Paediatric Analgesia Guidelines and Anticipatory Prescribing Guidance - V6.0 October 2020 - RCHT
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Paediatric Analgesia Guidelines and
Anticipatory Prescribing Guidance
V6.0
October 2020Contents
1. Aim/Purpose of this Guideline..................................................................................................... 3
2. The Guidance ............................................................................................................................. 3
2.1. Definitions / Glossary .............................................................................................................. 3
2.3. Standards and Practice ........................................................................................................... 5
2.3.1. Hints and Tips ...................................................................................................................... 5
2.3.2. Guidelines for Paediatric Analgesia ..................................................................................... 6
2.3.3. Guidance for the use or oral sucrose solution prior to minor painful procedures in babies
under 4 months .................................................................................................................................. 7
2.3.4. Intranasal Diamorphine (Ayendi) ......................................................................................... 8
2.3.5. Intranasal Diamorphine10mg (Only to be used if Ayendi is unavailable) ............................. 9
2.3.6. Intranasal Fentanyl ONLY TO BE USED IF DIAMORPHINE IS UNAVAILABLE ............... 10
2.3.7. IV Morphine Infusion .......................................................................................................... 11
2.3.8. Morphine Patient Controlled Analgesia (PCA) ................................................................... 12
2.3.9. Morphine Nurse Controlled Analgesia (NCA) .................................................................... 13
2.3.10. Fentanyl Infusion and PCA ................................................................................................ 14
2.3.11. Paediatric Recovery........................................................................................................... 16
2.3.12. Epidurals............................................................................................................................ 17
2.3.13. Management of Leg Weakness with Epidurals .................................................................. 19
2.3.14. Mean Values for weight, height and gender by age ........................................................... 20
3. Monitoring compliance and effectiveness ................................................................................. 21
4. Equality and Diversity ............................................................................................................... 21
Appendix 1. Governance Information ............................................................................................... 22
Appendix 2. Equality Impact Assessment ........................................................................................ 24
Appendix 3. Guidance for Anticipatory Prescribing and Symptom Control in Paediatric Patients .... 26
Paediatric Analgesia Guidelines and Anticipatory Prescribing Guidance V6.0
Page 2 of 291. Aim/Purpose of this Guideline
1.1. This policy has been drawn up to ensure that Paediatric patients within the
Trust receives appropriate pain relief.
1.2. This version supersedes any previous versions of this document.
Data Protection Act 2018 (General Data Protection Regulation – GDPR)
Legislation
The Trust has a duty under the DPA18 to ensure that there is a valid legal basis to
process personal and sensitive data. The legal basis for processing must be identified
and documented before the processing begins. In many cases we may need consent;
this must be explicit, informed and documented. We cannot rely on opt out, it must be
opt in.
DPA18 is applicable to all staff; this includes those working as contractors and providers
of services.
For more information about your obligations under the DPA18 please see the
Information Use Framework Policy or contact the Information Governance Team
rch-tr.infogov@nhs.net
2. The Guidance
The purpose of this policy is to inform all staff of the appropriate analgesia regimes for
paediatric patients.
This policy applies to anyone who looks after children within RCHT.
2.1. Definitions / Glossary
BD Twice daily
hr hour
IV Intravenous
kg kilogram
mg milligram
ml Milliliter
NCA Nurse Controlled Analgesia
NSAID Non-Steroidal Anti-Inflammatories
OD Once daily
PCA Patient Controlled Analgesia
PO oral route
PR rectal route
TTO Tablets to Take Out
2.2. Ownership and Responsibilities
The Acute Paediatric Pain Service is responsible for the development, management
and implementation of this policy/procedure.
Dr Julian Berry
Paediatric Analgesia Guidelines and Anticipatory Prescribing Guidance V6.0
Page 3 of 29 Medicines Practice Committee
Acute Paediatric Pain Service
Anaesthetist (Paediatric)
Child Health Audit and Guidelines
2.3. Standards and Practice
See next page
Paediatric Analgesia Guidelines and Anticipatory Prescribing Guidance V6.0
Page 4 of 29Standards and Practice
2.3.1. Hints and Tips
Hints and Tips
(Not for use with children under 3 months of age)
PROTOCOLS ON EPMA
Whenever possible use a pre-prescribed weight-based EPMA protocol:
PAED PERI- For children going to theatre.
PAED PAIN- For inpatient analgesia
FEMUR CHILD- For children admitted with a fractured femur.
Paracetamol
Orally is rapidly absorbed from the small bowel, almost 100% bioavailability, and has a
similar onset time to IV preparation.
IV dose will result in higher plasma and effect site concentrations1
Rectally uptake is slower and more variable; doses of 20mg/kg are often not therapeutic
and take 2-4 hrs to reach therapeutic concentrations2. Therefore only use if oral route is
not available.
Always go for oral dosing first, as the cost of rectal and IV preparations are comparable and are 10
times greater than oral.
NSAIDs: Ibuprofen
NSAIDs ‘‘opioid-sparing’’ effect of 30–40%3
Only 2% with asthma have a deterioration in lung function when given aspirin, only 5% of
those patients have a cross sensitivity to other NSAIDS therefore risk is low.
In orthopaedic procedures benefits outweigh the risks of reduced bone healing in most
cases. Avoid if non-union or scoliosis surgery4.
Cochrane review has demonstrated that there is no increase in bleeding post tonsillectomy
Diclofenac: No longer routinely used in Paediatrics.
Codeine Phosphate and Oral Morphine
Codeine should only be used to relieve acute moderate pain in children older than 12 years
and only if it cannot be relieved by other painkillers such as Paracetamol or Ibuprofen
alone.
A significant risk of serious and life-threatening adverse reactions has been identified in
children with obstructive sleep apnoea who received codeine after tonsillectomy or
adenoidectomy (or both). Codeine is now contraindicated in all children younger than 18
years who undergo these procedures for obstructive sleep apnoea5
Oral Morphine should be used at doses of 100 - 300 micrograms/kg max 4 hourly for in-
patient analgesia.
If TTOs are required they should be prescribed as 50-100 micrograms/kg max 6 hourly.
Ensure that simple analgesia doses are appropriate and given regularly before adding
Oral Morphine.
