PediMUGs - Hospice Pharmacia

P e d i M U G s 

P e d i at r i c M e d i c at i o n U s e G u i d e l i n e s 

s e c o n d E D I T I O N 

1601 Cherry Street, Suite 1700 • Philadelphia, PA 19102 • 877.882.7820 • www.hospicepharmacia.com 

Copyright © 2008 excelleRx, Inc.

We believe this information is the best available on hospice medication management. It is 

subject to revision as additional knowledge and experience are gained. excelleRx makes no 

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Outcomes System (PPOS), ComfortPak, Maximum Collaborative Dose (MCD), 

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This book is the property of excelleRx, Inc.

P e d i M U G s 

P e d i at r i c M e d i c at i o n U s e G u i d e l i n e s 

s e c o n d E D I T I O N

Table of Contents 

Contact Information 5 

Introduction 6 

Acknowledgements 9 

General Pediatric Principles 

Common Conversions 10 

Formulas for Estimating Pediatric Doses 10 

Principles of Drug Therapy in Pediatric Patients 

Influence of Age on Drug Therapy 11 

Alternative Routes of Drug Absorption 12 

Drug Distribution 13 

Drug Metabolism 14 

Drug Excretion 14 

Palability of Medications 15 

Symptom Management in Pediatric Palliative Care 

Pain Assessment 16 

Pediatric Pain Scales 16 

Guidelines for Non-Pharmacological Therapy 20 

Non-Pharmacological Therapies 21 

Guidelines for Pharmacological Therapy 22 

The HP Pediatric ComfortPak 24 

Inclusion Code A 

Agitation/Psychosis 26 

Anxiety 29 

Constipation 31 

Corticosteroids Dosing 34 

Cough 35 

Table of Contents

Table of Contents 

Depression 38 

Diarrhea 39 

Dyspepsia/Gastroesophageal Reflux 41 

Dyspnea 44 

Edema 48 

Fever 50 

Infections 52 

Insomnia 57 

Muscle Spasm 58 

Nausea/Vomiting 59 

Oral Conditions 63 

Pain – Neuropathic 65 

Pain – Nociceptive 68 

Pruritus 74 

Secretions 76 

Seizures 77 

Somnolence 82 

Inclusion Code C 

Cachexia 83 

Inclusion Code H 

Cardiomyopathy/CHF/Cardiac Disease 84 

Inclusion Code O 

Cystic Fibrosis 95 

References 101 

Commonly Compounded Medications by Ingredient 103 

 

Table of Contents

Contact Information 

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Contact Information

introduction 

In the United States more than 50,000 children die every year, resulting in more than 

250,000 bereaved parents, siblings, and other loved ones whose lives are significantly and 

permanently altered. 

Palliative care was defined in 1990 by the World Health Organization 1 as: 

The active total care of patients whose disease is not responsive to curative treatment. It involves 

the control of pain, of other symptoms, and of psychological, social and spiritual problems. 

The goal of palliative care is the achievement of the best quality of life for patients and their 

families. Pediatric palliative care involves the medical care and study of children with lifelimiting 

illness. 

Compared with adult end-of-life care, pediatric palliative care has: 

• A smaller population. 

• A broad spectrum of illnesses, including many rare diseases that often require the involvement 

of a number of disciplines to provide care. 

• Unpredictable illness trajectories with significant prognostic uncertainty (often impossible 

to predict the progression of life-threatening illnesses in pediatric patients). Palliative care 

may overlap with chronic curative care, with palliative care becoming more prominent as 

the child progresses from being chronically to terminally ill. 

• More uncertainty about whether treatments are supportive/palliative versus those that 

primarily mitigate disease or prolong life. 

Need for Palliative Care 

• One group is children for whom curative treatment is possible but may fail (e.g., cancer). 

• Another group includes diseases where premature death is most likely the end result, but 

long periods of intensive treatment may possibly prolong the child’s quality of life (e.g., 

AIDS, cystic fibrosis). 

• Patients with progressive conditions where treatment is exclusively palliative may continue 

to live for many years (e.g., Tay Sachs, Batten disease). 

• Some patients may have conditions with severe neurological disability causing weakness and 

susceptibility to complications (e.g., hypoxic ischemic encephalopathy or hydroencephaly). 

The Medication Use Guidelines (MUGs®) facilitate evidence-based symptom management. 

The Hospice Pharmacia (HP) palliative care pharmacist collaborates with the hospice nurse 

and the prescriber to outline the most appropriate symptom management care plan. By consulting 

with an HP pharmacist and using the MUGs, a hospice can contain medication costs 

while providing consistent, standardized, high-quality palliative care for patients. 

This document is a guide to managing pain and palliating symptoms suffered by pediatric 

hospice patients. The information contained herein has been derived from peer-reviewed 

medical literature and tertiary literature sources. Individual dose and therapy adjustments 

may be necessary based on age, weight, hepatic/renal function, and co-morbid medical conditions. 

Your HP palliative care pharmacists are here to help individualize therapy. 

 

Introduction

introduction 

These guidelines are derived from evidence-based literature and standards of practice. 

Where evidence-based literature is lacking, recommendations are based on clinical experience, 

anecdotal case reporting, and prescribing trends. Common standards of practice in 

pediatrics include “off-labeled” use of medications since many FDA-approved medications do 

not have pediatric labeling information. 

The Pediatric Medication Use Guidelines (Pedi-MUGs) are to be used in concert with 

the adult MUGs. The adult version provides a number of symptom guidelines and therapy 

options that are not repeated in the Pedi-MUGs. Pedi-MUGs address the most common 

symptoms experienced by the pediatric patient and therapy options that have documented 

clinical utility and pediatric-specific dosing data. If a therapy is not listed in Pedi-MUGs, there 

may be a lack of data on its use or a lack of safe dosing information in the pediatric 

population. However, all therapies listed in the most recent edition of the adult MUGs that 

were previously provided will continue to be included for pediatric patients. 

In the Pedi-MUGs, unless otherwise noted, the route of administration is oral. 

Per Diem Partnerships 

Medications within the Pedi-MUGs are included under the per diem if related to the patient’s 

terminal diagnosis, and fall within the appropriate inclusion code of the MUGs. 

Inclusion Codes 

The diagnosis Inclusion Codes define the groups of medications covered under the per diem 

based on a hospice patient’s terminal diagnosis. For instance, medications used to treat cystic 

fibrosis would not be included within the per diem for a patient admitted with a terminal 

diagnosis of congestive heart failure. A patient ‘s HP record can have only one terminal 

diagnosis. 

The Inclusion Codes are as follows: 

A: All symptoms related to the terminal diagnosis 

C: Cancer/AIDS diagnoses (ICD-9: 042, 140-239) 

H: Cardiac diagnoses (ICD-9: 391-429, 440-459) 

L: Lung diagnoses (ICD-9: 460-519) 

O: All other terminal diagnoses that do not fall in one of the other Inclusion Codes or 

ICD-9 ranges (e.g., ICD-9 for CVA: 430-438) 

Introduction

Introduction 

Per Diem Exclusions 

• Brand name medications: If a brand name medication is requested when a generic is available, 

the brand name medication will be billed outside the per diem. 

• Second-line agents: Medications that are available as second-line agents are included in the 

per diem only after the patient has already tried a course of a first-line agent or is clinically 

unable to take a first-line agent. 

• Any medications not related to the primary diagnosis: Only medications related to the 

patient’s primary hospice diagnosis (based on HP diagnosis Inclusion Codes) are included 

in the per diem. 

• The per diem does not provide for dispensing devices (e.g., pill counters, unit-of-use 

prepackaged oral syringes) or the labor involved in fulfilling special dispensing services (e.g., 

filling pill counters, cutting tablets in half). While it may be possible to request such dispensing 

devices through the local pharmacy or through HP, an additional charge may apply. 

Please refer to the adult MUGs or the Quick Guide to Services booklet for further explanation 

of Inclusion Codes and all other HP policies and procedures. 

 

Introduction

acknowledgements 

We extend our thanks to everyone who participated in reviewing the Pedi-MUGs, including: 

External Review Panel 

Bruce M. Frey, PharmD, Clinical Pharmacist in Pediatrics and Neonatology, Medical University 

of South Carolina 

Carlton K. K. Lee, PharmD, MPH, FASHP, Clinical Specialist–Pediatrics, Department of 

Pharmacy, The Johns Hopkins Hospital, Assistant Professor–Pediatrics, School of Medicine, 

Johns Hopkins University 

Kristine Rapan, PharmD, Pediatric Pharmacy Specialty Resident, Department of Pharmacy, The 

Johns Hopkins Hospital 

Hospice Pharmacia Staff 

Editors: 

Jennifer L. Johansen, PharmD, BCPS 

Douglas J. Weschules, PharmD, BCPS 

Internal Reviewers: 

Thomas J McCool, RPh, PharmD(c) 

Cassandra Cooper, PharmD 

Linda Pincus, PharmD 

Laura Scarpaci, PharmD, BCPS 

Contact MUGs@hospicepharmacia.com or your Regional Director of Client Development 

if you are interested in becoming a reviewer. 

Acknowledgements

General Pediatric Principles 

Common Conversions and Useful Formulas for Dosage Estimation 

Pounds to kilograms: 2.2 lb = 1 kg 

Inches to centimeters: 1 inch = 2.54 cm 

Body surface area (BSA): BSA (m 2 ) = √[height (cm) x weight (kg)]/3600 

Ideal body weight (IBW) (1–18 years of age): IBW (kg) = (height [cm] 2 x 1.65) 

1000 

Pediatric Age Definitions 2 

Newborn, Premature 

Newborn, Term 

Neonate 

Infant 

Child 

Adolescent 

Principles of Drug Therapy in Pediatrics 3 

Influence of Age on Drug Therapy 

Gastrointestinal absorption—A number of patient variables can affect the rate and extent 

of GI absorption of a drug, including pH-dependent diffusion; the presence, absence, and 

type of gastric contents; gastric emptying time; and GI motility. These physiologic processes 

reflect a clear but highly variable dependence on a patient’s age (see the following table): 

Parameter Neonate Infant Child 

Gastric acid secretion Reduced Normal Normal 

Gastric emptying time Decreased Increased Increased 

Intestinal motility Reduced Normal Normal 

Biliary function Reduced Normal Normal 

Microbial flora Acquiring Adult pattern Adult pattern 

From Nelson Textbook of Pediatrics, 17th ed, Philadelphia: Saunders. 3 

pH—The acid lability and acidity of the medication are important to consider as these 

directly influence absorption of a medication, especially when given orally. Acid-labile 

medications (e.g., penicillins) are better absorbed in neonates than in older children and 

adults. Similarly, acidic medications such as phenobarbital, require higher doses to achieve 

therapeutic concentrations in neonates. 

Gastric emptying and motility—These factors are also important to consider, especially 

when dosing neonates and infants. In general, the rate at which most drugs are absorbed is 

slower in neonates and young infants when compared to older children 4 , thus prolonging the 

time to maximum peak levels. 

Drug formulation—The extent to which age changes influence GI drug absorption also 

depends on the specific drug formulation administered. A solid dosage form must dissolve into 

solution before the drug can cross cell membranes. Most drugs administered to infants and 

young children are available in a liquid formulation, including suspensions. Generally, the rate of 

absorption is faster after administration of a liquid dosing formulation (solution > suspension) 

as compared with solid formulations (capsule >/= tablet > sustained/delayed-release tablet). 

Alternative Routes of Drug Absorption 

Sublingual administration—Sublingual or buccal routes of administration may also be an 

option for some medications. Since the stratum corneum is absent and because of a rich 

blood supply, absorption can be rapid and the first-pass effect can be avoided. Medications 

that are lipid soluble and have a higher pKa are more likely to be absorbed via this route. 

Medication needs prolonged contact with mucosa to ensure absorption. Taste may also be 

an issue for many children when using this route of administration. 

Enteral (i.e. feeding tubes)—Due to intestinal fragility, avoid administering medications via 

this route if possible, especially in neonates. Enteral feeds can dilute hyperosmolar 

medications–only consider this route if the child is receiving 100 mL/kg/24 h or more. 


11


Intramuscular—Another common means of extravascular drug administration in infants and 

children is the intramuscular route. Drugs should be water-soluble at physiologic pH. This 

route requires adequate blood flow to and from the injection site to ensure absorption into 

the systemic circulation. Systemic circulation can be compromised in seriously ill infants and 

children with poor peripheral perfusion due to low cardiac output and respiratory disease. 

Small infants should not receive more than 0.5 mL per injection to minimize discomfort. 

Maximum volumes are: older infant = 1 mL, school-age child = 2 mL, and adolescent = 3 mL 5 . 

Only the outer aspect of the thigh should be used until child is 1 year of age or walking. 

Subcutaneous—This route involves similar considerations as the intramuscular route regarding 

pH and blood flow. The sites most commonly used are the upper outer arm or the outer 

aspect of the upper thigh. Rotation of injection sites for medications administered via the 

subcutaneous route (e.g., insulin) is recommended to prevent nodule formation and other 

localized reactions. 

Topical—The skin is a very important but often overlooked organ for absorption of various 

therapeutic agents and environmental chemicals. The percutaneous absorption of a compound 

is directly related to the degree of skin hydration and inversely related to the thickness 

of the stratum corneum. The ratio of the newborn’s skin surface area to body weight 

is approximately three times greater than an adult. Therefore, the amount of drug absorbed 

into the systemic circulation (bioavailability) for an identical percutaneous dose of a drug 

is approximately three times greater in an infant than in an adult. Toxicities from topically 

administered hexachlorophene soaps, lindane, hydrocortisone, rubbing alcohol, povidone 

iodine, and salicylic acid ointment have been reported in neonates and infants. 

Inhaled—The respiratory tract can be useful for the administration of many medications, 

especially those used to manage pulmonary-related conditions. Water-soluble medications 

tend to remain on the tissues of the upper airway, and fat-soluble medications are more 

likely to reach the distal airways. Respiratory patterns and delivery systems can also affect 

drug delivery via this route. 

Rectal—This route is an option for children who cannot take anything by mouth, who are 

experiencing acute nausea and vomiting, or who have altered GI motility. Medications best 

absorbed rectally are lipid soluble and non-ionic. The first-pass effect of the liver may be 

bypassed when a drug is given rectally. Avoid this route in neonates, if possible, as data is lacking 

on absorption. This route should also be avoided in immunosuppressed patients. Several 

factors should be considered when using the rectal route including pH of rectal contents, 

retention of drug administered, and drug formulation. The pH of the rectal vault in children 

ranges from 7.2 to 12.2. 

12 

Principles of Drug Therapy in Pediatrics 3


Drug Distribution 

Volume of Distribution (V d 

)—The value of V d 

for a number of drugs differs markedly among 

newborns (premature versus full term), infants, and children as compared with adults. 

Differences are the result of age-dependent variables: composition and size of body water 

compartments, protein-binding characteristics, and hemodynamic factors. Changes in body water 

compartment sizes and water distribution account for the differences observed in the V d 

of 

water-soluble drugs (e.g., aminoglycosides) in infants and children. Total body water composition: 

Premature infant: 85% 

Term infant: 75% 

3 months of age: 78% 

1 year of age: 73% 

Adult: 55–60% 

NOTE: Adult values are approached at 12 years of age. 

Changes in body fat are also significant in infants. Premature infants have approximately 

1–2% body fat; term neonates have 10–15%; and infants 1 year of age have about 20–25% 

fat. Therefore, lipophilic medications have a lower V d 

in neonates than in infants and need to 

be dosed accordingly. 

Protein Binding—Drug binding to plasma proteins depends on a number of age-related variables: 

absolute amount of protein available, the respective number of available binding sites, the 

affinity constant of the drug for the protein, the influence of pathophysiologic conditions, and 

the presence of endogenous substances which may compete for protein binding (i.e., bilirubin). 

Serum albumin (which binds acidic drugs) and total protein concentrations are decreased 

during infancy, approaching adult values by the age of 10–12 months. Thus, the free fraction 

and subsequent bioavailability of drugs highly protein bound to albumin will be increased 

(e.g. phenobarbital, digoxin). Similar pattern of maturation with alpha 1-acid glycoprotein 

(binds to basic drugs); concentrations are approximately three times lower in neonatal 

plasma compared with concentrations in maternal plasma, achieving values comparable to 

those of adults by 12 months of age. During the neonatal period, free fatty acids, bilirubin, 

and 2-hydroxybenzoylglycine compete for albumin-binding sites and influence the resultant 

balance between free and bound drug concentrations. 

Assess a drug’s potential for displacement of bilirubin from protein-binding sites before 

administration to premature and newborn infants. (Examples include sulfamethoxazole– 

trimethoprim, bumetanide, phenytoin, and lidocaine). Elevated bilirubin in neonates can lead 

to a neurological condition called kernicterus. 

Clinically significant protein-binding displacement reactions occur only when a drug is more 

than 80–90% protein bound, the clearance (Cl) of a drug is limited, and its apparent V d 

is 

small, usually less than 0.15 L/kg. 


13


CNS Drug Penetration—The immaturity of the blood-brain barrier, due to incomplete CNS 

myelination, increases CNS penetration of some medications in neonates. 

Drug Metabolism 

Phase I reactions—The specific subfamilies, or isozymes, most responsible for human drug 

metabolism involve cytochrome P450 (CYP450) 1A2, 2D6, 2C19, and 3A4. At birth, the 

concentration of drug-oxidizing enzymes in fetal liver is similar to that in adult liver. However, 

the activity of these oxidizing enzyme systems is reduced. This is reflected by prolonged body 

elimination for drugs that depend on oxidation pathways (e.g., phenytoin, diazepam). Postnatally, 

the hepatic cytochrome P450 mono-oxygenase system appears to mature rapidly; metabolic 

activity similar to or in excess of the adult value is achieved by approximately 6 months of 

age. In general: 

• 1A2: Not significant in newborns, it reaches adult levels by 4–5 months and exceeds adult 

activity throughout childhood. 

• 2C enzyme family, 2D6: Wide interpatient variability. The 2D6 enzymes reach adult activity 

by 1–6 months, exceed adult activity by 3–10 years, and then decline thereafter. 

• 3A4: Wide interpatient variability. Fetus has 30–75% of adult activity, an infant can achieve 

adult levels by 2 years of age. 

