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
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
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
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”)
Time
Death
“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
Palliative Care… The “What If…?” Tour Guides
•
•
“What if…? •
•
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?
Disease-focused Care
(“Aggressive Care”)
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
Talking about Death with Children … ctd
Kreicbergs et al NEJM 2004; 351(12):1175-1186.
Did you talk about death with your child at any time?
n = 147
(34 %)
n = 282
No (66 %)
Yes
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%
Sensed Child Aware Of Dying:
47%
53%
Did Not Sense Child Aware:
13%
87%
Identify and facilitate communication
What Symptoms
Do Children With
Advanced Illness
Experience?
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):363-377.
 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
Symptoms At The End of Life in Children
With Cancer
Wolfe J. et al, NEJM 2000; 342(5) p 326-333
80
70
%
60
50
40
30
20
10
27 %
Pain
Successfully
Treated
(% Of Affected
Children)
16 %
10 %
Dyspnea
Nausea And Vomiting
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; 1179-1186
Abstract from the 7th International Symposium on Pediatric Pain
Stenekes S, Hughes A, Grégoire MC, Frager G 2006
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):1219-1226.
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):1125-1128.
Symptoms in Children with
Neurodegenerative Illness
%
80
70
Hunt and Burne, 1995
69
60
60
50
44
38
40
35
31
31
Excess
Secretions
Sleep
Disorders
30
20
10
0
Feeding
Problems
Seizures
Constipation Respiratory
Symptoms
Pain
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
“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
Various Patterns Of Pediatric Palliative Care Involvement
Cure-Oriented; Disease-Focused
Palliative
Patient Groups For Pediatric Palliative Care Services
Group 1
Group 2
Advanced life-limiting condition from
which death within 12 months would
not be unexpected
Children with progressive lifelimiting/life-threatening conditions
who are not expected to survive into
Group 1A
Comfort-focused approach has
been chosen, or disease-focused
adulthood, but whose prognosis is
anticipated to exceed one year
interventions not possible
Group 1B
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 lifesustaining options are being pursued
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
Keeping The Momentum – Recent
Developments
 2003: Canadian Network of Palliative Care for Children (CNPCC)see http://cnpcc.ca
 March 2006- 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
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?"
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
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
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?”
General Principles For The Prevention And Management Of Pain In
Newborns
1. Pain often unrecognized and undertreated. Neonates do feel pain, and analgesia
should be prescribed when indicated during their medical care.
2. If something hurts adults, it will hurt newborns, even if they are preterm.
3. 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.
4. Adequate treatment of pain may be associated with ↓complications and ↓ mortality.
5. The appropriate use of environmental, behavioral, and pharmacological
interventions can prevent, reduce, or eliminate neonatal pain in many clinical
situations.
6. Sedation does not provide pain relief and may mask the neonate's response to
pain.
7. Health care professionals have the responsibility for assessment, prevention, and
management of pain in neonates.
8. 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):173-180.
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
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
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], 144-150. 1999)
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
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:
 50 - 100% of the q4h dose given q1h prn
• Patient Taking Long-Acting Enteral Opioids:
 10 - 20% 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
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
Recommended Opioid Analgesic Doses (> 6 Months Age)*
Agent
Intermittent Dose
Codeine
Enteral
0.5 – 1.0 mg/kg q4h
Morphine
Sulfate
Enteral
0.2 – 0.3 mg/kg q 4h
IV/SQ
0.05 – 0.2 mg/kg q 2-4h
Enteral
30 – 80 micrograms/kg q4h
IV/SQ
15 micrograms/kg q 2 – 4h
Hydromorphone
Oxycodone
0.05 – 0.15 mg/kg po q4h
Fentanyl Citrate
0.5 – 2 micrograms/kg IV
Parenteral Infusion Dose
Not recommended parenterally
0.05 mg/kg IV load over 10 min
then 0.01 – 0.03 mg/kg/hr
10 – 20 micrograms/kg IV load
over 10 min then 2 – 8
micrograms/kg/hr
N/A
0.5 – 2 micrograms/kg/hr IV
* For infants < 6 months start with ¼ of the pediatric starting dose and titrate
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
Opioid-Induced Pruritus
 Not rare; up to 23% in children > 12 yo in one study of longacting 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
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)
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
Intranasal Meds
Drug
Tmax (min)
Bioavailability (%)
11 – 14*
55 – 83
Fentanyl3
5
71
Sufentanil3
10
78
20 – 25
55
Midazolam1,2
Hydromorphone4
* Available to the cerebral cortex 2 – 5 min. after nasal use5
Reasonable to start with recommended mg/kg
for IV dosing and adjust empirically
1.
