Pediatric Anesthesia

Normal Physiological Values for Children

Normal Length and Weight of Children

AgeLength (cm)Weight (kg)
Newborn503,5
3 month 606
1 year7510
3 year9515
7 year12025
10 year14030

Normal Reference Values for Children

 Pulse
hr/min
Blood pressure
syst/dia
Respiratory Rate
Blood VolumeHgb-values
(g/l)
Newborn100-18060/35 (MAP 40-45)40-6085 ml/kg150-180
0-6 months100-16060-90/30-6030-6085 ml/kg90-100
6-12 months100-16080-95/45-6525-5085 ml/kg100
1-2 years old100-15085-105/55-6525-3580 ml/kg100
Preschool70-11095-105/55-6520-3575 ml/kg100-110
School age (7-12)65-11095-115/55-7018-3075 ml/kg110-120
Teen Age60-90110-130/65-8012-1675 ml/kg120-130

Target values for blood pressure in children in general anesthesia (MAP in mmHg)

AgeDuring anesthesiaAwake
0-3 months42-4752
3-6 months45-5257
6-12 months51-5763
1-3 years51-5763
3-6 years54-6168
6-14 years58-6570
> 14 years58-6573


Calculation of Correct Pediatric Anesthetic Drug Doses

This doses calculator was constructed by Carina Malmqvist Head Nurse of Intensive Care. Sahlgrenska University Hospital.

and Sara Eriksson Nurse of Intensive Care. Sahlgrenska University Hospital.

Updated 2018-12-21


Enter the weight of the child and get recommended drug doses for anesthesia.

HEADERPatient data (date of birth - age)EMPTYEMPTY
Weight (kg)EMPTY
EMPTY_ROW
SECTIONDrugs - InjectionsEMPTY
HEADERNameStandard dosageConcentrationDose in mgDose in mlNotes
CALC1Adrenaline (Epinephrine)0,01 mg/kg0,1 mg/mlIn acute situations!
CALC1Atropine0,01 mg/kg0,5 mg/ml
CALC1Fentanyl2 µg/kg50 ug/mlN.B.! dose in µg!
CALC1Midazolam0,1 mg/kg1 mg/ml
CALC1Morphine0,1 mg/kg1 mg/ml
CALC1Naloxone0,02 mg/kg0,02 mg/ml
CALC1Propofol2 mg/kg10 mg/ml>3 years of age
CALC1Rocuronium0,6 mg/kg10 mg/ml
EMPTY_ROW
SECTIONFluid therapyEMPTY
HEADERml/kg/hourml/hourml/dayEMPTY
CALC2Low2 ml/kg/hourEMPTY
CALC2Normal3 ml/kg/hourEMPTY
CALC2Hög4 ml/kg/hourEMPTY
EMPTY_ROW
SECTIONTidal volume in the ventilatorEMPTY
EMPTYml/breathEMPTYEMPTY
CALC38 ml/kgEMPTYEMPTY


Resuscitation of Critically Ill Children

Medications at cardiac arrest in children

Age03 months1 year5 years9 years12 years14 years15 years and older 
Weight3 kg5 kg10 kg20 kg30 kg40 kg50 kg> 50 kg
Epinephrine (0,1 mg/ml)* 0,01 mg/kg, 0,1 ml/kg0.30.51234510ml
Amiodarone (15 mg/ml)* 5 mg/kg,
0,33 ml/kg
11.73710131720ml
Glucose 100 mg/ml, 2 ml/kg61020406080100ml
Ringer's Acetate 20 ml/kg601002004006008001000ml
Tribonate (0,5 mmol/ml) 2 ml/kg61020406080100100ml
Defibrillation 4 J/kg12204080120150-200150-200150-360J
Endotracheal tube inner diameter33.5456777mm
*Amiodarone 50 mg/ml. 6 ml diluted with 14 ml glucose 50 mg/ml = 15 mg/ml

Drugs delivered during CPR

At asystole/bradycardia/PEA:

  • Epinephrine 0.01 mg/kg imediately
  • Repeat every four minutes

At VF/pulseless VT:

  • Epinephrine 0.01 mg /kg after third defibrillation. Repeat every four minutes.
  • Amiodarone 5 mg/kg after third defibrillation.
  • Repeat the same dose after the fifth defibrillation.