Phase II reactions—Because elimination of metabolites is reduced in preterm and full-term 

infants, accumulation of active metabolites not considered clinically relevant in older infants, 

children, and adults may occur in infants (i.e., theophylline to caffeine). This pathway becomes 

more important in neonates because theophylline is less readily metabolized, making it more 

available for N-methylation. Caffeine itself is normally metabolized before elimination, but in 

preterm infants with immature liver enzymes caffeine is mainly eliminated renally. This renal 

elimination is slow because of the immaturity of renal function in young infants, resulting in 

the potential for marked caffeine accumulation and toxicity. 

Glucuronidation activity is reduced in infants, and it does not reach maturity until 3 years of 

age. Thus, morphine doses in infants may need to be adjusted upward, as infants cannot readily 

synthesize morphine-6-glucuronide, morphine’s primary active metabolite. 

Drug Excretion 

The amount of drug that is filtered by the glomerulus per unit of time depends on the 

functional ability of the glomerulus, on the integrity of renal blood flow, and on the extent of 

drug–protein binding. Although highly variable, renal blood flow averages 12 mL/min at birth, 

approaching the adult value by 5–12 months of age. The glomerular filtration rate increases 

rapidly during the first 2 weeks of life and approaches the adult value by 8–12 months of age 4 . 

Before week 34 of gestation, glomerular filtration is markedly reduced and increases slowly. 

14 

Principles of Drug Therapy in Pediatrics 3


Estimation of creatinine clearance (CrCl): 

Infants and children up to 18 year of age (Schwartz equation) 

CrCl (mL/min/1.73 m 2 ) = 

K x L 

serum creatinine (SCr) 

L = length in centimeters (cm) 

K = age-specific constant of proportionality 

Low birth weight ≤1 year of age K = 0.33 

Full term ≤1 year of age K = 0.45 

2–12 years of age K = 0.55 

13–21 years of age, female K = 0.55 

13–21 years of age, male K = 0.70 

Palatability of Medication 

Palatability of medication is very important, especially in pediatric patients. An unpleasant 

tasting medication can lead to noncompliance and, potentially, therapeutic failure. The palatability 

of a medication consists of its initial taste, texture, flavor, and aftertaste. While it is difficult 

to change the gritty texture of a suspension to improve its palatability, flavoring agents 

can be added to most medications to improve taste. HP can add flavoring to medications 

upon request. However, care-planning with an HP pharmacist must occur to discuss the practicality 

of the flavoring addition and expectations of the taste, as flavoring agents may affect 

the bioavailability of the medication or change its concentration by dilution. To hide certain 

tastes, the following flavors can be helpful: 

• Bitter: chocolate, licorice flavoring 

• Salty: cinnamon, peanut butter flavoring 

• Sour: citrus flavoring (except grapefruit) 

A small amount of the flavoring can be mixed with the dose immediately prior to administration 

of the dose. As long as the child consumes the full mixture, the dose is assured. 


15


Pain control is of paramount importance in reducing the suffering of the child, family, and caregivers; 

however, many dying children do not have their pain successfully treated. In end-of-life care, it is 

important to form and initiate a pain treatment plan even when the diagnosis may be unclear, the 

prognosis uncertain, and the ability of the child to communicate limited. Many children are unable 

to verbalize and will communicate their discomfort nonverbally; presumptive therapy should be 

initiated promptly and treatment plans should be modified based on response. 

Pain Assessment 14 

“ABCs” of pain assessment in children 

• Assess: Always evaluate a child for potential pain; children may experience pain even 

though they may be unable to express it in words. Infants and toddlers can show pain only 

by how they look and act; older children may deny pain for fear of more painful treatment. 

• Body: Consider pain assessment as an integral part of the physical exam. The physical exam 

should include a comprehensive check of all body areas for potential pain sites. The child’s 

reaction during the exam (grimacing, contracture, rigidity, etc.) may indicate pain. 

• Context: Consider impact of family, health care, and environmental factors on the child’s pain. 

• Document: Record severity of a child’s pain regularly. Use a pain scale that is simple and 

appropriate for the developmental level of the child. 

• Evaluate: Assess effectiveness of pain interventions regularly and modify the treatment plan 

as necessary until the child’s pain is alleviated or minimized. 

When children are unable to describe pain in words, they must be carefully watched for 

behavioral signs of pain. Children under the age of 6 describe only the general pain they feel, 

while older children can also describe other aspects including the severity, quality, location, 

duration, and changes over time. 

INFANTS: 

a. Physiologic response: increased blood pressure, heart rate, respiratory rate; oxygen desaturation; 

crying, sweating, flushing, pallor. Note that these responses are unreliable in assessing 

chronic pain. 

b. Behavioral response: 

Primary Behavioral Signs Indicative of Pain in Children 

Behavioral Signs 

Brief 

Crying + 

Distressed facial expression + 

Duration of Pain 

Persistent 

Motor disturbances + 

Lack of interest in surroundings + 

Decreased ability to concentrate + 

Sleeping difficulties + 

16 

Symptom Management in Pediatric Palliative Care


Premature Infant Pain Profile (PIPP) 6 

Process Indicator 0 1 2 3 Score 

Gestational Age 

Observe Infant 15 

seconds 

Observational 

baseline: 

Heart Rate: 

Oxygen 

Saturation: _____ 

Observe Infant 30 

seconds 

Gestational 

Age (at time 

of observation) 

Behavioral 

State 

Heart Rate 

Max: _____ 

- Oxygen 

Saturation 

Min: 

36 weeks 

and more 

active/ 

awake, eyes 

open, facial 

movements, 

crying (with 

eyes open 

or closed) 

0 to 4 

beats/ 

minute 

increase 

0% to 2.4% 

decrease 

32 weeks to 

35 weeks, 6 

days 

quiet/awake, 

eyes 

open, no 

facial movements 

5 to 14 

beats/ 

minute 

increase 

2.5% to 

4.9% 

decrease 

28 weeks to 

31 weeks, 6 

days 

active/sleep, 

eyes closed, 

facial movements 

15 to 24 

beats/ 

minute 

increase 

5% to 7.4% 

decrease 

less than 28 

weeks 

quiet/sleep, 

eyes closed, 

no facial 

movements 

25 beats/ 

minute 

or more 

increase 

7.5% or 

more 

decrease 

- Brow Bulge None* Minimum# Moderate^ Maximum** 

- Eye Squeeze None* Minimum# Moderate^ Maximum** 

- Nasolabial 

Furrow 

*None = 0-9% of the time 

#Minimum=10-39% of the time 

^Moderate=40-69% of the time 

**Maximum=70% of the time or more 

Scoring Method for the PIPP 

None* Minimum# Moderate^ Maximum** 

1. Familiarize yourself with each indicator and how it is to be scored by looking at the 

measure. 

2. Score gestational age (from the chart) before you begin. 

3. Score behavioral state by observing infant for 15 seconds immediately before event. 

4. Record baseline heart rate and oxygen saturation. 

5. Observe the infant for 30 seconds immediately after the event. You will have to look back 

and forth from the monitor to the baby’s face. Score physiologic and facial changes seen 

during that time and record immediately after the observation period 

6. Calculate the final score. A total PIPP score of 6 or less generally indicates minimal or 

no pain. 


17


CRIES 7 Pediatric Pain Scale 

Variable 0 1 2 

Crying No High-Pitched Inconsolable 

Requiring blood oxygenation 

levels of >95% 

Increased Vital Signs 

No 30% 

HR or BP ≤ Pre-Op/ 

Procedure 

HR or BP 20% of 

Pre-Op/ Procedure 

Expression None Grimace Grimace/Grunt 

Sleeplessness No Wakes at Frequent 

Intervals 

Instructions: 

1. Use in pre-term and term infants until 6 months of age. 

2. Administration 

• Assign a score for each variable 

• Add scores for each variable together to get total score 

3. The higher the score the greater the subjective expression of pain. 

Constantly Awake 

Note: If you are unable to score a variable (e.g., blood pressure), your total score may 

be out of 8 rather than out of 10. 

PRESCHOOLERS: 

Use “FACES” tool in addition to physiologic and behavioral responses listed above. 

Wong-baker Faces Pain Rating Scale 8 

18 



CHEOPS 9 (6 months to 3 years) 

Item Behavior Score Definition 

Cry No Cry 1 Not crying 

Moaning 2 Moaning or silent cry 

Crying 2 Gentle or whimpering cry 

Scream 3 Full-lunged cry 

Facial Smiling 0 Positive expression 

Composed 1 Neutral expression 

Grimace 2 Negative expression 

Verbal Positive 0 Positive statements without complaint 

None 1 Not talking 

Other Complaints 1 Complaints, but not about pain 

Pain Complaints 2 Complaints about pain 

Both Complaints 2 Complaints about pain and other things 

Torso Neutral 1 Body at rest, torso inactive 

Shifting 2 Body motion shifting or serpentine 

Tense 2 Body arched or rigid 

Shivering 2 Body shuddering or shaking involuntarily 

Upright 2 Body vertical or upright 

Restrained 2 Body restrained 

Touch Not Touching 1 Child not touching or grabbing at wound 

Reach 2 Reaching for wound or touching gently or vigorously 

at wound 

Restrained 2 Arms are being restrained 

Legs Neutral 1 Legs in any position but are relaxed 

Squirming/Kicking 2 Definitive uneasy or restless movements in legs; striking 

out with foot; legs pulled up tightly to body 

Restrained 2 Legs are being restrained 

CHEOPS is an observation scale which includes six categories of pain behavior: cry, facial, 

verbal, torso, touch, and legs. Each category has three or four grades. 

Scoring Method for the CHEOPS 

1. Assign a score for each category 

2. Add the scores together to get a total score. 

CHEOPS has a minimum possible score of 4 points (no pain) to a maximum of 13 points 

(the worst pain). 


19


SCHOOL-AGE AND ADOLESCENT: 

Children this age can typically describe the pain, its location, and character. Children 8 years 

of age or older can use a Numeric Analog Scale (e.g., Likert scale, 0 – 10/10). Also evaluate 

physiologic and behavioral responses listed above. 

0-10 Numeric Pain Scale 

0 1 2 3 4 5 6 7 8 9 10 

Guidelines for Non-Pharmacologic Therapy 

Non-pharmacologic approaches should supplement, but not replace, appropriate drug treatment. 

• Supportive methods: Supportive therapies support and empower the child and family. An 

empathic approach is essential, and information should be given a little at a time, repeated as 

frequently as needed. Booklets, videos, drawings, and dolls can be useful tools in this process. 

Ideally, children should be given choices about which techniques to use to control pain. 

• Cognitive methods: Cognitive therapies influence children’s thoughts. Active distraction 

of children’s attention is important: the more involved a child becomes in an activity, the 

greater the distraction from pain. Two types of cognitive methods are: 

1. Imagery—The process in which a child concentrates on the image of a pleasant and 

interesting experience instead of on the pain. 

2. True hypnosis—This approach requires special training, but pain can be modified by 

words of comfort and relief spoken in a particular way. 

• Behavioral methods: Behavioral therapies change behaviors. Some behavioral methods 

include deep breathing and progressive relaxation. 

• Physical methods: Physical therapies affect sensory systems. Two physical methods include: 

1. Touch—This technique includes stroking; holding and rocking; caressing; massaging hands, 

back, feet, head, and stomach; and swaddling. Vibration or tapping can also be comforting. 

2. Transcutaneous electrical nerve stimulation (TENS)—TENS utilizes a battery-operated 

device that delivers electrical stimulation through electrodes placed on the skin. 

Non-drug Methods of Pain Relief 

Supportive Cognitive Behavioral Physical 

Family-centered care Distraction Deep breathing Touch 

Empathy Music Relaxation Heat and cold 

Choices Imagery TENS 

Play 

Hypnosis 

Information 

20 



Non-Pharmacological Therapies 10 

Infants: Birth to 12 Months 

Positioning/Swaddling 

Rocking/Cuddling 

Pacifier 

Soft Music/Lullabies/Soft Voice 

Touch 

Dim Lighting 

Background Noise Reduction (PICU/ICN/TCN) 

Visual Distraction (rotating mobiles, moving 

toys, etc.) 

Access to Parent 

Preschool: 3 to 6 Years 

Pre-Procedural and Post-Procedural Play/ 

Preparation 

Bubbles, Pin Wheels, Party Blowers 

Manipulative Toys (GameBoy, etc.) 

Distraction (pop-up books, I Spy, counting) 

Music, Singing Songs 

Holding/Squeezing a Hand, PlayDoh 


Toddlers: 13 Months to 3 Years 

Pre-Procedural and Post-Procedural Play/Preparation 

Security Object (blanket, stuffed animal, pacifier) 

Soothing Tone of Voice 

Bubbles 


Distraction (toys, pop-up books, counting, singing) 


Music (lullabies, children’s songs, relaxation) 

School Age: 6 to 12 years 

Pre-Procedural and Post-Procedural Play/Preparation 

Breathing Techniques (focused, controlled) 

Music (with or without headset) 

Manipulative Toys (hand-held computer games, etc.) 

Guided Imagery 


Distraction (pop-up books, I Spy, Where’s Waldo?) 

Visual Focusing (eye contact with person, focal point) 

Adolescent/Adult 

Breathing Techniques (focused, controlled) 

Music (with or without headset) 

Manipulative Toys (hand-held computer games, etc.) 

Visual Focusing 

Neurostimulation (tens unit, massage, acupuncture) 

Supportive Care/Support Groups 

Altering Patient’s Behavior or Mood 

Biofeedback 

Imagery 

Aromatherapy 

Relaxation 

Hypnosis 

Cognitive Coping Skills (deep breathing exercises, distraction) 


21


Guidelines for Pharmacologic Therapy 

Correct use of analgesic drugs will relieve pain in most children. 

• By the ladder: A three-step analgesic ladder is used for pain control. 

• By the clock: Drugs should be administered according to a regular schedule rather than a 

prn schedule. 

• By the appropriate route: In general, 

- IM injections should not be used unless absolutely necessary; they are painful and frightening 

and the child may respond by failing to request pain medication or by denying 

pain. 

- Rectal administration is unpleasant for children but is preferred to IM. If injections are 

needed, use of a topical anesthetic may reduce pain. 

- Patient Controlled Analgesia (PCA) is a good approach to IV or SQ administration of 

drugs. 

• By the child: Doses are individualized and are child-specific. Doses of medications must be 

based upon each child’s circumstances. The opioid dose that effectively relieves pain varies 

widely among children and in the same child at different times. Children receiving opioids 

may also develop altered sleep patterns, becoming wakeful at night, fearful and complaining 

about pain and sleeping intermittently during the day. Adequate analgesics should be given 

at night, together with hypnotics or antidepressants as necessary to enable the child to sleep 

through the night. 

Routes of Drug Administration: Advantages and Disadvantages 

Oral Transdermal IV SQ IM Rectal 

Painless Painless Rapid pain 

control 

Preferred 

by 

children 

Restricted to fentanylcontraindicated 

in opioidnaïve 

patients or in 

patients taking less than 

50 mg/24 h of oral 

morphine equivalent. 

Not recommended for 

children less than 2 years 

of age. 

Not indicated for acute 

pain 

Not indicated for 

escalating pain 

Can be used if pain has 

been stabilized 

Easiest to 

titrate and 

adjust to 

rapidly 

changing 

pain levels 

Useful for 

intermittent 

bolus and 

continuous 

infusion 

Appropriate 

for PCA 

Avoids need 

for IV line 

Useful for 

home 

setting 

Useful for 

continuous 

infusion 

Appropriate 

for PCA 

Painful 

Not 

recommended 

Wide 

variability in 

therapeutic 

blood levels 

Generally 

disliked by 

children 

Wide 

variability in 

therapeutic 

blood levels 

Variable 

absorption 

Can be used 

if there is 

transient 

vomiting 

22 



Non-narcotic analgesics: These drugs are commonly used in the management of mild-to-moderate 

pain of nonvisceral origin. They can be administered alone or in combination with opioids. 

• Acetaminophen (APAP): Weak analgesic with antipyretic activity. 

• Non-steroidal anti-inflammatories (NSAIDs): Especially useful for sickle cell, bony, 

rheumatic, and inflammatory pain. Consider concurrent H2 blocker (ranitidine, famotidine) 

or PPI (omeprazole) therapy with prolonged NSAID use. 

Opioid Use Guidelines 3 

Clarify the differences between tolerance versus physical dependence versus addiction. 

Dispel myth that strong medications are saved for last. 

Anticipate and treat/prevent common side effects (constipation, pruritus, nausea, dysphoria, somnolence). 

Always start constipation treatment when opioids are started. 

Begin with low doses of opioids for mild pain; titrate dose upward for unresponsive/persisting pain. 

Start with short-acting opioids at regular intervals and then convert to long-acting preparations 

when dose requirements have been established. 

Consider a switch to a different opioid when limited by side effects (e.g., myoclonus). 

Consider subcutaneous infusions when oral/rectal route is no longer possible. 

Pain and Symptom Management 3 

Establish realistic goals of treatment—maintaining comfort is the priority. 

Anticipate and plan for symptoms before they occur. 

Utilize stepwise approach to pain management. 

Choose the least invasive route of administration, oral when possible. 

Prescribe regular (not PRN) medications for constant pain. 

Consider the use of adjuvant agents: 

• Antidepressants and anticonvulsants for neuropathic pain 

• Neuroleptics for nausea and agitation 

• Sedatives and hypnotics for anxiety or muscle spasm 

• Steroids for resistant pain 

• Stimulants for opioid-induced somnolence 

Consider anesthetic blocks for regional pain. Use topical local anesthetics when possible. 

Always include cognitive (guided imagery, distraction), physical (TENS, physiotherapy, massage), and 

behavioral (biofeedback, behavior modification) techniques. 


23


The HP Pediatric ComfortPak 

The label on the Pediatric ComfortPak instructs the patient to place it in the refrigerator and 

only open it if directed by the hospice nurse or physician. 

The Pediatric ComfortPak is intended to contain a limited quantity of medications for urgent 

symptom management needs. While HP can supply the medications listed below in a kit, not 

all medications are appropriate for all age groups. Please review appropriateness and dosing 

with your HP pharmacist prior to prescribing. 

