PatchSA Paediatric Palliative Care Formulary

Based on the (APPM) Association of Paediatric Palliative Care Medicine Master Formulary created by Dr Sat Jassal, the PatchSA Paediatric Palliative Care Formulary provides medical professionals with a list of medicines appropriate in providing paediatric palliative care in South Africa.

Drug Formulary

The following Formulary is an excerpt from the Association for Paediatric Palliative Medicine’s (APPM) 2020 formulary. The full version is available from the APPM website. This formulary is the leading international resource and only authoritative guide on prescribing in Paediatric Palliative Care. Many of these medicines are prescribed “off-licence” and “on expert opinion” as it is difficult to do studies in this vulnerable population.

An alphabetical list of the most common drugs mentioned in this book and their doses follows. Please see full formulary for further information on cautions, side effects and drug interactions. Do note not all of the formulations mentioned in this resources are available in South Africa.

Amitriptyline

Use:
Neuropathic pain
Drooling, refractory cough (same dosing)

Dose and routes:
By mouth

Child 2–11 years: Initial dose of 200 microgram/kg (maximum 10mg) given once daily at night. Dose may be increased gradually, if necessary and beneficial, to a suggested maximum of 1mg/kg/dose twice daily (under specialist supervision).

Child 12–17 years: Initial dose of 10 mg at night increased gradually, if necessary, every 3-5 days to a suggested initial maximum of 75 mg/day

Higher doses up to 150 mg/day in divided doses may be used under specialist advice.
Twice daily dosing rarely needed, if used then give 25-30% of daily dose in morning and 30-75% at night.

Available as: tablets (10 mg, 25 mg, 50 mg) and oral solution (10 mg/5 mL, 25 mg/5 mL, 50 mg/5 mL; other strengths may be available as ‘specials’).


Atropine

Use:
Reduction of death rattle
Hypersalivation / Hypersecretion

Dose and route:
By sublingual administration

Neonates: Injection solution, 20-40 micrograms/kg/dose 2-3 times a day as required

Child 10-19 kg: Eye drop solution 0.5%, 1 drop three times a day at 6 hourly intervals

Child 5-18 years (>20 kg): Eye drop solution 0.5-1%,1-2 drops 4-6 hourly intervals

Available as: 1% (10 mg/ml) eye drops. 10 ml or 0.5 ml pack size. 0.5% eye drops in other parts of world


Baclofen

Use:
Chronic severe spasticity or spasms of voluntary muscle
Considered as third line neuropathic agent
Hiccup (strong evidence in adults but none in children)

Dose and routes:

By mouth

Initial dose for child under 18 years: 300 microgram/kg/day in 4 divided doses, increased gradually at weekly intervals to a usual maintenance dose of 0.75-2 mg/kg/day in divided doses with the following maximum daily doses:

Child 1 month-7 years: maximum total daily dose 40 mg/day

Child 8-18 years: maximum total daily dose 60 mg/day

Available as: tablets (10 mg) and oral solution (5 mg/5 mL)


Carbamazepine

Use:
Neuropathic pain
Some movement disorders
Anticonvulsant

Dose and routes:

By mouth

Neonates: Experience is limited. Initial dose 5 mg/kg twice daily.

Child 1 month–11 years: Initial dose of 5 mg/kg at night or 2.5 mg/kg twice daily, increased as necessary by 2.5-5 mg/kg every 3–7 days; usual maintenance dose 5 mg/kg 2–3 times daily. Doses up to 20 mg/kg/day in divided doses have been used.

Child 12–17 years: Initial dose of 100–200 mg 1–2 times daily; increased slowly to usual maintenance of 200-400 mg 2–3 times daily. Maximum 1.8 g/day in divided doses.

 

By rectum:

Child 1 month–17 years: Use approximately 25% more than the oral dose (maximum single dose 250 mg) up to 4 times a day.

Available as: tablets (100 mg, 200 mg, 400 mg), liquid (100 mg/5 mL), suppositories (125 mg, 250 mg), and modified release tablets (200 mg, 400 mg)


Clonidine

Use:
Anxiety / sedation (prior to procedure)
Pain / sedation / opioid sparing/ prevention of opioid withdrawal effects
Regional nerve block
Spasticity / dystonia
Status dystonicus
Behavioural symptoms of irritability, impulsiveness, aggression

Doses and routes:

Anxiety / Sedation / Pre-procedure

Oral / Intranasal /Rectal:

Neonate: 4 micrograms/kg orally OR 5 micrograms/kg rectally provides adequate sedation

Child >1 month: 4 micrograms/kg as a single dose

(suggested maximum 150 micrograms single dose)
If used as premedicant prior to a procedure, give 45-60 minutes before.

Pain/ Sedation/ Opioid sparing/ Prevention of opioid withdrawal effects (most experience on PICU): 

Oral / IV Bolus:

Child >1 month: Initial dose 1 microgram/kg/dose 3-4 times daily. Increase gradually as needed and tolerated to maximum of 5 micrograms/kg/dose four times a day.

Available as: tablets 25 micrograms, 100 micrograms


Cyclizine

Use:
Antiemetic of choice for raised intracranial pressure.
Nausea and vomiting where other more specific antiemetics (metoclopramide,5HT3 antagonists) have failed.

Dose and routes:

By mouth or by slow IV injection over 3–5 min:

Child 1 month–5 years:5–1 mg/kg up to 3 times daily, maximum single dose 25 mg

Child 6–11 years: 25 mg up to 3 times daily

Child 12–17 years: 50 mg up to 3 times daily

 

By rectum:

Child 2–5 years:5 mg up to 3 times daily

Child 6–11 years: 25 mg up to 3 times daily

Child 12–17 years: 50 mg up to 3 times daily
By continuous IV or SC infusion:
Some evidence 50% bioavailability when given orally.

Child 1 month-23 months: 5-3 mg/kg over 24 hours (maximum 25 mg/24 hours),

Child 2-5 years: 25-50 mg over 24 hours

Child 6–11 years: 5-75 mg over 24 hours

Child 12–17 years: 75-150 mg over 24 hours

NB: Care should be taken with subcutaneous or intravenous use of cyclizine, which is acidic and can cause injection site reactions.