Opiates
In Paediatrics morphine PCA provides superior analgesia to the intramuscular route or to
continuous infusion of morphine, with comparable outcome to epidural morphine.6
See intravenous opiate guidelines
1. Morton, N S.(2007) Arch Dis Child Educ Pract Ed 92: ep14-ep19
2. Anderson, B J. (1998) What we don’t know about Paracetamol in children. Paediatric Anaesthesia ;8:451–60
3. Kokki, H. (2003) Non-steroidal anti-inflammatory drugs for postoperative pain: a focus on children. Paediatric Drugs; 5:103-23
4. Ippokratis Pountos, Theodora Georgouli, Giorgio M. Calori, and Peter V. Giannoudis (2012). Do Nonsteroidal Anti-Inflammatory Drugs
Affect Bone Healing? A Critical Analysis. The Scientific World Journal, Volume 2012, Article ID 606404.
5. MHRA (2013) Drug safety update. MHRA; Volume 6, Issue 12.
6. Morton, N. (1997) Paediatric Patient Controlled Analgesia. Paediatric Perinat Drug Ther; 1:9–13.
Paediatric Analgesia Guidelines and Anticipatory Prescribing Guidance V6.0
Page 5 of 292.3.2. Guidelines for Paediatric Analgesia
Guidelines for Paediatric Analgesia
(NOT FOR USE IF UNDER 3 MONTHS)
Whenever possible use a pre-prescribed weight-based EPMA protocol: ‘Paed Pain (ward), ‘Paed Peri’ (theatre) or ‘Femur Child’ (#
femur in ED).
Adequate and regular dosing is essential. Use the oral route if pain is not severe. Use parenteral administration if the drug can only be
used this way or if enteral administration has failed or ineffective.
Prescribe ONE drug from each colour only.
*If more than two IV opiate doses are required, consider IV infusion/PCA/NCA with guidelines.
Contact Paediatric Pain Team on bleep 2283 (office hours) or Senior Anaesthetic Trainee (bleep3513) for advice or help.
DRUG ROUTE DOSE ESCALATING
ANALGESIA
Suspension- 250mg/5ml 20mg/kg 6 hourly PO/PR for 48 hours
Paracetamol Tablets- 500mg
Soluble tablets- 500mg Then reduce to
Suppositories- 60, 125, 250, 500mg
15mg/kg 6 hourly
NOT exceeding 4g / day
ONLY TO BE PRESCRIBED IF
Intravenous ORAL ROUTE NOT 10kg- 15mg/kg 6 hourly
>50kg- 1g max 6 hourly
50mls-500mg
100mls- 1g
Ibuprofen Suspension- 100mg/5ml 3-6months- 5mg/kg 8 hourly PO
Tablets- 200, 400mg >6 months- 10mg/kg 8 hourly PO
Maximum daily dose 30mg/kg or 1.2g
Suspension- Orally
Morphine 10mg/5ml Tablets- 12 months- 100-300micrograms/kg 4 hourly
Intravenous*-
6 months 100 micrograms/kg 4 hourly
TTO’s of Oral Morphine-
>12 months- 100 micrograms/kg 6hourly
If OSA/altered respiratory drive-
50micrograms/kg 6 hourly
INTRANASAL- ONCE ONLY
Diamorphine Intranasal spray- See separate guideline on intranet
720micrograms/spray intranetanaestheticguidelinespaediatric pain
1600micrograms/spray
RESPIRATORY DEPRESSION
Give oxygen, contact paediatric or ITU consultant. Consider PERT call.
< 12 years- Naloxone 10micrograms/kg IV bolus and repeat if necessary. If no response, give subsequent doses of 100 micrograms/kg (max
2mg)
>12 years- Naloxone 100micrograms IV bolus and repeat if necessary. If no response, give subsequent doses in increments of
100micrograms every 2 minutes if required (max dose 10mg).
FIRST-LINE ANTI-EMETIC
Ondansetron Intravenous 0.1mg/kg 8 hourly Can cause severe constipation
See BNFC for Orally 4 years – 4mg 8 hourly vomiting
CONSIDER ENTONOX FOR PROCEDURAL PAIN RELIEF
Paediatric Analgesia Guidelines and Anticipatory Prescribing Guidance V6.0
Page 6 of 292.3.3. Guidance for the use or oral sucrose solution prior to minor painful procedures
in babies under 4 months
Indication for use
In conjunction with non-nutritive sucking, oral sucrose solution can relieve pain in neonates
during minor procedures such as venipuncture, heel prick, cannulation, intramuscular
injections, subcutaneous injection, lumbar puncture etc.
Sucrose is only effective when given orally, directly onto the infant's tongue.
There is no analgesic effect if sucrose is given directly into the stomach via a nasogastric
tube.
Breast feeding is more efficacious than sucrose.
The efficacy and safety of repeated doses/maximum doses is not known.
Contraindications
Necrotising enterocolitis.
Suspected hyperglycaemia.
Do not use in ventilated or paralysed babies.
Dose
Must be documented on their drug chart or notes.
Ideally, obtain consent from the parent to use.
The dose is administered onto the baby’s tongue approximately 2 minutes prior to the
procedure. After administration the baby should be given a dummy or comforter to suck on
as this can potentiate the analgesic effect of sucrose. The effect may last for approximately
10 minutes.
Preterm neonates 3kgs 1-2ml of 24% sucrose 6-8 times a day
solution
There is no data regarding repeated doses or long term effects of using sucrose.
Holsti, L. and Grunau, R.E. (2010) Considerations for using sucrose to reduce procedural pain in preterm infants,
Pediatrics, 125(5) pp 1042-1047.
Stevens B, Yamada J, Ohlsson A, Haliburton S, Shorkey A. Sucrose for analgesia in newborn infants undergoing
painful procedures. Cochrane Database of Systematic Reviews 2016, Issue 7. Art. No.: CD001069. DOI:
10.1002/14651858.CD001069.pub5.
Paediatric Analgesia Guidelines and Anticipatory Prescribing Guidance V6.0
Page 7 of 292.3.4. Intranasal Diamorphine (Ayendi)
Indications
First line treatment of severe pain in a child without IV access e.g.
Clinically suspected limb fractures
Painful dressings/burns
Procedural pain
Intranasal Diamorphine is usually effective within 5-10 minutes but allow 20 minutes
for maximum pain control. Analgesic effect lasts for up to 4 hours.
Oxygen saturation monitoring will be required once Diamorphine has been
administered and for 1 hour post administration.
Ensure that intravenous access is obtained as soon as possible.
Ensure that supplementary analgesia is prescribed (see coloured paediatric
analgesia dosing guideline) e.g. Paracetamol and NSAIDs.
Naloxone must be prescribed (see coloured paediatric analgesia dosing guideline).
*Child less than 12kg weight (unlicensed) only to be administered by a senior doctor
(ST3 and above).
Contraindications
Nasal trauma or epistaxis.
