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Medications for Children Living with Life Threatening Conditions

Medications for Children Living with Life Threatening Conditions. John Mulder, MD VP of Medical Services Faith Hospice. “Death I understand very well, it is suffering that I cannot understand.” -- Isaac C. Singer.

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Medications for Children Living with Life Threatening Conditions

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  1. Medications for Children Living with Life Threatening Conditions John Mulder, MD VP of Medical Services Faith Hospice

  2. “Death I understand very well, it is suffering that I cannot understand.” -- Isaac C. Singer

  3. “No patient should ever wish for death because of a physician’s reluctance to use adequate amounts of effective opioids.” -- Jerome H. Jaffe (Goodman and Gilman, 1990)

  4. General Principles • Children feel pain. • Most pain in children’s diseases comes from medical diagnostic and therapeutic procedures. • Pain in CA pts can be a result of disease • Common at time of diagnosis, relapse, and at terminal phase

  5. General Principles • As non-invasive as possible • As few doses/day with as little pain or disruption as possible. • PO preferred; RTC when available. • Chronically ill may have central lines. • Neurologically impaired may have gastrostomy tubes. • Subcutaneous route available for most palliative meds.

  6. General Principles • Common not to have research-based, pediatric-specific indications for medications. • Children w/malignancies or HIV often have low platelet and WBC counts making rectal administration less acceptable.

  7. General Principles • Children may have increased sensitivity to extrapyramidal side effects. • Children may have paradoxical reactions to benzodiazepines. • High-pitched crying and agitation • Children may have paradoxical reactions to barbituates. • Hyperactive

  8. Annual mortality from life limiting illnesses • 1 per 10 000 children aged 1-17 years • Prevalence of life limiting illnesses • 10 per 10 000 children aged 0-19 years • In a health district of 250 000 people, with a child population of about 50 000, in one year • 5 children are likely to die from a life limiting illness—Cancer (2), heart disease (1), other (2) • 50 children are likely to have a life limiting illness, about half of whom will need palliative care at any time Numbers of children with life limiting illness BMJ 1998;316:49-52

  9. Diseases for which curative treatment may be feasible but may fail Diseases in which premature death is anticipated but intensive treatment may prolong good quality life Cancer Cystic Fibrosis, HIV infection, AIDS Groups of life limiting diseases in children GROUPEXAMPLE BMJ 1998;316:49-52

  10. Progressive diseases for which treatment is exclusively palliative and may extend over many years Conditions with severe neurological disability that, although not progressive, lead to vulnerability and complications likely to cause premature death Batten disease, Mucopolysaccharidoses Severe cerebral palsy Groups of life limiting diseases in children GROUPEXAMPLE BMJ 1998;316:49-52

  11. The percentages of children who, according to parental report, had a specific symptom in the last month of life and who had "a great deal" or "a lot" of suffering as a result. NEJM 2000; 342 (5): 326

  12. The percentages of children who, according to parental report, were treated for a specific symptom in the last month of life, and in whom treatment was successful. NEJM 2000; 342 (5): 326

  13. Discordance between the Reports of Parents and Physicians Regarding the Children's Symptoms in the Last Month of Life. NEJM 2000; 342 (5): 326

  14. Symptom-specific medications • Anxiety • Lorazepam 0.02-0.1 mg/kg IV q4-6h 0.1-0.2 mg/kg PR • Olanzapine 1.25-2.5 mg/d • Anorexia • Prednisone 0.5-2 mg/kg PO > 1 yr: 5 mg/day • Dexamethasone 0.2 mg/kg PO

  15. Symptom-specific medications • Constipation • Bisacodyl 1 tab PO (6-12 yr) 2 tabs PO (> 12 yr) ½ - 10 mg supp (< 12 yr) 1 – 10 mg supp (> 12 yr) • Docusate 10-40 mg PO (< 3 yr) [syrup 20 mg/5cc] 20-60 mg PO (3-6 yr) 40-120 mg PO (6-12 yr) 50-300 mg PO (> 12 yr)

  16. Symptom-specific medications • Constipation • Senna 2.5-3.75 ml PO (2-6 yr) [syrup] 5-7.5 ml PO (6-12 yr) 10-15 ml PO (> 12 yr)

  17. Symptom-specific medications • Dyspepsia • Ranitidine 1-2 mg/kg PO/d • Diarrhea • Diphenoxylate • Loperamide • Kaopectate • Donnagel