Available as: tablets (50 mg), suppositories (12.5 mg, 25 mg, 50 mg, 100 mg from ‘specials’ manufacturers) and injection (50 mg/mL).

Tablets may be crushed for oral administration. The tablets do not disperse well in water, but if shaken in 10 mL water for 5 minutes, the resulting dispersion may be administered immediately via an enteral feeding tube.


Dexamethasone

Use:
Dexamethasone has a wide range of potential uses associated with its capacity to reduce inflammation.  They include:
– Headache associated with raised intracranial pressure caused by a tumour.
– Anti-inflammatory in brain and other tumours which cause pressure on nerves or bone or obstruction of hollow viscus.
– Analgesic role in nerve compression, spinal cord compression and bone pain.
– Antiemetic either as an adjuvant or in highly emetogenic cytotoxic therapies.

Dose and routes:

Prescribe as dexamethasone base.

Headache associated with raised intracranial pressure

By mouth or IV:

Child 1 month–12 years: 250 micrograms/kg twice a day for 5 days; then reduce or stop.

To relieve symptoms of brain or other tumour

Numerous other indications in cancer management such as spinal cord and/or nerve compression, some causes of dyspnoea, bone pain, superior vena caval obstruction etc,, only in discussion with specialist palliative medicine team. High doses < 16 mg/24 hrs may be advised.

Antiemetic

By mouth or IV:

Child < 1 year: Initial dose 250 micrograms 3 times daily. This dose may be increased as necessary and as tolerated up to 1mg 3 times daily

Child 1–5 years: Initial dose 1 mg 3 times daily. This dose may be increased as necessary and as tolerated up to 2 mg 3 times daily

Child 6–11 years: Initial dose 2 mg 3 times daily. This dose may be increased as necessary and as tolerated up to 4 mg 3 times daily

Child 12–17 years: 4 mg 3 times daily

Available as: tablets (500 micrograms, 2 mg), soluble tablets 2 mg, 4 mg, 8 mg, oral solution (2 mg/5 mL 10 mg/5 mL and 20 mg/5 mL and injection as dexamethasone sodium phosphate (equivalent to 3.8 mg/mL dexamethasone base or 3.3 mg/mL dexamethasone base.

Tablets may be dispersed in water if oral liquid unavailable. Oral solution or tablets dispersed in water may be administered via an enteral feeding tube.


Diazepam

Use:
Short term anxiety relief
Agitation
Panic attacks
Relief of muscle spasm
Treatment of status epilepticus

Dose and routes:

Short term anxiety relief, panic attacks and agitation

By mouth:

Child 2–11 years: 0.5-2 mg 3 times daily

Child 12–18 years: Initial dose of 2 mg 3 times daily increasing as necessary and as tolerated to a maximum of 10 mg 3 times daily.

Relief of muscle spasm

By mouth:

Child 1–11 months: Initial dose of 250 micrograms/kg twice a day

Child 1–4 years: Initial dose of 2.5 mg twice a day

Child 5–11 years: Initial dose of 5 mg twice a day

Child 12–17 years: Initial dose of 10 mg twice a day; maximum total daily dose 40 mg

Status epilepticus

By IV injection over 3–5 minutes:

Neonate: 300-400 micrograms/kg as a single dose repeated once after 10 minutes if necessary

Child 1 month–11 years: 300-400 micrograms/kg (max 10 mg) repeated once after     10 minutes if necessary

Child 12–17 years: 10 mg repeated once after 10 minutes if necessary.
By rectum (rectal solution):

Neonate: 1.25–2.5 mg repeated once after 10 minutes if necessary

Child 1 month–1 year: 5 mg repeated once after 10 minutes if necessary

Child 2–11 years: 5–10 mg repeated once after 10 minutes if necessary

Child 12–17 years: 10-20 mg repeated once after 10 minutes if necessary.

Available as: tablets (2 mg, 5 mg, 10 mg), oral solution/suspension (2 mg/5 mL, 5 mg/5 mL), rectal tubes (2.5 mg, 5 mg, 10m g), and injection (5 mg/mL solution and 5 mg/mL emulsion).Schedule 4 (CD Benz).


Fentanyl

Use:
Step 3 WHO pain ladder (moderate to severe pain).

Dose and routes:

Normally convert using oral morphine equivalent (OME) from previous analgesia. Use the following starting doses in the opioid naive patient. The maximum dose stated applies to starting dose only.

By transdermal patch or continuous infusion:

Based on oral morphine dose equivalent (given as 24 hour totals).

72 hour Fentanyl patches are approximately equivalent to the following 24 hour doses of oral morphine

morphine salt 30 mg daily fentanyl ‘12’ patch
morphine salt 60 mg daily fentanyl ‘25’ patch
morphine salt 120 mg daily fentanyl ‘50’ patch
morphine salt 180 mg daily fentanyl ‘75’ patch
morphine salt 240 mg daily fentanyl ‘100’ patch

By intranasal (starting doses for opioid naïve patients and acute pain)

Neonate – Child<2 years: 1 microgram/kg as a single dose

Child 2-18 years: 1-2 micrograms/kg as a single dose, with initial maximum single dose of 50 micrograms
By continuous intravenous/subcutaneous infusion

Neonate or infant:15-0.5 micrograms/kg/ hour

Child:25-1 microgram/kg/hour
By intravenous/subcutaneous injection (lower doses are required in non-ventilated neonatesand opioid naïve patients)

Neonate or infant:
     Non-ventilated: 15-0.25 micrograms/kg per dose slowly over 3-5 minutes; repeated 30-60 minutes
     Ventilated: 25-0.5 micrograms/kg per dose slowly over 3-5 minutes; repeated every 30-60 minutes

Child over 1 year: 25–0.5 micrograms/kg per dose, slowly over 3-5 minutes, repeated every 30-60 minutes.

Fentanyl transdermal patches

The patch formulation is not usually suitable for the initiation or titration phases of opioid management in palliative care since the patches represent large dose increments and because of the time lag to achieve steady state.

