne Wolfe at the 16th International Congress on the Care of The Terminally Ill
Functional
Status
Decline
Crises
(“Scary Dips”)
Death
Time

5. “Prognostic Irrelevance”
In the view of patient, family, and/or care team, there may be unwillingness to even consider the possibility of death
Service availability should not only accommodate prognostic uncertainty, but should not require acceptance of a threatened life

6. Palliative Care… The “What If…?” Tour Guides
What would things look like?
Time frame?
Where care might take place
What should the patient/family expect (perhaps demand?) regarding care?
How might the palliative care team help patient, family, health care team?
“What if…?
Disease-focused Care
(“Aggressive Care”)

7. Addressing The “What-Ifs…” Silence Is Not Golden
Children (even young children) are very perceptive, and can tell when something serious is happening
Even when pursuing cure for their child, parents are often aware in their “heart of hearts” that things may not unfold as hoped for
Palliative Care has a role in:
helping families navigate through difficult decisions, at times conflicted about which course is best for their child… “path of least regret”
ensuring that comfort and quality of life are minimally affected by the impact of illness, tests, and treatments
facilitating communication about fears and worries, and open dialogue about what to expect

8. Talking about Death with Children … ctd
Kreicbergs et al NEJM 2004; 351(12):
Did you talk about death with your child at any time?
Yes
n = 147
(34 %) No
n = 282
(66 %)
Do you regret having done so?
Do you regret not having done so?
No parents regretted having talked with their children about dying
Yes No
Overall:
27%
73%
Identify and facilitate communication
Sensed Child Aware Of Dying:
47%
53%
Did Not Sense Child Aware:
13%
87%

9. What Symptoms Do Children With Advanced Illness Experience?

10. n = 160 cancer patients receiving treatment aged 10 – 18 yo
The Measurement Of Symptoms In Children With Cancer Collins JJ, Byrnes ME, Dunkel IJ, Lapin J, Nadel T, Thaler HT et al. J Pain Symptom Manage 2000; 19(5):
n = 160 cancer patients receiving treatment
aged 10 – 18 yo
30-item patient-rated instrument (MSAS 10-18)
Inpatients averaged 13 symptoms, outpatients 6.5
Patients who had recently received chemotherapy had more than double the symptoms of those who had not

11. Symptoms At The End of Life in Children With Cancer
Wolfe J. et al, NEJM 2000; 342(5) p 80 70 % 60 50 40 30 20
Successfully
Treated
(% Of Affected
Children) 10
27 %
16 %
10 %
Pain
Dyspnea
Nausea And Vomiting

12. Pain In Advanced Childhood Illness
Symptom Prevalence At Study Entry And In Last Month Of Life UK Children’s Cancer Study Group/Paediatric Oncol Nurses Forum Survey Goldman A et al; Pediatrics 2006; 117;
Abstract from the 7th International Symposium on Pediatric Pain
Stenekes S, Hughes A, Grégoire MC, Frager G
Breau LM, Camfield CS, McGrath PJ, Finley GA. The incidence of pain in children with severe cognitive impairments. Arch Pediatr Adolesc Med 2003; 157(12):
Engel JM, Jensen MP, Hoffman AJ, Kartin D. Pain in persons with cerebral palsy: extension and cross validation Arch Phys Med Rehabil 2003; 84(8):

13. Symptoms in Children with Neurodegenerative Illness%
Hunt and Burne, 1995

14. 2002 College Of Physicians And Surgeons Of Manitoba Child Health Standards Committee Report
2002 Manitoba Deaths
Unlikely role for Palliative Care in symptom management, though potentially in family and staff support
Potential role for Palliative Care in symptom management as well as family and staff support

15. “Palliative in Parallel”
Palliative care for children should not be exclusive of ongoing cure-focused care
Can be involved as a parallel process, with a variable profile depending on goals of care and clinical circumstances
It is not unusual for children/families/clinicians to harbour seemingly conflicting thoughts and contradictory goals
There are some situations where one could argue that the standard of care should require involvement of a palliative service… eg:
Phase One Clinical trials
Organ Transplant waiting lists