Decreased conscious level or head injury
Allergy to opiates.
Dose schedule
Dosing is based on weight and should be prescribed as a STAT dose.
Preparation and administration-
Reconstitute, if required and date the bottle. Attach pump and nasal tip, remove
green collar and prime with 8 sprays.
Subsequent doses- Remove the green safety collar. Attached new nasal tip and
before use prime using 2 sprays.
Administer the required number of sprays (alternate nostrils).
Discard the used nasal tip and replace the green safety collar.
CD register- Record both the wastage from priming and the number of sprays in the
register.
NB AFTER RECONSTITUTION THE BOTTLE MUST BE DISPOSED OF AFTER 14 DAYS.
WEIGHT OF CHILD APPROX AGE TOTAL NUMBER TOTAL DOSE
OF SPRAYS DELIVERED
720micrograms/spray 10-30kg
*10-11.9kg 1-2.3.5. Intranasal Diamorphine10mg (Only to be used if Ayendi is unavailable)
Indications
Second line treatment of severe pain in a child without IV access e.g.
Clinically suspected limb fractures
Painful dressings/burns
Procedural pain
Intranasal Diamorphine is usually effective within 5-10 minutes but allow 20 minutes
for maximum pain control. Analgesic effect last for up to 4 hours.
Oxygen saturation monitoring will be required once Diamorphine has been
administered and for 1 hour post administration.
Ensure that IV access is obtained as soon as possible.
Ensure that supplementary analgesia is prescribed (see coloured paediatric
analgesia dosing guideline) e.g. Paracetamol and NSAIDs.
Naloxone must be prescribed (see coloured paediatric analgesia dosing guideline).
Contraindications
Child less than 10kg weight (only to be administered by a senior doctor, ST3 and
above).
Nasal trauma or epistaxis.
Decreased conscious level or head injury
Allergy to opiates.
Dose schedule
Dosing is based on weight and should be prescribed as a STAT dose.
Obtain the weight of the child in kg = Column A. If between weights give lower dose.
Add appropriate volume of saline in ml = Column B, to a 10mg vial of Diamorphine.
Draw up 0.2mls and administer 0.1ml in each nostril. Discard the rest of the vial.
A B C
Weight (kg) Volume saline (ml) Amount (mg) per 0.2ml
10 2ml 1mg
15 1.3ml 1.5mg
20 1ml 2mg
25 0.8ml 2.5mg
30 0.7ml 3mg
35 0.6ml 3.5mg
40 0.5ml 4mg
50 0.4ml 5mg
ALL CHILDREN RECEIVE 0.2ML OF THE MIXTURE.
THE SMALLER THE CHILD, THE GREATER THE AMOUNT OF DILUENT USED
Paediatric Analgesia Guidelines and Anticipatory Prescribing Guidance V6.0
Page 9 of 292.3.6. Intranasal Fentanyl ONLY TO BE USED IF DIAMORPHINE IS UNAVAILABLE
Indications
Third line treatment of severe pain in a child without IV access e.g.
Clinically suspected limb fractures
Painful dressings/burns
Procedural pain
Fentanyl is short acting (up to 60 minutes duration)
Oxygen saturation monitoring will be required once fentanyl has been administered
and for 1 hour post administration.
Ensure that IV access is obtained as soon as possible.
Ensure that supplementary analgesia is prescribed (see coloured paediatric analgesia
dosing guideline) e.g. Paracetamol, NSAID.
Naloxone must be prescribed (see coloured paediatric analgesia dosing guideline).
*Child less than 12kg weight only to be administered by a senior doctor (ST3 and
above).
Contraindications
Nasal trauma or epistaxis.
Decreased conscious level or head injury.
Allergy to opiates.
1mL into both
nostrils
5. Hold atomiser in place for a further 5 seconds to prevent medication dribbling
out of the nostril
6. Monitor patient for excessive sedation and/or respiratory depression
One repeat dose may be given after 10 minutes
WEIGHT OF CHILD DOSE VOLUME of Fentanyl 50mcg/mL to be
kg (mcg) given (mL)
*10-11 15 0.3 mL
12-13 18 0.35mL
14-15 20 0.4mL
16-17 25 0.5mL
18-19 27.5 0.55mL
20-24 30 0.6mL
26-29 37.5 0.75mL
30-34 45 0.9mL
35-39 52.5 1.05mL
40-44 60 1.2mL
45-49 67.5 1.35mL
50-54 75 1.5mL
55-59 82.5 1.65mL
≥60 90 1.8mL
Paediatric Analgesia Guidelines and Anticipatory Prescribing Guidance V6.0
Page 10 of 292.3.7. IV Morphine Infusion
IV Morphine infusion
Any patient requiring a morphine infusion with complex medical or surgical needs
requires paediatric HDU.
Early discussion with Paediatric Consultant on call required before commencing case.
Young infants require reduced doses.
Prematurely-born neonates and infants must be discussed with a consultant
anaesthetist.
The current pump to use is a PCAM pump with the handset removed. It
should be programmed with the background as ml/hr with no bolus.
Ensure adequate loading dose of 100 micrograms/Kg.
A continuous infusion will provide a relatively steady state.
Rate can be adjusted to pain score.
Must have naloxone prescribed (see coloured paediatric analgesia dosing guideline).
Please complete yellow paediatric pain audit form to ensure follow-up.
TO MAKE INFUSION
Dose: 1mg/kg morphine made up to 50ml with normal saline.
Maximum dose is 50mg of morphine in 50mls of saline
Example For a 20kg child, use 20mg morphine and dilute to 50ml with normal
saline. 20mg divided by 50ml = 0.4 mg/ml (or 400 micrograms/ml).
Results in 1ml/hr = 400 micrograms/hr or 20 micrograms/kg/hr.
Infusion 0-1 months: maximum of 5 micrograms/kg//hour = max 0.25mL/hour
regimes 1-3 months: maximum of 10 micrograms/kg/hour = max 0.5mL/hour
Over 3 months: maximum of 40 micrograms/kg/hour = max 2mL/hour
Maximum infusion rate should be 2ml/hr, which is equal to 40
micrograms/kg/hr.
ALARIS PCAM pump setup
Pumps are kept in recovery, need drug keys to unlock. Keys for PCA machines
are kept together with the controlled drug keys by the nurse in charge.
Select protocol C; Paediatric Morphine protocol.