Correct reversible causes

  • Hypoxia
  • Hypovolaemia
  • Hypothermia
  • Hyper/hypokalaemia
  • Hypoglycemia
  • Cardiac tamponade
  • Pressure pneumothorax
  • Toxic conditions
  • Thromboembolic events

Clinical Aspects of Pediatric Anesthesia

Fasting for children before general anesthesia:

  • 6 hours of fasting on anything but clear liquids (2 hours)
  • Prior to the age of 6 months, 4 hours apply to breast milk (compensation?)
  • If breastfeeding after 6 months of age: (4 or 6 hours of fasting?)
  • Ice cream is not considered a clear liquid.

 

Some practical anesthesia routines:

  • Only one (1) parent accompanies to the operating room if the child is over 4 months.
  • Limit for outpatient care: 3 months of age (corrected age).
  • Atropine given only on specific indication
  • Always endotracheal tubes with a cuff
  • Endotracheal tube positioning (cm from lips) = patient length (cm)/10 + 5. Nasal: + 20%
  • Recommended concentration of Propofol is always 5 mg/ml, lidocaine is not required
  • Volume pumps (20 kg limit), no children’s units
  • Often TIVA mode for children but never TCI <16 years of age
  • A lot of topical anesthesia (transdermal) EMLA, even newborn.

 

Some common anesthetic procedures for children:

  • Induction: Propofol 5 mg/ml (as 10 mg/ml infusion); Thiopentone 25 mg/ml (for cardiac procedures only); Esketamine (different concentrations depending on the size of the child, often 1 or 5 mg/ml)
  • Anesthetic gas: Sevoflurane (induction by inhalation, laryngeal mask). Isoflurane (for cardiac procedures or neurosurgery). Desflurane (other anesthetic procedures).
  • Opioid: Fentanyl 50 mcg/ml; Remifentanil 10 or 25 mcg/ml. Alfentanil is not routinely used. Morphine is always available.
  • Muscle relaxants: Rocuronium 10 mg/ml. (Succinylcholine 50 mg/ml is always available, as well as atropine during anesthetic procedures)

Resuscitation of Children

If the child shows no signs of life:

  • Start cardiac and pulmonary resuscitation (CPR) with five insufflations
  • Then make three series with 30 compressions and two insufflations
  • Alarm others
  • Continue CPR switching between 30 compressions and two insufflations until help is in place or the child breathes normally

Cardiopulmonary Resuscitation (CPR) to infants

CPR is going to last all the time. Do not stop breathing or pulse control. If possible, replace the one that compresses every two minutes. Just quit CPR if the child begins to breathe normally. Keep in mind that you should not take too long between compression and inflation.

Check in turn: Consciousness. Breathing. Are there any signs of life? Does the baby touch, swallow or breathe normally? Then give the necessary help.

  • Is the child aware? Shout to the baby and nip or shake it gently in the shoulders. If the child does not respond, cry out loudly for help from the surrounding area. Put the child on the back.
  • Does the child breathe?
  • Create open airway
  • See if the chest and stomach moves and what color the child has. Listen if air flows in and out through the mouth and nose. Feel the airflow against your chin. If the child breathes normally: put it in a stable side body position. Continue to check that the baby is breathing. Alarm. If the child does not breathe: Give five slow insufflations. If it is not possible to insufflate air or if the chest is not raised when blowing, there may be some objects in the child’s throat.

The open airway can be created in two different ways: Jaw lift. Carefully bend the child’s head backwards by placing one hand on the child’s forehead. Lift the child’s jaw with the other hand’s pointer and middle finger. In younger infants it is important not to bend the head too far backwards. Bending the head back too strongly may cause airway blocking. Lift the jaw manually. Put one hand on the child’s forehead. Now use the other hand’s thumb to grab the point of the chin of the little child and the mandibel of children over a year. Hold your index finger over the chin and lift the chin upwards. Ventilations.

Infants zero to one years old

Make a jaw lift. Put your mouth over the baby’s mouth and nose. Blow slowly in air for 1-1.5 second, five times. Blow in so much air that the chest is raised and lowered. Check signs of life, any spontaneous movements, swallowing or normal breathing in conjunction with the insufflations.

Infants zero to one years old

The baby can lay on hard surfaces. Start with five insufflations. Use the pointer and middle finger and press the lower third of the sternum. Press 30 times, almost two compressions per second. Each time you push down the baby’s chest a third. Release the chest between the compressions. After 30 compressions, you make two blowouts. Then start over again, with 30 compressions followed by two insufflations. If you’re alone, call 911 (local alarm number) after three series with 30 compressions and two insufflations. Then continue with cardiovascular and pulmonary resuscitation, 30 compressions and two insufflations until the helper is in place or the child breathes normally.