Contents 

Morphine sulfate 

oral concentrate 

20 mg/ml 

CII 

Prochlorperazine 

syrup a 

5 mg/ml 

Lorazepam oral 

concentrate 

2 mg/ml 

CIV 

Hyoscyamine oral 

solution b 

0.125 mg/ml 

Haloperidol oral 

solution c 

1 mg/ml 

Diphenhydramine 

syrup d 

2.5 mg/ml 

Dosage Calculation & Assessment 

Notes (Dose/weight (kg) x 

Weight (kg) = Dose) 

0.2 mg/kg x _______kg = ________mg 

OR 

0.5 mg/kg x _______kg = ________mg 

*Consult with an HP pharmacist to 

select most appropriate dose between 

the dose range calculated above* 

Symptom Qty Administration 

Guidelines 

Pain, 

Shortness 

of breath 

0.1 mg/kg x _______ kg=________mg Nausea, 

Vomiting 

0.05 mg/kg x ______kg = _______mg 

OR 

0.1 mg/kg x _______kg = ________mg 

* Consult with an HP pharmacist to 


the dose range calculated above * 

3 mcg/kg x ________kg = ______mcg 

*For patients less than 5kg, the dose 

for hyoscyamine (as seen to the right) 

cannot be accurately measured. Use 

the following alternate dosing regimen 

according to patient weight: 

5 kg = 20.8mcg/dose 

3.4kg = 16.7 mcg/dose 

2.3kg = 12.5 mcg/dose 

0.025 mg/kg x _______kg = ______mg 

OR 

0.05 mg/kg x ________kg = ______mg 




Anxiety, 

Agitation 

1 mg/kg x _______kg =_________mg Insomnia, 

Itching 

15 ml Take ______mg 

by mouth or 

under the tongue 

every 4 hours 

prn for pain or 

shortness of 

breath 


by mouth 

divided 4 times 

daily prn for 

nausea and/or 

vomiting 


by mouth every 

4 hours prn for 

anxiety or agitation 

Secretions 15 ml Take _____mcg 



excess secretions 

Agitation 15 ml Take ______mg 

by mouth or 

under the tongue 

divided 3 times 

daily prn for 

agitation 




sleep or itching 

24 



Metoclopramide 

syrup 

5 mg/ml 

0.1 mg/kg x _______kg = ________mg 

OR 

0.2 mg/kg x _______kg = ________mg 




Nausea, 

Vomiting 

15 ml Take _______ 

_mg by mouth 

every 6 hours 

prn for nausea 

and/or vomiting 

a. Prochlorperazine should only be used in children older than 2 years of age or heavier than 

10 kg; high incidence of EPS. 

b. Contains 5% alcohol. 

c. Haloperidol should only be used in children 3 years of age or older. 

d. Paradoxical CNS excitation has been reported with diphenhydramine. 

• A 1-mL oral dosing syringe is included in each Pediatric ComfortPak. 

• All liquids will also have droppers. 

• For doses less than 0.25 mL, use the 1-mL oral syringe provided in Pediatric ComfortPak. 

When the patient develops one or more of the symptoms targeted by the Pediatric 

ComfortPak, the nurse may instruct the patient/family to use the specifically labeled 

contents as directed by the prescriber. Once it is opened, the nurse must notify HP to 

continue symptom management with the medication used from the kit and/or to prepare 

for the next symptom management need. When notified, HP will process a maintenance 

prescription to ensure that the patient does not run out of medication. There are no refills 

on Pediatric ComfortPak medications. A new prescription must be obtained from the physician. 

Please communicate these requests during normal business hours. 


25

Inclusion Code: A Section 

Commonly Experienced Symptoms

Agitation/Psychosis 

INCLUSION CODE: A 

Haloperidol 

PO: 

3–12 years of age: Initial dose: 0.025–0.05 mg/kg/24 h divided bid–tid 

Titration: 0.25–0.5 mg/24 h q5–7days prn 

Maximum dose: 0.15 mg/kg/24 h 

Usual maintenance dose 

Agitation 

Psychosis 

>12 years of age: 

IM: 

Acute agitation 

Psychosis 

0.01–0.03 mg/kg/24 h given once daily 

0.05–0.15 mg/kg/24 h divided bid–tid 

1–15 mg/dose; repeat dose in 1 h prn 

1–15 mg/24 h divided bid–tid 

6–12 years of age: 1–3 mg/dose(lactate) q4–8h 

Maximum dose: 0.15mg/kg/24h 


Acute agitation 

Psychosis 

2–5 mg/dose (as lactate); repeat dose in 1 h prn 

2–5 mg/dose q4–8h prn 

Clinical Notes 

• Acutely aggravated patients may require doses as frequent as every 60 min. 

• Safety and efficacy of haloperidol have not been demonstrated in children less than 3 

years of age. 

• Haloperidol is a substrate of CYP450 1A2, 2D6 (minor), and 3A4 enzymes; its metabolism 

may be altered by medications that share these pathways. 

• Haloperidol is a CYP450 2D6 inhibitor and 1A2, 2C, and 3A3/4 inducer; review medication 

profile for potential drug–drug interactions. 

• This drug may cause extrapyramidal symptoms (EPS), especially at higher doses. Monitor 

patient closely for signs and symptoms of EPS. 

• If using haloperidol injection, convert patient to oral route of administration as soon as 

possible. The lactate is an immediate-release form; do not confuse it with haloperidol decanoate, 

a depot form that is outside the per diem. 

• Relative contraindication exists for patients with a seizure history as haloperidol can lower 

seizure thresholds. 

26 

Agitation/Psychosis



Chlorpromazine 

≥ 6 months of age and children: 

PO: 

PR: 

IM/IV: 

0.5–1 mg/kg/dose q4–6h prn 

1 mg/kg/dose q6–8h prn 

0.5 – 1 mg/kg/dose q6 – 8h 

Maximum dose < 5 years of age (< 22.7 kg): 40 mg/24 h 

Maximum dose 5 – 12 years of age (22.7 – 45.5 kg): 75 mg/24 h 


• Do not administer the oral liquid dosage form together with carbamazepine oral suspension 

as an orange, rubbery precipitate may form. 

• Dosage adjustment is necessary in patients with hepatic impairment. 

• Safety in children less than 6 months of age has not been established. 

• Hypotension may occur when chlorpromazine is given parenterally. 

• Chlorpromazine is a substrate of CYP450 1A2, 2D6, and 3A3/4 enzymes; its metabolism 


• Chlorpromazine is an inhibitor of CYP450 2D6; review medication profile for potential 

drug–drug interactions. 

• This drug may cause EPS, especially at higher doses. Monitor patient closely for signs and 

symptoms of EPS. 

• Relative contraindication exists for patients with a seizure history as chlorpromazine can 

lower seizure thresholds. 


27



Risperidone 

Disruptive behavior in autism and other developmental disorders: 

5 – 12 years of age Initial: 0.01 mg/kg/dose PO daily x 2 days 

Titration: Increase by 0.02 mg/kg/dose daily. At day 8, dose may 

be increased or decreased to a maximum of 0.02 mg/kg/24 h at 

weekly intervals. 

Average daily dose: 0.04 mg/kg/24 h 


OR 

< 15 kg: Use with caution; no specific dosing recommendations available 

≥ 15 and < 20 kg: 

≥ 20 kg: 

Initial: 0.25 mg PO daily 

Titration: After 4 days or longer, may increase to 0.5 mg/day; dose 

should be maintained for ≥ 14 days. If response insufficient, may 

increase dose in increments of 0.25 mg/day at intervals not less 

than 2 weeks in duration. 

Maximum dose: 1 mg/day 

Initial: 0.5 mg PO daily 

Titration: After 4 days or longer, may increase to 1 mg/day; dose 

should be maintained for ≥ 14 days. If response insufficient, may 

increase dose in increments of 0.5 mg/day at intervals not less 

than 2 weeks in duration. 

Maximum dose: 2.5 mg/day (3 mg in children > 45 kg)* 


• *Doses >2 mg/24 h are outside per diem 

• Risperidone is a substrate of CYP450 2D6 and 3A4 enzymes; its metabolism may be 

altered by medications that share these pathways. 

• Risperidone is a weak inhibitor of CYP450 2D6; review medication profile for potential 




• Relative contraindication exists for patients with a seizure history as risperidone may lower 

seizure thresholds 

28 

Agitation/Psychosis


Anxiety 

Lorazepam 

PO/PR/IM/IV: 

0.05–0.1 mg/kg/dose q4–8h prn 

Maximum dose: 2 mg/dose 


• Paradoxical reactions to benzodiazepines occur more commonly in children than in adults. 

• Injectable product may be given rectally, however, pediatric suppositories are compounded 

by HP. 

• For IV push administration, lorazepam injection MUST be administered with an equal 

amount of compatible diluent (e.g., NSS) and over 2-5min. 

• Cumulative amounts of benzyl alcohol, polyethylene, and propylene glycol in the injection 

may be toxic to newborns. 

Diazepam 

PO/PR: 

IM/IV: 

0.12–0.8 mg/kg/24 h divided q6–8h 



Maximum dose: 0.6 mg/kg within an 8 hour period 



• Use with caution in patients with shock, or depression. 

• Administer IV product undiluted no faster than 2 mg/min. 

• IM diazepam is erratically absorbed. 

• Pediatric suppositories are compounded by HP. 

• The IV preparation contains benzyl alcohol and propylene glycol, which may be toxic to 

newborns when high doses of diazepam are administered. 

• The T ½ values are: neonates = 40–100 h, children = 18 h, and adults = 20–40 h. 

• Diazepam is a substrate of CYP450 1A2, 2C8, 2C19, and 3A4 (weak) enzymes; its metabolism 


• Valproic acid may displace diazepam from protein-binding sites; monitor for sedation. 

Clonazepam 

PO: 

0.01 mg/kg q12h 

Maximum dose: 0.1–0.2 mg/kg/24 h 



• Clonazepam is a substrate of CYP450 3A3/4 enzymes; its metabolism may be altered by 

medications that share these pathways. 

Anxiety 

29

Anxiety 


Hydroxyzine HCl/pamoate 

PO: 

IM: 

2 mg/kg/24 h divided q6–8h 



• Parenteral hydroxyzine is available only as the hydrochloride salt. 

• In general, the IV route of administration is not recommended. If the IV route is to be 

considered, only central lines should be used, due to reports of hypotension and pain. Accidental 

intra-arterial administration can lead to necrosis and gangrene. 

• Hydroxyzine may potentiate barbiturates, meperidine, and other CNS depressants. 

Chloral hydrate 

Infants and children: 

Sedative 

25–50 mg/kg/24 h PO/PR divided q6–8h 


Maximum dose, infants: 1000 mg/24h 

Maximum dose, children: 2000 mg/24h 


• Chronic administration in neonates can lead to accumulation of active metabolites; monitor 

as with other sedatives. 

• Peak effect is within 30–60 min. 

• Do not exceed 2 weeks of chronic use. 

• Sudden withdrawal may cause delirium tremens. 

• Chloral hydrate is contraindicated in patients with severe hepatic or renal disease. 

• The syrup may be administered rectally, if necessary. 

30 

Anxiety


Constipation 

Constipation is common in neurologic disorders and with the use of opioids . The first step 

is to assess stool frequency and quantity. Children with minimal solid intake may be comfortable 

with bowel movements as infrequent as weekly. Children prescribed opioid therapy 

should routinely be placed on stool softeners (e.g., docusate) and may also need laxative 

agents (e.g., senna derivatives/lactulose). 

Docusate sodium 

PO: 

12 years of age: 50–400 mg/24 h divided daily–qid 


• Oral dosage is effective after 1–3 days of therapy. 

• Oral liquid (50 mg/5 mL) can be bitter for children; it can be given with a small amount 

of milk, fruit juice, or formula. As long as the child consumes the full mixture, the dose is 

assured. 

• With older children and adults, docusate can be used rectally by adding 50–100 mg of 

docusate sodium liquid to the enema fluid (NSS or water). 

• Avoid using concurrently with mineral oil. 

Senna concentrate 

PO: 

Weight based: 

10–20 mg/kg/dose once daily 

Age based: 

1 month –1 year of age: 55–109 mg once daily (maximum: 218 mg/24 h) 

>1–5 years of age: 109–218 mg once daily (maximum: 436 mg/24 h) 

>5–15 years of age: 218–436 mg once daily (maximum: 872 mg/24 h) 


• The strength of senna preparations can be listed as either senna concentrate or sennosides 

equivalents. 187 mg standardized senna concentrate is approximately equal to 8.6 mg 

of sennosides. 

• Senna is available as an OTC syrup, 218 mg/5 mL (concentrate), and as an OTC liquid, 

33.3 mg/mL (concentrate). 

• Desired effect usually occurs within 6–24 h after oral administration. 

• This drug may discolor urine or feces. 

Constipation 

31

Constipation 


Glycerin 

3 years of age): 

Age based: 

OR 

3–12 years of age: 5–10 mg/24 h 

>12 years of age: 5–15 mg/24 h 

PR (as a single dose): 

0.3 mg/kg/24 h (maximum: 30 mg/24 h), 

11 years of age: 10 mg/24h (1 suppository) 


• Do not give an oral dose within 1 h of antacids or milk. 

• Avoid using in newborns. 

• Onset of action with oral administration is 6–10 h, and with rectal administration it is 15–60 min. 

Mineral oil 

PO: 

5–11 years of age: 5–15 mL/24 h divided daily–tid 

≥12 years of age and adults: 

PR: 

15–45 mL/24 h divided daily–tid 

5–11 years of age: 30–60 mL as a single dose 


60-150 mL as a single dose 

For disimpaction, doses up to 30 mL per year of age (maximum: 240 mL) bid can be given. 


• Duration of use as a laxative should not exceed 1 week, as prolonged administration may 

inhibit absorption of fat-soluble vitamins (A, D, E, and K). 

• Onset of action is 6–8 h. 

• Due to risk of aspiration, do not give dose at bedtime, and use with caution in children less 

than 5 years of age. 

32 

Constipation


Constipation 

Fleet® Enema/phospho-soda 

PR: 

2–4 years of age: 1 half bottle Fleet’s pediatric enema. May repeat once 

5–11 years of age: 1 full bottle Fleet’s pediatric enema. May repeat once 

>12 years of age and adults: 1 adult Fleet’s enema. May repeat once 

PO (mix with equal volume of water): 

5–9 years of age: 5 mL 

10–12 years of age: 10 mL 

>12 years of age: 20–30 mL 


• Onset of action for oral administration is 3–6 h, and for rectal administration it is 2–5 min. 

• Avoid retention of enema solution and DO NOT EXCEED recommended doses; such use 

may lead to severe electrolyte disturbances. 

• Mixed oral solution should be followed by at least one additional 4-8 ounce glass of cool 

water. 

Lactulose 

Constipation: 

Children: 

7.5 mL PO daily 

For prevention and treatment of portal or systemic encephalopathy (Dosage is adjusted 

every 1—2 days to produce 2—3 soft stools per day): 

Infants: 

Children: 

2.5 – 10 mL PO daily, given in 3 – 4 divided doses 

40 – 90 mL PO daily, divided every 6 – 8 hours 


• Use with caution in patients with fragile diabetes mellitus. 

• Avoid using in dehydrated patients. 

• Electrolyte abnormalities may occur if used for more than 6 months at a time. 

Sorbitol 

Constipation (70% solution): 

Children 2 – 11 years of age: 

Children ≥ 12 years of age: 

1 – 3 mL/kg PO daily in divided doses 

30 – 150 mL PO daily in divided doses 


• Avoid using in dehydrated patients. 

• Electrolyte abnormalities may occur if used for more than 6 months at a time. 

Constipation 

33

Corticosteroid Dosing 


Dexamethasone 

Cerebral edema: 

PO/IV/IM: 

Airway edema: 

IV/IM: 

Anti-inflammatory: 

PO/IV/IM: 

Loading dose: 1–2 mg/kg/dose 

Maintenance dose: 1–1.5 mg/kg/24 h divided q4–6h 

Maximum dose: 16 mg/24 h 

0.5–2 mg/kg/24 h divided q6h (usually begin 24 h before extubation 

and continue for 4–6 doses after extubation) 

0.08–0.3 mg/kg/24 h divided q6–12h 

Spinal cord compression with neurological abnormalities: 

IV: 

Prednisone 

Anti-inflammatory/immunosuppressive: 

PO: 

2 mg/kg/24 h divided q6h 

0.05–2 mg/kg/24 h divided daily–bid 

Acute airway inflammation/bronchospasm, ≤ 12 years of age: 

PO: 

Acute: 1 mg/kg/dose PO q6h (maximum: 120 mg/24 h) for 48h 

Maintenance:1–2 mg/kg/24 h divided daily–bid for 5–7 days 


Acute airway inflammation/bronchospasm, > 12 years of age: 

PO: 

Methylprednisolone 

Anti-inflammatory/immunosuppressive: 

PO: 

Acute airway inflammation/bronchospasm: 

≤12 years of age 

Acute: 120 – 180 mg PO daily, divided every 6 – 8 hours for 48 hours 

Maintenance: 60 – 80 mg/24 h, administered daily or bid in divided 

doses 

Maximum: 80 mg/24 h 

0.5–1.7 mg/kg/24 h in divided doses q6–12h 

“Burst” dosing: 1–2 mg/kg/24 h PO in divided doses once or twice 

daily for 3–10 days 

Maintenance dosing: 0.25–2 mg/kg/24 h given daily or every other day 


>12 years of age “Burst” dosing: 40–60 mg/24 h PO in divided doses once or twice 

daily for 3–10 days 

Maintenance dosing: 7.5–60 mg/24 h given daily or every other day 

34 

Corticosteroid Dosing


Cough 

NOTE: Antitussive agents should not be used in children less than 2 years of age 

because it can mask symptoms of pertussis. 

In addition, the FDA has expressed safety concerns for use of over-the-counter cough/ 

cold preparations in children under the age of 12 and made recommendations for use in 

this age group. See http://www.fda.gov/bbs/topics/NEWS/2008/NEW01778.html. The FDA 

is currently reviewing the information about the safety of OTC cough and cold medicines 

in children 2 through 11 years of age. 

Guaifenesin 

6–12 years of age: 100–200 mg PO q4h 


>12 years of age: 200–400 mg PO q4h 


Guaifenesin-codeine 

2–6 years of age: 1.5 mg/kg/24 h of codeine divided qid PO or 2.5–5 mg/dose of 

codeine q4–6h 

Maximum dose: 30 mg of codeine/24 h 

>6–12 years of age: 5–10 mg/dose of codeine PO q4–6h 

Maximum dose: 60 mg codeine/24 h 

> 12 years of age: 10 – 20 mg/dose of codeine PO q4-6h 

Maximum dose: 120 mg codeine/24 h 


• Each teaspoonful (5 mL) of syrup contains guaifenesin 100 mg and codeine 10 mg. 