The default is set to 200 micrograms/ml, this needs adjusting depending on weight:
o The milligrams/ml concentration; child’s weight divided by 50, then convert to
micrograms.
o Go to modify protocol, scroll to Drug Concentration and alter.
o To set rate, scroll down to continuous and alter the rate in ml
Paediatric Analgesia Guidelines and Anticipatory Prescribing Guidance V6.0
Page 11 of 292.3.8. Morphine Patient Controlled Analgesia (PCA)
Indications for use
For use in 4 years and above, usually have the ability to understand and push the
button.
Need adequate loading dose to gain child’s confidence in PCA
Loading dose: 100 micrograms/kg. This can be repeated if required.
May need a background infusion for the first 24hrs of 6 micrograms/kg/hour
(0.3ml/hr).
Must prescribe naloxone (see coloured paediatric analgesia dosing guideline).
Bolus: press bolus button, then code, then enter amount.
Please complete yellow paediatric pain audit form to ensure follow-up.
Drawing up a Morphine PCA
Dose: 1mg/kg morphine made up to 50ml with normal saline.
Gives a final concentration of 20 micrograms/kg/ml.
Maximum dose is 50mg of morphine in 50mls of saline
Example 20kg child = 20mg of morphine in 50ml.
Gives 0.4mg per ml,= which is 400 micrograms/ml
BACKGROUND (IF 6 micrograms/kg/hour (0.3ml/hr).
USED)
BOLUS 1ml over 1minute, 20 micrograms/kg.
LOCKOUT 5 minutes.
ALARIS PCAM pump setup
Pumps are kept in recovery, keys for PCA machines are kept together with the
controlled drug keys by the nurse in charge.
Select protocol C; Paediatric Morphine protocol.
The default is set to 200 micrograms/ml, this need to be adjusted depending on
weight:
o The milligrams/ml concentration; child’s weight divided by 50, then convert to
micrograms.
o Go to modify protocol, scroll to Drug Concentration and alter.
o To set rate, scroll down to continuous and alter the rate in ml.
Paediatric Analgesia Guidelines and Anticipatory Prescribing Guidance V6.0
Page 12 of 292.3.9. Morphine Nurse Controlled Analgesia (NCA)
Indications for use
For children under 6 years or those incapable of using a PCA.
Use with constant background, and allows bolus for breakthrough and procedures.
Use on paediatric HDU only. Early discussion with Paediatric Consultant on call
required before commencing case.
Avoids delay with increasing background alone.
Must prescribe naloxone (see coloured paediatric analgesia dosing guideline).
Please complete yellow paediatric pain audit form to ensure follow-up.
Drawing up a Morphine NCA
Dose: 1mg/kg Morphine made up to 50ml with normal saline, example as
above for morphine.
Maximum dose is 50mg of morphine in 50mls of saline
BACKGROUND 10-20micrograms/kg/hr = 0.5-1ml/hr.
BOLUS 10-20 micrograms/kg = 0.5-1ml per bolus.
LOCKOUT 20- 30 minutes.
ALARIS PCAM pump setup
Pumps are kept in recovery, need drug keys to unlock. Keys for NCA/PCA
machines are kept together with the controlled drug keys by the nurse in charge.
Select protocol C; Paediatric Morphine protocol.
The default is set to 200 micrograms/ml; this will need adjusting, depending on weight:
o The milligrams/ml concentration; child’s weight divided by 50, then convert to
micrograms.
o Go to modify protocol, scroll to Drug Concentration and alter.
o To set rate, scroll down to continuous and alter the rate in ml.
Paediatric Analgesia Guidelines and Anticipatory Prescribing Guidance V6.0
Page 13 of 292.3.10. Fentanyl Infusion and PCA
FENTANYL PCA TO BE PRESCRIBED BY SENIOR CLINICIAN ONLY (ST3
and above)
Indicated for morphine intolerance; nausea and vomiting; poor renal function
Paediatric protocol up to 40 kg. Above 40kg use adult protocol included below
th
If patient BMI>30 calculate an ideal body weight using patient height-50 centile weight
chart (see page 20 or BNFc back page)
FENTANYL INFUSIONALARIS PCAM pump setup
Pumps are kept in recovery, need drug keys to unlock. Keys for NCA/PCA machines are
kept together with the controlled drug keys by the nurse in charge.
Select protocol E; Paediatric Fentanyl protocol.
The default is set to 10 micrograms/ml; this will need adjusting, depending on weight:
o The micrograms/ml concentration is1 microgram/kg/ml.
o Go to modify protocol, scroll to Drug Concentration and alter.
o To set rate, scroll down to continuous and alter the rate in mls
FENTANYL PCA >40KGS
(renal impairment or those with significant side effects to morphine)
500micrograms Fentanyl (=10mls neat fentanyl) made up to 50mls with Normal saline
There is no per kilogram calculation
Dose: 10micrograms/ml
BOLUS 1ml
LOCKOUT 5 minutes
4 HOURLY 50mls (500micrograms) in 4 hours
MAXIMUM DOSE
ALARIS PCAM pump setup
Pumps are kept in recovery, need drug keys to unlock. Keys for NCA/PCA machines are
kept together with the controlled drug keys by the nurse in charge.
Select protocol B; Fentanyl protocol.
Paediatric Analgesia Guidelines and Anticipatory Prescribing Guidance V6.0
Page 15 of 292.3.11. Paediatric Recovery
Use of IV Fentanyl post operatively in children < 50kgs
Indication for use
Acute post-operative pain score >5.
Rapid relief of moderate to severe pain relief.
Provides immediate pain relief, lasts approx. 20 minutes.
Ensure oxygen available. Monitor for respiratory depression, sedation and itch
If patient BMI>30 calculate an ideal body weight using patient height-50th centile weight
chart (see page 19 or BNFc back page).
Dose
0.25micrograms/kg per dose
Dose can be repeated every 15minutes up to a maximum 4 doses (1microgram/kg in 1
hour)
Practice points
Ensure supplementary analgesics (Paracetamol, NSAIDs) are prescribed regularly on
prescription chart.
If prolonged post-op pain likely, in addition consider morphine administration in recovery
and ensure IV and oral preparations prescribed on ward chart.
Must have naloxone prescribed (see coloured paediatric analgesia dosing guideline).
Must have anti-emetics prescribed (see coloured paediatric analgesia dosing guideline).
Paediatric Analgesia Guidelines and Anticipatory Prescribing Guidance V6.0
Page 16 of 292.3.12. Epidurals
Indications for use
Children require larger volume with lower concentrations of opiate to block dermatomes.
Bolus loading dose in theatre should be 0.5-1.0ml/kg of 0.25% Levobupivicaine.
Continuous infusion rates of around 0.4mg/kg/hr are effective for children > 3 months.
