Event 2: Nestor's Treatment

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?

Correct. The primary care physician talks to the orthopedist given the urgency of the child’s clinical condition. It is the obligation of the physician to advocate for the patient.


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?

Correct. Morphine is generally the initial opioid of choice for children with pain that does not respond to non-opioid therapies. It has the advantage of multiple modes of delivery (oral [liquid and tablet], IV and subcutaneous), and it is inexpensive.
Incorrect. Naproxen is a non-steroidal anti-inflammatory agent. If ibuprofen did not work, it is unlikely that naproxen will.
Incorrect. Lidocaine patch is not correct, but could be considered as an adjunctive therapy. The lidocaine is slowly released into the subcutaneous tissues and can provide local analgesia. Nestor’s pain may be too deep for the patch to be effective, but since it is safe and not systemically absorbed, a short trial is reasonable.
Incorrect. The fentanyl is a patch is a long-acting opioid and should not be considered until there has been a trial of a short acting opioid to assess efficacy of the opioids and get a sense of how much is required.
Incorrect. Methadone is tricky to dose and generally is done with the guidance of a physicians with expertise in pain management. In addition, it is not typically used as a first-line opioid.

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.

Major Opioid Medications Used in Pediatric Pain Management
Medication Route Duration of Analgesia Dose Clinical Comments



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 (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


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
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