16. Various Patterns Of Pediatric Palliative Care Involvement
Cure-Oriented; Disease-Focused
Palliative

17. Patient Groups For Pediatric Palliative Care Services
Advanced life-limiting condition from which death within 12 months would not be unexpected
Group 1
Children with progressive life-limiting/life-threatening conditions who are not expected to survive into adulthood, but whose prognosis is anticipated to exceed one year
Group 2
Comfort-focused approach has been chosen, or disease-focused interventions not possible
Group 1A
Advanced life-limiting illness with substantial disease and symptom burden for whom cure is nonetheless hoped for, or for whom all aggressive disease-focused and potentially life-sustaining options are being pursued
Group 1B

18. Pediatricians’ Sense Of Preparedness For Practice
Lieberman L, Hilliard LI; Medical Education 2006; 40: 539–546
n = 239 pediatricians certified in Canadian training programs between1999 and 2003
Medical expert providing anticipatory guidance, well child care
Medical expert dealing with child and youth maltreatment abuse
Medical expert dealing with the chronic care of complex problems
Medical expert dealing with palliative care
Medical expert dealing with death and bereaved parents
Procedural skills
Communicator - working successfully with difficult patients families
Communicator - working successfully with cultural or socioeconomic differences
Collaborator - working as a member of a team
Manager - learning principles of quality management
Manager - managing an efficient office practice
Health advocate for individual patients
Health advocate for disadvantaged children or child health issues
Scholar - ability to carry out a research project
Scholar - ability to critically appraise literature
Professional and ethical issues
Medical expert providing anticipatory guidance, well child care
Medical expert dealing with child and youth maltreatment abuse
Medical expert dealing with the chronic care of complex problems
Medical expert dealing with palliative care
Medical expert dealing with death and bereaved parents
Procedural skills
Communicator - working successfully with difficult patients families
Communicator - working successfully with cultural or socioeconomic differences
Collaborator - working as a member of a team
Manager - learning principles of quality management
Manager - managing an efficient office practice
Health advocate for individual patients
Health advocate for disadvantaged children or child health issues
Scholar - ability to carry out a research project
Scholar - ability to critically appraise literature
Professional and ethical issues
Medical expert providing anticipatory guidance, well child care
Medical expert dealing with child and youth maltreatment abuse
Medical expert dealing with the chronic care of complex problems
Medical expert dealing with palliative care
Medical expert dealing with death and bereaved parents
Procedural skills
Communicator - working successfully with difficult patients families
Communicator - working successfully with cultural or socioeconomic differences
Collaborator - working as a member of a team
Manager - learning principles of quality management
Manager - managing an efficient office practice
Health advocate for individual patients
Health advocate for disadvantaged children or child health issues
Scholar - ability to carry out a research project
Scholar - ability to critically appraise literature
Professional and ethical issues
Medical expert providing anticipatory guidance, well child care
Medical expert dealing with child and youth maltreatment abuse
Medical expert dealing with the chronic care of complex problems
Medical expert dealing with palliative care
Medical expert dealing with death and bereaved parents
Procedural skills
Communicator - working successfully with difficult patients families
Communicator - working successfully with cultural or socioeconomic differences
Collaborator - working as a member of a team
Manager - learning principles of quality management
Manager - managing an efficient office practice
Health advocate for individual patients
Health advocate for disadvantaged children or child health issues
Scholar - ability to carry out a research project
Scholar - ability to critically appraise literature
Professional and ethical issues

19. Keeping The Momentum – Recent Developments
2003: Canadian Network of Palliative Care for Children (CNPCC)- see
March Pediatric Hospice Palliative Care Guiding Principles And Norms Of Practice, through joint work by the CNPCC and CHPCA
2006: 1st major clinical textbook in pediatric palliative care, The Oxford Textbook of Palliative Care for Children.
2006: The Canadian Council on Health Services Accreditation (CCHSA) released in its standards for Hospice and End-of-Life Care
The Royal College of Physicians and Surgeons of Canada is exploring core competencies in Pediatric Palliative Care
There is increasing interest is there amongst physicians training in Pediatrics

20. Pain Assessment In Children
Pain can be measured by:
self-report (what children say) – “Gold Standard”
biological markers (how their bodies react)
behaviour (what children do)
Biological and behavioural measures tend to habituate over time; parameters may not be specific to pain.
May deny pain if the questioner is a stranger, if they believe they are supposed to be brave, if they are fearful, or if they anticipate receiving an injection for pain.
Much variability in developmental capacity for children to report and describe pain
Questioning should be patient & use words familiar to the child, eg.
"Do you have any hurt?"
"Is there an ‘owie’ or ‘boo-boo’ in your tummy?"