Guaifenesin-dextromethorphan 

6–12 years of age: 5–10 mg/dose dextromethorphan PO q4h or 15 mg/dose 

dextromethorphan q6–8h 

Maximum dose: 60 mg dextromethorphan/24 h 

>12 years and adults: 10–30 mg/dose dextromethorphan PO q4–8h 

Maximum dose: 120 mg dextromethorphan/24 h 


• Each teaspoonful (5 mL) of syrup contains guaifenesin 100 mg and dextromethorphan 10 mg. 

• Safety and efficacy in children less than 6 years of age have not been established. 

• Guaifenesin-dextromethorphan may be taken with food. 

• Guaifenesin-dextromethorphan is contraindicated with concurrent MAOI therapy and for 

14 days after stopping MAOI therapy. 

Cough 

35

Cough 


Promethazine-dextromethorphan 

2–6 years of age: 1.25–2.5 mL PO q4–6h prn 

Maximum dose: 10 mL/24 h 

>6–12 years of age: 2.5–5 mL PO q4–6h prn 


> 12 years of age: 5 mL PO q4-6h prn 



• Do NOT use in children less than 2 years of age because of potential for fatal 

respiratory depression. 

• Each teaspoonful (5 mL) of syrup contains promethazine 6.25 mg and dextromethorphan 

15 mg. 

• Promethazine-dextromethorphan may be taken with food. 

• Promethazine-dextromethorphan is contraindicated with concurrent MAOI therapy and 

for 14 days after stopping MAOI therapy. 

• Both promethazine and dextromethorphan are substrates of CYP450 2D6 enzyme; 

dextromethorphan is also a substrate for 3A3/4. Review medication profile for potential 


• EPS may occur with promethazine. Administration of diphenhydramine may reduce the 

incidence of EPS. 

Promethazine-codeine 

2–6 years of age: 1.25–2.5 mL PO q4–6h prn 


>6–12 years of age: 2.5–5 mL PO q4–6h prn 


> 12 years of age: 5 mL PO q4-6h prn 





• Each teaspoonful (5 mL) of syrup contains promethazine 6.25 mg and codeine 10 mg. 

• Promethazine-codeine may be taken with food. 

• Codeine is a substrate and inhibitor of CYP450 2D6 and promethazine is a substrate of 

CYP450 2D6; review medication profile for potential drug–drug interactions. 



36 

Cough


Cough 

Hydrocodone-homatropine 

6–12 years of age: 0.5 tablet or 0.5 teaspoonful (2.5 mL) PO q4–6h prn 

Maximum dose: 6 doses/24 h 

>12 years of age: 1 tablet or 1 teaspoonful (5 mL) PO q4–6h prn 

Maximum single dose: 2 tablets or 2 teaspoonsful/dose 


• Hydrocodone-homatropine is not FDA approved for use in children less than 6 years of age. 

• Each teaspoonful (5 mL) of syrup contains 5 mg of hydrocodone and 1.5 mg of homatropine. 

• Tablet contains 5 mg of hydrocodone and 1.5 mg of homatropine. 

Promethazine-phenylephrine-codeine 

2- 6 years of age: 1.25–2.5 mL PO q4–6h prn 

Maximum dose, 25 lb: 6 mL/24 h 




6–11 years of age: 2.5–5 mL PO q4–6h prn 


≥12 years of age: 

5 mL PO q4–6h prn 





• Each teaspoonful (5 mL) of syrup contains promethazine 6.25 mg, phenylephrine 5 mg, 

and codeine 10 mg. 

• This combination may be taken with food. 

• Codeine is a substrate and inhibitor of CYP450 2D6 and promethazine is a substrate of 


Cough 

37

Depression 


Fluoxetine 

PO: 

8-18 years of age: Initial dose: 10-20 mg/24 h 



• Fluoxetine is contraindicated in patients taking MAOIs. 

• Use with caution in patients with hepatic or renal failure. 

• Fluoxetine is a substrate of CYP450 2D6 (minor) and 3A4 enzymes; its metabolism may 

be altered by medications that share these pathways. 

• This drug is an inhibitor of CYP450 1A2, 2C9, 2C19, 2D6, and 3A4 enzymes. Numerous drug 

interactions occur with fluoxetine. Review medication profile for potential drug–drug interactions 

and adjust doses of medications metabolized by one or more of the enzymes listed. 

• The T ½ of the parent compound and the active metabolite is very long; therefore the full 

effect of a dosage change or upon initiation may not be observed for several weeks. 

Sertraline 

PO: 

6–12 years of age: Initial dose: 25 mg/24 h 

Titration: 25 mg increments every 3-7 days 


≥ 13 years of age: 

Initial dose: 50 mg/24 h 

Titration: 50 mg increments every 7 days 



• Sertraline is contraindicated in patients taking MAOIs. 

• Use with caution in patients with hepatic or renal failure. 

• Sertraline is a substrate of CYP450 2D6 (minor) and 3A4 enzymes; its metabolism may be 


• This drug is an inhibitor of CYP450 1A2 (weak), 2C19, 2D6 (weak), and 3A4 enzymes. Review 

medication profile for potential drug–drug interactions and adjust doses of medications 

metabolized by one or more of the enzymes listed. 

• Mix oral concentrate solution with 4 oz of water, ginger ale, lemon/lime soda, lemonade, or 

orange juice. After mixing, a slight haze may appear; this is normal. 

• Use oral concentrate cautiously in patients with a latex allergy because the dropper contains 

dry natural rubber. 

Methylphenidate 

See Somnolence guideline for dosing and titration guidelines. 

38 

Depression


Diarrhea 

Diarrhea may be a difficult symptom for both the child and the family. Severe diarrhea may 

be treated with opioids if needed. Paradoxical diarrhea, which is the result of overflow from 

constipation, must be considered. 

Loperamide 

Acute diarrhea 

The following are initial doses within the first 24 h of the initial loose stool: 

2–6 years of age (13–20 kg): 1 mg PO tid 

>6–8 years of age (20–30 kg): 2 mg PO bid 

>8–12 years of age (>30 kg): 2 mg PO tid 

Following the initial 24 h of diarrhea: 

2-12 years of age 0.1 mg/kg/dose PO after each loose stool (not to exceed above 

initial doses) 

Maximum single dose: 2 mg/dose 

> 12 years of age: 4 mg initially PO, then 2 mg following each loose stool 


Chronic diarrhea 

0.08–0.24 mg/kg/24 h PO divided bid–tid 

Maximum single dose: 2 mg/dose 


• Avoid use in children less than 2 years of age due to risk of necrotizing enterocolitis. 

• Discontinue use if no improvement is seen within 48 h, when used for acute diarrhea. 

• If chronic diarrhea symptoms do not improve following 10 days of treatment with maximum 

daily doses, then improvement is not likely to occur with further loperamide therapy. 

Bismuth Subsalicylate 

> 12 years: 30 mL given after each loose stool prn 

Maximum dose: 8 doses/day 

Clinical Notes: 

• Liquid is available as 262mg/15mL 

• Bismuth Subsalicylate is NOT recommended in children under the age of 12 years old, 

due to lack of adequate data to support its use. 

• Avoid in children less than 16 years of age for treatment of varicella, influenza, or flu-like 

symptoms because of concerns of Reye’s syndrome. 

• Use with caution in patients allergic to aspirin; in patients with a history of hepatic or renal 

dysfunction, CHF, or GI bleeding; or in patients taking anticoagulants. 

• Do not use in combination with other NSAIDs or in patients with bleeding diathesis. 

Diarrhea 

39

Diarrhea 


Morphine, camphorated (Paregoric®) 

Children: 

0.25–0.5 mL/kg PO 1–4 times daily 


• Concentration is 0.4 mg morphine equivalent/mL; do not confuse with tincture of opium. 

• Dosing listed does not include neonates; avoid use in this population. 

• This preparation contains anise oil, benzoic acid, camphor, and potentially high amounts of 

alcohol (up to 45%)—all excipients which may be problematic in some patients. Alternate 

morphine liquid preparations may be used if these concerns are present. 

Cholestyramine 

PO: 

240 mg/kg/24 h PO divided tid given orally as a slurry in water, 

juice, or milk before meals 


• All doses are in terms of anhydrous resin (4-g anhydrous resin/packet). 

• This drug is indicated for diarrhea associated with excess fecal bile acids or C. difficile 

(pseudomembraneous colitis). 

• Give other oral medications 4–6 h after or 1 h before cholestyramine to avoid a potential 

decrease in absorption. 

40 

Diarrhea


Dyspepsia/Gastroesophageal Reflux 

Aluminum hydroxide/aluminum and magnesium hydroxide 

(regular strength suspension) 

PO: 

Children: 

5–15 mL/dose PO q3–6h OR 1 – 3 hours after meals and at 

bedtime 


• Use with caution in patients with CHF, renal insufficiency, and edema. 

• These agents may decrease absorption of some medications that require an acidic gastric 

environment for absorption (e.g., ketoconazole, some cephalosporins, cyclosporine) and 

medications that bind to divalent ions (e.g., tetracyclines, fluoroquinolones). 

• Do not administer other medications within 1–2 h of dose. 

• Regular strength suspension contains: Aluminum Hydroxide, 225 mg/5ml, Magnesium 

Hydroxide, 200 mg/5ml. 


PO/IV/IM: 


0.1–0.2 mg/kg/dose up to qid 



• Avoid using in patients taking MAOIs. 

• In higher doses, metoclopramide has the potential to cause EPS; premedicating with diphenhydramine 

may reduce the incidence of EPS. 

• This drug is contraindicated in patients with a complete bowel obstruction or pheochromocytoma. 

• Relative contraindication exists for patients with a seizure history as metoclopramide can 


• Metoclopramide is a substrate of CYP450 1A2 and 2D6 enzymes; its metabolism may be 



41



Ranitidine 

General dosing: 

Neonates: 

2–4 mg/kg/24 h PO divided q8–12h 

Duodenal/gastric ulcer 

>1 month–16 years of age: 2–4 mg/kg/24 h PO divided q12h 

Maximum dose, treatment: 300 mg/24 h 

Maximum dose, maintenance: 150 mg/24 h 

GERD/erosive esophagitis (EE) 


Maximum dose, GERD: 300 mg/24 h 

Maximum dose, EE: 600 mg/24 h 

Dyspepsia 




• Duodenal/gastric ulcer doses for children are extrapolated from clinical adult trials and 

pediatric pharmacokinetic data. 

• Dosage needs to be adjusted for patients with renal impairment. 

• This drug may decrease absorption of some medications that require an acidic gastric 

environment for absorption (e.g., ketoconazole, some cephalosporins, cyclosporine). 

• Some patients may not tolerate the peppermint flavor of the oral syrup preparation. 

Famotidine 

Duodenal/gastric ulcer 

1–12 years of age: 0.5 mg/kg/24 h PO either daily (at bedtime) or divided bid 


>12 years of age: 20 mg PO daily (at bedtime) 


GERD/erosive esophagitis 

Neonates, infants 3 months–1 year of age: 0.5 mg/kg/dose PO bid 

0.5 mg/kg/24 h PO given either daily or divided bid 

>1–12 years of age: 1 mg/kg/24 h PO divided bid 

>12 years of age 20 mg PO bid 

Maximum dose (all ages): 80 mg/24 h 

Dyspepsia 

>12 years of age: 10–20 mg PO daily 


42 

Dyspepsia/Gastroesophageal Reflux





• Famotidine may decrease absorption of some medications requiring an acidic gastric environment 

for absorption (ketoconazole, some cephalosporins, cyclosporine). 

Simethicone 

12 years of age: 40–125 mg PO after meals and at bedtime prn 



• Efficacy has not been demonstrated for treating infant colic. 

• Oral liquid may be mixed with water, infant formula, or other liquids. 

Omeprazole 

GERD, ulcers, esophagitis: 

≥ 2 years of age: 

OR 

Initial dose: 1 mg/kg/24 h PO administered either once or twice daily 

Effective range: 0.2–3.5 mg/kg/24 h 

≤ 20 kg: 10 mg PO daily 

> 20 kg: 20 mg PO daily 


• Administer all doses before meals. 

• If using with sucralfate, administer 30 min prior to sucralfate dose. However, the added 

benefit of combination therapy of sucralfate and an acid-reducing agent is controversial. 

• To administer dose, open capsules and administer intact pellets in an acidic beverage 

(apple/cranberry juice) or applesauce. 

• Extemporaneously compounded oral suspension is available. However, preparation may 

have less bioavailability due to loss of omeprazole’s enteric coating. 

• Omeprazole may decrease absorption of some medications that require an acidic gastric environment 

for absorption (e.g., ketoconazole, some cephalosporins, cyclosporine). 

• Omeprazole is a substrate and inhibitor of CYP450 2C19 and induces CYP450 1A2; its 

metabolism may be altered by medications that share these pathways. 


43

Dyspnea 


Dyspnea is very common in the dying child because many children with chronic illnesses 

have difficulty swallowing and handling their airway secretions. As death approaches, respirations 

become noisy due to secretions buildup known as “death rattle.” The child is not usually 

in distress. If treatment is desired, anticholinergics work best (e.g., hyoscyamine). Please refer 

to Secretions guideline. Pneumonia is also a frequent complication of the dying child. Please 

refer to Infections section. 

Oxygen may be helpful in certain cases to relieve hypoxemia-related headaches. One spacer 

for use with metered-dose inhalers (MDIs) is included for each patient under the per diem. 

Spacers are tube-like devices used in combination with metered dose inhalers to improve 

delivery of aerosolized medication to the lungs. Spacers work by optimizing the size and 

speed of the aerosolized medication particles, which helps to reduce the amount of medication 

deposited on the back of the mouth or throat, reduce throat irritation, and increase the 

amount of medication delivered to the lungs. 

Bronchodilators 

Albuterol 

MDI (use with spacer): 

>4 years of age: 1 - 2 puffs q4–6h prn 

Maximum dose: 12 inhalations/24 h 

Tablets (short-acting): 

2–6 years of age: 0.1–0.2 mg/kg/dose tid 

Maximum dose: 12 mg 

>6–12 years of age: 2 mg PO tid or qid 


>12 years of age: 2–4 mg PO tid or qid 



• The oral dosage form should be discouraged due to increased side effects and decreased 

efficacy compared to inhalation formulations. 

Nebulized, acute airway inflammation/bronchospams: 

0.15 mg/kg (minimum dose: 2.5 mg; maximum: 5 mg) every 20 minutes x 3 doses, 

then 0.15 mg/kg (maximum dose: 10 mg) every 1 – 4 hours as needed 

44 

Dyspnea


Dyspnea 

Nebulized, maintenance: 

Age-based: 

5–12 years of age: 2.5 mg/dose q4–6h 

>12 years of age 2.5-5mg/dose q4-6h 

Weight-based: 

OR 

10 – 15 kg: 1.25 mg/dose q6-8h 

> 15 kg: 2.5 mg/dose q4-6h 

Clinical Note 

• Both premixed albuterol nebs (0.083%) and albuterol inhalation solution (5 mg/mL) are 

available. Albuterol 5mg/ml solution must be diluted with NSS or can be diluted into premixed 

ipratropium if used in combination. 

Ipratropium 

MDI (use with spacer): 

3–12 years of age: 1–2 puffs q6h 

Maximum dose: 6 puffs/24 h 

>12 years of age: 2 puffs qid 



• Avoid using in patients with a peanut or soy allergy. 

Nebulized: 

12 years of age: 250 mcg (½ vial)–500 mcg (one vial) tid–qid 


• Nebulized solution can be mixed with albuterol. 

• Nebulization onto the eyes may result in anisocoria. 

Dyspnea 

45

Dyspnea 


Theophylline 

PO: 

6weeks-6 months: 

10 mg/kg/24h divided q12h 

6 months–1 year of age: 12–18 mg/kg/24 h divided q6-8h 

1–9 years of age: 20–24 mg/kg/24 h divided q6-8h 

>9–12 years of age: 16 mg/kg/24 h divided q6-8h 

>12–16 years of age: 13 mg/kg/24 h divided q6-8h 

Clinical Note 

• Target serum level of theophylline is 10–15 mcg/mL. 

• Theophylline is a substrate of CYP450 1A2 and 3A4 enzymes; its metabolism may be 


• Several disease states may affect theophylline’s metabolism, (e.g., CHF and fever) increase 

theophylline levels. Also, a high- protein diet or char-broiled foods decrease theophylline 

levels. 

• CYP450 1A2 enzyme activity is reduced in children less than 6 months of age but it is 

more active than adults until puberty. 

• Use ideal body weight in obese patients when calculating dosage. 

Corticosteroids 

Patients should be instructed to rinse their throat (gargling with water) after using inhaled 

corticosteroids to prevent sore throats, yeast infections and hoarseness. Patients prescribed 

both bronchodilators and inhaled corticosteroids should administer the bronchodilator first 

then wait 5 minutes to administer the inhaled corticosteroid. This opens up the airways to 

ensure greater benefit from the inhaled corticosteroid. 

Beclomethasone MDI (use with spacer): 

5–11 years of age: Initial dose: 40 mcg bid 

Maximum dose: 80 mcg bid 


Initial dose: 40–160 mcg bid 

Maximum dose: 320 mcg bid 

Triamcinolone MDI (use with spacer): 

6–12 years of age: 1–2 puffs tid–qid or 2–4 puffs bid 


>12 years of age: 2 puffs tid–qid or 4 puffs bid 


Prednisone, Dexamethasone, and Methylprednisolone 

Please see Corticosteroid dosing section. 

46 

Dyspnea


Dyspnea 

Respiratory sedatives 

Morphine 

Neonates: 

PO/SL: 

IV/IM/SQ: 


PO (immediate release): 

PO (long acting - LA): 

IM/IV/SQ: 


0.05–0.2 mg/kg/dose q3–4h prn (Initial doses should not exceed 

0.1 mg/kg/dose) 


Dose is determined by previous daily prn usage and tolerability. 

Please see clinical notes. 




• Neonates may require higher initial doses due to decreased amounts of active metabolites. 

• Morphine long-acting (LA) tablets are used ONLY for opioid-tolerant patients. 

• To convert from immediate release to a long-acting product, give ½ of patient’s total daily 

dose q12h or 1/3 of patient’s total daily dose q8h. 

Lorazepam 

PO/PR/IV: 

0.05– 0.1 mg/kg/dose q4–8h prn 




• Injectable product may be given rectally, however, pediatric suppositories are compounded 

by HP. 