Children 1 years old to puberty

Clamp the nostrils with thumb and index finger. Put your mouth over the baby’s mouth and slowly blow it in for 1-1.5 second, five times. Blow in so much air that the chest is raised and lowered. Check signs of life, movements, swallowing or normal breathing in conjunction with the insufflations .

Does the child show life signs?

If the child shows signs of life but does not breathe normally: Make 20 insufflations for one minute and then call 112. If possible, carry the child to the phone if you are alone. Then continue with insufflations. About 20 insufflations per minute are right. If the child does not show any signs of life: Give cardiac and pulmonary resuscitation (CPR).

 



Inhalation of Racemic Epinephrine

In case of krupp, pseudokrupp or severe bronchospasm.

Dosage for Inhalation Therapy

Body WeightRacepinephrine 22,5 mg/ml
< 5 kg0,25 ml
5-10 kg0,3 ml
10-15 kg0,5 ml
15-20 kg0,7 ml

Syringe Sizes for Pediatric Use

Recomended Syringe Sizes for Children up to 15 kg

MedicationSyringe size
Propofol (Propofol®) 5 ml syringe
Ketamin (Ketalar®) 5 ml syringe
All muscle relaxants1 ml syringe
Fentanyl (Fentanyl®) 1 ml syringe
Morphine (Morphine®)1 ml syringe
Alfentanil (Rapifen®) 1 ml syringe
Anticolinergics (Atropine, Glycopyrrolone)1 ml syringe
(Robinul-Neostigmine®)1 ml syringe
Sodium Thiopentone (Pentothal®) 5 ml syringe (sodium thiopentone)

Recomended Syringe Sizes for Children over 15 kg

MedicationSyringe Size
Propofol (Propofol®) 10 ml syringe
Ketamin (Ketalar®)10 ml syringe
All muscle relaxants3 ml syringe
Fentanyl (Fentanyl®) 3 ml syringe
Morphine (Morphine®)3 ml syringe
Alfentanil (Rapifen®) 3 ml syringe
Anticolinergics (Atropine, Glycopyrrolone)1 ml syringe
(Robinul-Neostigmine®)1 ml syringe
Sodium Chloride10 ml alternativt 5 ml syringe
SuccamethoniumBranded with white syringe label with red text.
Sodium Thiopentone (Pentothal®) 10 ml syringe (thiopentalnatrium)

Tube Sizes for Children

Recomended sizes of Endotracheal Tubes for Children.

Age03 months1 year5 years9 years12 years14 years> 15 years
Weight3 kg5 kg10 kg20 kg30 kg40 kg50 kg> 50 kg
Endotracheal tube inner diameter (mm)33.5456777

Premedication to Children. Paracetamol.

There are a variety of medicines used in premedication to children to get analgesia and anxiolysis. The main principle is that these medicines should be pain relieving and relaxing. The general preoperative care of children with parents is essential to gaining trust from the patient and parents with good and safe anesthesia. Scared and anxious parents can easily spread their concern to the child, preoperative information is essential. During anesthesia induction, it is advisable if only a parent who is calm is present.

Clonidine

Dosage: 2-5 μg/kg orally, provides good sedation in the premedication. The disadvantage is that the drug has a slow onset and must be given in good time, at least 60-90 minutes in advance. Premedication with Mixtur Clonidine Hydrochloride 20 μg/ml or Tablet Clonidine 75 μg.

Dexmedetomidine and Clonidine for Children. Sedation ("Sedanalgesia").

Dexmedetomidine 100 µg/ml Clonidine 150 µg/ml(Catapres)  
IntravenouslyIntranasallyIntravenouslyOrallyEpidurally (EDA)
1 µg/kg (max 200 µg) in an infusion or by a slow injection 1,5-2 µg/kg (MR 4 µg/kg) Max 200 µg1-4 µg/kg x 31-4 µg/kg x 30,1-0,3 µg/kg/tim

Dosage

Dosage interval: 2-4- (6) μg/kg. Dose: We recommend 3 μg/kg. Children <3 years and all children with ENT surgery 2-3 μg/kg. For an eample; the weight of a child is 15 kg x 3 μg/kg = 45 μg gives 2.2 ml (20 μg/ml) clonidine hydrochloride.