21. Pain Assessment Self-Reporting and Developmental Stage
Children have words for pain by about 18 months if age; may prefer the word hurt rather than pain; may use idiosyncratic, family words
Most children > 2 yrs can report presence & location of pain
3 – 4 yrs: cognitive skills to describe pain intensity (eg. “a little”, “a lot”)
4-5 yrs: can use the Poker Chip scale
Can test ability to use pain-rating tools with simple test of seriation
By about 5 yrs – capacity to provide good qualitative and quantitative information

22. Pain Assessment Self-Reporting and Developmental Stage ctd…
5+ yrs can usually rate and score pain; the Bieri Faces Pain Scale may be used
Children point to a face on the scale that matches how they feel.
The child should be trained by asking how he or she would feel following some minor pain. The child is asked about how much a more serious pain would hurt.
7+ yrs: children can rate pain on a 0 (no pain) – 10 (worst possible pain) scale
8+ yrs are able to describe the quality of the pain experience
Describing how pain affects emotions requires more abstract concepts
Adolescents are quite capable of using scales that use adjectives to describe both affect and sensory intensity

23. Faces Pain Scale – Revised
Children Beginning At 3-4 yo
Avoid affective descriptors (eg. “Point to the face that shows how you are feeling”)
May be misinterpreted as “are you happy/sad?”

24. General Principles For The Prevention And Management Of Pain In Newborns
Pain often unrecognized and undertreated. Neonates do feel pain, and analgesia should be prescribed when indicated during their medical care.
If something hurts adults, it will hurt newborns, even if they are preterm.
Compared with older age groups, newborns may experience a greater sensitivity to pain and are more susceptible to the long-term effects of painful stimulation.
Adequate treatment of pain may be associated with ↓complications and ↓ mortality.
The appropriate use of environmental, behavioral, and pharmacological interventions can prevent, reduce, or eliminate neonatal pain in many clinical situations.
Sedation does not provide pain relief and may mask the neonate's response to pain.
Health care professionals have the responsibility for assessment, prevention, and management of pain in neonates.
Clinical units providing health care to newborns should develop written guidelines and protocols for the management of neonatal pain.
Anand KJ. Consensus statement for the prevention and management of pain in the newborn. Arch Pediatr Adolesc Med 2001; 155(2):

25. Approach To Analgesia Use In Pediatric Palliative Care
The oral (enteral) route preferred for most children, most of the time
However… many alternate routes available if needed:
IV (peripheral and central)
Subcutaneous
Transmucosal (nasal, buccal, sublingual)
Transdermal / transcutaneous
Spinal (epidural, intrathecal)
Rectal (usually not well tolerated)
Use adjuvants as appropriate
The W.H.O. ladder is a good template on which to base analgesic use
Virtually always prescribe laxatives with opioid Rx

26. Weak Opioids Used In Pediatric Palliative Care
Codeine remains the most commonly prescribed weak opioid, however there are considerations:
Codeine is a pro-drug of morphine, from which its analgesic effect is derived
Up to 10% of the Caucasian population lack the enzyme necessary for transformation of codeine to morphine; perhaps up to 47% of those < 12 yrs old
If 1 mg/kg codeine ineffective, switch to morphine or alternative
Oxycodone:
has some κ receptor agonist activity as well as μ
No ceiling dose – can potentially be continued throughout course of illness

27. STRONG OPIOIDS
Children > 3 months are probably at no greater risk of signif. resp depression than adults; younger infants may have ↑ risk due to metabolic immaturity affecting pharmacokinetics
Morphine elimination t ½ (h):
Preterm infants: 9 – 10
Term Infants: 7
Children: 3 – 4 (Saaranmaa E, Huttunen P, Leppaluoto J, Meretoja O, Fellman V. Advantages of fentanyl over morphine in analgesia for ventilated newborn infants after birth: A randomized trial. J Pediatrics 134[2], )

28. STRONG OPIOIDS ctd most commonly use: morphine
hydromorphone (Dilaudid ®)
fentanyl (IV infusions)
oxycodone
methadone
DO NOT use meperidine (Demerol®) long-term
active metabolite normeperidine → seizures

29. Using Opioids for Breakthrough Pain
Patient/Family must feel in control, empowered
Use aggressive dose and interval
There should be confidence in the effectiveness of the breakthrough dose; empirically and reliably effective
Patient Taking Short-Acting Enteral Opioids:
% of the q4h dose given q1h prn
Patient Taking Long-Acting Enteral Opioids:
% of total daily dose given q1h prn using short-acting opioid preparation
Patient On Continuous Parenteral Infusion (non-PCA):
1 – 2 hrs worth of opioid, given q15 minutes prn