Dyspnea 

47

Edema 


Furosemide 

Neonates: 

PO: 

IV/IM: 


PO: 

IV/IM: 

1 – 4 mg/kg/dose q12 – 24h 

0.5–1 mg/kg/dose q8–24h 

Maximum dose, PO: 6 mg/kg/dose 

Maximum dose, IV: 2 mg/kg/dose 

0.5–2 mg/kg/dose q6–12h 

1–2 mg/kg/dose q6–12h 

Maximum dose, PO,IV: 6 mg/kg/24 h 


• Furosemide is contraindicated in anuria and hepatic coma; use with caution in patients with 

hepatic disease. 

• Prolonged use in premature infants may result in nephrocalcinosis. 

• Furosemide-resistant edema in pediatric patients may benefit from addition of metolazone. 

Alternatively, since furosemide has a low oral bioavailability, some pediatric patients may 

benefit from switching furosemide to bumetanide. 

• Maximum rate of intermittent IV dose administration is 0.5 mg/kg/min. 

• Cross-allergenicity may occur in patients allergic to sulfonamides. 

Bumetanide 

Neonates and infants < 6 

months of age: 

≥6 months of age and children: 

0.01–0.05 mg/kg/dose PO q24–48h 

0.015–0.1 mg/kg/dose PO q24–48h 



• Bumetanide may displace bilirubin in critically ill neonates! 


• Dosage reduction may be necessary in patients with hepatic dysfunction. 

• Administer oral doses with food. 

• Drug elimination has been reported to be slower in neonates with respiratory disorders 

compared to neonates without such disorders. 

Hydrochlorothiazide 

Neonates and infants < 6 

months of age: 

≥6 months of age and children: 

2–4 mg/kg/24 h PO divided bid 

Maximum dose: 37.5 mg/24 h 

2 mg/kg/24 h PO divided bid 



• Drug may not be effective when CrCl


Edema 

Metolazone 

PO: 

Children: 

0.2–0.4 mg/kg/24 h divided daily–bid 


• Metolazone is contraindicated in patients with anuria or hepatic coma. 

• It is more effective than thiazides in patients with impaired renal function. 

• Furosemide-resistant edema in pediatric patients may benefit from addition of metolazone. 


Spironolactone 

PO: 

Neonates: 

Children: 

1–3 mg/kg/24 h divided daily–bid 

1–3.3 mg/kg/24 h divided daily–bid 

Diagnosis of primary aldosteronism 

Children: 

125–375 mg/m 2 /24 h divided bid–qid 


• Spironolactone is contraindicated in patients with acute renal failure. 

• Use with caution in patients taking potassium supplements or potassium-sparing medications 

(e.g., triamterene, ACE inhibitors). 

Potassium supplementation 

PO: 

1–4 mEq/kg/24 h divided bid–qid 


• Potassium replacement is based on maintenance requirements, deficit, and ongoing losses. 

• Potassium supplements are included under the per diem for all patients receiving diuretic 

therapy related to the terminal diagnosis. 

• Serum electrolytes should be monitored periodically. 

• Oral administration may cause GI disturbance and ulceration. 

• Oral liquid supplements should be diluted in water or fruit juice prior to administration. 

• Sustained-release tablets must be swallowed whole and not dissolved in the mouth or 

chewed. 

Edema 

49

Fever 


Acetaminophen 

PO/PR: 

Neonates: 

Pediatric: 



Maximum dose: 75 mg/kg/24 h, with a maximum of 4000 mg/24 h 

Or acetaminophen may be dosed by age: 

Age Dose Age Dose 

0–3 months 40 mg/dose 4–5 years 240 mg/dose 



2–3 years 160 mg/dose 11–12 years 480 mg/dose 


• For rectal dosing, some use 30 mg/kg/dose as a loading dose for neonates; 40 – 45 mg/kg/ 

dose has been used as a loading dose for other children. 

• Use with caution in patients with G6PD deficiency. 

Ibuprofen 

PO/PR: 







50 

Fever


Fever 

Aspirin 

PO/PR: 

Analgesic/antipyretic 

Anti-inflammatory 

Kawasaki disease 


Maximum dose: 60–80 mg/kg/24 h or 4 g/24 h 

60–100 mg/kg/24 h divided q6–8h 

80–100 mg/kg/24 h divided qid during febrile phase, then decrease 

to 3–5 mg/kg/24 h qam. 

Continue for at least 8 weeks or until platelet count and ESR are 

normal. 






• Administer with water, food, or milk to minimize GI upset. 


Fever 

51

Infections 


Pediatric patients frequently require a suspension formulation of an antibiotic rather than a 

tablet or capsule. Because most of these suspensions are temperature labile (an exception 

is sulfamethoxazole–trimethoprim) HP is unable to dispense the suspension formulation to 

the patient via national courier. When a suspension is necessary, it can be procured from a 

local pharmacy and billed via the PBM Plus Prescription Card. Please let your HP pharmacist 

know about the prescription request so the proper quantity/days supply can be authorized 

in advance. 

Doses listed are for children with normal renal function. Some antimicrobials need to be 

dose adjusted based on patient-specific factors (e.g., renal insufficiency). Consult your HP 

pharmacist for appropriate dosage. 

Policies for antibiotic/antifungal use: 

• Parenteral antibiotics or rectally administered antibiotics are not included within the per 

diem. Current evidence does not support the rectal administration of most antibiotics. 

• All antimicrobials are limited to a 14-day course of therapy regardless of the infection (except 

for azithromycin or opthalmic preparations). The patient must then be reassessed for 

appropriateness of therapy for either discontinuation of therapy, continuation of current 

regimen, or switch to an alternate therapy option. 

• Prophylactic or suppressive antimicrobial therapy is not included in the per diem. 

Amoxicillin 

Infants < 3 months of age: 

Children >3 months of age 

20 – 30 mg/kg/24 h PO in divided doses q12h 

Standard dose: 20–50 mg/kg/24 h in divided doses q8h 

High dose (for penicillin-resistant pneumococci in respiratory infections, 

acute otitis media, and sinusitis): 80–90 mg/kg/24 h PO 

divided q8h or q12h 

Amoxicillin–clavulanate (dose listed is based on the amoxicillin 

component) 

Infants 3 months of age and


Infections 

Amoxicillin–Clavulanic Acid Dosage Form Amoxicillin Clavulanic Acid Dosing Interval 

250 mg tablet 250 mg 125 mg q8h 


125 mg chewable tablet/suspension 125 mg 31.25 mg q8h 




400 mg chewable tablet/suspension 400 mg 57 mg q12h 

ES suspension 600 mg 42.9 mg q12h 

XR tablet 1000 mg 62.5 mg q12h 


• Children under 40 kg should not be given the 250 mg film-coated tablet due to the 

increased amount of clavulanic acid compared to the chewable tablet 

Azithromycin 

Respiratory Tract Infection, Pertussis: 

< 6 months of age: 10 mg/kg PO once daily for 3 days 

(maximum: 500 mg/24 h) 

≥6 months of age: 

Otitis Media: 

10 mg/kg PO on day 1 (maximum: 500 mg) 

followed by 5 mg/kg/24 h for 4 days 


≥ 6 months of age 

Single dose regimen: 

Three day regimen: 

Five day regimen: 

OR 

OR 

30 mg/kg PO as a single dose 

(maximum: 1500 mg) 

10 mg/kg PO once daily x 3 days 


10 mg/kg PO on Day 1(maximum: 500 mg/24 h), then 

5 mg/kg24 h for 4 days (maximum: 250 mg/24 h) 

Cefpodoxime proxetil 

2 months – 12 years of age: 10 mg/kg/24 h PO divided q12h 

Maximum dose: 400 mg/24 h (200 mg/24 h for pharyngitis, tonsillitis) 

>12 years of age: 100–400 mg PO q12h 

Infections 

53

Infections 


Cefuroxime axetil 

Pharyngitis/tonsilitis/maxillary sinusitis: 

3 months–12 years of age: 20–30 mg/kg/24 h PO in divided doses q12h 



Otitis media: 

250–500 mg bid 

3 months–12 years of age: 30 mg/kg/24 h PO divided q12h (maximum dose: 1000 mg/24 h) 

Ciprofloxacin 

Usual dose for most 

indications: 

Complicated UTI: 

Cystic fibrosis: 

20–30 mg/kg/24 h PO in divided doses q12h 


20–40 mg/kg/24 h PO in divided doses q12h x 10–21 days 


40 mg/kg/24 h PO in divided doses q12h 



• Safety and effectiveness of fluoroquinolones in patients less than 18 years of age have not been 

established. 

• As with other fluoroquinolones, high doses of ciprofloxacin have been shown to cause 

articular damage in animal studies. 

• Ciprofloxacin suspension should not be administered via any feeding tube. 

• Ciprofloxacin should not be administered via a j-tube. 

• Avoid antacids, iron, or zinc 4 h prior to or 2 h after administration of ciprofloxacin. 

• Ciprofloxacin is an inhibitor of CYP450 1A2 enzyme and may inhibit metabolism of medications 

that share these pathways. Adjust doses of affected medications as appropriate. 

Clindamycin palmitate HCl 

Infants and children >10 kg: 

10–30 mg/kg/24 h PO given in 3 or 4 divided doses 


• Dose depends on the severity of the infection. 

• This drug exhibits poor CNS penetration. 

• The taste of clindamycin suspension may be objectionable to some children; opening 

capsules and mixing powder in pudding may mask taste of drug. 

54 

Infections


Infections 

Dicloxacillin 

8 years of age: 

2–4 mg/kg/24 h PO divided q12h 



• The use of tetracyclines during tooth development (last half of pregnancy, infancy, and childhood 

to the age of 8–9 years) may cause permanent discoloration of the teeth (yellow/grey/ 

brown). This adverse reaction is more common during long-term use of the drugs, but it 

has been observed following repeated short-term courses. Enamel hypoplasia has also been 

reported. Risk versus benefit must be considered in pediatric hospice patients. 

• Except for anthrax including inhalational anthrax (post-exposure) and Rocky Mountain 

Spotted Fever, tetracycline drugs should not be used in the above age groups unless other 

drugs are not likely to be effective or are contraindicated. 

• Tetracyclines may increase intracranial pressure (pseudotumor cerebri). 

Erythromycin (as ethylsuccinate or base) 

Infants >7 days of age: 

Children: 

30 mg/kg/24 h PO divided q8h 

30–50 mg/kg/24 h PO divided q6–8h 

Maximum dose: 2000 mg/24 h (as base); 3200 mg/24 h 

(ethylsuccinate) 


• Erythromycin may also be used to promote GI motility in patients with gastroparesis, but 

at much lower doses than for infections. 

• Erythromycin is a potent inhibitor of CYP450 3A4, 1A2 and is a CYP450 3A4 substrate. 

Therefore, this drug has a significant drug–drug interaction profile; adjust doses or avoid the 

concurrent use of medications metabolized by hepatic Cytochrome P450 3A4 and 1A2. 

Infections 

55

Infections 


Levofloxacin 43 

Children 6 months–5 years of age: 

Children ≥ 5 years of age 

30 mg/kg/24 h PO divided q8h 

10 mg/kg/24 h PO 



• Safety and effectiveness in patients less than 18 years of age have not been established (product 

info Levaquin ® , 2006). Risk versus benefit must be considered in the pediatric hospice patient. 

• Information in the primary literature regarding pediatric dosing is limited. 

• As with other fluoroquinolones, high doses of levofloxacin have been shown to cause 

articular damage in animal studies 12 . 

• Avoid antacids, iron, or zinc 4 h prior to or 2 h after administration of levofloxacin. 

Sulfamethoxazole–trimethoprim 

Children >2 months of age 

Mild-to-moderate infections: 

Serious infection/Pneumocystis: 

6–12 mg trimethoprim/kg/24 h PO in 2 divided doses 

15–20 mg trimethoprim/kg/24 h PO in 3 - 4 divided doses 


• Sulfamethoxazole–trimethoprim is not recommended for children less than 2 months of age. 

• Sulfamethoxazole–trimethoprim may cause hemolysis in G6PD patients. 

Ophthalmic preparations 

Artificial tears (various) 

Bacitracin ophthalmic ointment 

500 units/g 

Neomycin, polymyxin–B, bacitracin 

ointment 

Erythromycin ophthalmic ointment 

5% 

Instill in affected eye(s) as needed. 

Apply 0.25 to 0.5 inch q3–4h while awake for 7–10 days. 

Apply 0.25 to 0.5 inch q3–4h while awake for 7–10 days. 

Apply 0.5 inch to affected eye(s) 2–8 times daily for 7–10 days. 

Otic preparation 

Neomycin, polymyxin B, 

hydrocortisone suspension 

Instill 3 or 4 drops in affected ear tid–qid. 


• Per milliliter, the concentrations in the neomycin–polymyxin B–hydrocortisone suspension 

are 5 mg, 10,000 units, and 10 mg, respectively. 

• Instill drops into the ear without inserting the dropper into the ear. 

• The head should remain tilted for at least 2 min after the drops are instilled. 

56 

Infections


Insomnia 

Lorazepam 

PO/PR/IV: 

0.05 – 0.1 mg/kg/dose hs prn 




• The injectable product may be given rectally, however, pediatric suppositories are 

compounded by HP. 





Chloral hydrate 


Sedative 

25–50 mg/kg/24 h PO/PR hs 


Maximum dose, infants: 1000 mg/24h 

Maximum dose, children: 2000 mg/24h 


• Chronic administration in neonates can lead to accumulation of active metabolites; monitor 

as with other sedatives. 

• Peak effect is within 30–60 min. 

• Do not exceed 2 weeks of chronic use. 

• Sudden withdrawal may cause delirium tremens. 

• Chloral hydrate is contraindicated in patients with severe hepatic or renal disease. 

• The syrup may be administered rectally, if necessary. 


2–11 years of age: 1 mg/kg/dose PO hs 

Maximum dose: 50 mg hs 


25–50 mg PO hs 


• This drug may cause paradoxical excitement in some children. 

• It is contraindicated with concurrent MAOI use, acute asthma attacks, or urinary obstruction. 

• Anticholinergic side effects are relatively common; monitor for tolerability. 

• Use with caution in infants and young children; diphenhydramine should not be used in 

neonates due to potential CNS effects. 

Insomnia 

57

Muscle spasm 


Baclofen 

Children ≥2 years of age: 

Initial dose: 10–15 mg/24 h PO divided q8h 

Titration: 5–15 mg/24 h q3days 

Maximum dose if


Nausea & Vomiting 

Nausea: 

• Search for common causes (drug effects, constipation, primary disease, metabolic disturbance) 

and then promptly start treatment. 

• Selection of antiemetics should be based on suspected etiology of nausea, as well as 

desired secondary effects in some instances (e.g., if sedation is desired, use a sedating 

phenothiazine). 

Vomiting: 

• Vomiting may accompany nausea but it can also occur without nausea if a bowel 

obstruction is present. 


Postoperative or generalized 

Children ( 14 years of age and adults: 10 mg PO/IM/IV q6 – 8h prn 

Chemotherapy induced 

Children and adults: 

1- 2 mg/kg/dose q2–4h PO/IM/IV (see Clinical Notes) 



• In higher doses (chemotherapy induced), metoclopramide has the potential to cause EPS; 

premedicating with diphenhydramine is necessary to reduce the incidence of EPS. 

• Metoclopramide is contraindicated in patients with a complete bowel obstruction and/or 

pheochromocytoma. 





Prochlorperazine 

>10 kg or >2 years of age: 

PO/PR: 

IM/IV: 

0.4 mg/kg/24 h divided tid–qid 

0.1–0.15 mg/kg/dose tid–qid 



• Orthostatic hypotension may occur when given parenterally. 

• EPS may occur with prochlorperazine. Administration of diphenhydramine may reduce the 


• Relative contraindication exists for patients with a seizure history as prochlorperazine can 



59



Promethazine 


Nausea & vomiting 

Motion sickness 

0.25–1 mg/kg/dose PO/IV/IM/PR q4–6h prn 

Maximum: 25 mg/dose 

0.5 mg/kg/dose PO/PR q12h prn 

Maximum: 25 mg/dose 






• Avoid administering subcutaneously. 

• Avoid administering in patients with Reye’s syndrome or hypertensive crisis. 

• It is a substrate of CYP450 2D6 enzymes; metabolism of promethazine may be altered by 


• Relative contraindication exists for patients with a seizure history as promethazine can 


• Due to significant risk of extravasation, only the 25mg/ml concentration should be used for 

intravenous use. 

Haloperidol 11 


PO: 

0.05–0.15 mg/kg/24 h divided bid–tid 


• Do not administer intravenously. 

• Safety and efficacy of haloperidol have not been demonstrated in children less than 

3 years of age. 

• Haloperidol is a substrate of CYP450 1A2, 2D6 (minor), and 3A4 enzymes; its metabolism 


• Haloperidol is a CYP450 2D6 inhibitor and 1A2, 2C, and 3A3/4 inducer; review medication 




• Relative contraindication exists for patients with a seizure history as haloperidol can lower 

seizure thresholds. 

60 

Nausea & Vomiting



Chlorpromazine 

≥ 6 months of age and children: 

PO: 

PR: 

IM/IV: 


1 mg/kg/dose q6–8h prn 

0.5 – 1 mg/kg/dose q6 – 8h 

Maximum dose < 5 years of age (< 22.7 kg): 40 mg/24 h 

Maximum dose 5 – 12 years of age (22.7 – 45.5 kg): 75 mg/24 h 


• Do not administer oral liquid dosage form together with carbamazepine oral suspension 

as an orange, rubbery precipitate may form. 

• Dosage adjustment is necessary in patients with hepatic impairment. 

• Safety in children less than 6 months of age has not been established. 

• Hypotension may occur when given parenterally. 

• Chlorpromazine is a substrate of CYP450 1A2, 2D6, and 3A4 enzymes; its metabolism 

may be altered by medications that share these pathways. In addition, it is an inhibitor of 




• Relative contraindication exists for patients with a seizure history as chlorpromazine can 



Children: 

5 mg/kg/24 h PO/IM/IV divided q6h 



• Diphenhydramine may cause paradoxical excitement in some children. 

• This drug is contraindicated with concurrent MAOI use, acute asthma attacks, or urinary 

obstruction. 


• Use with caution in infants and young children; diphenhydramine should not be used in 

neonates due to potential CNS effects. 


PO: 

IM: 

2 mg/kg/24 h divided q6 - 8h 



• Parenteral hydroxyzine is available only as the hydrochloride salt. 

• In general, the IV route of administration is not recommended. 



61



Lorazepam (antiemetic adjunct) 

PO/IV: 

0.02–0.05 mg/kg/dose q6h prn 




• The injectable product may be given rectally, however, pediatric suppositories are compounded 

by HP. 


amount of compatible diluent (e.g., NSS) and over 2-5 min. 