Fentanyl patches takes up to 17 hours to reach steady state. Commence fentanyl patch with last dose of slow release morphine.
Fentanyl patches should be changed every 72 hours and the site of application rotated. In some children who are rapid metabolisers the patch may not last for 72 hours and the patches may need to be changed every 36-48 hours.
Conversion ratio is 1:1 for transdermal fentanyl to intravenous/ subcutaneous routes.
A reservoir of fentanyl accumulates in the body, and significant blood concentrations persist for at least 24 hours after discontinuing transdermal fentanyl. It takes 17 hours or more for the plasma-fentanyl concentration to decrease by 50%; replacement opioid therapy should therefore be initiated at a low dose and increased gradually.
For rapidly escalating symptoms in the last few hours and days of life, continue transdermal fentanyl and give additional SC morphine PRN. If >2 PRN doses are required in 24 hours, give morphine by continuous subcutaneous infusion, while continuing transdermal fentanyl, starting with a dose equal to the sum of the PRN doses over the preceding 24 hours. If necessary, adjust the PRN dose taking into account the total opioid dose (i.e. transdermal fentanyl + continuous subcutaneous morphine).

 Formulations

Patches: various manufacturers (12 micrograms/hour, 25 micrograms/hour,  50 micrograms/hour, 75 micrograms/hour, 100 micrograms/hour); Ionys® transdermal system (40 microgram/dose)
Injection: 50 microgram per mL 


Fluoxetine

Use:
Major depression

Dose and routes:

By mouth:

Child 8–17 years: Initial dose 10 mg once a day. May be increased after 1-2 weeks if necessary to a maximum of 20 mg once daily.

Available as: capsules (20 mg, 60 mg), dispersible tablets (20 mg) and oral liquid  (20 mg/5 mL)


Gabapentin

Use:
Adjuvant in neuropathic pain
Neuroirritability
Visceral hyperalgesia
Third line management of abnormal tone and movement disorders in cerebral palsy
Epilepsy

Dose and routes:

Neuropathic pain

By mouth:

Neonate-Child 1 year: 5 mg/kg given as below

Child 2 -11 years: 5-10 mg/kg given as below

Day 1 – give 5-10 mg/kg as a single dose (maximum single dose 300 mg),
Day 2 – give 5-10 mg/kg twice daily (maximum single dose 300 mg),
Day 3 onwards – give 5-10 mg/kg three times daily (maximum single dose 300 mg)

Increase further if necessary to maximum of 20 mg/kg/dose (maximum single dose 600 mg). See notes for day 3 onward titration regimes.

From 12 years: Initially 300 mg once daily for day 1, then 300 mg twice daily for day 2, then 300 mg 3 times a day for day 3, then increase in steps of 300 mg every 3-7 days given in 3 divided doses daily.The maximum daily dose can be increased according to response to a maximum of 3600 mg/day.

Available as: capsules (100 mg, 300 mg, 400 mg); tablets (600 mg, 800 mg), oral solution 250 mg/5 mL (Neurontin, United States import).


Glycopyrronium bromide

Use:
Control of upper airways secretion and hypersalivation.

Dose and routes:

By mouth:

Child 1 month-17 years: Initial dose of 40 micrograms/kg 3–4 times daily. The dose may be increased as necessary to 100 micrograms/kg 3-4 times daily.

Maximum 2 mg/dose given 3-4 times daily

Subcutaneous / Intravenous injection:

Child 1 month-11 years: Initial dose of 4 micrograms/kg 3 to 4 times daily. The dose may be increased as necessary to 10 micrograms/kg 3-4 times daily,

Maximum 200 micrograms/dose given 4 times daily

Child 12-17 years: 200 micrograms every 4 hours when required
Continuous subcutaneous / intravenous infusion:

Child 1 month-11 years: Initial dose of 12 micrograms/kg/24 hours. The dose may be increased as necessary to 40 micrograms/kg/24 hours

(maximum 1.2 mg/24 hours)

Child 12-17 years: Initial dose of 600 micrograms /24 hours. The dose may be increased as necessary to 1.2 mg/24 hours. Maximum recommended dose is 2.4 mg/24 hours.

Available as: tablets (1 mg, 2 mg), oral solution (200 micrograms/mL as glycopyrronium bromide (various) and 400 micrograms/mL as glycopyrronium bromide (Sialanar®), injection (200 micrograms/mL 1 mL and 3 ml ampoules)


Haloperidol

Use:
Nausea and vomiting where cause is metabolic, or in difficult to manage cases such as end stage renal failure.
Restlessness and confusion / terminal agitation.
Persistent severe aggression in autism or pervasive developmental disorders.
Intractable hiccups.
Psychosis (including steroid induced), hallucinations.

Dose and routes:

By mouth for nausea and vomiting:

Child 1 month–11 years: 10-20 micrograms/dose every 8-12 hours increased as necessary to a maximum of 50-60 micrograms/kg/dose every 8-12 hours

Child 12–17 years: 1.5 mg once daily at night, increased as necessary to 1.5 mg twice a day; maximum 5 mg twice a day.
By mouth for restlessness and confusion:

Child 1 month–17 years: 10–20 micrograms/kg every 8–12 hours; maximum 5 mg twice a day.
By mouth for intractable hiccups:

Child 1 month–11 years: Initial dose of 50 micrograms/kg/24 hours (initial maximum 3 mg/24 hrs) in divided doses. The dose may be increased as necessary to a maximum of 170 micrograms/kg/24 hours in divided doses

Child 12–17 years:5 mg 3 times daily.
By continuous IV or SC infusion (for any indication):

Child 1 month–11 years: Initial dose of 25 micrograms/kg/24 hours (initial maximum 1.5 mg/24hrs). The dose may be increased as necessary to a maximum of 85 microgram/kg/24 hours

Child 12–17 years: Initial dose of 1.5 mg/24 hours. The dose may be increased as necessary to a suggested maximum of 5 mg/24 hours although higher doses may be used under specialist advice.