2.
3.
4.
5.
P. D.Knoester ; Pharmacokinetics and pharmacodynamics of midazolam administered as a concentrated
intranasal spray. A study in healthy volunteers; Br J Clin Pharmacol. 2002 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; 355-357
Dale O, Hjortkjaer R, Kharasch ED; Nasal administration of opioids for pain management in adults; Acta
Anaesthesiol Scand. 2002 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. 2003 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. 2002 Feb;17(2):123-6
http://www.wolfetory.com/nasal.html
Management Of:
• Nausea And Vomiting
• Dyspnea
• Secretions
In Pediatric Palliative Care
Cortex
CTZ
GI
VOMITING
CENTRE
Vestibular
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 (45-60
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.
Stimulus
Area
Drugs,
Metabolic
Chemoreceptor
trigger zone
Motion,
Position
Vestibular
Organs
? Nonspecific
CNS
↑ ICP
Cerebral cortex
Dopamine
D2
5HT
5HT
Visceral
D2
Receptors
5HT
H1
Serotonin Histamine
M
H1
H1
M
D2
5HT
VOMITING
CENTRE
CB1
H1
M
Muscarinic
Effector
Organs
CB1
Cannabinoid
From:
Nausea and vomiting associated with cancer chemotherapy:
drug management in theory and in practice
Arch. Dis. Child. 2004;89;877-880
E S Antonarakis and R D W Hain
Antinauseants / Antiemetics
Examples for Breakthrough Nausea (Not necessarily the same as for
Chemotherapy Protocols)
Drug Class
Serotonin
Antagonists
•
•
Granisetron1 : ≥ 4 yo: 20-40 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
•
•
Prochlorperazine (Stemetil®): 0.1 – 0.15 mg/kg po/pr q6h
Methotrimeprazine: 1 mo. - 12 y: 0.1 - 0.4 mg/kg continuous infusion over 24h (or 0.025 0.1 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)
Dopamine
Antagonists
(Consider concomitant
diphenhydramine 0.5 – 1.0
mg/kg)
•
•
•
Prokinetics
See metoclopramide and domperidone above
•
Cannabinoids
•
Corticosteroids
1
Dronabinol: 2.5-7.5 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; 18-30 kg: 1 mg bid; >30 kg: 1 mg tid
Dexamethasone: 1 - 2 mg/kg initially then 0.25-0.5 mg/kg q6h
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):1095-1101.
2 Principles and Practice of Pediatric Oncology 4th Ed.; Edited by Pizzo & Poplack
Palliative Management
of Secretions
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; 1179-1186
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
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
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:
40 – 100 micrograms/kg 3 – 4 times daily
Refs:
Parenteral:
• 2006 British National Formulary For Children
• IWK Health Centre (Halifax) Formulary
4 – 10 micrograms/kg 3 – 4 times daily (10x the enteral dose)
Ref:
IWK Health Centre (Halifax) Formulary
Scopolamine
For Palliative Management Of Secretions
Ref: 2006 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: 40-60 microgram/kg/day (1.67 – 2.5 microgram/kg/h)
Ref: 2006 Rainbow Hospice Guidelines
Dyspnea
In
Pediatric Palliative Care
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
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
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
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
Enteral
0.2 – 0.3 mg/kg q 4h
IV/SQ
0.05 – 0.2 mg/kg q 2-4h
0.05 mg/kg IV load over 10 min then 0.01 –
0.03 mgkg/hr
Enteral
30 – 80 micrograms/kg q4h
IV/SQ
15 micrograms/kg q 2 – 4h
Hydromorphone
Oxycodone
0.05 – 0.15 mg/kg po q4h
Fentanyl Citrate
0.5 – 2 micrograms/kg IV
Lorazepam
0.05 mg/kg IV/SL
Midazolam
Methotrimeprazine
IV
0.025 – 0.05 mg/kg titrated
carefully, with 2-3 min. between
fractions
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
0.025 - 0.1 mg/kg q6h po/SQ
10 – 20 micrograms/kg IV load over 10 min
then 2 – 8 micrograms/kg/hr
N/A
0.5 – 2 micrograms/kg/hr IV
• Infusion would be guided by prn doses
• “…neither surgical anesthesia nor fatal
intoxication is produced by benzodiazepines
in the absence of other drugs with CNSdepressant actions; an important exception
is midazolam, which has been associated
with decreased tidal volume and respiratory
rate” (Goodman & Gilman)
0.1 - 0.4 mg/kg/24 hr IV/SQ