Dexamethasone 

IV: 

PO/IV 11 : 

OR 

Initial: 10 mg/m 2 /dose, then 5 mg/m 2 q6h thereafter 

2–4 mg/kg q6h 



• Doses described above have been studied for prophylaxis of chemotherapy-induced nausea 

and vomiting. However, a lower dose (0.0625mg/kg/dose given q6h) has been shown to be 

as effective as higher dose (1mg/kg/dose) for preventing post-operative nausea/vomiting. 42 

62 

Nausea & Vomiting


Oral Conditions 

Dry mouth 

Saliva substitute 

Apply topically inside the mouth as needed to keep mouth wet 

as needed as directed. 


• Saliva substitute products contain sorbitol, which may induce bloating and/or diarrhea. 

Monitoring and judicious use may be warranted. 

Dry nose 

Sodium chloride nasal spray 

(0.65%) 

Use 1 spray in each nostril as needed as directed. 

Candidiasis 

Parenterally administered antifungals are not included within the per diem. 

Prophylactic or maintenance antifungal therapy is not included in the per diem. 

Nystatin suspension 

Preterm infants: 

Term infants: 

Children: 

0.5 mL (50,000 units) to each side of mouth qid 

1 mL (100,000 units) to each side of mouth qid 

4–6 mL (400,000–600,000) swish and swallow/spit qid 


• Duration of nystatin therapy is limited to 14 days. Patient must be reassessed for appropriateness 

of therapy at that time for either continuation of current regimen or switching to 

alternate therapy. 


63



Clotrimazole troche 

>3 years: Slowly dissolve one troche (10 mg) in mouth 5 times daily for 14 

days. 

Clinical Note 

• Liver enzyme elevation and nausea and vomiting may occur with clotrimazole troches. 

Fluconazole 

Neonates > 14 days, infants, children: 

Candidiasis, oropharyngeal 

Candidiasis, esophageal 

6 mg/kg/24 h PO on day 1, then 3 mg/kg daily for up to 2 weeks 

to decrease likelihood of relapse 

6 mg/kg/24 h PO on day 1, then 3 mg/kg once daily for at least 

3 weeks; continue treatment for 2 weeks following resolution of 

symptoms 

Maximum dose: 12 mg/kg/24 h 

Neonates 0 – 14 days old: 

Same dosing as for older children, but used with dosing intervals 

of q48 – 72h. 


• Efficacy is not established in children less than 6 months of age; however, a small number 

of children ranging in age from 1 day to 6 months have been treated with fluconazole. 

• Fluconazole is an inhibitor of CYP450 2C9/10 and 3A4 (weak) enzymes; review medication 


• Review current medication profile and adjust doses of medications metabolized by these 

enzymes. 

• Adjust dose in patients with renal failure; if CrCl is less than 50 mL/min, administer one-half 

of the usual dose. 

• Fluconazole should be administered cautiously in patients with potentially proarrhythmic 

conditions, including patients with a history of torsade de pointes. Some azole antifungals, 

including fluconazole, have been associated with QT prolongation 

64 

Oral Conditions


Pain - Neuropathic 

Antidepressants 

Tricyclic antidepressants (TCAs) are commonly used to treat neuropathic pain. TCAs can 

also improve sleep and may enhance opioid analgesia, especially in patients with a mixed pain 

presentation. Pain relief can be seen within 2–3 days of starting therapy or adjusting doses. 

However, the full analgesic effect may not be seen for at least 2 weeks in some patients. Anticholinergic 

side effects can be problematic in both children and adults and are dose limiting. 

TCAs also have the potential to prolong the QTc interval; use with caution in children with 

increased risk for cardiac dysfunction. 

Amitriptyline 


PO: 

Initial dose: 0.1 mg/kg/dose hs 

Titration: Increase by 25% every 2–3 days to response or as 

tolerated. 

Maintenance dose: 0.5–2 mg/kg/24 h 

Maximum dose: 2 mg/kg/dose hs, or 150 mg/24 h 


• Safety and effectiveness in children below the age of 12 years have not been established 


• Bedtime dosing can minimize daytime sedation. 

• When using doses greater than 3 mg/kg/24 h, ECG, BP, and heart rate should be monitored 

as TCAs can prolong the QTc interval. 

• Amitriptyline is a substrate of CYP450 1A2, 2C9, 2C19, 2D6, and 3A4 enzymes; its 


• TCAs as a group interact with many medications. Review patient’s medication profile carefully 

for potential drug–drug interactions. 

Nortriptyline 11 

PO: 

Initial dose: 0.2–1 mg/kg/dose hs 

Titration: 0.25 mg/kg q5–7days 

Maintenance dose: 0.2–3 mg/kg/24 h 

Maximum dose: 3 mg/kg/dose hs, or 150 mg/24 h 



• Nortriptyline has fewer CNS and anticholinergic side effects than amitriptyline. 

• Bedtime dosing can minimize daytime sedation. 

• Nortriptyline is a substrate of CYP450 1A2 and 2D6 enzymes; its metabolism may be 


• TCAs as a group interact with many medications. Review patient’s medication profile carefully 

for potential drug–drug interactions. 


65



Anticonvulsants 

The therapeutic levels of anticonvulsants associated with relief of neuropathic pain have not 

been studied in children. Doses of these agents should be titrated to response and tolerability. 

Children should be monitored regularly for side effects and adverse reactions, especially 

allergic reactions, hematological abnormalities, and hepatotoxicity. 

Carbamazepine 

12 years of age: Initial dose: 200 mg PO bid 

Titration: Increase weekly by 200 mg/24 h 

Maximum dose, 12–15 years of age: 1000 mg/24 h 

Maximum dose, >15 years of age–adult: 1200 mg/24 h 

Maximum dose, adult: 1600–2400 mg/24 h 


• Pancytopenia may occur secondary to carbamazepine and may be exacerbated by concurrent 

chemotherapy. CBC should be monitored periodically. 

• Use with extreme caution in children with compromised bone marrow function. 

• Dose may need to be adjusted upward every 2–3 weeks due to auto-induction of hepatic 

metabolism (can occur during days 3–28 of therapy). 

• Minimize CNS and GI side effects by giving the largest dose at bedtime. 

• This drug has a significant drug–drug interaction profile; adjust doses of medications metabolized 

by hepatic enzymes (cytochrome P450) accordingly. 

• Chewable tablets are preferred over oral suspensions due to potential problems with 

consistent drug delivery with suspensions (toxicities have occurred when suspensions are not 

shaken well prior to dispensing of dose). 

• The therapeutic blood level is 4–12 mg/L. 

Valproic Acid 

PO: 

Initial dose: 10 – 15 mg/kg/24 h divided up to tid or given daily (in 

rare cases) 

Titration: 5 – 10 mg/kg/24 h at weekly intervals 

Usual maintenance dose: 30 – 60 mg/kg/24 h, divided bid - tid 



• Use with caution in children < 2 years of age, since data indicates greater risk for fatal 

hepatotoxicity. 

66 

Pain - Neuropathic



• Contraindicated in patients with liver disease or dysfunction. 

• May cause hepatotoxicity within 3 days to 6 months of initiating therapy; discontinue 

valproic acid immediately if hepatotoxicity occurs. 

• Valproic acid may cause thrombocytopenia, encephalopathy, rash, hyperammonemia, and 

pancreatitis, among other adverse events. CBC and LFTs should be drawn prior to starting 

therapy and periodically thereafter. 

• This drug has a significant drug–drug interaction profile; adjust doses of medications 

metabolized by hepatic enzymes (cytochrome P450) accordingly. 

• Do not use Depakote ER preparation (outside the per diem) in patients 10 years of age 

or less. 

• Depakote and Depakote ER (outside the per diem) are not bioequivalent; doses of the ER 

formulation are 8 – 20% higher than Depakote tablets. 

• The therapeutic blood level is 50 – 100 mg/L. 

Gabapentin 

PO: 

> 3yrs of age Initial dose: 5 mg/kg/24 h, administered at bedtime 

Titration: 5 mg/kg bid on day 2, increasing to 5 mg/kg tid on day 3 

Maximum dose 11 : 400 mg/dose, or 1800 mg/24 h 


• Children < 3 years: Safe and effective use not established. 

• This drug undergoes renal elimination; adjust doses downward in patients with renal 

impairment. 

• Gabapentin is not absorbed rectally; do not administer via this route. 

• Do not withdraw this medication abruptly; taper therapy if possible. 

• Gabapentin may be taken with or without food. 

Clonazepam 

PO: 

Initial dose: 0.01 mg/kg q12h 

Titration: 10–25% q2–3 days as needed and tolerated 

Maximum dose: 0.1–0.2 mg/kg/24 h, divided q8h 



• Clonazepam is a substrate of CYP450 3A4 enzymes; its metabolism may be altered by 



67

Pain - Nociceptive 


See Pain Assessment section on page 16. 

Non-narcotic analgesics: 

These drugs are commonly used in the management of mild-to-moderate pain of nonvisceral 

origin. They can be administered alone or in combination with opioids. Acetaminophen 

(APAP) is a weak analgesic with antipyretic activity. Non-steroidal anti-inflammatories 

(NSAIDs) are especially useful for sickle cell, bony, rheumatic, and inflammatory pain. 

Consider concurrent H2blocker (ranitidine, famotidine) or PPI (omeprazole) therapy with 

prolonged NSAID use. 

Acetaminophen 

PO/PR: 

Neonates: 

Pediatric: 




Or acetaminophen may be dosed by age: 

Age Dose Age Dose 




2–3 years 160 mg/dose 11–12 years 480 mg/dose 


• For rectal dosing, some use 30 mg/kg/dose as a loading dose for neonates; 

40 – 45 mg/kg/dose has been used as a loading dose for other children. 

• Use with caution in patients with G6PD deficiency. 

Ibuprofen 

PO/PR: 


5 –10 mg/kg/dose q6–8h 






68 

Pain - Nociceptive



Naproxen 

Children >2 years of age: 

Analgesia 

5–7 mg/kg/dose PO/PR q8–12h 






• Naproxen may cause more dyspepsia than ibuprofen or choline magnesium trisalicylate. 

Choline magnesium trisalicylate 

Children > 12kg: 

Analgesia 

30–60 mg/kg/24 h divided bid–tid PO 

Maximum dose 11 : 60 mg/kg/24 h based on salicylate 




• Choline magnesium trisalicylate produces less GI irritation than aspirin and other NSAIDs 

and has no effect on platelet function. 




Aspirin 


Anti-inflammatory 

Kawasaki disease 

10–15 mg/kg/dose PO/PR q4–6h 

Maximum dose: 60–80 mg/kg/24 h or 4000 mg/24 h 

60–100 mg/kg/24 h q6–8h PO/PR 

80–100 mg/kg/24 h PO/PR divided qid during febrile phase, then 

decrease to 3–5 mg/kg/24 h. Continue for at least 8 weeks or 

until platelet count and ESR are normal. 









69



Opioid analgesics: 

Codeine with acetaminophen 

Analgesia 

>3 years of age: 0.5–1 mg codeine/kg/dose PO q4–6h prn, 

Maximum acetaminophen dose is 75 mg/kg/day PO or 4 g/day 

PO, whichever is less. 

Using elixir: 

3–6 years of age: 5 mL PO q6–8h prn 

7–12 years of age: 10 mL PO q6–8h prn 


15 mL PO q4h prn 

Clinical Note 

• Each 5 mL of solution contains 12 mg of codeine and 120 mg of acetaminophen. 

Hydromorphone 

Children



Parenteral morphine infusion dosing 

Neonates: 


0.01–0.02 mg/kg/h continuously 

0.02 - 0.03 mg/kg/h continuously 


• Neonates may require higher doses due to decreased amounts of active metabolites. 

• Morphine long-acting (LA) tablets are used ONLY for opioid-tolerant patients. 

• To convert from immediate release to a LA product, give ½ of patient’s total daily dose 

q12h or 1/3 of patient’s total daily dose q8h. 

Oxycodone 

Children: 

PO/SL: (immediate-release) 

0.05–0.2 mg/kg/dose q4 - 6h prn 

Clinical Note 

• Oxycodone long-acting (LA) tablets are excluded from the per diem. Please see the 

long-acting opioid policies in the Pain - Nociceptive section of the adult MUGs for further 

clarification. 

Fentanyl, transdermal 

≥ 2 years of age and receiving 

at least 30 mg of oral morphine 

equivalents previously: 

Initial dose: 12.5 mcg/h q72h 

Titration: commonly in 12.5–25 mcg/hr increments 

Comparison of oral morphine equivalents and corresponding transdermal fentanyl doses 

used in pediatric cancer and/or palliative care patients. Please note - the studies on the next 

page, with the exception of Finkel, et al., included small sample sizes (n



fentanyl 

dose q72h 

12.5 mcg/hr 30 – 44 mg 

total daily morphine equivalents 

Finkel et al 37 Collins et al 38 Noyes and 

Irving 39 Hunt et al 40 Irving et al 41 

25 mcg/hr 45 – 134 mg 60 – 134 mg < 134 mg < 135 mg 30 – 134 mg 

37.5 mcg/hr 135 – 180 mg 

50 mcg/hr 181 – 224 mg 135 – 224 mg 135 – 224 mg 135 – 224 mg 135 – 224 mg 

62.5 mcg/hr 225 – 270 mg 


87.5 mcg/hr 315 – 360 mg 


112.5 mcg/hr 405 – 450 mg 

125 mcg/hr 451 – 494 mg 405 – 494 mg 405 – 494 mg 405 – 494 mg 

137.5 mcg/hr 495 – 540 mg 

150 mcg/hr 541 – 584 mg 495 – 584 mg 495 – 584 mg 495 – 584 mg 

162.5 mcg/hr 585 – 630 mg 

175 mcg/hr 631 – 674 mg 585 – 674 mg 585 – 674 mg 

187.5 mcg/hr 675 – 720 mg 

200 mcg/hr 721 – 764 mg 675 – 764 mg 675 – 764 mg 

Comments 

TD fentanyl 

dose had to 

be increased 

in 39% of 

patients; mean 

time to first 

dose increase 

= 5.6 days. 

Dose 

adjustment 

performed; 

no details 

provided. 

10/13 

(76.9%) of 

patients 

required a 

dose increase 

of TD fentanyl 

during study. 

35% of patients 

in study required 

one dose increase 

within 3 days; 50% 

required one dose 

increase within 6 

days; 20% required 

2 dose increases 

within 6 days 

8/10 (80%) 

of patients 

require a 

dose increase 

at some point 

during study. 


• Transdermal fentanyl is used ONLY for opioid-tolerant patients; this preparation can cause 

respiratory depression in opioid-naïve patients. 

• Conversion to transdermal fentanyl from oral morphine or other opioids should be 

performed conservatively, using manufacturer’s conversion recommendations as a starting 

point (see table above). Close monitoring and availability of adequate breakthrough opioid 

is essential for safe and effective titration of transdermal fentanyl in children. 

• Due to delay in onset, difficulty in titration for changing pain, and absorption issues, transdermal 

fentanyl is recommended for use when: 

- Patient is unable to swallow oral long-acting medications. 

- There is a concern of diversion in the household (may be easier to track than tablets). 

- Severe non-compliance is present in the household, and caregiver is unable to administer 

medications to the patient safely and reliably. 

- Patient has a feeding tube in place and is unable to use oral long-acting preparations. 

• Transdermal fentanyl will be charged outside the per diem if one of these criteria is not met. 

72 

Pain - Nociceptive



Methadone 

PO: 

Children: 

0.1 mg/kg/dose q4h for first 2–3 doses then q6–12h prn 

OR 

0.7 mg/kg/24 h divided q4–6h prn 



• Average T ½ for children is 19 h compared to 35 h in adults. 

• Duration of action of oral methadone is 6–8 h initially and 22–48 h after repeated doses; it 

requires close monitoring. 

• Methadone is usually reserved for children who do not respond to or are unable to tolerate 

morphine or hydromorphone. 

• When converting to methadone as part of a taper, give 30% of the total converted dose 

initially and assess the need for a higher dose at subsequent intervals. 

Disclaimer: This table is for reference only and does not imply per diem inclusion of all therapies listed. In 

addition, opioid conversions are approximations; conversion calculations must factor in patient-specific 

considerations to ensure safe and appropriate dosing. 

Drug 

Equianalgesic 

Doses 

(mg/kg/ dose) 

Route 

Onset 

(min) 

Duration 

(hr) 

Comments 

Codeine 1.2 PO 30–60 3–4 Use with acetaminophen 

for synergy. 

Fentanyl 0.001 

0.001 

0.01 

Hydromorphone 

0.015 

0.02–0.1 

Meperidine 1 

1.5–2 

Methadone 0.05–1 

0.1 

Morphine 0.1 

0.1–0.2 

0.3–0.5 

IV 

Transdermal 

Transmucosal 

IV/SC 

PO 

IV 

PO 

IV 

PO 

IV 

IM/SC 

PO 

1–2 

12 

15 

5–10 (IV) 

30–60 

5–10 

30–60 

5–10 

30–60 

5–10 

10–30 

30–60 

0.5–1 

2–3 

Levels of unbound drug are 

higher in newborns than 

older patients. 

3–4 This drug may produce 

less sedation, nausea, and 

pruritus than morphine. 

3–4 

2–4 

4–24 

4–24 

3–4 

4–5 

4–5 

Euphoric effects are greater 

than with morphine. Low 

doses stop shivering 

(0.1–0.25 mg/kg). 

Initial dose may produce 

analgesia for 3–4 h; duration 

of action increased with 

repeated dosing. 

LA form is available for 

chronic dosing. 

Oxycodone 0.1 PO 30–60 3–4 Much less nauseating than 

codeine. LA form is available 

for chronic dosing. 

From Yaster M et al. Pediatric pain management and sedation handbook. St. Louis: Mosby-Year Book; 1997. 15 


73

Pruritus/Itching 


Pruritus may be secondary to systemic disorders or drug therapy. Non-pharmacologic treatment 

includes avoiding excessive use of soap, using moisturizers, trimming fingernails, and wearing loosefitting 

clothing. In addition, administration of topical or systemic steroids may be necessary. Oral 

antihistamines and other specific therapies may also be indicated (i.e., cholestyramine in biliary 

disease). Please refer to adult MUGs for a complete list of topical therapy options. 