Available as:
 Tablets (500 micrograms, 1.5 mg, 5 mg, 10 mg), capsules (500 micrograms), oral liquid (200 micrograms/mL, 1 mg/mL, 2 mg/mL), and injection (5 mg/mL)


Hyoscine butylbromide

Use:
Adjuvant where pain is caused by spasm of the gastrointestinal or genitourinary tract (smooth muscle spasm)
Antisecretory effect in bowel obstruction
Management of secretions, especially where drug crossing the blood brain barrier is an issue
Management of noisy breathing at the end of life (may be more effective if started early)

Dose and routes:

By mouth or IM or IV injection:

Child 1 month-4 years: 300–500 micrograms/kg (maximum 5 mg/dose) 3–4 times daily
Child 5-11 years: 5-10 mg 3–4 times daily
Child 12-17 years: 10–20 mg 3–4 times daily
By continuous subcutaneous infusion:

Child 1 month-4 years:5 mg/kg/24 hours (max 15 mg/24 hours)
Child 5-11 years: 30 mg/24 hours
Child 12-17 years:Up to 60-80 mg/24 hours

Higher doses may be needed; doses used in adults range from 20-120 mg/24 hours (maximum dose 300 mg/24 hours).

Available as: tablets (10 mg) and injection (20 mg/mL)


Hyoscine hydrobromide

Use:
Control of upper airways secretions and hypersalivation
Bowel colic pain
Paraneoplastic sweating or pyrexia

Dose and routes:

By mouth or sublingual:

Child 2–11 years: 10 micrograms/kg (maximum 300 micrograms single dose)      4 times daily
Child 12–17 years: 300 micrograms 4 times daily
By transdermal route:

Neonate >32 weeks CorGA – Child 2 years: Quarter of a patch every every72 hours

Child 3–9 years: Half of a patch every 72 hours

Child 10–17 years: One patch every 72 hours

By SC or IV injection or infusion:

Child 1 month–17 years: 10 micrograms/kg (maximum 600 micrograms) every 4–8 hours or CSCI/IV infusion 40-60 micrograms/kg/24 hours. Maximum suggested dose is 2.4 mg in 24 hours although higher doses are often used by specialist units.

Available as: tablets (150 micrograms, 300 micrograms), patches (releasing 1 mg/72 hours), and injection (400 microgram/mL, 600 microgram/mL)


Ibuprofen

Use:
Simple analgesic
Pyrexia
Adjuvant for musculoskeletal pain

Dose and routes

By mouth:

Neonate: 5 mg/kg/dose every 12 hours
Child 1–2 months: 5 mg/kg 3–4 times daily preferably after food
Child 3–5 months: 50 mg 3 times daily preferably after food; in severe conditions up to 30mg/kg daily in 3–4 divided doses
Child 6 months–11 months: 50 mg 3–4 times daily preferably after food; in severe conditions up to 30 mg/kg daily in 3–4 divided doses
Child 1-3 years: 100 mg 3 times daily preferably after food. In severe conditions up to 30 mg/kg daily in 3–4 divided doses
Child 4–6 years: 150 mg 3 times daily, preferably after food. In severe conditions, up to 30 mg/kg daily in 3–4 divided doses
Child 7–9 years: 200 mg 3 times daily, preferably after food. In severe conditions, up to 30 mg/kg daily in 3–4 divided doses. Maximum daily dose 2.4 g
Child 10–11 years: 300 mg 3 times daily, preferably after food. In severe conditions, up to 30 mg/kg daily in 3–4 divided doses. Maximum daily dose 2.4 g
Child 12-17 years: 300-400 mg 3-4 times daily preferably after food. In severe conditions the dose may be increased to a maximum of 2.4 g/day

 Available as: tablets (200 mg, 400 mg, 600 mg), oral syrup (100 mg/5ml)


Lactulose

Use:
Constipation, faecal incontinence related to constipation.
Hepatic encephalopathy (portal systemic encephalopathy) and coma.

Dose:

For constipation:

By mouth: initial dose twice daily then adjusted to suit patient

Neonate: 2.5 mL/dose twice a day
Child 1 month-11 months: 2.5 mL/dose 1-3 times daily
Child 1 year – 4 years: 5 mL/dose 1-3 times daily
Child 5-9 years: 10 mL/dose 1-3 times daily
Child 10-17 years: 15 mL/dose 1-3 times daily

For hepatic encephalopathy:

Child 12-17 years: use 30-50mL three times daily as initial dose. Adjust dose to produce 2-3 soft stools per day.

Available as: oral solution 10 g/15 mL or 680 mg/1 mL


Loperamide

Use:
Diarrhoea from non-infectious cause
Faecal incontinence
Management of high ileostomy output

Dose and routes

For management of chronic diarrhoea

By mouth:

Child 1–11 months: Initial dose of 100 micrograms/kg twice daily given 30 minutes before feeds. Increase as necessary up to a maximum of 2 mg/kg/day given in divided doses
Child 1–11 years: Initial dose of 100 micrograms/kg (maximum single dose 2 mg) 3-4 times daily. Increase as necessary up to a maximum of 1.25 mg/kg/day given in divided doses (maximum 16 mg/day)
Child 12–17 years: Initial dose of 2 mg 2-4 times daily. Increase as necessary up to a maximum of 16 mg/day given in divided doses.

Available as: tablets (2 mg), capsules (2 mg), orodispersible tablets (2 mg) and oral syrup (1 mg/5 mL)


Lorazepam

Use
Background anxiety.
Agitation and distress.
Adjuvant in cerebral irritation.
Background management of dyspnoea.
Muscle spasm.
Status epilepticus

Dose and routes

For all indications except status epilepticus:

By mouth:

Child < 2 years: 25 micrograms/kg 2–3 times daily
Child 2–5 years: 500 micrograms 2–3 times daily
Child 6–10 years: 750 micrograms 3 times daily
Child 11–14 years: 1 mg 3 times daily
Child 15–18 years: 1–2 mg 3 times daily
Sublingual:

Children of all ages: 25 micrograms/kg as a single dose. Increase to 50 micrograms/kg (maximum 1 mg/dose) if necessary

Usual adult dose: 500 micrograms–1mg as a single dose, repeat as required.