30. PCA Opioids
Ref: Pain In Infants, Children, And Adolescents 2nd Ed, 2003; Schechter, Berde, and Yaster Editors
Allows patients to self administer small amounts of opioids when needed
Usually IV or SQ
Most commonly morphine or hydromorphone
May have a continuous background opioid infusion in addition to PCA boluses
A child able to play a video game can also operate a PCA pump (5 – 6 yo)
Varying policies on whether nurse or parent are allowed to initiate a bolus – doing so will lose the inherent safety of being too drowsy to self-overdose

31. Parenteral Infusion Dose
Recommended Opioid Analgesic Doses (> 6 Months Age)*
Agent
Intermittent Dose
Parenteral Infusion Dose
Codeine
Enteral
0.5 – 1.0 mg/kg q4h
Not recommended parenterally
Morphine
Sulfate
0.2 – 0.3 mg/kg q 4h
0.05 mg/kg IV load over 10 min then 0.01 – 0.03 mg/kg/hr
IV/SQ
0.05 – 0.2 mg/kg q 2-4h
Hydromorphone
30 – 80 micrograms/kg q4h
10 – 20 micrograms/kg IV load over 10 min then 2 – 8 micrograms/kg/hr
15 micrograms/kg q 2 – 4h
Oxycodone
0.05 – 0.15 mg/kg po q4h
N/A
Fentanyl Citrate
0.5 – 2 micrograms/kg IV
0.5 – 2 micrograms/kg/hr IV
* For infants < 6 months start with ¼ of the pediatric starting dose and titrate

32. Opioid Side Effects
Constipation – need proactive laxative use
Nausea/vomiting – consider treating with dopamine antagonists and/or prokinetics (metoclopramide, domperidone, prochlorperazine [Stemetil], haloperidol)
Urinary retention
Itch/rash – worse in children; may need low-dose naloxone infusion. May try antihistamines, however not great success
Dry mouth
Respiratory depression – uncommon when titrated in response to symptom
Drug interactions
Neurotoxicity (OIN): delirium, myoclonus ® seizures

33. Opioid-Induced Pruritus
Not rare; up to 23% in children > 12 yo in one study of long-acting morphine (Zernickow B, Lindena G; Medical and Pediatric Oncology 36:451±458 (2001))
Pathophysiology unclear
opioid m receptors are relevant to the modulation of pain and itch in the central nervous system.
Opioid peptides may also have a peripheral action potentiating itch due to other agents
Consider switching opioids; may have less pruritus with fentanyl, methadone, oxycodone
Try antihistamines (diphenhydramine, Atarax, trimeprazine)
Naloxone 1 – 2 micrograms/kg/hour as an infusion

34. Adjuvants Used In Palliative Care
General / Non-specific
corticosteroids
Bone Pain
NSAIDs
bisphosphonates
(calcitonin)
Neuropathic Pain
gabapentin
antidepressants
ketamine
topiramate
clonidine
cannabinoids (not yet commonly used for pain)

35. Gabapentin For Neuropathic Pain
Common Starting Regimen:
5 mg/kg hs days 1-3, then
5 mg/kg bid days 4-6, then
5 mg/kg tid and slowly titrate up
Usual effective range: 8 – 35 mg/kg/day
Sedation is usual limiting factor.
Doses may need to be rounded of due to the capsule strengths

36. Intranasal Meds Drug Tmax (min) Bioavailability (%) Midazolam1,2
11 – 14*
55 – 83
Fentanyl3 5 71
Sufentanil3 10 78
Hydromorphone4
20 – 25 55
Reasonable to start with recommended mg/kg
for IV dosing and adjust empirically
* Available to the cerebral cortex 2 – 5 min. after nasal use5
P. D.Knoester ; Pharmacokinetics and pharmacodynamics of midazolam administered as a concentrated intranasal spray. A study in healthy volunteers; Br J Clin Pharmacol May;53(5):501-7
Rey E. et al; Pharmacokinetics of midazolam in children: comparative study of intranasal and intravenous administration; Eur J Clin Pharmacol 41(4) 1991;
Dale O, Hjortkjaer R, Kharasch ED; Nasal administration of opioids for pain management in adults; Acta Anaesthesiol Scand Aug;46(7):759-70
Coda BA, Rudy AC, Archer SM, Wermeling DP; Pharmacokinetics and bioavailability of single-dose intranasal hydromorphone hydrochloride in healthy volunteers; Anesth Analg Jul;97(1):117-23
Fisgin T et al; Effects of intranasal midazolam and rectal diazepam on acute convulsions in children: prospective randomized study; J Child Neurol Feb;17(2):123-6