Dexmedetomidine

Provides a good premedication for small children who come for ENT surgery and anesthesia. Injection dexmedetomidine (Dexdor®) 100 μg/ml can be given both nasally and buccally. Nasal administration is preferred as it provides better absorption and faster effect. The solution has no taste and does not scratch the nose. Dexmedetomidine is a specific alpha2 receptor agonist and its effect is similar to Clonidine, but more pronounced. The main effects are sedation and some analgesia. Dexmedetomidine has a shorter half-life, approximately 2 hours versus Clonidine 5-10 hours. Onset time is significantly longer compared to orally administered Midazolam, approximately 20-40 minutes.

Dosage

Children 1-3 years are given 1 μg /kg. Children 3-10 years are given 1-2 μg/kg. Children over 10 years of age are given 1-3 μg/kg. The dose may be increased with increasing age to a maximum of 3 μg /kg. Easily, nasal administration is performed with MAD (Mucosal Atomization Device) or MADdy (Pediatric Version) connected to a syringe. Ordinary dose of drug is diluted to the desired volume (usually 0.3-0.5 ml) with physiological saline.

Monitoring

The children must have the presence of parents or staff during the waiting period after application. Peroperative monitoring of blood pressure and ECG. The child may need a prolonged awakening time compared to patients without premedication.

Paracetamol (acetaminophen)

Administered alone or in combination. Common combinations of premedication in children usually contain paracetamol (30 mg/kg x 1) with benzodiazepines or benzodiazepine-like drugs, sometimes with the addition of an NSAID preparation or atropine. Paracetamol is given either as a tablet, oral suspension or as a suppository (Table 6). Children under 6 months are usually not premedicated. Several different drug combinations are common. Different variants of sedative sympathetic stimulants have become more common lately as premedication, such as clonidine and dexmedetomidine. These are usually given as oral solutions but may also be administered intravenously. Routinely, dosage of paracetamol (max oral 30 ml/kg) is given in premedication. Common practice is to give oral paracetamol 24 mg/ml, 1 ml/kg in the care department for most operations. Prior to more painful surgery, children >6 months often receive NSAIDs.

Premedication and Maintenance Therapy with Paracetamol for Children 6-25 kg
 Premedication Maintenance first 2 days
dosage 20 mg/kg body weight
Child weight (kg)Oral solution Paracetamol 24 mg/mlSupp Paracetamol (mg)Tablet Paracetamol (mg)Oral solution Paracetamol 24 mg/mlTablet Paracetamol (mg)Supp Paracetamol (mg)
6 - 8 kg8,5 ml250 mg-2,5 ml x 4-60 mg x 4
8 - 10 kg12 ml310 mg-3,5 ml x 4-125 mg x 3
10 - 12 kg14 ml375 mg-5 ml x 3-125 mg x 4
12 - 15 kg17,5 ml500 mg-5 ml x 4-185 mg x 4
15 - 20 kg22 ml625 mg-7,5 ml x 4-250 mg x 3
20 - 25 kg28 ml750 mg500 mg10 ml x 4500 mg x 3250 mg x 4
Intravenous Paracetamol Dosage for Children
Paracetamol intravenously10 mg/ml
Weight (kg)Dosage
<1 mån7,5 mg/kg
>1 mån15 mg/kg
4 - 10 kg6 - 15 ml x 4
10 - 20 kg15 - 30 ml x 4
20 - 33 kg30 - 50 ml x 4
33 - 50 kg50 - 75 ml x 4
50 - 66 kg75 - 100 ml x 4
>66 kg100 ml x 4
Paracetamol Dosage for Children Orally or Rectally
Loading dose  Maintenance dose  
Weight (kg)Oral solution 24 mg/mlSupp.Weight (kg)Oral solution 24 mg/mlSupp.
32,5 mlS. 60 mg32,5 ml x 3S. 60 mg x 3
43,5 mlS. 60 mg43,5 ml x 3S. 60 mg x 4
55 mlS. 125 mg54 ml x 4S. 125 mg x 3
6 - 87 mlS. 250 mg6 - 85 ml x 4S. 125 mg x 4
9 - 1212 mlS. 310 mg9 - 127,5 ml x 4S. 185 mg x 4
13 - 1516 ml13 - 1511 ml x 4
Weight (kg)Oral solutionTabletWeight (kg)Oral solutionTablet
16 - 1920 mlT. 500 mg16 - 1913 ml x 4T. 250 mg x 4
20 - 2425 mlT. 500 mg20 - 2417 ml x 4T. 500 mg x 3
25 - 3030 mlT. 750 mg25 - 3021 ml x 4T. 500 mg x 4
31 - 3440 mlT. 1000 mg31 - 3425 ml x 4T. 750 mg x 3
35 - 4240 mlT. 1000 mg35 - 4230 ml x 4T. 750 mg x 4
43 - 5050 mlT. 1250 mg43 - 5035 ml x 4T. 1000 mg x 3
50 - 7060 mlT. 1500 mg50 - 7040 ml x 4T. 1000 mg x 4
>70 kg80 mlT. 2000 mg>70 kg40 ml x 4T. 1000 mg x 4

Benzodiazepines – alone or in combination.