For status epilepticus

By Slow IV injection:

Neonate: 100 micrograms/kg for a single dose then 100 microgram/kg after 10 minutes if required
Child 1 month – 11 years: As above with a maximum single dose of 4mg
Child 12-17 years: 4 mg for a single dose then a further 4 mg after 10 minutes if required.

Available as: tablets (1 mg, 2.5 mg) and injection (2 mg/mL and 4 mg/mL)


Macrogols

Use
Constipation.
Faecal impaction.
Suitable for opioid-induced constipation

Dose and routes:

Paediatric sachets for those less than 12 years of age
By mouth for constipation or prevention of faecal impaction:

Child under 1 year: ½-1 paediatric sachet daily
Child 1–5 years: 1 paediatric sachet daily (adjust dose according to response; maximum 4 sachets daily)
Child 6–11 years: 2 paediatric sachets daily (adjust dose according to response; maximum 4 sachets daily)
Child 12–17 years: 1–3 adult sachets daily
By mouth for faecal impaction:

Child under 1 year: ½-1 paediatric sachet daily
Child 1–4 years: 2 paediatric sachets on first day and increase by 2 sachets every 2 days (maximum 8 sachets daily). Treat until impaction resolved then switch to maintenance laxative therapy
Child 5–11 years: 4 paediatric sachets on first day and increase by 2 sachets every 2 days (maximum 12 sachets daily). Treat until impaction resolved then switch to maintenance laxative therapy
Child 12–17 years: 4 sachets daily of adult preparation, then increase by 2 sachets daily to a maximum of 8 adult sachets daily. Total daily dose should be drunk within a 6 hour period. After disimpaction switch to maintenance laxative therapy.

Available as: Macrogol oral powder is available as Movicol and Movicol Paediatric Sachets, CosmoColand CosmoCol Paediatric Sachets, Laxido and Laxido Paediatric Sachets, Macilax and Macilax Paediatric Sachets. Movicol is also available as a liquid concentrate (dilute with water before administration).


Melatonin

Use:
Sleep disturbance due to disruption of circadian rhythm (not anxiolytic).

Dose and routes

By mouth:

Child 1 month-17 years: Initial dose 2–3 mg, increasing every 1–2 weeks dependent on effectiveness up to maximum 10mg daily.

Licensed UK formulations: 1 mg and 5 mg m/r tablets (Slenyto®) and 2 mg m/r tablets (Circadin®) and 1 mg/mL oral solution (Colonis®)). Various unlicensed formulations, including immediate release capsules and oral liquid may be available from ‘specials’ manufacturers or specialist importing companies.


Metoclopramide

Use of metoclopramide is contraindicated in children younger than 1 year.

In children aged 1-18 years, metoclopramide should only be used as a second-line option for prevention of delayed chemotherapy-induced nausea and vomiting, and for treatment of established postoperative nausea and vomiting, and only when other treatments do not work or cannot be used.

Metoclopramide should only be prescribed for short term use (up to 5 days).

Use
Antiemetic if vomiting caused by gastric compression or hepatic disease.
Prokinetic for slow transit time (not in complete obstruction or with anticholinergics).
Hiccups

Dose and routes

By mouth, IM injection, SC injection or IV injection (over at least 3 minutes):

Neonate: 100 microgram/kg every 6–8 hours (by mouth or IV only).
Child 1 month–11 months and body weight up to 10 kg: 100 microgram/kg (maximum 1 mg/dose) twice daily.
Child 1–18 years: 100-150 microgram/kg repeated up to 3 times daily. The maximum dose in 24 hours is 500 microgram/kg (maximum 10 mg/dose; 30 mg per day).

If preferred the appropriate total daily dose may be administered as a continuous SC or IV infusion over 24 hours.

Intravenous doses should be administered as a slow bolus over at least 3 minutes to reduce the risk of adverse effects.
Oral liquid formulations should be given via a graduated oral syringe to ensure dose accuracy in children. The oral liquid may be administered via an enteral feeding tube.There is no specific information on jejunal administration. Administer using the above method and monitor for efficacy.

Available as: tablets (10 mg), oral solution (5 mg/5 mL) and injection (5 mg/mL)


Midazolam

Use:
Status epilepticus and terminal seizure control.
Management of anxiety/agitation associated with symptoms at the end of life.
Anxiety associated with dyspnoea.
Adjuvant for pain of cerebral irritation.

Dose and routes

Drug doses are quite different depending on underlying disease (i.e. children with cancer or organ failure) and children with severe neurological impairment (SNI). Use lower doses for children with cancer or organ failure and higher doses for children with SNI.

By SC or IV infusion over 24 hours for seizure control at end of life:

NeonateChild 18 years:Initial dose 1-3 mg/kg/24 hours increasing up to 7 mg/kg/24 hours (maximum 60 mg/24 hours or 150 mg/24 hours in specialist units for patients with refractory epilepsy).
Seek specialist advice, and consider addition of other agents such as phenobarbital if midazolam is not effective.

Buccal or Intranasal doses for status epilepticus:

Neonate: 300 microgram/kg as a single dose, repeated once if necessary.
Child 1–2 months: 30 microgram/kg (maximum initial dose 2.5mg), repeated once if necessary.
Child 3 months–11 months: 2.5mg, repeated once if necessary.
Child 1–4 years: 5mg, repeated once if necessary.
Child 5–9 years: 7.5mg, repeated once if necessary.
Child 10–17 years: 10mg, repeated once if necessary.

By buccal or intranasal administration for status epilepticus, wait 10 minutes before repeating dose.

NB – In single dose for seizures, midazolam is twice as potent as rectal diazepam. For patients who usually receive rectal diazepam for management of status, consider an initial dose of buccal midazolam that is 50% of their usual rectal diazepam dose to minimise the risk of respiratory depression


Conscious sedation (to be administered 30-60 minutes before a procedure; or to be administered for terminal haemorrhage in conjunction with an opiate):

By oral administration

Child: 500 micrograms/kg (maximum 20 mg) as a single dose
By buccal or intranasal administration

Child 6 months-9years: 200-300micrograms/kg (maximum 5 mg) as a single dose
Child 10-17years: 6-7 mg as a single dose

By rectum

Child 6 months–11 years: 300–500 micrograms/kg(maximum 20 mg) as a single dose
By intravenous or subcutaneous injection

The dosages below are based on the BNFc [2]. However research  evidence and adult formularies [5] suggests that buccal/intranasal and subcutaneous injections have very similar bioavailability. Many units therefore will use doses of 100 micrograms/kg.