Maximal dose of Levobupivicaine in children is 2.5mg/kg.
Must have naloxone prescribed (see coloured analgesia dosing guideline).
All patients should have a urethral catheter.
Must have working cannula in-situ at all times.
Please complete a yellow paediatric acute pain audit form to ensure follow-up.
Infusion
Strength 0.125% Levobupivicaine + 2mcg/ml Fentanyl
Rate 0.2-0.4ml/kg/hr
Example For a 10kg child the rate would be 2-4ml/hr
2-4ml/hr = 2.5mg – 5mg of Levobupivicaine/hr
= 4-8 micrograms of Fentanyl/hr
Always check the dosing is appropriate for the child in front of
you.
McKinley Pump Setup
Keys for epidural machines are kept together with the controlled drug keys by the nurse in
charge.
After switching on enter code
First prime the line through the pump.
Then select protocol depending on strength of epidural mix.
Paediatric Analgesia Guidelines and Anticipatory Prescribing Guidance V6.0
Page 17 of 29Trouble Shooting for Epidurals
PROBLEM ACTION
Infusion rate too low On-call should give a bolus dose of epidural mixture and
increase rate.
Bolus dose is 0.25ml/kg of 0.25% Levobupivicaine, e.g. 0.25
x 20kg = 5mls of 0.25%.
A bolus of epidural mix can also be given, 0.25mls/kg. Press
and hold bolus, enter code, then amount, MAX 10ml.
Catheter not in epidural Check catheter site for leakage.
space, or kinked Consider removing and replacing with PCA.
Regular review of site.
Child may have full bladder Consider catheterisation.
Patchy Block Consider top-up in correcting position.
Remove and replace with PCA.
Witnessed catheter Clean the end of the catheter with 2% Chlorhexidine, allow
disconnection from filter. drying and holding the catheter with a sterile swab, cut the
catheter with a sterile scissors approximately 2 – 3 cm and
insert into the filter.
Un-witnessed catheter Epidural will require removal. If in doubt contact the Acute
disconnection from filter. Pain Team or 1st Call Anaesthetist
Side effects
SIDE EFFECTS TREATMENT
Ventilatory Depression Oxygen.
Naloxone
Should be prescribed for all patients receiving IV or
neuraxial opioids (opioid delivered into the brain and
spinal cord).
< 12 years- Naloxone 10micrograms/kg IV bolus
and repeat if necessary. If no response, give
subsequent doses of 100 micrograms/kg (max 2mg)
>12 years- Naloxone 100micrograms IV bolus and
repeat if necessary. If no response, give
subsequent doses in increments of 100micrograms
every 2 minutes if required (max dose 10mg).
Consider infusion 5-20 micrograms/kg/hr and
contact Consultant
Pruritus/ Urinary retention Naloxone
1 microgram/kg (NB small dose, care in drawing up)
Local anaesthetic toxicity. STOP infusion, contact Senior Anaesthetic Trainee bleep
Signs and symptoms: 3513 as an emergency.
Dizziness, blurred vision, Local anaesthetic rescue boxes are located in:
decreased hearing, tingling in General and trauma recovery.
mouth and lips, restlessness, Eden Ward
tremor, hypotension, bradycardia, ITU
arrhythmias, seizures, sudden loss
of consciousness.
Leg weakness/ motor block Stop infusion, monitor sensory and motor block every 15
minutes, contact on call anaesthetist or pain team, the
DENSE MOTOR BLOCK IS concern is epidural haematoma.
ABNORMAL! See flow chart on next page.
Paediatric Analgesia Guidelines and Anticipatory Prescribing Guidance V6.0
Page 18 of 292.3.13. Management of Leg Weakness with Epidurals
Contact the
Increasing leg weakness? Paediatric Pain
Motor block score 3 or 4 Team or Senior
Anaesthetic Trainee
bleep 3513 to inform
Yes
them of the situation
Routine
observations
Switch epidural
infusion off
Yes
SCORE 4
Unable to move
Recommence legs
epidural Reassess leg SCORE 3
infusion Unable to lift
strength every
heels, moves
30 minutes toes.
Yes SCORE 2
Able to flex hips,
knees and free
movement of
Patient Leg strength feet.
Yes
comfortable? improving?
SCORE 1
Free movement
of hips, knees
and feet
No
No
Motor Function assessment
(Modified Bromage scale)
Contact Paediatric More than 4 hours
Pain Team or on call since stopping
anaesthetist to assess epidural infusion?
patients analgesia
Yes
Suspect an epidural haematoma?
Contact Paediatric Pain Team 2283 or Senior
Anaesthetic Trainee bleep 3513
An epidural haematoma has to be evacuated
within 8 hours of the onset of symptoms for
your patient to have the best chance of
recovery of neurological function. DO NOT
DELAY.
Paediatric Analgesia Guidelines and Anticipatory Prescribing Guidance V6.0
Page 19 of 292.3.14. Mean Values for weight, height and gender by age
The table below shows the mean values for weight, height and gender by age; these
values have been derived from the UK-WHO growth charts 2009 and UK1990 standard
centile charts, by extrapolating the 50th centile, and may be used to calculate doses in
the absence of actual measurements.
However, the child’s actual weight and height might vary considerably from the values
in the table and it is important to see the child to ensure that the value chosen is
appropriate. In most cases the child’s actual measurement should be obtained as soon
as possible and the dose re-calculated.
For children at extremes of weight please refer to RCHT guidance which can be found
on all Paediatric ward area.
Age Weight Height
kg cm
Full term neonate 3.5 51
1 month 4.3 55
2 months 5.4 58
3 months 6.1 61
4 months 6.7 63
6 months 7.6 67
1 year 9 75
3 years 14 96
5 years 18 109
7 years 23 122
10 years 32 138
12 years 39 149
14 year-old boy 49 163
14 year-old girl 50 159
Adult male 68 176
Adult female 58 164
BNF for Children 2019-2020
Paediatric Analgesia Guidelines and Anticipatory Prescribing Guidance V6.0
Page 20 of 293. Monitoring compliance and effectiveness
Element to be Adherence to the published RCHT guidelines
monitored
Lead Dr. Julian Berry
Acute Paediatric Pain Service
Tool Regular audit of the acute paediatric pain service is undertaken by
the lead clinician along with weekly review of complicated cases,
using a WORD or Excel template
Frequency See above
Reporting The committee reviewing the audit will be the anaesthesia
arrangements directorate. Cases will be discussed at audit meetings and the
details will be recorded in the minutes.
Acting on As above
recommendations The audits/recommendations will also be shared with Child Health
and Lead(s) through the children’s business and audit group.
Change in Required changes to practice will be identified and actioned within a
practice and month. A lead member of the team will be identified to take each
lessons to be change forward where appropriate. Lessons will be shared with all
shared the relevant stakeholders
4. Equality and Diversity
4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service
Equality and Diversity statement which can be found in the 'Equality, Inclusion &
Human Rights Policy' or the Equality and Diversity website.
4.2. Equality Impact Assessment
The Initial Equality Impact Assessment Screening Form is at Appendix 2.
Paediatric Analgesia Guidelines and Anticipatory Prescribing Guidance V6.0
Page 21 of 29Appendix 1. Governance Information
Paediatric Analgesia Guidelines and Anticipatory
Document Title
Prescribing Guidance V6.0
This document replaces (exact title of
Paediatric Analgesia Guidelines 5.2
previous version):
Date Issued/Approved: September 2020
Date Valid From: October 2020
Date Valid To: October 2023
Directorate / Department responsible Dr Julian Berry
(author/owner): Consultant Anaesthetist
Contact details: 01872 252648
The guidance is to inform all staff of the appropriate
Brief summary of contents
analgesia regimes for paediatric patients.
Paediatric analgesia, Children’s analgesia PCA,
Suggested Keywords: NCA, Epidural, palliative, anticipatory
prescribing, symptom control.
RCHT CFT KCCG
Target Audience
Executive Director responsible for Policy: Medical Director
Medical Practice Committee
Approval route for consultation and
Anaesthetic Governance Leads
ratification:
Child Health audit and guidelines Group
General Manager confirming approval
Mary Baulch
processes
Name of Governance Lead confirming
approval by specialty and care group Caroline Amukusana
management meetings
The Association of Paediatric Anaesthetists of
Links to key external standards
Great Britain and Ireland
Related Documents: References included within the document
Training Need Identified? No, for reference purposes only
Publication Location (refer to Policy on
Internet & Intranet Intranet Only
Policies – Approvals and Ratification):
Clinical/ Paediatrics
Document Library Folder/Sub Folder
Clinical/ Anaesthetics
Paediatric Analgesia Guidelines and Anticipatory Prescribing Guidance V6.0
Page 22 of 29Version Control Table
Version Changes Made by
Date Summary of Changes (Name and Job
No
Title)
Dr Julian Berry
July 11 V1.0 Initial Issue
Lead For APPS
Dr Julian Berry
Dec 11 V2.0 Additional guidance introduced
Lead for APPS
Change of format Dr Julian Berry
Sept 12 V3.0
Update of guidance Lead for APPS
Dr Julian Berry
Sept 13 V3.1 Change in practice regarding Codeine
Lead for APPS
Dr Julian Berry
Jan 15 V4.0 Update of guidance
Lead for APPS
Update of guidance including change of
Diamorphine formulation. Dr Julian Berry
June 17 V5.0
Removal of Diclofenac from coloured analgesia Lead for APPS
chart.
Dr Julian Berry
July 17 V5.1 Change to intranasal Diamorphine priming
Lead for APPS
Appendix3 - Guidance for anticipatory
Dr Julian Berry
Sept 2017 V5.2 prescribing and symptom control in paediatric
Sabrina Tierney
patients
Full Update
Dr Julian Berry
August Oral Morphine doses updated
V6.0 Sabrina Tierney
2020 Intranasal Fentanyl and Diamorphine 10mg
Sarah Fox
guidance added.
Modified Bromage score added to managing
leg weakness
All or part of this document can with epidurals.under the Freedom of Information Act
be released
2000
This document is to be retained for 10 years from the date of expiry.
This document is only valid on the day of printing
Controlled Document
This document has been created following the Royal Cornwall Hospitals NHS Trust Policy
for the Development and Management of Knowledge, Procedural and Web Documents (The
Policy on Policies). It should not be altered in any way without the express permission of the
author or their Line Manager.
Paediatric Analgesia Guidelines and Anticipatory Prescribing Guidance V6.0
Page 23 of 29Appendix 2. Equality Impact Assessment
Section 1: Equality Impact Assessment Form
Name of the strategy / policy /proposal / service function to be assessed
Paediatric Analgesia Guidelines and Anticipatory Prescribing Guidance V6.0
Directorate and service area: Is this a new or existing Policy?
Child Health Existing
Name of individual/group completing EIA Contact details:
Child Health Audit and Guidelines Group 01872 252648
1. Policy Aim
Who is the
strategy / policy / To inform staff of the appropriate analgesia for paediatric patients
proposal / service
function aimed at?
2. Policy Objectives To inform staff of the appropriate analgesia for paediatric patients
3. Policy Intended
Outcomes
Improve post-operative analgesia for all children
Standardise care for children
4. How will
you measure Monitor through audit, incident reporting and case discussions at
the outcome? governance meetings
5. Who is intended
to benefit from the All children who attend RCHT
policy?
6a). Who did you Local External
Workforce Patients Other
consult with? groups organisations
x
Please record specific names of groups:
b). Please list any Medicines Practice Committee
groups who have Anaesthetic Governance
been consulted Child Health Audit and Guidelines
about this procedure.
c). What was the
outcome of the
consultation?
Approved at Child Health Audit and Guidelines group on 17th
September 2020
Paediatric Analgesia Guidelines and Anticipatory Prescribing Guidance V6.0
Page 24 of 297. The Impact
Please complete the following table. If you are unsure/don’t know if there is a negative impact
you need to repeat the consultation step.
Are there concerns that the policy could have a positive/negative impact on:
Protected
Yes No Unsure Rationale for Assessment / Existing Evidence
Characteristic
Age
X
Sex (male, female
non-binary, asexual X
etc.)
Gender
reassignment X
Race/ethnic Any information provided should be in an
communities accessible format for the parent/carer/patient’s
/groups X
needs – i.e. available in different languages if
required/access to an interpreter if required
Disability
(learning disability, Those parent/carer/patients with any identified
physical disability, additional needs will be referred for additional
sensory impairment, support as appropriate - i.e. to the Liaison team
X
mental health or for specialised equipment.
problems and some Written information will be provided in a format to
long term health meet the family’s needs e.g. easy read, audio etc.
conditions)
Religion/
other beliefs X
Marriage and civil
partnership X
Pregnancy and
maternity X
Sexual orientation
(bisexual, gay, X
heterosexual, lesbian)
If all characteristics are ticked ‘no’, and this is not a major working or service
change, you can end the assessment here as long as you have a robust rationale
in place.
