Appendix 1: Pediatric Pharmacotherapy, Nutrition, and Neonatal Critical Care

Intermittent IV or PO bolus administration (not as needed)

In 2018, the FDA announced limiting use of prescription opioid cough and cold medications containing codeine or hydrocodone in children <18 years old. Weak opioids (eg, codeine, hydrocodone, and oxycodone) often are combined with acetaminophen or an NSAID for moderate pain. With dose escalation of combination oral products, be aware that the dose does not exceed recommended daily amounts for acetaminophen or ibuprofen. One percent to 7% of the general population and up to 28% of some ethnic groups have a genetic variation in the enzyme cytochrome P450 2D6 that causes codeine to be converted to morphine faster and more completely. In 2012, the FDA issued a Drug Safety Communication stating that codeine use in certain children after tonsillectomy or adenoidectomy for obstructive sleep apnea syndrome led to deaths and life-threatening respiratory depression. Consider alternative analgesics for children undergoing tonsillectomy or adenoidectomy. If codeine or codeine-containing products are prescribed, then use the lowest effective dose for the shortest period of time on an as-needed basis. IV administration of codeine has been associated with allergic reactions related to histamine release. Parenteral administration of codeine is not recommended. Intermittent opioid administration is associated with wide fluctuation between peak and trough concentrations, so the patient may alternate between peak blood concentrations associated with untoward effects and trough concentrations associated with inadequate pain relief when being treated for severe pain.

Oxycodone and morphine are available in a sustained-release formulation for use with chronic pain (not acute pain). The tablet must be swallowed whole and cannot be administered to patients through gastric tubes.

IV continuous infusion

Loading dose is administered to rapidly achieve a therapeutic blood concentration and pain relief (ie, morphine loading dose of 0.05–0.15 mg/kg in children; 0.1 mg/kg infused over 90 minutes in neonates). Loading dose is followed by a maintenance continuous infusion. Doses that are considered safe in children can cause respiratory depression and seizures in neonates because of decreased clearance, immature blood–brain barrier at birth that is more permeable to morphine, and an increased unbound fraction of morphine that increases CNS effects of the drug.

PCA

Gives patient some control over his or her pain therapy. PCA allows the patient to self-administer small opioid doses. The PCA-Plus (Abbott, Chicago, IL) pump allows the patient to receive a continuous infusion together with a set number of self-administered doses per hour. PCA helps to eliminate wide peak and trough fluctuations so that blood concentrations remain in a therapeutic range. Children as young as 5 or 6 years of age can master the use of PCA.

Epidural and intrathecal analgesia

Effective in the management of severe postoperative, chronic, or cancer pain. Spinal opioids can be administered by a single bolus injection into the epidural ...