Nelson Textbook of Pediatrics 22nd Edition โ Chapter 93 | Table 93.11: Practical Aspects of Prescribing Opioids (pharmacology, equianalgesic dosing, tolerance vs dependence vs addiction) | Table 93.8: Management of Opioid-Induced Adverse Effects (respiratory depression, nausea, pruritus, constipation, urinary retention).
๐ paeds.online โ Pakistan's Pediatric Platform| Principle | Details |
|---|---|
| First-line opioids for severe pain | Morphine, hydromorphone, or fentanyl (IV/PO). Avoid meperidine (normeperidine toxicity). |
| Titration | Dosing should be individualized. The right dose is the dose that relieves pain with acceptable side effects. |
| Caution in infants | Lower clearance, prolonged half-life. Start with lower doses and monitor carefully. |
| Renal impairment | Morphine has active metabolite (M6G) that accumulates โ toxicity. Fentanyl preferred in renal failure. |
| Hepatic impairment | Reduce dose; monitor for sedation. Fentanyl is safest. |
| Equianalgesic doses (IV:PO) | Morphine 1:3, Hydromorphone 1:3-4, Oxycodone N/A (PO only), Fentanyl 1:10 (oral transmucosal). |
| PCA (Patient-Controlled Analgesia) | Basal rate + demand doses with lockout. For children โฅ5-6 years. Nurse-controlled for younger. |
| Tolerance vs Dependence vs Addiction | Tolerance: decreasing effect with continued use. Dependence: withdrawal upon abrupt cessation. Addiction: compulsive use despite harm (rare in children treated for pain). |
| Weaning opioids | After >1 week of use, taper gradually (e.g., 25% reduction per day) to prevent withdrawal. |
| Avoid codeine and tramadol | FDA contraindicated in children <12 years (ultra-rapid metabolizers โ respiratory depression). |
| Adverse Effect | Management |
|---|---|
| Respiratory depression | Naloxone 0.01-0.02 mg/kg IV/IM/IN (full reversal dose). For opioid-tolerant patients, use lower dose (0.001-0.005 mg/kg) to avoid withdrawal. Duration 1-4 hr; repeat as needed or start infusion. |
| Excessive sedation (no respiratory depression) | Reduce opioid dose or change opioid. Consider methylphenidate or dextroamphetamine (palliative care). |
| Nausea and vomiting | Ondansetron 0.1 mg/kg IV (max 4 mg), metoclopramide, prochlorperazine. Change opioid if persistent. |
| Pruritus | Diphenhydramine 0.5 mg/kg PO/IV. Nalbuphine 0.1 mg/kg IV for epidural/intrathecal opioids. Low-dose naloxone infusion (0.5-2 mcg/kg/hr). Change opioid. |
| Constipation | Proactive: stool softener (docusate) + stimulant (senna). Polyethylene glycol (MiraLAX). Methylnaltrexone (peripheral ฮผ-antagonist) for refractory cases. |
| Urinary retention | Straight catheterization, decrease opioid dose, consider naloxone infusion. |