38. In Pediatric Palliative Care
Management Of:
Nausea And Vomiting
Dyspnea
Secretions
In Pediatric Palliative Care

39. Cortex
CTZ GI
VOMITING
CENTRE
Vestibular

40. Managing Nausea & Vomiting in Palliative Care
Some Differences in Children vs. Adults
Assessment, communication challenges
Higher risk of extrapyramidal reactions, akathisia, and somnolence with dopamine antagonists in children than adults
Metoclopramide (Maxeran®)
Prochlorperazine (Stemetil®)
Haloperidol (Haldol®)
Chlorpromazine
If using dopamine antagonists, consider slow administration ( min.), as well as concomitant use of diphenhydramine (Benadryl®) 0.5 – 1 mg/kg q4-6h po/IV continued for additional 24hrs after dopamine antagonist stopped.

41. Chemoreceptor trigger zone
Stimulus
Area
Receptors
Drugs,
Metabolic
Chemoreceptor trigger zone
Motion,
Position
Vestibular
Visceral
Organs
? Non-specific
CNS
↑ ICP
Cerebral cortex D 2
5HT M
5HT H1 M H1
VOMITING
CENTRE D 2
5HT
CB1 H1
Effector
Organs D 2
5HT H1 M
CB1
Dopamine
Serotonin
Histamine
Muscarinic
Cannabinoid

42. From:
Nausea and vomiting associated with cancer chemotherapy: drug management in theory and in practice
Arch. Dis. Child. 2004;89;
E S Antonarakis and R D W Hain

43. Antinauseants / Antiemetics
Drug Class
Examples for Breakthrough Nausea (Not necessarily the same as for Chemotherapy Protocols)
Serotonin Antagonists
Granisetron1 : ≥ 4 yo: mcg/kg/day divided once or twice daily single dose po/IV
Ondansetron2: 0.15 mg/kg/dose enterally/IV q 6-8h
H1 Antagonists
Dimenhydrinate (Gravol®): 1.25 mg/kg q6h (max. 50 mg/dose); not recommended < 2 yo
Dopamine
Antagonists
(Consider concomitant diphenhydramine 0.5 – 1.0 mg/kg)
Prochlorperazine (Stemetil®): 0.1 – 0.15 mg/kg po/pr q6h
Methotrimeprazine: 1 mo y: mg/kg continuous infusion over 24h (or mg/kg q6h)
Metoclopramide: 0.1 – 0.2 mg/kg po/IV/SQ q6h prn (don’t use if Hx seizures)
Haloperidol: 0.01 – 0.02 mg/kg po/IV/SQ/SL/pr q 8-12h
Domperidone: 1.2 – 2.4 mg/kg/day divided TID – QID (doesn’t cross BBB)
Prokinetics
See metoclopramide and domperidone above
Cannabinoids
Dronabinol: mg/m2 q4h prn; alternatively 0.04 to 0.12 mg/kg/day (much lower dose)
Nabilone: (> 4 yo): < 18 kg: 0.5 mg bid; kg: 1 mg bid; >30 kg: 1 mg tid
Corticosteroids
Dexamethasone: mg/kg initially then mg/kg q6h
1 Komada Y et al. A randomised dose-comparison trial of granisetron in preventing emesis in children with leukaemia receiving emetogenic chemotherapy. Eur J Cancer 1999; 35(7):
2 Principles and Practice of Pediatric Oncology 4th Ed.; Edited by Pizzo & Poplack

44. Palliative Management of Secretions

45. Secretions - Prevalence At Study Entry And In Last Month Of Life UK Children’s Cancer Study Group/Paediatric Oncology Nurses Forum Survey Goldman A et al; Pediatrics 2006; 117;

46. Managing Secretions in Palliative Patients
Factors influencing approach management:
Oral secretions vs. lower respiratory
Level of alertness and expectations thereof
Proximity of expected death
“Death Rattle” – up to 50% in final hours of life
At times the issue is more one of creating an environment less upsetting to visiting family/friends
Suctioning: “If you can see it, you can suction it”
Suctioning
Increased
Secretions
Mucosal
Trauma