A common combination for small children (< 20 kg) is midazolam + atropine in a solution as premedication. This combination is dosed according to a schedule based on weight. Midazolam often leads to a trouble-free peripheral venous catheterization (PVC) if a topical analgetic such as EMLA has been used initially. Midazolam can be given either rectally, 0.3 mg/kg (max 10 mg), or as nasal spray 0.2 mg/kg (max 5 mg) and orally 0.5 mg/kg (max 15 mg).

Midazolam Dosage for Sedation of Children
IntravenouslyRectallyNasallyOrally/PEG 
0,1 mg/kg (max 5 mg)0,2-0,3 mg/kg (max 7,5-10 mg)0,2 mg/kg (max 5 mg)0,3-0,5 mg/kg (max 10-15 mg)
An additional dose can be given according to the schedule below
0,05 mg/kg (after 5 minuter)0,05 mg/kg (after 20 minuter)0,05 mg/kg (after 10 min)0,05 mg/kg (after 20 min)
At least one hour of monitoring after the last doseAt least one and a half hour of monitoring after the last doseAt least one hour of monitoring after the last dose

Some children, such as very anxious or who have previously experienced some anesthesia related pain may require heavier premedication. Flunitrazepam in tablet form 0.05 mg/kg, gives about 20 minutes heavy sedation with moderate effect lasting at least 1 hour. This premedication can be given at the care giving department and the time must be coordinated with the operation department. In some cases, midazolam may be given by the anesthetic staff themselves to facilitate a difficult induction. The child must not be left alone after receiving flunitrazepam or midazolam. Older children may experience moments before the operation to be long and worrisome. Diazepam (Stesolid), tablet or suppository, 0.5 mg/kg, max 25 mg rectally, may cause some relief. Atropine is given by the physician’s ordinance before surgery, either intravenously, p o, s c, rectally or sublingually.

Premedication with midazolam

A common standard mix for children is midazolam + atropine in mixtures given orally (children 10-25 kg). In addition, paracetamol is usually given 30 mg/kg x 1. Pharmacy prepared oral solution Midazolam 1 mg/ml + Atropine 0.05 mg/ml. Dosage: 0.4 mg (= 0.4 ml)/kg according to list below. Maximum dose for the mixture is 10 ml (orange flavor).

Premixed Oral Solution of Midazolam 1 mg /ml with Atropine 0.05 mg/ml for Children 10-25 kg.
Weight (kg)Dose in ml Midazolam/Atropine
104,0
114,5
125,0
135,0
145,5
156,0
166,5
177,0
187,0
197,5
208,0
218,0
228,5
239,0
249,5
2510,0

Premedication with midazolam (children 10-25 kg).

Midazolam + Atropine in mixtures that are mixed in the operating department by the anesthesia staff. Midazolam 1 mg/ml is mixed with Atropin 0.5 mg/ml and fruity juice to a solution of 5-12 ml. Dosage: Midazolam 0.4 mg/kg + Atropine 0.02 m /kg orally according to the list below. In addition, paracetamol is usually given at 30 ml/kg x 1.

Premedication with a blend of Midazolam 1 mg/ml + Atropine 0.05 mg/ml mixed by the Anaesthesia Staff
Weight (kg)Volume in ml of the solutionDose of respective drugs in the solution
Midazolam/Atropine (mg)
104,44,0/0,20
114,94,5/0,225
125,55,0/0,25
135,55,0/0,25
145,555,5/0,275
156,66,0/0,30
167,156,5/0,325
177,77,0/0,35
187,77,0/0,35
198,257,5/0,375
208,88,0/0,40
218,88,0/0,40
229,358,5/0,425
239,99,0/0,45
2410,459,5/0,475
251110,0/0,50

Premedication for rectal administration of midazolam (children 5-20 kg).