I am confident that section 2 of this EIA does not need completing as there are no highlighted
risks of negative impact occurring because of this policy.
Name of person confirming result of initial
Child Health Audit and Guidelines group
impact assessment:
If you have ticked ‘yes’ to any characteristic above OR this is a major working or
service change, you will need to complete section 2 of the EIA form available here:
Section 2. Full Equality Analysis
For guidance please refer to the Equality Impact Assessments Policy (available
from the document library) or contact the Human Rights, Equality and Inclusion
Lead debby.lewis@nhs.net
Paediatric Analgesia Guidelines and Anticipatory Prescribing Guidance V6.0
Page 25 of 29Appendix 3. Guidance for Anticipatory Prescribing and Symptom Control in Paediatric Patients
GUIDANCE FOR ANTICIPATORY PRESCRIBING AND SYMPTOM CONTROL IN PAEDIATRIC PATIENTS
1 MONTH – 16 YEARS (IF > 16 SEE ADULT GUIDELINE)
For s/c doses subsequent pages
Symptom Drug Form Route Starting Dose Maximum TOTAL
dose over 24
hours
Pain Immediate release (Oral) 12 months- 100-300micrograms/kg 4 hourly
on alternative Morphine >12 years AND >50kg: 2.5 – 10mg 4 hourly (if < 50kg does as per 1-12 yrs)
opioids see Injection (IV) 6 months– 12 years: 100micrograms/kg 4 hourly (max 2.5mg initial dose) No upper limit
conversion > 12 years AND > 50kg: 2.5-5mg 4 hourly
chart for Regular Modified release caps Dose calculated based on 24-hour opioid requirements No upper limit
appropriate (Zomorph)/susp (MST)
dosing
If renal Buprenorphine Regular Patch Initial dose based on 24-hour opioid requirement – see conversion chart No upper limit
impairment NOTE: Only NOT TO BE USED FOR UNSTABLE PAIN
seek specialist partially reversed by
advice naloxone
Intranasal spray 6 months– 2 years: 1microgram/kg/dose Max
Prescribe PRN/Breakthrough (see intranasal fentanyl section in > 2 years: 1-2micrograms/kg/dose 50micrograms/
naloxone prn main analgesia guideline for No more than 2 doses per pain episode. If more than 4 episodes of breakthrough dose initially
in case of administration information) pain/24 hours, increase background analgesia
opiate toxicity For older children dosing may allow
Fentanyl
for use of Pecfent or Instanyl
devices
Lozenges >2 years AND > 10kg: 15micrograms/kg/dose Max
Dose to be given over 15mins and can be repeated. As above for frequency. 400micrograms/do
se
Regular Patch Initial dose based on 24-hour opioid requirement – see conversion chart No upper limit
NOTE:Matrifen brand can be cut NOT TO BE USED FOR UNSTABLE PAIN
Oral Child 1 month–11 years: Initial dose 200 micrograms/kg (maximum single dose 5 No upper limit
Standard release mg) every 4 -6 hours. Titrate to pain
PRN/Breakthrough Child 12-17 years: Initial dose 5 mg every 4-6 hours.
Oxycodone Injection (IV) 1- 12 months: 30-75micrograms/kg 4 hourly No upper limit
1- 12 years: 75-100 micrograms/kg (max 2.5mg initial dose) 4 hourly
12- 18 years: 2.5 mg 4 hourly
Regular Oral 0- 7 years: No dosing available No upper limit
Modified Release 8- 12 years: 5mg 12 hourly
12- 18 years: 10mg 12 hourly
PRN/Breakthrough Intranasal See separate dosing schedule in paediatric analgesia policy
Diamorphine
Dose may be repeated 4 hourly.
Hyoscine Oral/IM/IV 1 months- 4 years: 300-500micrograms/kg (max 5mg) 6 hourly
Butylbromide (for (NOTE: Injection may be given 5- 12 years: 5-10mg 6 hourly
Regular
gut spasm) orally) 12- 18 years: 10-20mg 6 hourly
“BUSCOPAN”
Paediatric Analgesia Guidelines and Anticipatory Prescribing Guidance V6.0
Page 26 of 29GUIDANCE FOR ANTICIPATORY PRESCRIBING AND SYMPTOM CONTROL IN PAEDIATRIC PATIENTS
1 MONTH – 16 YEARS (IF > 16 SEE ADULT GUIDELINE)
Symptom Drug Route Starting Dose Maximum TOTAL dose over 24
hours
Anxiety S/L (use standard tablets) 25micrograms/kg single dose May be increased to
(Not to be used in gastric stasis – use midazolam) 50micrograms/kg/dose, Max
1mg/dose
DO NOT Oral < 2 years: 25micrograms/kg 8 hourly
PRESCRIBE MORE Lorazepam
2-5 years: 500micrograms 8 hourly
THAN ONE DRUG 6-10 years: 750micrograms 8 hourly
FROM THIS > 11 years: 1mg 8 hourly
SECTION
Injection (IV infusion) < 3 months 0.5-1mg over 24 hours Increase by 25-50% as needed
* (Consider SC infusion if required) 3-11 months 0.5-2mg over 24 hours Max 50mg/24hours
Midazolam 1-5 years 1-2.5mg over 24 hours
These doses are not Doses to be given over 24 hours 6-10 years 2.5-5mg over 24 hours
suitable for seizure > 11years 5-10mg over 24 hours
control- Please check Buccal (May also be given intranasal) 6 years 100 micrograms/kg stat patients
prescribing see BNFC for dosing. Stock held on CLIC May be repeated after 10 mins if required
Nausea/Vomiting Ondansetron Injection (IV) 0.1mg/kg 8 hourly 4mg/dose
(5-HT3 antagonist) In exceptional circumstances 8mg
CONTRAINDICATED in may be used (by infusion)
children at risk of Oral (as tablets, orodispersible tablets or liquid) < 10kg: 2mg 12 hourly Oral max doses – as described
prolonged QTc < 40kg: 4mg 12 hourly
> 40kg: 4 - 8mg 12 hourly
Cyclizine Injection (IV) or Oral 6 months– 5 years: 1mg/kg 8 hourly (max 25mg/dose) Max 75mg/day if under 12 years
(Antihistamine/ 6– 11 years: 25mg 8 hourly Max 150mg/day if > 12 years
Antimuscarinic) > 12 years: 50mg 8 hourly
(Not with metoclopramide)
Metoclopramide† Injection (IV, IM) or Oral (tablets, liquid) < 1 year or 1 year 100-150micrograms/kg 8 hourly (max 10mg/dose) 500micrograms/kg/day up to
neurological toxicity antagonist) max 5 days tx except in palliative care 30mg/day
stop treatment and (Not with Cyclizine)
consider using
Levomepromazine† Injection (IV infusion) 1 month - 12 years: 100micrograms/kg over 24 hours 400micrograms/kg/24 hours or
procyclidine. See
(Antipsychotic) > 12 years: 5mg over 24 hours 25mg/24 hours
BNFC for dosing. (may also be used for
Stock kept on CLIC anxiety & agitation) Oral (tablets) 2 -12 years: 50-100 micrograms/kg od-bd Max 25mg/dose
Injection may also be given orally >12 years: 3.125mg od-bd Max 1mg/dose if ≤10kg
Hyoscine Hydrobromide Injection (IV) (for excessive secretions) 10 micrograms/kg every 4 hours 600 micrograms per dose IV
(Antimuscarinic) Max 2.4mg/24hours
(may also be used for Patch 1 month–2 years: 250micrograms every 72hrs
excessive respiratory (Can take up to 12 hours to take effect) 3–9 years 500micrograms every 72 hours
secretions) 10–17 years 1 mg every 72 hours
Paediatric Analgesia Guidelines and Anticipatory Prescribing Guidance V6.0
Page 27 of 29GUIDANCE FOR ANTICIPATORY PRESCRIBING AND SYMPTOM CONTROL IN PAEDIATRIC PATIENTS
1 MONTH – 16 YEARS (IF > 16 SEE ADULT GUIDELINE)
OPIOID DOSE CONVERSION
This chart should be used as a guide only – dose conversions are not exact as individual patients metabolise different drugs at varying rates
Patches can take 12-24 hours to take effect. When transferring from 12 hourly MR morphine give last dose as you are applying the patch. For immediate release morphine continue given 4
hourly doses for the first 12 hours after applying the patch.
