Appendix E
WORLD
HEALTH ORGANIZATION
CANCER PAIN RELIEF AND PALLIATIVE CARE IN CHILDREN, GENEVA: 1998
Table 2: Opioid Dosage Guidelines for Pain in Children <50kg*
GUIDELINES FOR ANALGESIC DRUG THERAPY
The four key concepts underlying the use of analgesics are : “by the ladder,” “by the clock,” “by the appropriate route,” and “by the child.”
The ladder approach is based on the premise that health care professionals should learn how to use a few drugs well. [...] Medication should be administered to children by the simplest, most effective and least painful route. To select the best route, one should consider the severity of the pain, the type of pain, the potency of the drug, and the required dosing interval.
The opioid dose that effectively relieves pain varies between children and in the same child at different times. [...] Non-opioid analgesics have a ceiling effect. Opioid drugs do not. The correct dose of opioid is the dose that provides adequate relief of pain with an acceptable degree of side effects.
The strong opioid of choice included in WHO's Model List of Essential Drugs is morphine. Alternatives are hydromorphone, methadone and fentanyl. Dosage guidelines are summarized in Table 2.
Table 2. OPIOID DOSAGE GUIDELINES FOR PAIN IN CHILDREN <50kg*
(a) Equianalgesic doses are based on single-dose studies in adults.
(b) Usual starting dose is the commonly used standard dose and not always based on equianalgesic principles (ie. starting dose of hydromorphone may be 2mg despite the parenteral:oral ratio of 1:5). For infants under 6 months of age, starting doses should be one-quarter to one-third the suggested dose and titrated to effect.
(c) Pethidine is not recommended for chronic use because of its long half-life and the possibility of accumulation of a toxic metabolite.
(d) Continuous infusion of fentanyl at 100µg/hour is approximately analgesic to a morphine infusion of 2.5mg/hour.
(e) Methadone may cause some irritation when administered SC. Extreme care is needed when using methadone, both for initiation of therapy and when doses are increased, because of the extremely long biological half-life.
N/R = not recommended; N/A = not applicable.