Jeffrey L. Segar, MD, Elizabeth W. Amelon, Pharm.D., BCPS, Sarah B. Tierney, Pharm.D.
Peer Review Status: Internally Peer Reviewed (6/19/2014)

Systemic narcotics are the most commonly used agents for management of pain in the post-operative patient. They are also the most frequently used agents given to ventilated children, particularly when paralyzed with neuromuscular blockers, or those with bronchopulmonary dysplasia.

Analgesics and Sedatives
Drug Dose Onset/Duration of Action Comments
Narcotic analgesic and sedative:
Morphine
IV infusion: 10 - 20 mcg/kg/hr IV (may need up to 50 mcg/kg/hr) IV: 0.05 - 0.1 mg/kg IV q 1 h PRNPO: 0.05 - 0.1 mg/kg PO q 4-6 h PRN IV: Peak effect occurs in 20 minutes and lasts for 6-8 hours in preterm infants and 2-4 hours in full-term infants.PO: Peak effect occurs in 1 hour. Increased entero-hepatic circulation prolongs half-life in preterm infants.  Can cause histamine release.  Higher doses may be needed as tolerance develops.
Narcotic analgesic and sedative:
Fentanyl
IV infusion: 1 - 5 mcg/kg/hr IV IV: 2 - 5 mcg/kg IV q 1 h PRNand up to 10 mcg/kg IV PRN for procedures IV: Onset of action is almost immediate and lasts ~ 1 hour. Minimal hemodynamic effects.  No histamine release. Rapid onset of tolerance.
Benzodiazepine:
Lorazepam
IV/PO: 0.05 - 0.1 mg/kg IV q 1-2 h PRN IV: Onset of action occurs within 5 minutes with peak effect occurring in 45 minutes.  Duration of action is 3-24 hours.PO: Onset occurs within 60 minutes. May repeat dose in 10-15 minutes for status epilepticus.  Note: some products contain benzyl alcohol and propylene glycol.  Do not exceed 25 mg/kg/day of benzyl alcohol.
Benzodiazepine:
Midazolam
IV: 0.05 - 0.15 mg/kg IV q 2-4 h PRN PO: 0.25 mg/kg PO 30-60 min prior to procedureIntranasal: 0.3 mg/kg prior to procedure Rapid onset of action.  Duration of action is 2-6 hours. Intranasal: Onset occurs in 5 minutes and lasts 30-60 minutes.  Can repeat dose once in 5-15 minutes. Contains benzyl alcohol.  Do not exceed 25 mg/kg/day of benzyl alcohol.
Non-narcotic analgesic and sedative:
Dexmedetomidine
IV infusion: 0.25 - 1 mcg/kg/hr (start at 0.25 mcg/kg/hr and increase dose by 0.25 mcg/kg/hr q 2-4 h PRN)   Must wean off drip.  To wean, decrease dose by 0.1 mcg/kg/hr q 12-48 h.  Consider starting PO clonidine if patient has been on dexmedetomidine for > 3 days.  Overlap clonidine with dexmedetomidine therapy for 2 days.  Clonidine PO dose: 2 mcg/kg q 6 h, then 1 mcg/kg q 6 h, then 1 mcg/kg q 12 h, then 0.5 mcg/kg q 12 h.
Barbiturate sedative/ anticonvulsant:
Phenobarbital
PO/IV: 2.5 mg/kg/dose BID PO: Onset occurs within 20-60 minutes. IV: Onset occurs within 5 minutes with peak effect in 30 minutes.Half life is 40-200 hours. Phenobarbital is not necessarily recommended for sedation in neonates.  Tolerance to sedation develops rapidly.  Also used for Neonatal Abstinence Syndrome (see protocol).*
Non-narcotic analgesic:
Ibuprofen
PO: 5 - 10 mg/kg PO q 6-8 h PRN (max: 40 mg/kg/24 h) PO: Onset occurs within ~ 1 hour with peak effect in 2-4 hours.  Duration of action is 6-8 hours. Recommended for pain in children who are > 6 months of age.
Non-narcotic analgesic:
Acetaminophen
PO: 10 - 15 mg/kg PO q 4-6 h PRN
  • Max (GA 28-32 weeks): 40 mg/kg/24 h
  • Max (GA 33-37 weeks or term neonate < 10 days): 60 mg/kg/24 h
  • Max (term neonates > 10 days): 90 mg/kg/24 h
PR: 15 - 30 mg/kg PR q 6 h PRN
  • Max (GA 28-32 weeks): 40 mg/kg/24 h
  • Max (GA 33-37 weeks or term neonates < 10 days): 60 mg/kg/24 h
  • Max (term infants > 10 days): 90 mg/kg/24 h
IV:
  • Preterm infants > 32 weeks: 10 mg/kg/dose q 6 h PRN
  • Term infants: 7.5 mg/kg/dose q 6 h PRN (max: 30 mg/kg/24 h)
PO: Peak effect occurs within 1 hour.  Duration of action is 4-6 hours. PR: Absorption is erratic and onset of action can be prolonged.IV: Onset of action is within 5-10 minutes with peak effect in 1 hour.  Duration of action is 4-6 hours.  Note: Higher rectal doses may be used (up to 40 mg/kg/dose PR).
Hypnotic:
Chloral hydrate
PO: 25 - 50 mg/kg/doseq 6-12 h   Note: Chloral hydrate is no longer available because it was discontinued by the manufacturer.  Can cause cardiac toxicity at high levels. Repeated high doses in TPN dependent patients increases the risk of cholestasis.

*Treatment of withdrawal (abstinence) from narcotics: