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Pediatric palliative care: Medications used to treat common symptoms in children*

Pediatric palliative care: Medications used to treat common symptoms in children*
Symptoms Drug Oral dose and frequency Intravenous dose and frequency Other routes
Dyspnea Morphine 0.1 mg/kg every 3 to 4 hours as needed 0.05 mg/kg every 3 to 4 hours as needed 0.1 mg/kg sublingual (concentrated oral solution) every 3 to 4 hours as needed; 0.05 mg/kg subcutaneous every 3 to 4 hours as needed
Lorazepam 0.025 to 0.05 mg/kg every 6 hours as needed (maximum initial dose 2 mg) 0.025 to 0.05 mg/kg every 6 hours as needed (maximum initial dose 2 mg) 0.025 to 0.05 mg/kg subcutaneous every 6 hours as needed (maximum initial dose 2 mg)
Respiratory secretions ("death rattle") Glycopyrrolate 0.04 to 0.1 mg/kg every 4 to 8 hours (maximum initial dose 1 to 2 mg) 4 mcg/kg every 4 hours as needed (maximum initial dose 0.1 mg)  
Hyoscyamine Age <2 years – 0.03 mg/dose every 4 hours as needed   Age <2 years – 0.03 mg/dose sublingual every 4 hours as needed
Age 2 to 12 years – 0.06 to 0.125 mg/dose every 4 hours as needed Age 2 to 12 years – 0.06 to 0.125 mg/dose sublingual every 4 hours as needed
Age >12 years – 0.125 to 0.25 mg/dose every 4 hours as needed Age >12 years – 0.125 to 0.25 mg/dose sublingual every 6 hours as needed
Scopolamine hydrobromide Adolescents – 0.4 mg/dose every 8 hours as needed 6 mcg/kg every 8 hours as needed (maximum initial dose 0.3 mg) 6 mcg/kg subcutaneous every 8 hours as needed (maximum initial dose 0.3 mg)
Adolescents – 1.5 mg transdermal patch behind ear every 72 hours
Fatigue Methylphenidate (immediate release) Age ≥6 years – 0.05 to 0.1 mg/kg per dose given in the morning and at noon (maximum 2.5 mg per dose initially)    
Anorexia/weight loss Megestrol acetate Use only in children >10 years old    
Initial dose – 3.75 mg/kg twice a day (maximum initial dose 100 mg)
If no effect in 2 weeks – Increase to 5 mg/kg twice a day (maximum 200 mg per dose)
Dexamethasone 0.15 mg/kg per dose twice a day (maximum initial dose 8 mg) 0.15 mg/kg per dose twice a day (maximum initial dose 8 mg)  
Dronabinol Age ≥6 years – 2.5 mg/m2 per dose every 6 hours    
Cyproheptadine Age ≥8 years – 2 mg every 8 hours    
Constipation Polyethylene glycol 3350 0.7 gram/kg (up to 8.5 grams initially) once daily    
Increase to 1.5 gram/kg (maximum 17 grams) once daily as needed
Senna (syrup [8.8 mg sennosides per 5 mL strength syrup] or tablet [8.6 mg sennosides]) 6 months to 2 years – 2.2 mg (1.25 mL) to 4.4 mg (2.5 mL) at bedtime    
2 to 6 years – 4.4 mg (2.5 mL) to 6.6 mg (3.75 mL) at bedtime or one-half tablet at bedtime
6 to 12 years – 8.8 mg (5 mL) to 13.2 mg (7.5 mL) at bedtime or 1 tablet at bedtime
Lactulose (10 gram per 15 mL strength solution) 7.5 mL once daily as needed or 5 to 10 mL every 2 hours until bowel movement (maximum 60 mL per 24 hours)    
Bisacodyl 3 to 12 years – 0.3 mg/kg per 24 hours (10 mg maximum) once daily as needed (onset 6 hours)   6 months to 2 years – 5 mg per rectum once daily as needed
2 to 11 years – 5 to 10 mg per rectum once daily as needed
Glycerin     6 months to 6 years – 2 to 5 mL rectal solution or 1 infant suppository per rectum once daily as needed
>6 years – 5 to 15 mL rectal solution or 1 adult suppository per rectum once daily as needed
Docusate 6 months to 3 years – 10 mg once to twice daily    
3 to 6 years – 20 mg once to twice daily
6 to 12 years – 40 mg once to twice daily
Mineral oil enema (Fleet)     2 to 11 years – 30 to 60 mL per rectum once daily as needed
Nausea/vomiting MetoclopramideΔ 0.1 to 0.2 mg/kg per dose 3 times daily before meals as needed (maximum initial dose 10 mg) 0.1 to 0.2 mg/kg per dose 3 times daily before meals as needed (maximum initial dose 10 mg)  
Prochlorperazine >10 years – 0.1 mg/kg per dose every 8 hours as needed (maximum initial dose 5) >10 years – 0.1 to 0.15 mg/kg per dose every 8 hours as needed (maximum initial dose 5) >10 years – 0.1 mg/kg per dose as a suppository per rectum every 8 hours as needed (maximum initial dose 5)
Promethazine ≥2 years – 0.25 to 0.5 mg/kg per dose every 4 to 6 hours as needed (maximum initial dose 12.5 mg) Not recommended, due to risk of tissue injury depending on intravenous line placement and condition ≥2 years – 0.25 to 0.5 mg/kg per dose as a suppository per rectum every 4 to 6 hours as needed (maximum initial dose 12.5 mg)
Ondansetron <0.3 m2 – 1 mg every 8 hours as needed 0.15 mg/kg every 8 hours as needed (maximum initial dose 8 mg)  
0.3 to 0.6 m2 – 2 mg every 8 hours as needed
0.6 to 1 m2 – 3 mg every eight hours as needed
>1 m2 – 4 to 8 mg every 8 hours as needed
>11 years – 8 mg every 8 hours as needed
Haloperidol◊ 0.01 mg/kg per dose 3 times daily as needed (maximum initial dose 0.5 mg)    
Diphenhydramine§ 1 mg/kg per dose every 6 hours as needed 1 mg/kg per dose every 6 hours as needed  
Lorazepam◊ 0.025 to 0.05 mg/kg every 6 hours as needed (maximum initial dose 2 mg) 0.02 to 0.05 mg/kg every 6 hours as needed (maximum initial dose 2 mg) 0.02 to 0.05 mg/kg sublingual every 6 hours as needed (maximum initial dose 2 mg)
Dexamethasone◊ 0.1 mg/kg 3 times a day (maximum initial dose 5 mg) 0.1 mg/kg 3 times a day (maximum initial dose 5 mg)  
Dosing to prevent nausea/vomiting due to emetogenic chemotherapy or radiotherapy – Initial dose 10 mg/m2 (maximum initial dose 20 mg), then 5 mg/m2 (maximum initial dose 5 mg) every 6 hours
Fever Acetaminophen 15 mg/kg per dose every 4 to 6 hours as needed   15 mg/kg per rectum every 4 to 6 hours as needed
Ibuprofen 10 mg/kg every 6 to 8 hours as needed Adolescent ≥17 years – 100 to 200 mg every 4 to 6 hours as needed  
Insomnia Melatonin 2 to 3 mg at bedtime    
Trazodone ≥6 years – 0.75 to 1 mg/kg at bedtime (12.5 to 50 mg)    
Anxiety Lorazepam 0.025 to 0.05 mg/kg every 6 hours as needed (maximum initial dose 2 mg) 0.02 to 0.05 mg/kg every 6 hours as needed (maximum initial dose 2 mg) 0.02 to 0.05 mg/kg sublingual every 6 hours as needed (maximum initial dose 2 mg)
Agitation/delirium Haloperidol 0.01 mg/kg 3 times a day as needed (maximum initial dose 0.5 mg) 0.01 mg/kg 3 times a day as needed (maximum initial dose 0.5 mg)  
For acute agitation – 0.02 to 0.05 mg/kg, may repeat with a dose of 0.025 mg/kg in 1 hour as needed For acute agitation – 0.02 to 0.05 mg/kg, may repeat with a dose of 0.025 mg/kg in 1 hour as needed  
Clonazepam 0.005 to 0.01 mg/kg every 8 to 12 hours (maximum initial dose 0.5 mg)    
Olanzapine Adolescents – 2.5 to 5 mg once daily    
Muscle spasm Diazepam 0.04 to 0.2 mg/kg per dose every 6 to 8 hours as needed (up to 2.5 mg per dose initially) 0.04 to 0.2 mg/kg per dose every 6 to 8 hours as needed (up to 2.5 mg per dose initially)  
Baclofen ≥2 years – 5 mg 3 times a day; may increase every 3 days by 5 to 15 mg/day to a maximum dose of 40 mg/day    