Child 1 month–5 years: Initially 25–50 micrograms/kg, to be administered over 2–3 minutes, 5–10 minutes before procedure, dose can be increased if necessary in small steps to maximum total dose per course; maximum 6 mg per course.
Child 6–11 years: Initially 25–50 micrograms/kg, to be administered over 2–3 minutes, 5–10 minutes before procedure, dose can be increased if necessary in small steps to maximum total dose per course; maximum 7.5 mg per course.
Child 12–17 years: Initially 25–50 micrograms/kg, to be administered over 2–3 minutes, 5–10 minutes before procedure, dose can be increased if necessary in small steps to maximum total dose per course; maximum 10 mg per course.


For anxiety/ agitation/ dyspnoea:

Use 25-50% of the conscious sedation dose.

Available as: tablets: 15 mg or 7,5mg, IV ampules: 5mg/5ml or 15mg/3ml


Morphine

Use:
Major opioid.
First line opioid for pain.
Cough suppressant

Dose and routes:

Opioid naive patient: Use the following starting doses. (The maximum dose stated applies to starting dose only).

Opioid conversion: Convert using OME (Oral Morphine Equivalent) from previous opioid.

By mouth or by rectum

Neonate:Initially 25-50 micrograms/kg every 6-8 hours adjusted to response
Child 1–2 months: Iinitially 50 micrograms/kg every 4 hours, adjusted according to response
Child 3–5 months: Initially 50-100micrograms/kg every 4 hours, adjusted according to response
Child 6–11 months: Initially 100-200 micrograms/kg every 4 hours, adjusted according to response
Child 1–11 years: Iinitially 200–300 micrograms/kg (initial maximum 5-10 mg) every 4 hours, adjusted according to response
Child 12–17 years:Iinitially 5–10 mg every 4 hours, adjusted according to response

By single SC injection or IV injection (over at least 5 minutes):

Neonate: Initially 25 micrograms/kg every 6-8 hours adjusted according to response.
Child 1-5months: Initially 50-100micrograms/kg every 6 hours adjustedaccording to response.
Child 6 months-1 years: Initially 50-100micrograms/kg every 4 hours adjusted according to response.
Child 2-11 years: Initially 100 micrograms/kg every 4 hours adjusted according to response, maximum initial dose of 2.5 mg.
Child 12-17 years: Initially 2.5-5 mg every 4 hours adjusted according to response(maximum initial dose of 20 mg/24 hours).

By continuous SC or IV infusion:

Neonate: 120 micrograms/kg/24hours adjusted according to response,
Child 1-2 months: 240 micrograms/kg/24hours adjusted according to response,
Child 3 months–17 years: 480 micrograms/kg/24hours (maximum initial dose of 20 mg/24 hours)adjusted according to response.


Breakthrough pain

 For breakthrough pain use 10-16% of total daily morphine dose every 1-4 hours as needed.
Contact the medical palliative team if someone has needed three doses consecutively as they will need a review of their pain control.

Dyspnoea

30-50% of the dose used for pain.

Available as:
Tablets (10 mg, 20 mg, 50 mg).
Oral solution (5mg/5ml, 10 mg/5 mL, 20mg/5ml, 100 mg/5 mL).
Modified release tablets and capsules 12 hourly (5 mg, 10 mg, 15 mg, 30 mg, 60 mg, 100 mg, 200 mg).
Injection (1 mg/mL, 10 mg/mL, 15 mg/mL, 20 mg/mL and 30 mg/mL)


Ondansetron

Use:
Antiemetic, if vomiting caused by damage to gastrointestinal mucosa (eg chemotherapy or radiotherapy).
Pure 5HT3 antagonist, so receptor profile is complementary to levomepromazine – consider for N&V that breaks through despite regular levomepromazine.
Has been used in managing opioid induced pruritus.
For severe gastroenteritis.

Dose and routes

Prevention and treatment of chemotherapy- and radiotherapy-induced nausea and vomiting.

Terminal half life is 3 hours. Clearance reduced in younger infants -75% in neonates and 50% at 3 months. Children <4 months must be closely monitored.

By intravenous infusion over at least 15 minutes

Child 6 months–17 years: either 5 mg/m2 immediately before chemotherapy (max. single dose 8 mg), then give by mouth, or 150 micrograms/kg immediately before chemotherapy (max. single dose 8 mg) repeated every 4 hours for 2 further doses, then give by mouth; max. total daily dose 32 mg
By mouth following intravenous administration

Note: Oral dosing can start 12 hours after intravenous administration

Child 6 months–17 years:
  Body surface area less than 0.6 m2or body-weight 10 kg or less: 2 mg every 12 hours for up to 5 days (max. total daily dose 32 mg)
Body surface area 0.6 m2 – 1.2 m2 or greater or body-weight over 10 kg: 4 mg every 12 hours for up to 5 days (max. total daily dose 32 mg)
Body surface area greater than 1.2 mor body-weight over 40 kg: 8 mg every 12 hours for up to 5 days (max. total daily dose 32 mg)


Nausea and vomiting

By mouth or slow intravenous injection over 2-5 minutes or by intravenous infusion over 15 minutes

Child 1-17 years: 100 microgram/kg/dose every 8-12 hours.  Maximum single dose 4 mg.

Available as: tablets (4 mg, 8 mg, orodispersible films/tablets (4 mg, 8 mg), oral syrup (4 mg/5 mL), injection (2 mg/mL, 2 mL and 4 mL amps). 16mg suppositories also available.


Paracetamol

Use:

Mild to moderate pain (step 1 of WHO pain ladder).
Pyrexia

Dose:

Oral:

Neonate 28–32 weeks corrected gestational age: 20 mg/kg as a single dose then 10-15 mg/kg every 8 – 12 hours as necessary (maximum 30 mg/kg/day in divided doses).