Systemic therapy 

In some children, antihistamines may induce paradoxical CNS stimulation. It is generally not 

recommended to administer the 8-hour or 12-hour sustained release products to children < 6 

years of age. Antihistamines should not be used in neonates due to the possibility of paradoxical 

CNS stimulation or seizures. Antihistamines are contraindicated with concurrent MAOI use, 

and should be avoided in patients with an acute asthma attack or urinary obstruction. 

Chlorpheniramine maleate 

2–5 years of age: 1 mg PO q4–6h 





Cyproheptadine 

4 mg PO q4–6h 






> 14 years of age and adults: 4 – 20 mg/24 h divided q8h 


• Administer with food or milk. 

• May increase appetite. 


PO/IV/IM: 

5 mg/kg/24 h divided q6 - 8h 

Maximum dose: 300 mg/24 h, or 50 mg/dose 



74 

Pruritus/Itching




PO: 

IM: (hydrochloride) 

2 mg/kg/24 h divided q6–8h prn 



• Parenteral hydroxyzine is only available as the hydrochloride salt. 

• In general, the IV route of administration is not recommended. 


Cholestyramine 

PO: 

240 mg/kg/24 h divided tid given orally as a slurry in water, juice, 

or milk before meals 


• All doses are in terms of anhydrous resin (4-g resin per packet). 

• This drug can also be used for diarrhea associated with excess fecal bile acids or C. difficile 

(pseudomembraneous colitis). 

• Give other oral medications 4–6 h after or 1 h before cholestyramine to avoid a potential 

decrease in their absorption. 

Diaper rash/topical therapy 

Emollients: 

Balmex®, Diaper Rash Ointment, 

Vitamin A+D Ointment 

Apply to the affected area(s) as directed or as needed until rash 

resolves. 

Corticosteroids: 

Hydrocortisone cream/ointment, 

0.5, 1% 

Apply to the affected area(s) as directed or tid or qid until rash 

resolves. 

Clinical Note: 

• Apply sparingly! Overuse may result in systemic absorption and steroid side effects. 

Antifungals: 

Nystatin cream/ointment 

Nystatin–triamcinolone cream/ 

ointment 

Apply to the affected area(s) bid–qid until rash resolves. 

Apply to the affected area(s) bid–qid until rash resolves. 


• Apply sparingly! Overuse may result in systemic absorption and steroid side effects. 

Clotrimazole cream 1% 

>3 years of age: Apply sparingly to the affected area(s) bid until rash resolves. 


75

Secretions 


Anticholinergics 

Anticholinergics may have atropine-like side effects which could be potentiated if given with 

other medications possessing anticholinergic properties e.g. tricyclic antidepressants. Monitoring 

is warranted. Hyoscyamine and glycopyrrolate are less likely than other anticholinergic 

agents to cause CNS side effects (drowsiness, confusion, delirium, hallucinations, paradoxical 

agitation, and restlessness). Use with caution in children with spastic paralysis. 

Hyoscyamine 

PO/SL: 

Dose as per tables is repeated q4h prn 

12 years of age and adults: 0.125–0.25 mg PO/SL q4h prn 


• Low doses may cause a paradoxical decrease in heart rate. 

Glycopyrrolate 

PO: 

0.04–0.1 mg/kg/dose q4–8h 

Scopolamine hydrobromide, transdermal 

≥15 kg and adults: 

Apply 1 patch behind ear q72h 

Clinical Note 

• Because the patch may take up to 12 hours for effect, it has limited benefits for actively 

dying patients. 

76 

Secretions


Seizures 

Status epilepticus 

Diazepam 

Neonates: 

IV: 

>1 month: 

IV: 

0.3–0.75 mg/kg/dose q15–30min for 2 or 3 doses 

0.2–0.5 mg/kg/dose q15–30min for 2 or 3 doses 

Maximum total dose,

Seizures 


Lorazepam 

PR/IV: 

Neonates, infants, children, 

adolescents: 

0.05–0.1 mg/kg/dose (IV over 2–5 min) every 10 - 15 min for up 

to 3 doses 




• The injectable product may be given rectally, however, pediatric suppositories are compounded 

by HP. 





Phenobarbital 

Loading dose, IV: 

Neonates, infants, children: 

PO: 

Maintenance dose: 

15–20 mg/kg/dose in a single or divided dose 

May give additional 5 mg/kg doses q15–30min to a maximum of 

30 mg/kg. 

Refer to dosing information under the Primary Anticonvulsant 

agent section. 


• Phenobarbital is available as 15-, 30-, 60-, 64.8-, and 100 mg tablets; a 20 mg/5- ml elixir; 

a 30 mg/mL suspension; a 130 mg/mL injection; and 30- and 60 mg suppositories (compounded 

by HP). 

• Due to its side effect profile, this agent is usually reserved for patients who have failed 

other antiepileptic therapies. 

• Phenobarbital MUST be diluted with at least an equal volume of compatible fluid and 

slowly injected at a rate no greater than 2 mg/kg/minute in infants and usually no more 

than 30 mg/minute in older children. If hypotension occurs, the administration rate should 

be reduced by 50 percent. During injection, vital signs, especially blood pressure and respiratory 

rate, should be monitored. 

• Phenobarbital has a significant drug–drug interaction profile; adjust doses of medications 

metabolized by CYP450 1A2, 2C enzyme family and 3A4 enzymes accordingly. 

• The therapeutic blood level is 10–40 mcg/mL. 

• This drug is well absorbed rectally; oral to rectal conversion ratio is 1:1. 

78 

Seizures


Seizures 

Primary anticonvulsant agents 

Carbamazepine 

PO: 

Children 12 years: 

Initial dose: 10–20 mg/kg/24 h divided bid–tid (administer qid for 

suspension) 

Titration: q5–7days up to 35 mg/kg/24 h 

Maximum dose: 35mg/kg/24h 

Initial dose: 10 mg/kg/24 h divided bid 

Maximum initial dose: 100 mg bid 

Titration: 100 mg/24 h at 7-day intervals (doses divided tid–qid) 

until desired response is obtained 

Maintenance: 20–30 mg/kg/24 h divided bid–qid; (usual maintenance 

dose is 400–800 mg/24 h) 


Initial dose: 200 mg bid 

Titration: 200 mg/24 h at 7-day intervals (doses divided bid–qid) 

until desired response is obtained 

Maintenance: 800–1200 mg/24 h divided bid–qid 

Maximum dose: 12–15 years of age: 1000 mg/24 h 

>15 years of age: 1200 mg/24 h 

Adults: 1600–2400 mg/24 h 


• Carbamazepine is available as 100-mg chewable tablets, 200-mg tablets, a 250-mg/5-mL 

suspension, and 200-, 300-, and 400- mg suppositories (compounded by HP). 

• Chewable tablets are preferred over oral suspensions due to potential problems with consistent 

drug delivery with suspensions (toxicities have occurred when suspensions were 

not shaken well prior to dispensing the dose). 

• Dose may need to be adjusted upward every 2–3 weeks due to auto-induction of hepatic 

metabolism (can occur during days 3–28 of therapy). 


by CYP450 1A2, 2C, and 3A4 enzymes accordingly. 

• Pancytopenia may occur secondary to carbamazepine administration and may be exacerbated 

by concurrent chemotherapy. CBC should be monitored periodically. 

• Minimize CNS and GI side effects by giving the largest dose at bedtime. 

• Use with extreme caution in children with compromised bone marrow function. 


• Well absorbed rectally; oral to rectal conversion ratio is 1:1. 

• Suggested dosing intervals for specific dosage forms of carbamazepine are: extendedrelease 

tablets or capsules = bid; chewable and immediate-release tablets = bid–tid; and 

suspension = qid. 

Seizures 

79

Seizures 


Valproic Acid 

PO: 

PR: 

Initial dose: 10 – 15 mg/kg/24 h given once daily or divided up to tid 

Titration: 5 – 10 mg/kg/24 h at weekly intervals 

Usual maintenance dose: 30 – 60 mg/kg/24 h, divided bid - tid 


Loading dose: 20 mg/kg/dose 

Maintenance dose: 10 – 15 mg/kg/dose q8h 


• Use with caution in children < 2 years of age. 

• Contraindicated in patients with liver disease or dysfunction. 

• May cause hepatotoxicity within 3 days to 6 months of initiating therapy; discontinue 

valproic acid immediately if hepatotoxicity occurs. 

• Valproic acid may cause thrombocytopenia, encephalopathy, rash, hyperammonemia, and 

pancreatitis, among other adverse events. CBC and LFTs should be drawn prior to starting 

therapy and periodically thereafter. 


by hepatic enzymes (cytochrome P450) accordingly. 

• Do not use Depakote ER preparation (outside the per diem) in patients 10 years of age 

or less. 

• Depakote and Depakote ER (outside the per diem) are not bioequivalent; doses of the ER 

formulation are 8 – 20% higher than Depakote tablets. 

• The therapeutic blood level is 50 – 100 mg/L. 

Adjuvant Agents 

Clonazepam 

PO: 

Children


Seizures 

Gabapentin 

PO: 

3–12 years of age: Initial dose: 10–15 mg/kg/24 h divided tid then gradually titrate 

dose upward to the following doses over a 3-day period: 

3–4 years of age: 40 mg/kg/24 h divided tid 

≥5 years: 25–35 mg/kg/24 h divided tid 


>12 years of age and adults: Day 1: 300 mg at bedtime 

Day 2: 300 mg bid 

Day 3: 300 mg tid 

Usual effective doses: 900–1800 mg/24 h divided tid 



• Gabapentin is available as 100-, 300-, and 400-mg capsules; 600- and 800-mg tablets; and a 

250-mg/5-mL suspension. 

• Use as an adjunct to a first-line agent for partial seizures, but do not use as monotherapy. 

• Gabapentin undergoes renal elimination; adjust doses downward in patients with renal 

impairment. 

• This drug is not absorbed rectally; do not administer via this route. 

• Do not withdraw medication abruptly. 

• This drug may be taken with or without food. 

• With BID dosing, do not exceed 12 h between doses. 

Phenobarbital 

PO/IV: Maintenance dose 

Neonates: 

Infants: 



Children: 

1–5 years of age: 6–8 mg/kg/24 h divided daily–bid 

>5–12 years of age: 4–6 mg/kg/24 h divided daily–bid 

>12 years of age: 1–3 mg/kg/24 h divided daily–bid 


• Phenobarbital is available as 15-, 30-, 60-, 64.8-, and 100 mg tablets; a 20 mg/5- ml elixir; 

a 30 mg/mL suspension; a 130 mg/mL injection; and 30- and 60 mg suppositories (compounded 

by HP). 

• Due to its side effect profile, this agent is usually reserved for patients who have failed 

other antiepileptic therapies. 

• Phenobarbital has a significant drug–drug interaction profile; adjust doses of medications 

metabolized by CYP450 1A2, 2C enzyme family and 3A4 enzymes accordingly. 


• This drug is well absorbed rectally; oral to rectal conversion ratio is 1:1. 

Seizures 

81

Somnolence 


Methylphenidate 11 

PO: 

Initial dose: 0.1 mg/kg/dose q4h prn, or bid at 8 am and 12 noon 

Maximum dose: 2 mg/kg/24 h or 60 mg/24 h 


• Sustained-release dosage forms should not be used for this indication and are not included 

under the per diem. 

• Use with caution in patients with hypertension or epilepsy. 

• Methylphenidate may increase serum concentrations of TCAs, phenytoin, phenobarbital, 

and warfarin. 


82 

Somnolence

Inclusion Code: C Section 

Cancer/AIDS diagnoses (ICD-9: 042, 140-239)

INCLUSION CODE: C, O 

(terminal diagnosis of failure to thrive only [ICD-9: 783.41]) 

Cachexia 

Prednisone 11 

PO: 

>1 year of age: 0.5–2 mg/kg/24 h divided daily–qid OR 5 mg PO daily 

Maximum dose: 2 mg/kg/24 h OR 

60–80 mg/24 h for children >40 kg 

Megestrol acetate 11 

PO: 

Children: 

7.5 – 10 mg/kg/24 h in 1 – 4 divided doses 

Maximum dose: 15 mg/kg/24 h OR 800 mg/24 h 


• Chronic use of megestrol therapy in children may result in severe adrenal suppression; 

replacement glucocorticoids may be necessary. 

• Therapy should be used with caution in patients with a history of diabetes, thromboembolism, 

or in those at high risk for developing thromboembolism. 

• Use of megestrol suspension should be avoided in neonates, as these products contain 

benzyl alcohol which is toxic in newborns. 

• Megestrol acetate is not recommended if life expectancy is less than 30 days, due to controversy 

surrounding the true benefit of cachexia treatment in end-stage patients. 

• Megestrol acetate tablets are outside the per diem, regardless of daily dose prescribed. 

Cachexia 

83

Inclusion Code: H Section 

Cardiac diagnoses (ICD-9: 391-429, 440-459)

Cardiomyopathy/Congestive Heart 

Failure/Cardiac Disease 

INCLUSION CODE: H 

ACE inhibitors (ACEIs) 

Patients with bilateral renal artery stenosis should avoid the use of ACEIs. ACEIs are contraindicated 

in patients with ACE inhibitor-induced angioedema and in patients with a history of 

angioedema or hereditary or idiopathic angioedema. Titrate according to patient’s response; 

use lower doses (half of those listed) for patients with hyponatremia, hypovolemia, severe 

CHF, decreased renal function, or in those receiving diuretics. Use with caution in collagen 

vascular disease and when administered with concomitant potassium-sparing diuretics. 

Captopril 

Neonates: 

Infants: 

Children: 

Adolescents: 

0.1–0.4 mg/kg/24 h PO divided q6–8h 

Initial dose: 0.15–0.3 mg/kg/dose; titrate upward if needed. 

Maximum dose: 6 mg/kg/24 h divided daily–qid 

Initial dose: 0.3–0.5 mg/kg/dose PO q8h; titrate upward if needed. 

Maximum dose: 6 mg/kg/24 h divided bid–qid 

Initial dose: 12.5–25 mg/dose PO bid–tid; titrate weekly if necessary 

by 25 mg/dose. 



• Onset is within 15–30 min of administration; peak effect is within 1–2 h. 

• Administer on empty stomach 1 h before or 2 h after meals. 

Enalapril 

Neonates: 


0.1 mg/kg/24 h PO, increase dose and interval as required every 

few days 

0.1 mg/kg/24 h PO divided daily–bid; increase PRN over 2 weeks. 



• Enalapril is converted to the active form enalaprilat by the liver. 

Fosinopril 

Safety and efficacy have not been established in children. 

Lisinopril 

Children 6–16 years of age: 

Initial: 0.07 mg/kg/24 h PO (up to total of 5 mg); adjust dose 

based on response and increase dose at 1–2-week intervals. 

Maximum dose: 0.6 mg/kg/24 h, or 40 mg/24 h 

84 Cardiomyopathy/Congestive Heart Failure/Cardiac Disease





• Efficacy has not been established in children less than 6 years of age. 

• This drug may be administered without regard to meals. 

Angiotensin II inhibitor 

Valsartan 

Safety and effectiveness have not been established in children. 

Antianginals 

Isosorbide dinitrate 


Isosorbide mononitrate 


Antiarrhythmic agents 

All antiarrhythmic agents are contraindicated in the presence of second- or third-degree 

heart block except in the presence of a pacemaker. Other contraindications or precautions 

for individual agents are outlined below. 

Digoxin 

Digitalizing: 

For total digitalizing dose (TDD) and maintenance doses in mcg/kg/24 h: 

Digoxin Digitalizing and Maintenance Doses 

TDD 

Maintenance 

Age PO IV/IM PO IV/IM 

Premature 20 15 5 3–4 

Full term 30 20 8–10 6–8 

10 years and




Digoxin (continued) 

Initial dose: 

Maintenance dose: 

½ TDD, then ¼ TDD divided q8–12h x2 doses; obtain ECG 6 h 

after dose to assess for toxicity. 




Propranolol 

Arrhythmias: 

PO: 

Initial dose: 0.5–1 mg/kg/24 h divided q6–8h 

Titration: Increase dosage q3–5 days as needed. 

Usual dose range: 2–4 mg/kg/24 h divided q6–8h 

Maximum dose: 60 mg/24 h, or 16 mg/kg/24 h 


• Propranolol is contraindicated in patients with asthma, Raynaud’s syndrome or CHF. 

• Use with caution in presence of obstructive lung disease, diabetes mellitus, or renal or 


• This drug is a substrate of CYP450 1A2, 2C18, 2C19, and 2D6 isoenzymes. Adjust dose 

of propranolol as appropriate if patient is taking medications that share one or more of 

these enzyme pathways. 

Quinidine 

All doses expressed as salt forms: 

PO: 

Test dose: 2 mg/kg x 1 dose 

Maximum test dose: 200 mg 

Therapeutic dose (as sulfate): 15–60 mg/kg/24 h divided q6h 


• Quinidine sulfate 200 mg is equivalent to 267 mg of quinidine gluconate. 

• A test dose is given to assess for idiosyncratic reactions to quinidine. 

• Quinidine is a substrate of CYP450 3A3/4 and 3A5/7 enzymes and an inhibitor of CYP450 

2D6 and 3A3/4 enzymes. Numerous drug–drug interactions exist with quinidine; an 

especially noteworthy interaction is quinidine and digoxin. Review medication profile for 

potential drug–drug interactions. Adjust doses of medications as appropriate. 

• Use with caution in patients with renal insufficiency. 

• Therapeutic levels are 3–7 mg/L. 

Cardiomyopathy/Congestive Heart Failure/Cardiac Disease 

87




Antiplatelet medications 

Aspirin 

PO: 

Suggested doses: 

Mechanical prosthetic heart 

valves: 

Doses range from 3–5 mg/kg/24 h to 5–10 mg/kg/24 h given as a 

single daily dose and rounded to a convenient amount 

(e.g., ½ of an 80-mg tablet). 

6–20 mg/kg/24 h given as a single daily dose 

Clinical Note 

• Aspirin is used in combination with an oral anticoagulant in children who have systemic 

embolism despite adequate oral anticoagulation therapy (INR 2.5–3.5) and used in combination 

with low-dose anticoagulation (INR 2–3) and dipyridamole when full-dose oral 

anticoagulation is contraindicated. 

PO: 

Blalock-Taussig shunts: 

3–5 mg/kg/24 h given as a single daily dose 


• Adequate pediatric studies on antiplatelet indication have not been performed; doses are 

derived from adult studies and clinical experience and are not well established. 





dysfunction, CHF, and GI bleeding; or in patients taking anticoagulants. 


