Commonly used options for prevention and treatment of opioid-related side effects in children^[1-3]

	Drug dose or action	Comments
Constipation
Docusate (solution, 4 or 10 mg/mL or tablet, 50 or 100 mg/tab)	Infants >6 months but <2 years: 12.5 mg orally three times daily Children >2 and adolescents: 40 to 150 mg/day in 1 to 4 divided doses	For prophylaxis of OIC we usually administer 25 to 50 mg twice daily. Not for use in neonates because of benzyl alcohol content.
Senna (syrup, 8.8 mg sennoside/5 mL or tablets, 8.6 mg sennosides/tab)	1 to 2 years: 1.25 to 2.5 mL orally once or twice daily 2 to 6 years: 2.5 to 3.75 mL orally once or twice daily 6 to 12 years: 5 to 7.5 mL (or 1 to 2 tabs) orally once or twice daily ≥12 years: 5 to 15 mL (or 1 to 3 tabs) orally once or twice daily	Usually given once daily at bedtime. Given routinely with docusate for OIC unless contraindicated.
Glycerin suppository	2 to 5 years: 1 pediatric suppository daily ≥6 years: 1 adult suppository daily	Usually used as a stimulant in infants. Do not administer suppository if patient is neutropenic.
Polyethylene glycol 3350	0.2 to 0.8 g/kg/day, to a maximum of 17 g orally per day	For constipation unresponsive to above measures
Nausea/vomiting*
Ondansetron	0.15 mg/kg IV every 8 hours, usual maximum 4 mg per dose	If this dose inadequate, consider adding another antiemetic
Metoclopramide	0.1 mg/kg IV every 6 to 8 hours as needed, usual maximum 10 mg per dose	Occasionally used as second line drug
Pruritus*
Nalbuphine	0.1 mg/kg to a maximum of 5 mg by slow infusion over 20 minutes every 6 hours as needed
Naloxone	Infusion: 0.25 mcg/kg/hour IV	Usually restricted to patients who are on PCA or continuous infusions of opioid
Urinary retention
Nalbuphine	0.1 mg/kg to a maximum of 5 mg IV over 20 minutes every 6 hours as needed	Nalbuphine may be helpful in some patients. Bladder catheterization may be necessary for opioid induced urinary retention.
Excessive sedation	Reduce opioid dose and/or rotate to a different opioid Check for other sedatives concomitantly prescribed Utilize opioid sparing analgesics such as NSAIDs, acetaminophen, regional anesthesia, topical lidocaine
Respiratory depression/respiratory arrest	Stop infusion or reduce dose immediately depending on severity Apply physiologic monitors including pulse oximeter If spontaneously breathing, provide oxygen, ensure adequate chest movement/air entry Administer partial reversal: Naloxone 5 mcg/kg IV every 2 minutes until respiratory rate is age appropriate and patient is responsive If apneic or breathing inadequately, support ventilation with bag, mask and oxygen Administer full reversal: Naloxone 10 mcg/kg IV every 2 mins (may administer 0.4 to 2 mg every 2 minutes) until awake and breathing Observe closely for re-narcotization over an extended time period

Opioid-related side effects may be reduced by using multimodal opioid sparing analgesic techniques (eg, regional analgesia, nonopioid analgesics, nonpharmacologic analgesic techniques).

OIC: opioid induced constipation; IV: intravenous; PCA: patient controlled analgesia.
* Use extreme caution with administration of antihistamines for the treatment of itching, nausea/vomiting, or benzodiazepines for the treatment of nausea/vomiting. Although effective in some patients, these medications are associated with the risk of excessive sedation and respiratory compromise when administered with opioids. If needed, use a reduced dose and administer by the oral route if possible.

References:

Maxwell LG, Kaufmann SC, Bitzer S, et al. The effects of a small-dose naloxone infusion on opioid-induced side effects and analgesia in children and adolescents treated with intravenous patient-controlled analgesia: a double-blind, prospective, randomized, controlled study. Anesth Analg 2005; 100:953.
Malinovsky JM, Lepage JY, Karam G, Pinaud M. Nalbuphine reverses urinary effects of epidural morphine: a case report. J Clin Anesth 2002; 14:535.
Verhamme KM, Sturkenboom MC, Stricker BH, Bosch R. Drug-induced urinary retention: incidence, management and prevention. Drug Saf 2008; 31:373.

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Commonly used options for prevention and treatment of opioid-related side effects in children[1-3]

Commonly used options for prevention and treatment of opioid-related side effects in children^[1-3]