Midazolam + atropine in mixtures that are prepared by the anesthesia staff. Midazolam 5 mg/ml is mixed with 2 ml NaCl to the concentration of 3 mg/ml. Dosage 0.3 mg/kg = 0.1 ml/kg + Atropine 0.5 mg/ml is mixed.

Dose of premedication for Rectal Administration of Midazolam/Atropine to Children 5-20 kg
Weight (kg)Midazolam 3 mg/ml
Dose (mg)
Midazolam 3 mg/ml
Volume (ml)
Atropine 0,5 mg/ml
Dose (mg)
Atropine 0,5 mg/ml
Volume (ml)
51,50,50,150,3
7,52,250,750,150,3
10310,150,3
12,53,751,250,250,5
154,51,50,250,5
206,020,250,5
Flumazenil for Reversal of Bensodiazepines
Flumazenil 0,1 mg/ml ivAntidote for bensodiazepine overdose    
5 µg/kg (0,05 ml/kg) intravenously once per minute up to 40 µg/kg (maximum dose 2 mg)If lack of effect: continous infusion 2-10 µg/kg/hour

Ketamine

Another option, especially for children with heart diseases aged 1-4 years, is ketamine in a dosage of 7 mg/kg mixed with midazolam 0.3 mg/kg. In cases where the child does not participate at all, ketamine may be administered intramuscularly. It is possible to give 3-5 mg/kg, occasionally up to 10 mg/kg, preferably as an injection in the deltoid muscle. If you do not want to inject and the child does not cooperate, ketamine may be given orally. Oral induction is time consuming, 20 minutes is needed, until peripheral venous catherization can occur. You can give 6 mg/kg blended in small amounts of liquid, eg. Coca-Cola for oral administration.

Ketamine for Sedation of Children
Ketamine (Ketalar)10 mg/ml50 mg/ml
Iv bolus:0,5 mg/kgIv infusion 0,02-0,12 mg/kg/hour
Rectally4-5 mg/kg
Esketamin (Ketanest)5 mg/ml25 mg/ml
Rectally3 mg/kg
Nasally1,5 mg/kg
Must be combined with Midazolam or Dexmedetomidine!

Barbiturates – Sodium thiopental (thiopentone)

Rectal induction with thiopental (Trapanal, Pentocur – “Pentorect”/”Sleeping tail”) can be given to small children 1-4 years old (10-20 kg) if you do not want to insert a needle when the child is awake. This is an older form of anesthetic that is hardly used anymore. Thiopental (thiopentone) can be given rectally at the dose of 30 mg/kg from a concentrated solution (100 mg/ml). This premedication works well as an anesthetic induction and is given in the operating department. Weight limits are not sharp, this induction often works well for sensitive children weighing 5-30 kg. Maximum dose rectally is 600 mg Thiopental. Thiopental can be used as the sole drug for minor surgical procedures or when you only want the child to lie still, for example, during x-ray examinations and some radiological interventions.

NSAID-drugs

Some medications that can be used for smaller children are ibuprofen (Brufen) and supp diclofenac (Voltaren).

Premedication with Oral Ibuprofen 20 mg/ml for Children 6-10 kg (> 6 months)
Weight (kg)Dose (ml)
7 kg2,5 ml x 3
8 kg3,0 ml x 3
9 kg3,5 ml x 3
10 kg4,0 ml x 3
Ibuprofen for Treatment of Postoperative Pain in Children
IbuprofenOral suspension 20 mg/ml
≥ 6 months 7,5 mg/kg x 4 alt. 10 mg/kg x 3Max 1200 mg/day
0,375 ml/kg x 4 alt. 0,5 ml/kg x 3.Max 60 ml/day
Premedication with Suppositories Diclofenac (Voltaren) 25 mg (>1 year and >10 kg)
Weight (kg)Dosage of suppositories (number)
10 kg½ supp x 2
12,5 kg½ supp x 2
15 kg½ supp x 3
20 kg1 supp x 2
25 kg1 supp x 3
30-40 kg1½ supp x 3
Oral or Rectal Administration of Diclofenac to Children (Only to children ≥ 6 months)
Weight (kg)Supp.Tablet
8-14 kg25 mg25 mg
15-1925+0+25 mg25+0+25 mg
20-2425+0+25 mg25+0+25 mg
25-2750+0+25 mg25+0+25 mg
30-3450+0+25 mg50+0+25 mg
35-4050+0+50 mg50+0+50 mg
40-5050+0+50 mg50+0+50 mg
>50 kg50+50+50 mg50+50+50 mg