Overlap may also be required when starting a syringe driver – if patient stable it is recommended to start the syringe driver 1-2 hours before current medication is due to wear off
Oral Subcutaneous Subcutaneous Fentanyl Subcutaneous
Morphine Morphine Diamorphine Transdermal Oxycodone
Total dose (over 24 24 hr total dose (mg) 24 hr total dose (mg) Patch strength 24 hr total dose (mg)
hours) (micrograms/hr)
15 7.5 5 - 4
30 15 10 12 7.5
60 30 20 25 15
90 45 30 25 25
120 60 40 37 30
180 90 60 50 45
240 120 80 75 60
300 150 100 75 75
360 180 120 100 90
420 210 140 125 100
480 240 160 125 120
540 270 180 150 135
600 300 200 150 150
Total Morphine requirement over 24 hours Approximate equivalent buprenorphine patch
12mg Butrans “5” 7 day patch
24mg Butrans “10” 7 day patch
48mg Butrans “20” 7 day patch
84mg Transtec “35” 7 day patch
126mg Transtec “52.5” 4 day patch
168mg Transtec “70” 4 day patch
Paediatric Analgesia Guidelines and Anticipatory Prescribing Guidance V6.0
Page 28 of 29GUIDANCE FOR ANTICIPATORY PRESCRIBING AND SYMPTOM CONTROL IN PAEDIATRIC PATIENTS
SUBCUTANEOUS DOSES FOR SYRINGE DRIVERS AND BREAKTHROUGH 1 MONTH – 16 YEARS (IF > 16 SEE ADULT
GUIDELINE)
Check compatibilities and suitable diluents before combining medications. NB 10ml in a 10ml syringe, 17ml in a 20ml syringe, and 23ml in a 30ml syringe
Symptom Drug S/C PRN dose for break through symptoms Starting Dose range over 24 hours in Maximum TOTAL dose over 24 hours
syringe driver (s/c)
Pain Morphine 1/6th of 24hour subcutaneous opioid dose unless Initial dose based on 24-hour opioid No upper limit
opioid naïve (see below) requirement – see conversion chart If large doses required and volume is an
If renal impairment seek specialist If opioid naïve: issue consider switching to diamorphine
advice 1-5months: 100micrograms/kg 6 hourly If opioid naïve: (see conversion chart)
6 months-1 yr: 50-100micrograms/kg 4 hrly 1-2 months: 240 micrograms/kg/24hours
2-11 years: 100 micrograms/kg 4 hourly (max 3 months–17 years: 480
initial dose 2.5 mg). micrograms/kg/24hours (max initial dose 20
12-17 years: 2.5-5 mg 4 hourly (maximum initial mg/24 hours)
dose of 20 mg/24 hours)
Oxycodone 1/6th of 24hour subcutaneous opioid dose unless Initial dose based on 24-hour opioid No upper limit
opioid naïve (see below) requirement – see conversion chart
If opioid naïve:
1-12 months: 30– 75micrograms/kg/dose
1-12 years: 75-100micrograms/kg/dose
> 12 years: 2.5mg (Suggested initial max 2.5mg)
Anxiety Midazolam Use buccal (see previous) < 3months 0.5-1mg over 24 hours Increase by 25-50% as needed
Doses are not suitable for seizure control Do not exceed maximum daily dose 3-11 months 0.5-2mg over 24 hours Max 50mg/24hours
1-5 years 1-2.5mg over 24 hours
6-10 years 2.5-5mg over 24 hours
> 11years 5-10mg over 24 hours
Nausea/ Cyclizine N/A 1–23 months: 3 mg/kg over 24 hours 1–23 months: 3 mg/kg over 24 hours
Vomiting (in water for injection) Max dose in syringe driver (max 50mg/24 hours) (max 50mg/24 hours)
(Not with metoclopramide) 2–5 years: 50 mg over 24 hours 2–5 yrs: 50 mg over 24 hours
6–11 years: 75 mg over 24 hours 6–11 yrs: 75 mg over 24 hours
12–17 years: 150 mg over 24 hours 12–17 yrs: 150 mg over 24 hours
Metoclopramide N/A 1 -12 months or 10kg:
effects 300 – 450micrograms/kg/ 24 hrs
Levomepromazine N/A 1 months - 12 yrs:100micrograms/kg over 400micrograms/kg over 24 hours (Max
(may also be used for anxiety & agitation– 24 hours 25mg over 24 hours)
see BNFC) > 12 yrs:5mg over 24 hours
Hyoscine Hydrobromide N/A 40 micrograms/kg over 24 hours 60 micrograms/kg over 24 hours (up to
“SCOPOLAMINE” 2.4mg/24 hours)
May also be used for respiratory
secretions
Paediatric Analgesia Guidelines and Anticipatory Prescribing Guidance V6.0
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