Dipyridamole 

PO: 

Suggested doses: 

Mechanical prosthetic heart 

valves: 

3–6 mg/kg/24 h in 3 divided doses 

2–5 mg/kg/24 h 


• Dipyridamole is used in combination with an oral anticoagulant in children who have 

systemic embolism despite adequate oral anticoagulant therapy (INR 2.5–3.5) and used in 

combination with low-dose oral anticoagulation (INR 2–3) plus aspirin in children in whom 

full-dose oral anticoagulation is contraindicated. 

• Doses of 4–10 mg/kg/24 h have been used investigationally to treat proteinuria in pediatric 

renal disease. 





• Dipyridamole may further decrease blood pressure in patients with hypotension due to 

peripheral vasodilation. 

• Administer with water on an empty stomach 1 h before or 2 h after meals; may take with 

food or milk to decrease GI upset. 

Anticoagulants 

Heparin 

Parenteral line maintenance: 

Children




Warfarin Continued 

• It is a substrate for CYP450 1A2, 2C8, 2C9, 2C18, 2C19, and 3A3/4 and it inhibits CYP450 

2C9. Numerous drug–drug interactions exist with warfarin. Review medication profile for 

potential drug–drug interactions. Dose may need to be adjusted accordingly. 

• Onset of action occurs within 36–72 h and peak effects occur within 5–7 days. 

• As a patient safety standard, HP requires the documentation of an INR at least monthly to 

monitor patients receiving this therapy. If a patient or provider decides to forgo monitoring and 

an INR was not documented in Xeris within 30 days, additional warfarin will be outside the per 

diem. Additional information can be found in the adult MUGs under inclusion code H section. 

Arterial vasodilator 

Hydralazine 


Initial dose: 0.75 – 1 mg/kg/24 h in 2- 4 divided doses; 

Maximum initial dose: 25 mg/dose 

Maximum dose (whichever is less): 200 mg/24 h 

OR 

Infants: 5 mg/kg/24 h Children: 7.5 mg/kg/24 h 


• Use hydralazine with caution in patients with severe renal or cardiac disease. 

• Discontinue hydralazine in patients who develop lupus-like syndrome or positive ANA; 

patients who are slow acetylators, those receiving high-dose hydralazine on a chronic basis, 

and patients with renal insufficiency are at highest risk. 

Beta blockers 

Beta-blockers should generally be avoided in patients with bronchospastic disease; however, 

the use of cardioselective beta-blockers (e.g. atenolol or metoprolol) may be preferred. 

Beta-blockers are contraindicated in patients with sinus bradycardia, heart block greater than 

first degree, sick sinus syndrome (except patients with functioning pacemaker), cardiogenic 

shock, or uncompensated CHF. Use with caution in conjunction with verapamil, diltiazem, or 

anesthetic agents that decrease myocardial function; bradycardia or heart block may occur. 

Beta-blockers may mask signs of thyrotoxicosis or hypoglycemia; therefore should be used 

with caution in patients with diabetes and thyroid disorders. Do not abruptly discontinue 

beta-blocker therapy; taper dosage gradually over 1–2 weeks. 

Atenolol 

PO: 

0.8 –1.5 mg/kg/24 h 



• Use with caution in patients with asthma. Wheezing and dyspnea have occurred when 

daily dosage exceeds 100 mg. 





• Avoid abrupt withdrawal of the drug. 

• Atenolol does not cross the blood-brain barrier; it has a lower incidence of CNS side 

effects compared to propranolol. 

• Adjust dose of atenolol in patients with renal impairment. 

Carvedilol 

PO: 

Initial dose: 0.1mg/kg/24 h administered bid 

Maximum dose: 1 mg/kg/24 h, up to 50 mg/24 h 


• Safety and effectiveness have not been established in children. Although no difference in 

heart failure outcomes have been demonstrated in one randomized placebo-controlled 

trial, other clinical trials have shown improved left ventricular function, symptoms, and/or 

functional class in pediatric patients receiving carvedilol for heart failure, including patients 

with dilated cardiomyopathy or congenital heart disease. 

Metoprolol tartrate/succinate 

PO: 

Initial dose: 1–2 mg/kg/24 h administered bid 

Maximum dose: 6 mg/kg/24 h, up to 200 mg/24 h 


• Safety and effectiveness have not been established in children. 

• Limited information is available. Sixteen hypertensive adolescents (>13 years of age) were 

treated with an initial dose of 50 mg PO bid; patients were seen every 4–6 weeks and 

doses were increased to 100 mg bid if blood pressure was not controlled16. 

• Both immediate-release and sustained-release (Toprol XL®) formulations are considered 

to be within the per diem. 

Propranolol 

PO: 

Initial dose: 0.5–1 mg/kg/24 h PO divided q6–12h 

Titration: May increase dose q3–5days as needed. 



• Propranolol is contraindicated in asthma, Raynaud’s syndrome, heart failure, and heart block. 

• Use with caution in the presence of obstructive lung disease, diabetes mellitus, or renal or 


• This drug is metabolized by CYP450 1A2, 2C18, 2C19, and 2D6 isoenzymes; the dose of 

propranolol should be adjusted accordingly when administered with medications sharing 

these enzyme pathways. 

• Both immediate-release and sustained-release formulations are included in the per diem. 


91




Calcium channel blockers 

Amlodipine 

PO: 

Initial dose: 0.1 mg/kg/dose daily–bid 

Maximum dose: Dosage may be gradually increased 

to a maximum of 0.6 mg/kg/24 h up to 20 mg/24 h. 


• Use with caution in combination with other antihypertensives. 

• Younger children may require higher mg/kg doses than older children and adults; a bid dosing 

regimen may provide better efficacy in children. 

• Reduce dose in patients with hepatic insufficiency. 

• Allow 5–7 days of continuous initial dose therapy before making dosage adjustments because 

of the gradual onset of action and lengthy elimination half-life. 

• Dose-related side effects include edema, dizziness, flushing, fatigue, and palpitations. 

Diltiazem 

Children: 

Adolescents: 

1.5–2 mg/kg/24 h PO divided tid–qid 

Maximum dose: 3.5 mg/kg/24 h. 

Immediate release: 30–120 mg/dose PO tid–qid 

Usual dose range: 180–360 mg/24 h 

Extended release: 120–300 mg/24 h divided daily–bid 


• Diltiazem is contraindicated in patients with acute MI, pulmonary congestion, second- or 

third-degree heart block, LV dysfunction, or sick sinus syndrome. 

• This drug is a substrate and inhibitor of the CYP450 3A4 enzyme system; review medication 

profile for potential drug–drug interactions. Adjust doses of affected medications 

accordingly 

• Maximal antihypertensive effect seen within 2 weeks. 

• Not all sustained-release preparations included in the per diem MUG; refer to adult MUGs 

for exceptions. 

Verapamil 

PO: 

Weight-based: 

Aged-based: 

OR 

4–8 mg/kg/24 h PO divided tid 

1 – 5 years of age: 40 – 80 mg PO q8h 

> 5 years of age: 80 mg PO q6 – 8h 






• Immediate-release products should be administered tid; sustained-release products should 

be administered either daily or bid. 

• Contraindications include hypersensitivity, cardiogenic shock, severe CHF, sick sinus syndrome, 

or AV block. 

• Due to negative inotropic effects, verapamil should not be used to treat SVT in infants in 

an emergency setting. 

• Reduce dose in renal insufficiency. 

• Verapamil is a substrate of CYP450 1A2 and 3A3/4 enzymes and an inhibitor of CYP450 

3A4. Numerous drug–drug interactions occur with verapamil, many of which may result 

in serious adverse events or toxicity. Review medication profile and adjust doses of these 

medications and/or verapamil accordingly. 

• Not all sustained-release preparations are considered to be within the per diem. Consult 

your HP pharmacist or adult MUGs 

Cardiac glycosides 

Digoxin 

Please refer to Antiarrhythmic Agents section. 

Centrally acting agents 

Clonidine 

PO: 

Initial dose: 5–7 mcg/kg/24 h divided q6–12h 

Titration: If needed, increase every 5–7 days to 5–25 mcg/kg/24 h 

divided q6h 

Maximum dose: 0.9 mg/24 h 


• Do not abruptly discontinue because signs of sympathetic overactivity may occur; taper 

gradually over more than 1 week. 

• Beta-blockers may exacerbate rebound hypertension during and following the withdrawal 

of clonidine. If a patient is receiving both clonidine and a beta-blocker, and clonidine is being 

discontinued, the beta-blocker should be withdrawn several days prior to tapering the 

clonidine. If converting from clonidine to a beta-blocker, introduce the beta-blocker several 

days after discontinuing clonidine (following taper). 

• The T ½ is 44–72 h for neonates and 6–20 h for adults. 

• Transdermal clonidine is not included under the per diem. 


93




Diuretics 

See Edema guideline. 

Potassium supplementation 

PO: 

1–4 mEq/kg/24 h divided bid–qid 


• Potassium replacement is based on maintenance requirements, deficit, and ongoing losses. 

• Potassium supplements are included under the per diem for all patients receiving diuretic 

therapy related to the terminal diagnosis. 

• Serum electrolytes should be monitored periodically. 

• Oral administration may cause GI disturbance and ulceration. 

• Oral liquid supplements should be diluted in water or fruit juice prior to administration. 

• Sustained-release tablets must be swallowed whole and not dissolved in the mouth or chewed. 


Inclusion Code: O Section 

Other diagnoses (All other terminal 

diagnoses that do not fall in one of the 

other Inclusion Codes or ICD-9 ranges)

INCLUSION CODE: O 

Cystic Fibrosis 

Cystic fibrosis (CF) is a hereditary disease that causes certain glands to produce abnormal 

secretions, resulting in several symptoms, the most important of which affect the digestive 

tract and the lungs. In some glands, such as the pancreas and those in the intestines, the 

secretions are thick or solid and may block the gland completely. The mucus-producing glands 

in the airways of the lungs produce abnormal secretions that clog the airways and allow 

bacteria to multiply. The sweat glands, parotid glands, and small salivary glands secrete fluids 

containing more salt than normal. Recurrent bronchitis and pneumonia gradually destroy 

the lungs. Death usually results from a combination of respiratory failure and a failing heart 

caused by the underlying lung disease. A small number, however, will expire due to liver disease, 

bleeding into the airway, or complications of surgery. 

Non-pharmacologic therapy 

• Nutrition 

• Vitamin supplementation (A, D, E, and K). This therapy is outside the per diem. Dosing of 

multi-vitamins is generally based on the vitamin E content (5–10 units/kg/24 h). Additional 

vitamin K (outside the per diem) may be necessary for patients with liver disease 

(2.5–5 mg daily–qod). 

• Percussion and postural drainage 

Pharmacologic therapy 

Meconium ileus 

Meconium ileus, a form of intestinal obstruction in newborns, occurs in almost 20% of those 

with CF. Meconium, the dark green substance that emerges as the newborn’s first stool, is thick 

and passes more slowly than normal. If the meconium is too thick, it blocks the intestine. 

Lactulose can be used for the prevention of intestinal obstruction. 

Lactulose 

PO: 

Infants: 

Children: 

2.5–10 mL/24 h PO in 3 or 4 divided doses 

40–90 mL/24 h PO in 3 or 4 divided doses 


95



Pancreatic insufficiency 

A pancreas affected by CF does not produce enough enzymes to digest proteins and fats. 

Without the appropriate digestive enzymes, the body loses too much protein and fat in the 

stools, resulting in malnutrition and slowed growth. Stools are bulky and often foul smelling. 

PANCRELIPASE CAPSULES OR TABLETS: 

Infants: 

Children



- The baby should be given this enzyme–food mixture before the liquid feeding. The 

mouth should be checked to make sure that all the beads have been swallowed. 

- If retained in the mouth, the beads may irritate the mucous membranes. Feeding can 

commence once the beads are swallowed. One suggested method is the place the 

beads in the cheek and immediately offer fluids. 

- As infants learn to chew, be sure they do not chew the beads. 

• The pancreatic enzymes are acid labile, and if introduced into the stomach without the 

protection of a coating, they will be degraded in the acid medium of the stomach. 

• Caregivers can “hide the beads” in yogurt, applesauce, ice cream, or pudding (low pH 

foods). Feedings that are high in fat may require additional enzyme supplementation. Feedings 

of fruits or vegetables may not require any enzyme supplementation. 

• Snack doses are approximately half of meal doses but may vary depending on the food 

consumed. 

Dyspepsia 

Ranitidine 

>1 month–16 years of age: 2–4 mg/kg/24 h PO divided q8–12h 




• Ranitidine may decrease absorption of some medications requiring an acidic gastric environment 

for absorption (e.g., ketoconazole, some cephalosporins, cyclosporine). 

• Some patients may not tolerate the peppermint flavor of the oral syrup preparation. 

Famotidine 

1–16 years of age: 0.5 –1 mg/kg/24 h PO divided q12h 




• Famotidine may decrease absorption of some medications requiring an acidic gastric environment 

for absorption (ketoconazole, some cephalosporins, cyclosporine). 


97



Omeprazole 

PO: 

1 mg/kg/24 h administered daily or bid 

Effective range: 0.3–3.3 mg/kg/24 h 


• Administer all doses before meals. 

• To administer dose, the capsules may be opened and the intact pellets administered in an 

acidic beverage (apple/cranberry juice) or applesauce. 

• An extemporaneously compounded oral suspension is available. However, this preparation 

may be less bioavailable due to loss of omeprazole’s enteric coating. 

• Omeprazole may decrease absorption of some medications requiring an acidic gastric 

environment for absorption (e.g., ketoconazole, some cephalosporins, cyclosporine). 

• Omeprazole is a substrate and inhibitor of CYP450 2C19 and induces CYP450 1A2; its 



PO/IV/IM: 


0.1–0.2 mg/kg/dose up to qid 




• In higher doses, metoclopramide has the potential to cause EPS; premedicating with diphenhydramine 

may reduce the incidence of EPS. 

• Metoclopramide is contraindicated in patients with a complete bowel obstruction and 

pheochromocytoma. 





Diabetes mellitus 

Diabetes mellitus (DM) is a common medical complication affecting CF patients. An increase 

in the number of insulin receptors occurs with a decreased affinity for insulin, leading to 

glucose intolerance. The incidence of DM ranges from less than 1% in CF patients who are 

younger than 10 years of age to more than 10% in patients older than age 25. 

Insulin, regular 

Dosage is based on patient-specific factors. 

Insulin, NPH 


98 Cystic Fibrosis



Insulin, 70/30 


Dyspnea 

Thick bronchial secretions eventually block the small airways, which then become inflamed. 

As the disease progresses, the bronchial walls thicken, the airways fill with infected secretions; 

areas of contact and the lymph nodes enlarge. All these changes reduce the lung’s ability to 

transfer oxygen to the blood. 

Mucolytic therapy options dornase alpha and acetylcysteine are not currently included in the 

per diem. See Dyspnea guideline for bronchodilator, corticosteroid, and respiratory sedative 

therapy options. 


• Bioavailability of theophylline may be decreased and clearance may be different in CF patients. 

Respiratory tract infections 

Most CF infants have constant coughing, wheezing, and respiratory tract infections. CF 

patients typically do not clear their infections, as they become chronic colonizers of Pseudomonas 

aeruginosa. Coughing, the most notable symptom, is often accompanied by gagging, 

vomiting, and disturbed sleep. The most common pathogens found in the sputum include: 

• Staphylococcus aureus (prevalent in younger patients) 

• Pseudomonas aeruginosa 

• Haemophilus influenzae (prevalent in younger patients) 

• Burkholderia cepacia or Stenotrophamonas (more common in end-stage patients) 

Policies for antibiotic/antifungal use 

• Parenteral antibiotics, rectally administered antibiotics and nebulized antibiotics 

(e.g., tobramycin) are not included under the per diem. 

• A 28-day course of therapy may be used for oral antibiotics included within the per diem. 

However, patients must be reassessed for appropriateness of therapy for either discontinuation 

of therapy, continuation of current regimen, or switch to an alternate therapy option. 

• Prophylactic or suppressive antimicrobial therapy is not included in the per diem. 

• See Infections guideline of the Pedi-MUGs for therapy options. 


99



Cough/congestion 

• See Cough guideline. 

Anxiety 

• See Anxiety guideline. 

Inflammation 

Ibuprofen 

PO: 

Higher doses of 20–30 mg/kg/dose bid have been used for antiinflammatory 

effects. 


• Ibuprofen inhibits the migration and activation of neutrophils. 

• Greatest effect on lung function in clinical studies was seen in patients 5–13 years of age. 

• Ibuprofen requires regular monitoring of serum levels; peak plasma levels of 50–100 mcg/ 

mL are desirable. 

• Long-term safety in CF patients is not known at this time. 




See Pain-Nociceptive guideline, Dyspnea guideline, and Corticosteroid dosing section of the 

Pedi-MUGs for additional therapy option that may be useful in CF patients. 

100 Cystic Fibrosis

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102 

References

Compounded Medications by Ingredient 

The following compounds have been used in the pediatric hospice population when manufactured 

agents are not able to meet patient needs. The table is an alphabetical listing of 

compounds available upon request through Hospice Pharmacia that are pediatric-specific; 

please refer to the adult MUGs for the complete list of compounds available through Hospice 

Pharmacia. Some preparations and dosage forms that are not listed may be specifically compounded 

to meet your patient’s needs. Also, please refer to the section labeled “Palatability of 

Medications” at the front of this book for concerns regarding the flavoring of medications. 

Compound Dosage Form Dosage Strength 

bisacodyl (pediatric) Suppository 1.25 mg 

bisacodyl (pediatric) Suppository 5 mg 

chloral hydrate (pediatric) Suppository 50 mg 

diazepam (pediatric) Suppository 0.5 mg 

diazepam (pediatric) Suppository 1 mg 





diphenhydramine (pediatric) Suppository 5 mg 

haloperidol (pediatric) Solution 1 mg/mL 

lorazepam (pediatric) Solution 0.1 mg/mL 

lorazepam (pediatric) Solution 0.2 mg/mL 

lorazepam (pediatric) Suppository 0.3 mg 

lorazepam (pediatric) Suppository 0.5 mg 

morphine (pediatric) Solution 1 mg/5 mL 

morphine (pediatric) Suppository 2 mg 

morphine (pediatric) Suppository 5 mg 

phenobarbital (pediatric) Suppository 6 mg 



prochlorperazine (pediatric) Suppository 2.5 mg 

prochlorperazine (pediatric) Suppository 5 mg 

prochlorperazine (pediatric) Solution 5 mg/mL 

Compounded Medications by Ingredient 

103

PediMUGs - Hospice Pharmacia

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