Transcript The Role of Aggressive Therapies in Hospice Care

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
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.
General Principles
Common not to have researchbased, pediatric-specific indications
for medications.
 Children w/malignancies or HIV often
have low platelet and WBC counts
making rectal administration less
acceptable.

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
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
EXAMPLE
• Cancer
curative treatment may
be feasible but may fail
• Diseases in which
premature death is
anticipated but intensive
treatment may prolong
good quality life
• Cystic Fibrosis, HIV
infection, AIDS
BMJ 1998;316:49-52
Groups of life limiting diseases in children
GROUP
EXAMPLE
• Progressive diseases for
which treatment is
exclusively palliative and
may extend over many
years
• Batten disease,
• Conditions with severe
neurological disability that,
although not progressive,
lead to vulnerability and
complications likely to
cause premature death
• Severe cerebral palsy
Mucopolysaccharidoses
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

0.02-0.1 mg/kg IV
0.1-0.2 mg/kg PR
1.25-2.5 mg/d
Anorexia
– Prednisone
– Dexamethasone
0.5-2 mg/kg PO
> 1 yr: 5 mg/day
0.2 mg/kg PO
q4-6h
Symptom-specific medications

Constipation
– Bisacodyl
– Docusate
[syrup 20 mg/5cc]
1 tab PO (6-12 yr)
2 tabs PO (> 12 yr)
½ - 10 mg supp (< 12 yr)
1 – 10 mg supp (> 12 yr)
10-40 mg PO (< 3 yr)
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
[syrup]
2.5-3.75 ml PO (2-6 yr)
5-7.5 ml PO (6-12 yr)
10-15 ml PO (> 12 yr)
Symptom-specific medications

Dyspepsia
– Ranitidine
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Diarrhea
–
–
–
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Diphenoxylate
Loperamide
Kaopectate
Donnagel
1-2 mg/kg PO/d
Symptom-specific medications

Nausea/Vomiting
– Haloperidol
– Chlorpromazine
– Dexamethasone
– Metoclopramide
– Prochlorperazine
– Sea Bands
0.05-0.2 mg/kg PO  bid-tid
0.5 mg/kg PO (6-12 y/o)
1 mg/kg PR
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
Symptom-specific medications

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

Respiratory distress
– Theophylline
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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
No maximum dose
 No increased predisposition to
respiratory depression (>3-6 mo)
 Neuropathic and CNS-related pain
will generally require adjuvants
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Opioids
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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
Opioids

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

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

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

Corticosteroids - effects
– Anti-inflammatory effects
– Reduction of tumor edema
– Reduction of spontaneous discharge in
injured nerve
Adjuvants

Corticosteroids - indications
– Bone pain due to metastatic disease
– Cerebral edema (primary or metastatic
brain tumor)
– Epidural spinal cord compression
– Neuropathic pain
– Nausea
– Anorexia
Adjuvants

Corticosteroids – dexamethasone is
preferred agent
– High potency
– Longer duration of action
– Minimal mineralcorticoid effect
Adjuvants
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Anticonvulsants
– Neuropathic pain
• Carbamazepine, phenytoin, and valproate
problematic (effect on hematologic profile)
• Gabapentin well tolerated; benign efficacyto-toxicity ratio
Alternative analgesic
 Sucrose
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–
–
–
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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
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 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]