Nestor is prescribed ibuprofen 400 mg (10 mg/kg/dose) four times a day around the clock and an X-ray is obtained. You have made a referral to an orthopedist. The orthopedist is highly regarded but very busy. The next available appointment is in a month.
Test Your Knowledge
As the child’s pediatrician how do you respond to this delay in seeing the specialist?
Advocacy
Advocacy is more than good, careful medical decision-making. Advocacy is making sure what you recommend is actually implemented.
There are many obstacles for patients and families to get what they need, particularly families with chronically ill children with multiple medical needs. They may need assistance with basic needs such as transportation to appointments, timely appointments, and access to essential medications that are expensive and/or not covered by insurance.
Our obligation as health care providers goes beyond writing the right prescription for the right medication. It is advocating within the medical system to be sure that medication arrives at our patients’ doorstep.
Advocating for Nestor
Dr. Korones calls the orthopedist to advocate on behalf of Nestor.
Thanks to Dr. Korones' advocacy, Nestor is evaluated by an orthopedist who concurs that the patient appears to have pain on flexion of his left leg at the hip. The patient receives a local injection and his parents are also informed that he is not a candidate for surgery. The orthopedist recommends conservative management with pain medications.
Follow Up
You see Nestor back at his home 2 weeks after your initial visit. He is still having frequent episodes of intense pain, at least once a day, sometimes more. Even in between episodes he is irritable, not enjoying music like he used to, and is up more often in the night. The ibuprofen is not helping.
Test Your Knowledge
Which of the following options might you consider to help Nestor with his pain?
Major Opioid Medications in Pediatric Pain Management
The following table describes the major opioid medications used in pain management for the pediatric population. Note clinical considerations for each agent.
| Medication | Route | Duration of Analgesia | Dose | Clinical Comments |
|---|---|---|---|---|
| Morphine |
Intravenous PO PO (sustained-release) |
1 – 4 hours 3 – 4 hours 8 – 12 hours |
0.05 - 0.1 mg/kg/dose every 3 – 4 hours 0.15 - 0.3 mg/kg/dose every 3 – 4 hours |
Moderate to severe pain |
| Hydromorphone | Intravenous PO |
3 - 4 hours 3 - 4 hours |
0.015 mg/kd/dose every 2 - 4 hours 0.04 - 0.08 mg/kg/dose every 3 - 4 hours |
Moderate to severe pain |
| Fentanyl | Intravenous | 30 - 60 minutes | 0.5 - 1 mcg/kg/dose every 1 - 2 hours |
For severe pain Use with extreme caution and appropriate supervision Available as transdermal preparation |
| Oxycodone with or without APAP |
PO PO (sustained release) |
3 - 4 hours 12 hours |
0.2 mg/kg/dose every 3 - 4 hours |
Moderate pain Max dosing on APAP |
| Hydrocodone with APAP | PO | 3 - 4 hours | 0.2 mg/kg/dose every 4 - 6 hours |
Mild to moderate pain Max dosing on APAP |
Reference
Berde CB and Sethna NF. Analgesics for the treatment of pain in children. NEJM 2002; 347: 1094-1103. (Accessed August 26th, 2013)
Review of Nestor's Treatment
Dr. Korones reviews the effects of treatment with Nestor's mother.
Patient Case Revisited
Pharmacokinetics of Morphine
- Nestor is given morphine per g-tube to relieve pain
- Half-life in a 7-year old is approximately 2 hours
- Metabolized by glucorindation in the liver
- Side Effects
- Similar to adults- respiratory depression, constipation, somnolence
- Tolerance and dependence will develop
