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

“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)

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

General Principles

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As non-invasive as possible

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As few doses/day with as little pain or disruption as possible.

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PO preferred; RTC when available.

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Chronically ill may have central lines.

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Neurologically impaired may have gastrostomy tubes.

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Subcutaneous route available for most palliative meds.

General Principles

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Common not to have research based, pediatric-specific indications for medications.

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Children w/malignancies or HIV often have low platelet and WBC counts making rectal administration less acceptable.

General Principles

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Children may have increased sensitivity to extrapyramidal side effects.

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Children may have paradoxical reactions to benzodiazepines.

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High-pitched crying and agitation

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Children may have paradoxical reactions to barbituates.

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Hyperactive

Numbers of children with life limiting illness

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

BMJ

1998;316:49-52

Groups of life limiting diseases in children

•

GROUP

• 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 • •

EXAMPLE

Cancer Cystic Fibrosis, HIV infection, AIDS

BMJ

1998;316:49-52

Groups of life limiting diseases in children

• •

GROUP

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 • •

EXAMPLE

Batten disease, Mucopolysaccharidoses Severe cerebral palsy

BMJ

1998;316:49-52

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

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

Discordance between the Reports of Parents and Physicians Regarding the Children's Symptoms in the Last Month of Life.

NEJM

2000; 342 (5): 326

Symptom-specific medications



Anxiety

– Lorazepam – Olanzapine 

Anorexia

– Prednisone – Dexamethasone 0.02-0.1 mg/kg IV 0.1-0.2 mg/kg PR 1.25-2.5 mg/d q4-6h 0.5-2 mg/kg PO > 1 yr: 5 mg/day 0.2 mg/kg PO

Symptom-specific medications



Constipation

– Bisacodyl 1 tab PO (6-12 yr) – Docusate 2 tabs PO (> 12 yr) ½ - 10 mg supp (< 12 yr) 1 – 10 mg supp (> 12 yr) 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)

Symptom-specific medications

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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)

Symptom-specific medications

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Dyspepsia

– Ranitidine 

Diarrhea

– Diphenoxylate – Loperamide – Kaopectate – Donnagel 1-2 mg/kg PO/d

Symptom-specific medications

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Nausea/Vomiting

– Haloperidol – Chlorpromazine 0.05-0.2 mg/kg PO  bid-tid 0.5 mg/kg PO (6-12 y/o) 1 mg/kg PR – Dexamethasone – Metoclopramide – Prochlorperazine 2-4 mg/kg IV/PO (severe) 0.1-0.2 mg/kg PO/IV 0.1-0.2 mg/kg PO/IV 2.5 mg PR – Sea Bands

Symptom-specific medications

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Respiratory distress

– Morphine – Lorazepam 0.1-0.3 mg/kg PO 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

Symptom-specific medications

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Respiratory distress

– Theophylline • • • • • • • 0-6 wk 6-24 wk 6-12 mo 1-9 yr 9-12 yr 12-16 yr > 16 yr 4 mg/kg/d 10 mg/kg 12-18 mg/kg 20-24 mg/kg 16 mg/kg 13 mg/kg 10 mg/kg

Opioids

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No maximum dose

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No increased predisposition to respiratory depression (>3-6 mo)

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Neuropathic and CNS-related pain will generally require adjuvants

Opioids

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In pain crisis, load with incremental increases every 10-15 minutes to achieve 50% reduction in pain (arbitrary)

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Start infusion if necessary to maintain analgesia

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Important to have availability of rescue doses, ~ 5-10% of total daily dose q hour

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If > 6 rescues/24 hours, increase base rate

Opioids

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Morphine

(MS Contin, MSIR, Roxanol)

Infants < 3 mo > 3 mo (IV:PO = 1:3) Infusion: 0.15 mg/kg PO/SL 0.3 mg/kg PO/SL 0.03 mg/kg/hr



Oxycodone

(OxyContin, OxyIR, Oxyfast)

0.2 mg/kg PO/SL

Opioids

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Hydromorphone 0.06 mg/kg PO (IV:PO = 1:5)

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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

Adjuvants

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Antidepressants

–

Neuropathic pain

•

Amitryptyline 0.5-2 mg/kg qhs

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Psychostimulants

–

Potentiates opioid analgesia

–

Counteracts opioid-induced sedation

–

Improves cognitive dysfunction

Adjuvants

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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

Adjuvants

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Corticosteroids - effects

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Anti-inflammatory effects

–

Reduction of tumor edema

–

Reduction of spontaneous discharge in injured nerve

Adjuvants

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Corticosteroids - indications

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Bone pain due to metastatic disease

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Cerebral edema (primary or metastatic brain tumor)

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Epidural spinal cord compression

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Neuropathic pain

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Nausea

–

Anorexia

Adjuvants

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Corticosteroids – dexamethasone is preferred agent

–

High potency

–

Longer duration of action

–

Minimal mineralcorticoid effect

Adjuvants

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Anticonvulsants

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Neuropathic pain

•

Carbamazepine, phenytoin, and valproate problematic (effect on hematologic profile)

•

Gabapentin well tolerated; benign efficacy to-toxicity ratio

Alternative analgesic

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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

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

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

John Mulder, MD VP of Medical Services Faith Hospice 616-293-3615 [email protected]