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.Do you want to add Medilib to your home screen?