  18. Symptom-specific medications • Nausea/Vomiting • Haloperidol 0.05-0.2 mg/kg PO ¸bid-tid • Chlorpromazine 0.5 mg/kg PO (6-12 y/o) 1 mg/kg PR • Dexamethasone 2-4 mg/kg IV/PO (severe) • Metoclopramide 0.1-0.2 mg/kg PO/IV • Prochlorperazine 0.1-0.2 mg/kg PO/IV 2.5 mg PR • Sea Bands

  19. Symptom-specific medications • Respiratory distress • Morphine 0.1-0.3 mg/kg PO • Lorazepam 0.02-0.1 mg/kg IV 0.1-0.2 mg/kg PR/PO Nebulized meds: • Albuterol 2.5 mg • Morphine 2.5-5 mg

  20. Symptom-specific medications • Respiratory distress • Theophylline • 0-6 wk 4 mg/kg/d • 6-24 wk 10 mg/kg • 6-12 mo 12-18 mg/kg • 1-9 yr 20-24 mg/kg • 9-12 yr 16 mg/kg • 12-16 yr 13 mg/kg • > 16 yr 10 mg/kg

  21. Opioids • No maximum dose • No increased predisposition to respiratory depression (>3-6 mo) • Neuropathic and CNS-related pain will generally require adjuvants

  22. Opioids • In pain crisis, load with incremental increases every 10-15 minutes to achieve 50% reduction in pain (arbitrary) • Start infusion if necessary to maintain analgesia • Important to have availability of rescue doses, ~ 5-10% of total daily dose q hour • If > 6 rescues/24 hours, increase base rate

  23. Opioids • Morphine (MS Contin, MSIR, Roxanol) Infants < 3 mo 0.15 mg/kg PO/SL > 3 mo 0.3 mg/kg PO/SL (IV:PO = 1:3) Infusion: 0.03 mg/kg/hr • Oxycodone (OxyContin, OxyIR, Oxyfast) 0.2 mg/kg PO/SL

  24. Opioids • Hydromorphone 0.06 mg/kg PO (IV:PO = 1:5) • Methadone 0.2 mg/kg PO (IV:PO = 1:2) • Recommended as second line for children who cannot tolerate MS and hydromorphone; very long half life, requires close monitoring

  25. Adjuvants • Antidepressants • Neuropathic pain • Amitryptyline 0.5-2 mg/kg qhs • Psychostimulants • Potentiates opioid analgesia • Counteracts opioid-induced sedation • Improves cognitive dysfunction

  26. Adjuvants • Psychostimulants • Methylphenidate • initiate at 2.5 mg bid and titrate to effect • Dextroamphetamine • 2.5 mg qd (3-6 y/o) • 5 mg qd/bid

  27. Adjuvants • Corticosteroids - effects • Anti-inflammatory effects • Reduction of tumor edema • Reduction of spontaneous discharge in injured nerve

  28. Adjuvants • Corticosteroids - indications • Bone pain due to metastatic disease • Cerebral edema (primary or metastatic brain tumor) • Epidural spinal cord compression • Neuropathic pain • Nausea • Anorexia

  29. Adjuvants • Corticosteroids – dexamethasone is preferred agent • High potency • Longer duration of action • Minimal mineralcorticoid effect

  30. Adjuvants • Anticonvulsants • Neuropathic pain • Carbamazepine, phenytoin, and valproate problematic (effect on hematologic profile) • Gabapentin well tolerated; benign efficacy-to-toxicity ratio

  31. Alternative analgesic • Sucrose • 1 packet sugar in 10 cc water (29-30% sol’n) • Sweet Ease (24% sol’n) • 10 cc per bottle; swab oral mucosa; pacifier • Studied primarily in infants • Procedural pain • Relationship with holding and eye contact

  32. Education and Resources • EPERC • Education for Physicians in End-of-Life Care • ELNEC • End-of-Life Nursing Education Course • Pediatric Module • IPPC • Initiative for Pediatric Palliative Care • NHPCO • Pediatric Palliative Care Curriculum • NACWLTC

  33. Compendium of Pediatric Palliative Care Children’s International Project on Palliative/Hospice Services (ChIPPS) National Hospice and Palliative Care Organization 703-837-1500 www.nhpco.org

  34. John Mulder, MD VP of Medical Services Faith Hospice 616-293-3615 jmulder@hollandhome.org

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