Pediatrics : Pharmacologic management

- - Pharmacologic management
    - The World Health Organization states that the principles for pharmacologic pain management should include the following:
      - Using a two-step strategy
      - Dosing at regular intervals
      - Using the appropriate route of administration
      - Adapting treatment to the individual child
    - Nonopioids
      - They include acetaminophens and NSAIDs are suitable for mild to moderate pain
      - Nonsteroidal Anti-inflammatory Drugs for Children

Drug	Dosage	Comments
Acetaminophen (Tylenol)	10–15 mg/kg/dose q 4-6 h PO not to exceed five doses in 24 h or 75 mg/kg/day, or 4000 mg/day	Available in numerous preparations Nonprescription Higher dosage range may provide increased analgesia
Choline magnesium trisalicylate (Trilisate)	10–15 mg/kg q 8–12 h PO Maximum dose 3000 mg/day	Available in suspension, 500 mg/5 mL Prescription
Ibuprofen (children’s Motrin, children’s Advil)	Children >6 months of age: 5–10 mg/kg/dose q 6–8 h Maximum dose 30 mg/kg/day or 3200 mg/day	Available in numerous preparations Available in suspension, 100 mg/5 mL, and drops, 100 mg/2.5 mL Nonprescription
Naproxen (Naprosyn)	Children >2 years of age: 5–7 mg/kg/dose every 12 h Maximum 20 mg/kg/day or 1250 mg/day	Available in suspension, 125 mg/5 mL, and several different dosages for tablets Prescription
Indomethacin	1–2 mg/kg q 6–12 h Maximum 4g/kg/day or 200 mg/day	Available in 25-mg and 50-mg capsules and suspension 25 mg/5 mL Prescription
Diclofenac	0.5–0.75 mg/kg q 6–12 h PO Maximum 3 mg/kg day or 200 mg/day	Available in 50-mg tablet and extended-release 100-mg tablets Prescription

- - - Opioids
      - Needed for moderate to several pain
      - Morphine remains the standard agents used for comparison to other opioid agents
      - When morphine is not a suitable opioid, it can be substituted by drugs as:
        
        Hydromorphone hydrochloride (Dilaudid) and fentanyl citrate (Sublimaze)
        
        Codeine
        
        Oral opiate analgesic, is a weak opioid and has well-known safety and efficacy problems related to genetic variability in biotransformation
    - Coanalgesic drugs
      - It may be used alone or with opioids to control pain symptoms and opioid side effects
      - Drugs frequently used to relieve anxiety, cause sedation, and provide amnesia are diazepam (Valium) and midazolam (Versed)
        
        However, these drugs are not analgesics and should be used to enhance the effects of analgesics, not as a substitute for analgesics.
      - Other adjuvants include tricyclic antidepressants (e.g., amitriptyline, imipramine) and antiepileptics (e.g., gabapentin, carbamazepine, clonazepam)
      - Other medications commonly prescribed include stool softeners and laxatives for constipation, antiemetics for nausea and vomiting, diphenhydramine for itching, steroids for inflammation and bone pain, and dextroamphetamine and caffeine for possible increased pain and sedation

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