Seizures¥ Lorazepam   0.05 to 0.1 mg/kg per dose; may repeat in 10 to 15 minutes (maximum cumulative dose 10 mg over 20 minutes)  
Midazolam   Second-line (refractory seizures) – 0.15 mg/kg loading dose followed by continuous infusion of 1 mcg/kg per minute gradually titrated to effect 0.2 mg/kg intranasal; may repeat in 10 minutes‡ or
0.3 mg/kg buccal; may repeat in 10 minutes‡
Diazepam Adjunct for prevention of seizures – 0.04 to 0.2 mg/kg per dose every 6 hours (up to 2.5 mg per dose initially)   Rectal gel formulation (Diastat)
2 to 5 years – 0.5 mg/kg per rectum
6 to 11 years – 0.3 mg/kg per rectum
>12 years – 0.2 mg/kg per rectum
Doses should be rounded to 2.5, 5, 7.5, 10, 12.5, 15, 17.5, or 20 mg/dose; dose may be repeated in 4 to 12 hours if needed†
Neuropathic pain Gabapentin** ≥3 years of age:    
Day 1 to 3 – 5 mg/kg at bedtime
Day 4 to 6 – 5 mg/kg twice a day
Day 7 to 9 – 5 mg/kg/dose 3 times a day
Day 10 to 12 – 5 mg/kg per dose in the morning and midday and 10 mg/kg at bedtime
Nortriptyline¶¶ ≥6 years of age:    
Day 1 to 4 – 0.2 mg/kg at bedtime
Day 4 to 8 – 0.4 mg/kg at bedtime
* Doses are for individuals over 6 months of age (except where shown otherwise) with a maximum weight of 50 kg.
¶ Dosing shown is for scopolamine hydrobromide (oral, parenteral). Scopolamine butylbromide, widely available outside of the United States, is not equivalent to and is dosed differently than dosing shown.
Δ Dosing shown is for nausea/vomiting related to gastrointestinal dysmotility. Higher doses (in conjunction with diphenhydramine to prevent extrapyramidal symptoms) are used for chemotherapy-induced emesis.
◊ Most data for antiemetic use of this agent are as an adjunct for prevention of nausea/vomiting due to emetogenic chemotherapy or radiotherapy.
§ Also appropriate for management of opioid-induced pruritis or insomnia.
¥ Refer to UpToDate topics on treatment of seizures and epileptic syndromes in children and management of status epilepticus in children.
‡ Use is based on limited experience and case descriptions as adjunct. Refer to UpToDate topics on treatment of seizures and epileptic syndromes in children, section on transmucosal administration.
† Rectal diazepam gel has been repeated as frequently as every 15 minutes up to 3 doses total (in absence of intravenous access) to control prolonged seizure activity, based on limited experience in palliative care.
** Gabapentin dosing is increased until effective analgesia is achieved, side effects occur, or a maximum daily dose of 60 mg/kg per day is reached. Once a daily dose is established, one-half of the total daily dose may be given in the evening. Dose increases may be made more frequently (eg, every 1 to 3 days) as tolerated.
¶¶ Nortriptyline dosing is increased as tolerated until effective analgesia is achieved or a maximum daily dose of 1 mg/kg per day (50 mg maximum) is reached. Prior to dose escalation beyond these parameters, plasma levels and obtaining an electrocardiogram should be considered.
Data from:
  1. Custer JW, Rau RE, Lee C. The Harriet Lane Handbook, 18th ed, Elsevier Mosby, Philadelphia 2009.
  2. Lexicomp Online. Copyright © 1978-2023 Lexicomp, Inc. All Rights Reserved.
  3. Schechter NL, Berde CB, Yaster M, eds. Pain in infants, children, and adolescents, 2nd ed, Lippincott Williams & Wilkins, Philadelphia 2003.
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