Morphine and other strong analgesics for children

Morphine for Pediatric Use
AgeLoading dose morphine (mg/kg)Cont. infusion morphine (μg/kg/h)
0 - 3 months0.055-15
3 - 12 months0.110-20
1 - 5 years0.1510 - 40
6 -12 years0.210 - 40
12 - 16 years0.2510 - 40
Dosage of Morphine for Children
Morphine 1 mg/ml i v
AgeDosage
<3 months50 µg/kg (0,05 mg/kg = 0,05 ml/kg of morphine 1 mg/ml)
3-12 months100 µg/kg (0,1 mg/kg = 0,1 ml/kg of morphine 1 mg/ml)
1-5 years150 µg/kg (0,15 mg/kg = 0,15 ml/kg of morphine 1 mg/ml)
5-12 years200 µg/kg (0,20 mg/kg = 0,20 ml of morphine 1 mg/ml)
12-15 years250 µg/kg (0,25 mg/kg = 0,25 ml/kg of morphine 1 mg/ml)
Oxycodone to Children
Oxycodone1 mg/ml
Oral solution0,1-0,2 mg/kg (max 10 mg) up til 4 times/day
Given against severe opioid-sensitive pain.NOTE! At least one hour of monitoring after the last dose!
Fentanyl to Children
Fentanyl50 µg/ml (0.05 mg/ml)
Intravenously1 µg/kg
Nasally>3 years 1,5 µg/kg
Naloxone to Children
Naloxone i vDosage 2 µg/kgThe dose may be repeated if necessary
Weight (kg)Solution 20 µg/mlSolution 0,4 mg/ml (children > 20 kg)
3 - 5 kg0,3 - 0,5 ml
5 - 10 kg0,5 - 1,0 ml
10 - 20 kg1,0 - 2,0 ml
20 - 40 kg2,0 - 4,0 ml0,1 - 0,2 ml
40 - 80 kg4,0 - 8,0 ml0,2 - 0,4 ml

Antiemetics for Children

Ondansetron to Children (Dose 0,1 mg/kg)
Weight (kg)Intravenous Dose
Solution 2 mg/ml
Weight (kg)Oral dose
Solution 0,8 mg/ml
Oral dose
Tablet
≥1 months: 0,1 mg/kgMax 4 mg x 4≥1 months: 0,2 mg/kgMax 8 mg x 4
8 - 14 kg1 mg = 0,5 ml< 15 kg2 mg = 2,5 ml2 mg
15 - 24 kg2 mg = 1 ml15 - 30 kg4 mg = 5 ml4 mg
25 - 34 kg3 mg = 1,5 ml> 30 kg8 mg = 10 ml8 mg
> 35 kg4 mg = 2 ml
Other Antiemetics for Children
Betametasone 4 mg/mlIntravenous injection 
Dosage2 mg/kgMax dose 4 mg x 1
Metoclopramide  5 mg/mlIntravenous injectionChildren ≥ 1 year
Dosage0,15 mg/kg/doseMax dose 10 mg x 3
Phenergan  25 mg/mlChildren ≥ 1 year
Intravenously0,5 mg/kg
OrallyTablet or Solution Children ≥ 1 year. Max dose 25 mg x 4
Droperidol  (Dridol) 2,5 mg/mlIntravenously 0,010 - 0,075 mg/kgMax dose 1,25 mg x 4-6

