Pediatric Opioid Pharmacotherapy
Core Principles
- Age-appropriate pain assessment essential
- Weight-based dosing with careful titration
- Regular monitoring for side effects and efficacy
- Clear documentation of pain scores and responses
- Exit strategy planning from initiation
Key Considerations
- Developmental differences in opioid metabolism
- Risk-benefit assessment for each patient
- Multimodal analgesia approach
- Family education and involvement
Natural Opioids
Morphine
Clinical Applications
- Severe acute pain
- Post-operative pain
- Cancer-related pain
- Procedural pain management
Dosing Guidelines
- Oral: 0.2-0.5 mg/kg/dose every 4-6 hours
- IV/SC: 0.05-0.1 mg/kg/dose every 2-4 hours
- Continuous infusion: 0.01-0.04 mg/kg/hour
- Maximum single dose: 15 mg
Monitoring Parameters
- Respiratory rate and depth
- Sedation level
- Pain scores
- Bowel function
Semi-Synthetic Opioids
Hydromorphone
Clinical Applications
- Severe pain management
- Alternative to morphine in renal impairment
- When morphine side effects are problematic
Dosing
- Oral: 0.03-0.08 mg/kg/dose every 4-6 hours
- IV/SC: 0.01-0.02 mg/kg/dose every 3-4 hours
- Maximum single dose: 2 mg
Oxycodone
Clinical Applications
- Moderate to severe pain
- Post-operative pain
- Better oral bioavailability than morphine
Dosing
- Oral: 0.1-0.2 mg/kg/dose every 4-6 hours
- Maximum single dose: 10 mg
- Available in immediate and controlled release forms
Synthetic Opioids
Fentanyl
Clinical Applications
- Acute severe pain
- Procedural sedation
- Critical care settings
Dosing
- IV/IM: 1-2 mcg/kg/dose
- Continuous infusion: 1-3 mcg/kg/hour
- Intranasal: 1.5-2 mcg/kg/dose
Methadone
Special Considerations
- Complex pharmacokinetics
- Long half-life
- QT interval monitoring required
- Multiple drug interactions
Clinical Uses
- Chronic pain
- Opioid weaning
- Neonatal abstinence syndrome
Opioid Substitutes
Tramadol
Characteristics
- Weak μ-opioid agonist
- Serotonin and norepinephrine effects
- CYP2D6 dependent metabolism
Dosing
- 1-2 mg/kg/dose every 4-6 hours
- Maximum: 400 mg/day
- Age restriction: ≥12 years in most cases
Tapentadol
Properties
- Dual mechanism: μ-opioid agonist and NRI
- Lower abuse potential
- Limited pediatric data
Pain Management Strategies
Assessment Tools
- FLACC Scale (0-5 years)
- Wong-Baker FACES (≥3 years)
- Numeric Rating Scale (≥8 years)
- Behavioral observation
Multimodal Approach
- Non-pharmacological interventions
- Regional anesthesia when appropriate
- NSAIDs/acetaminophen combination
- Adjuvant medications
Risk Management
- Identify risk factors for adverse events
- Monitor for respiratory depression
- Naloxone availability
- Parent/caregiver education
- Safe storage and disposal
Weaning Strategies
- 10-20% dose reduction every 24-48 hours
- Monitor for withdrawal symptoms
- Use of adjunct medications
- Clear communication with family
Further Reading