47. Atropine Eye Drops For Palliative Management Of Secretions
Atropine 1% ophthalmic preparation
Local oral effect for excessive salivation/drooling
Dose is usually 1 – 2 drops SL or buccal q6h prn
There may be systemic absorption… watch for tachycardia, flushing

48. Glycopyrrolate For Palliative Management Of Secretions
Less sedating than scopolamine (doesn’t cross the blood-brain barrier), longer acting, however not as effective
Useful where patient is still alert; scopolamine will cause sedation and delirium in awake patients
Enteral: – 100 micrograms/kg 3 – 4 times daily
Refs:
2006 British National Formulary For Children
IWK Health Centre (Halifax) Formulary
Parenteral: 4 – 10 micrograms/kg 3 – 4 times daily (10x the enteral dose)
Ref:
IWK Health Centre (Halifax) Formulary

49. Scopolamine For Palliative Management Of Secretions
Ref: British National Formulary For Children
Transderm-V ® (Scopolamine)
Age
Dose
1 month – 3 yrs
250 micrograms every 72 hours (1/4 patch)
3 – 10 yrs
500 micrograms every 72 hours (1/2 patch)
10 – 18 yrs
1 mg every 72 hours (one patch)
Intermittent SQ/IV: 10 micrograms/kg (max. 600 micrograms) q 4h
Continuous SQ/IV: microgram/kg/day (1.67 – 2.5 microgram/kg/h)
Ref:
2006 Rainbow Hospice Guidelines

50. Dyspnea In Pediatric Palliative Care

51. DYSPNEA An uncomfortable awareness of breathing
Not the same as tachypnea, which is a fast rate of breathing
“...the most common severe symptom in the last days of life” (Davis C.L. The therapeutics of dyspnoea Cancer Surveys 1994 Vol.21 p 85 – 98)
Increasing incidence as death nears (approx. 80 %); pneumonia at the end of life

52. TREAT THE CAUSE OF DYSPNEA - IF POSSIBLE AND APPROPRIATE
Anti-tumor: chemo/radTx, hormone, laser
Infection
Anemia
CHF
SVCO
Pleural effusion
Pulmonary embolism
Airway obstruction

53. Opioids in Dyspnea Uncertain mechanism
Comfort achieved before resp compromise; rate often unchanged
Often patient already on opioids for analgesia; if dyspnea develops it will usually be the symptom that leads the need for titration
Dosage should be titrated empirically; may easily reach doses commonly seen in adults
May need rapid dose escalation in order to keep up with rapidly progressing distress

54. Parenteral Infusion Dose
Recommended Opioid And Sedative Doses For Dyspnea (> 6 Months Age)*
* For infants < 6 months start with ¼ of the pediatric starting dose and titrate
Agent
Intermittent Dose
Parenteral Infusion Dose
Codeine
Enteral
0.5 – 1.0 mg/kg q4h
Not recommended parenterally
Morphine
Sulfate
0.2 – 0.3 mg/kg q 4h
0.05 mg/kg IV load over 10 min then 0.01 – 0.03 mgkg/hr
IV/SQ
0.05 – 0.2 mg/kg q 2-4h
Hydromorphone
30 – 80 micrograms/kg q4h
10 – 20 micrograms/kg IV load over 10 min then 2 – 8 micrograms/kg/hr
15 micrograms/kg q 2 – 4h
Oxycodone
0.05 – 0.15 mg/kg po q4h
N/A
Fentanyl Citrate
0.5 – 2 micrograms/kg IV
0.5 – 2 micrograms/kg/hr IV
Lorazepam
0.05 mg/kg IV/SL
Midazolam IV
0.025 – 0.05 mg/kg titrated carefully, with 2-3 min. between fractions
Infusion would be guided by prn doses
“…neither surgical anesthesia nor fatal intoxication is produced by benzodiazepines in the absence of other drugs with CNS-depressant actions; an important exception is midazolam, which has been associated with decreased tidal volume and respiratory rate” (Goodman & Gilman)
Nasal
0.1 mg/kg in each nostril
po/SL
Child 1 month–18 years 0.5 micrograms/kg (max. 15 mg) 30–60 minutes before procedure
Methotrimeprazine
mg/kg q6h po/SQ
mg/kg/24 hr IV/SQ