Neonates over 32 weeks corrected gestational age: 20 mg/kg as a single dose then 10-15 mg/kg every 6 – 8 hours as necessary (maximum 60 mg/kg/day in divided doses).
Child 1 month–5 years: 20-30 mg/kg as a single dose then 15-20 mg/kg every 4-6 hours as necessary (maximum 75 mg/kg/day in divided doses).
Child 6-11 years: 20-30 mg/kg (max 1 g) as a single dose then 15-20 mg/kg every 4-6 hours as necessary (maximum 75 mg/kg/day or 4 g/day in divided doses).
Over 12 years: 15-20 mg/kg (maximum 500 mg -1 g) every 4-6 hours as necessary (maximum 4 g /day in divided doses)

Rectal:

Neonate 28–32 weeks corrected gestational age: 20 mg/kg as a single dose then 10-15 mg/kg every 12 hours as necessary (maximum 30 mg/kg/day in divided doses).
Neonates over 32 weeks corrected gestational age: 30 mg/kg as a single dose then15-20 mg/kg every 8 hours as necessary (maximum 60 mg/kg/day in divided doses).
Child 1–2 months: 30 mg/kg as a single dose, then 15-20 mg/kg every 4-6 hours as necessary (maximum 75 mg/kg/day in divided doses).
Child 3 months-11 years: 30 mg/kg as a single dose (maximum 1 g) then 15-20 mg/kg every 4-6 hours as necessary (maximum 75 mg/kg/day or 4 g/day in divided doses).
Over 12 years: 15-20 mg/kg (maximum 500 mg -1 g) every 4-6 hours as necessary (maximum 4 g/day in divided doses).
IV: as infusion over 15 minutes

Preterm neonate over 32 weeks corrected gestational age:5 mg/kg every 8 hours, maximum 25 mg/kg/day.
Neonate: 10 mg/kg every 4-6 hours (maximum 30 mg/kg/day).
Infant and child body weight <10 kg: 10 mg/kg every 4-6 hours (maximum 30 mg/kg/day)
Child body weight 10-50 kg: 15 mg/kg every 4-6 hours (maximum 60 mg/kg/day).
Body weight over 50 kg: 1 g every 4-6 hours (maximum 4 g/day).

Available as: tablets and caplets (500 mg), capsules (500 mg), soluble tablets (120 mg, 500 mg), oral suspension (120 mg/5 mL, 250 mg/5 mL), suppositories (60 mg, 125 mg, 250 mg, 500 mg and other strengths available from ‘specials’ manufacturers or specialist importing companies) and intravenous infusion (10 mg/mL in 50 mL and 100 mL vials)


Phenobarbital

Use:

Adjuvant in pain of cerebral irritation.
Control of terminal seizures.
Sedation (soporific and anxiolytic).
Epilepsy including status epilepticus. Commonly used first line for seizures in neonates (phenytoin or benzodiazepine are the main alternatives).
Agitation refractory to midazolam in end of life care.

Dose and routes

Status epilepticus / terminal seizures / agitation

Loading dose if required

Oral, intravenous or subcutaneous injection:

All ages: 20 mg/kg/dose (maximum 1 g) administered over 20 minutes if by IV or SC injection (but see notes below).
Subcutaneous or intravenous injection or infusion:

Neonates for control of ongoing seizures: 2.5-5 mg/kg once or twice daily as maintenance.
Child 1 month-11 years: 2.5-5 mg/kg (maximum single dose 300 mg) once or twice daily or may be given as a continuous infusion over 24 hours.
Child 12-17 years: 300 mg twice daily or may be given as a continuous infusion over 24 hours.


Epilepsy

By mouth:

Neonates for control of ongoing seizures: 2.5-5 mg/kg once or twice daily as maintenance.
Child 1 month–11 years: 1–1.5 mg/kg twice a day, increased by 2 mg/kg daily as required (usual maintenance dose 2.5–4 mg/kg once or twice a day).
Child 12–17 years: 60–180 mg once a day.

Available as: tablets (15 mg, 30 mg, 60 mg), oral elixir (15 mg/5 mL) and injection (15 mg/mL, 30 mg/mL, 60 mg/mL and 200 mg/mL)


Phenytoin

Use:
Epilepsy (3rd or 4th line oral antiepileptic) including for status epilepticus
Neuropathic pain (effective, at least short term, but not used first line)

Dose

All forms of epilepsy (including tonic-clonic, focal and neonatal seizures) except absence seizures.

Neuropathic pain.

Oral or slow IV injection:

Neonate: Initial loading dose by slow IV injection 18 mg/kg THEN by mouth 2.5-5 mg/kg twice daily adjusted according to response and plasma phenytoin levels. Usual maximum 7.5 mg/kg twice daily.
1 month -11 years: Initial dose of 1.5-2.5 mg/kg twice daily then adjust according to response and plasma phenytoin levels to 2.5-5 mg/kg twice daily as a usual target maintenance dose. Usual maximum dose of 7.5 mg/kg twice daily or 300 mg daily.
12 -17 years: initial dose of 75-150 mg twice daily then adjusted according to response and plasma phenytoin levels to 150-200 mg twice daily as a usual target maintenance dose. Usual maximum dose of 300 mg twice daily.

Status epilepticus, acute symptomatic seizures

Slow IV injection or infusion:

Neonate: 20 mg/kg loading dose over at least 20 minutes, then 2.5-5 mg/kg/dose (over 30 minutes) every 12 hours as a usual maintenance dose in first week of life. Adjust according to response and older babies may need the higher doses. After the first dose, oral doses usually as effective as intravenous in babies over 2 weeks old.
1 month – 11 years: 20 mg/kg loading dose over at least 20 minutes, then 2.5-5 mg/kg twice daily usual maintenance dose.
12 -17 years: 20 mg/kg loading dose over at least 20 minutes, then up to 100 mg (over 30 minutes) 3 to 4 times daily usual maintenance dose.

Available as: tablets (phenytoin sodium 100 mg, generic), capsules (phenytoin sodium 25 mg, 50 mg,100 mg, 300 mg), Epanutin R Infatabs (chewable tablets of phenytoin base 50 mg), oral suspension (EpanutinRphenytoin base 30 mg/5 mL) and injection (phenytoin sodium 50 mg/mL generic)


Pregabalin

Use:
Epilepsy (focal seizures with or without secondary generalisation)
Peripheral and central neuropathic pain
Generalised anxiety disorder

Dose and route:

Epilepsy (adjunctive therapy for partial seizures)

Child: suggested maintenance dose of 5-10 mg/kg/day. Start at low dose and increase gradually every 3-7 days as tolerated. Maximum 600 mg/day given in 2-3 divided doses. Younger children less than 6 years may need up to 15 mg/kg/day.

Neuropathic Pain

Child:
Day 1-3: 1 mg/kg once a day
Day 4-6: 1 mg/kg 12 hourly
Day 7:  Increase every 3-7 days by 1 mg/kg until
1. Effective analgesia reached, or
2. Side effects experienced, or
3.  Max total daily dose of 6mg/kg/day (although higher dses of 12 mg/kg have been used).

Available as: oral capsules 25 mg, 50 mg, 75 mg, 100 mg, 150 mg, 200 mg, 225 mg, 300 mg


Promethazine

The MHRA / CHM issued advice in March 2008 and February 2009 recommending that children under the age of 6 years should not be given over the counter preparations containing promethazine. This was on the back of serious events including deaths.

Use:
Sleep disturbance.
Mild sedation (soporific).
Can also be used to treat nausea and vomiting (including motion and opioid-induced), and vertigo.
Sedation in neonatal intensive care.

Dose and routes (for promethazine hydrochloride)

By mouth:

Symptomatic relief of allergy:

Child 2–4 years:5 mg twice daily or 5–15 mg at night.
Child 5–9 years:5–10 mg twice daily or 10–25 mg at night.
Child 10–17 years:10–20 mg 2–3 times daily or 25 mg at night increased to 25 mg twice daily if necessary.


Sedation (short term use):

Child 2–4 years: 15-20 mg at night
Child 5–9 years: 20-25 mg at night
Child 10–17 years: 25-50 mg at night


Nausea and vomiting (particularly in anticipation of motion sickness)

Child 2–4 years:5 mg twice daily
Child 5–9 years:10 mg twice daily
Child 10–17 years:20–25 mg twice daily

Sedation in neonatal intensive care

By mouth or by slow intravenous injection

Neonate >37 CorGA: 5–1 mg/kg 4 times daily, adjusted according to response
Available as: promethazine hydrochloride tablets (10 mg, 25 mg), oral elixir (5 mg/5 mL), and injection (25 mg/mL)


Senna

Use:
Constipation


Dose and routes

By mouth:

Initial doses which can be adjusted according to response and tolerance.


Syrup:

Child 1 month–3 years: 5-10 mL of syrup once a day.
Child 4-17 years: 5-20 mL of syrup a day.

Tablets:

Child 2-3 years: 0.5-2 tablets once daily.
Child 4-5 years: 0.5-4 tablets once daily.
Child 6-17 years: 1-4 tablets once daily.

 

Available as: tablets (7.5 mg sennoside B) and oral syrup (7.5 mg/5 mL sennoside B)


Sucrose

Use:
Analgesia for procedural pain in babies.

Dose and routes:

By mouth:

Neonate >32 weeks: 0.5-2mL of 24% sucrose orally 2 minutes before the procedure. Incremental doses 0.1mL can be used up to the maximum of 2mLs. A baby may be given multiple doses during a single procedure. Sucrose can be administered maximally up to 4 times per 24 hours in preterm infants, and up to 8 times in 24 hours in neonates and older babies.

Algopedol® is licensed for use in term and preterm infants less than 4 months of age.
Preservative-free oral solution of sucrose 24% (Algopedol®) in 2 mL vials for single patient use.


Tramadol

Use:
Minor opioid with additional non-opioid analgesic actions.

Dose and routes

By mouth:

Child 5-11 years: 1-2 mg/kg every 4-6 hours (maximum initial single dose of 50 mg; maximum of 4 doses in 24 hours). Increase if necessary to a maximum dose of 2 mg/kg (maximum single dose 100 mg) every 6 hours,
Child 12–17 years: Initial dose of 50 mg every 4–6hours. Increase if necessary to a maximum of 400 mg/day given in divided doses every 4-6 hours.
By IM or IV injection or infusion:

Child 5-11 years: 1-2 mg/kg every 4-6 hours (maximum initial single dose of 50 mg; maximum 4 doses in 24 hours). Increase if necessary to a maximum dose of 2 mg/kg (maximum single dose 100 mg) every 6 hours,
Child 12-17 years: Initial dose of 50 mg every 4-6 hours. Dose may be increased if necessary to 100 mg every 4-6 hours. Maximum 600 mg/day in divided doses.

Available as: capsules (50 mg, 100 mg),  soluble tablets (50 mg), orodispersible tablets (50 mg), and injection (50 mg/mL)


Tranexamic acid

Use:
Oozing of blood (e.g. from mucous membranes / capillaries), particularly when due to low or dysfunctional platelets.
Menorrhagia.

Dose and routes:

By mouth:

Inhibition of fibrinolysis

Child 1 month–17 years: 15–25 mg/kg (maximum 1.5 g) 2–3 times daily.

Menorrhagia

Child 12-17 years: 1 g 3 times daily for up to 4 days. If very heavy bleeding a maximum daily dose of 4 g (in divided doses) may be used. Treatment should not be initiated until menstruation has started.
By intravenous injection over at least 10 minutes:

Inhibition of fibrinolysis

Child 1 month -17 years: 10 mg/kg (maximum 1 g) 2-3 times a day.
By continuous intravenous infusion:

Inhibition of fibrinolysis

Child 1 month-17 years: 45 mg/kg over 24 hours.
By other routes

Mouthwash 5% solution:

Child 6-17 years: 5-10 mL 4 times a day for 2 days. Not to be swallowed.

Topical treatment:

Apply gauze soaked in 100mg/mL injection solution to affected area.
Available as: tablets (500 mg), syrup (500 mg/5 mL available from ‘specials’ manufacturers) and injection (100 mg/mL 5 mL ampoules).