Common Parenteral Medications for Children

Recommended Dosage of Parenteral Medications for Children

MedicationConcentrationDose
Adenosine1 mg/ml100 μg/kg, increased by 50 μg/kg for each dose, step up to 300 μg/kg. Quick flush. Preferred in CVC.
Epinephrine (Adrenalin)0,1 mg/mlFor anaphylaxis: 1-2 μg/kg. At heart stop: 10 μg/kg
Atropine0,5 mg/ml10 μg/kg. Max 0,5 mg/dose.
Betametasone (Betapred)4 mg/ml0,2 mg/kg. Max dose: PONV 4 mg Max dose: anafylaxi 8 mg
Calcium gluconate0,5 ml/kgMax 10 ml/dose.
Fentanyl50 μg/ml1-2 μg/kg
Furosemide10 mg/ml0,1-0,5 mg/kg
Clonidine15 μg/ml1-2 μg/kg x 3-6/day.
Midazolam1 mg/ml0,05-0,1 mg/kg
Morphine1 mg/ml0,05-1 mg/kg
Naloxone0,02 mg/ml10 μg/kg (adult 0.1-0.2 mg) Repeat as needed at 2 min intervals
Esomeprazole (Nexium)8 mg/ml0,5 mg/kg x 2
Ondansetrone2 mg/ml0,1 mg/kg. Max x 4/day.
Paracetamol10 mg/ml<1 year or 10 kg: 7.5 mg/kg.
>1 year: 15 mg/kg. Max x 4 / day
Hydrocortisone (Solu-Cortef)50 mg/ml5 mg/kg. Max 100 mg/dose.
Diazepam (Stesolid)5 mg/ml0,2-0,3 mg/kg
Klemastine (Tavegyl)1 mg/ml0,05 mg/kg. Max x 2/day. Slow infusion.
Sodium Bicarbonate (Tribonat)0,5 mmol/mlWeight x BE x 0.3 = mmol buffer. Start giving half the amount. At heart stop: 2 mmol/kg
Budesonide (Pulmicort)0,25 mg/ml 0,25 mg x 2
Salbutamol (Ventoline)1 mg/ml or 5 mg/ml0,15 mg/kg x 4 – 6 (max x 24) Max 5 mg/dose.
Micronefrin-RacepinephrineRacepinephrine conc: 22,5 mg/ml0,05 ml/kg/dose (max 0,75 ml/dose) <5 kg 0,25 ml
Remember to pull up drugs in as small syringes as possible! If the dose is <0.5 ml then pull into 1 ml syringe
These are no general ordinances but rather an aid in the work with children. All medicines must be prescribed in writing on the daily record by name, strength and amount.

Dosage of Infusions for Children

Recommended Dosage of Drug Infusions for Children

MedicationConcentrationInfusion doseNotes
Epinephrine (Adrenalin)20 μg/ml20-300 nanog/kg/minTo be given in CVC
Amiodarone- Cordarone15 mg/mlEv. loading dose 5 mg/kg
given for 1-4 hours. Maintenance dose 0.3-1 mg/kg/h
Max 1200 mg/24 h. Total treatment dose 100 mg/kg
Dopamine2 mg/ml2,5-20 μg/kg/minTo be administered in CVC
Furosemide10 mg/ml0,5-1 mg/kg/h
Potassium Chloride1 mmol/ml0,1-0,4 mmol/kg/hMax 15 mmol/h.
Clonidine15 μg/ml0,5-2 μg/kg/h
Midazolam<15 kg 1 mg/ml ≥15 kg 5 mg/ml0,05-0,2 mg/kg/hBolus dose: 0,05-0,1 mg/kg.
Morphine<15 kg 0,1 mg/ml ≥15 kg 1 mg/ml5-30 μg/kg/hBolus dose: 0,05-0,1 mg/kg.
Norepinephrine (Noradrenalin)20 μg/ml20-300 nanog/kg/minTo be administered in CVC
Propofol (Propolipid)20 mg/ml1-4 mg/kg/hChildren> 3 years. Bolus: 1-3 mg/kg

Parenteral Antibiotics for Children

Recommended Doses of Parenteral Antibiotics to Children

MedicationConcentrationDoseNote
Erythromycin (Abboticin®)10-15 mg/kg x 3Caution in liver failure and in heart disease (arrhythmias). Dose reduction in renal impairment.
Phenoxymethylpenicilline (Bensyl PCV)100 mg/ml25-50 mg/kg x 3 (3g x 3) alt. 50-100 mg/kg x 4 (3 g x 4)
Cefotaxime (Cefotaxim®)100 mg/ml30 mg/kg x 3. (1g x 3) alt. 75-100 mg/kg x 3 (3 g x 3)
Ceftazidime (Ceftazidim®)100 mg/ml25 mg/kg x 3 (1 g x 3) alt. 50 mg/kg x 3 (2 g x 3) alt. 35 mg/kg x 3 (2 g x 3) Children< 2 months: 25 mg/kg x 2 Diluted with sterile water. Given for 3-5 min.
Cefuroxime (Cefuroxime®)100 mg/ml20-30 mg/kg x 3 (0,75-1,5 g x 3)Diluted with sterile water. Given for 3-5 min.
Clindamycin (Dalacin®)10 mg / kg x 3 (600 mg x 3)
No child <4 weeks age
Cloxacillin (Cloxacillin®)50 mg/mlDiluted with sterile water. Given in CVC 3-5 min. All infusion in pvc: Then dilute once more with NaCl 9mg/ml to 20 mg/ml. 20-30 min.
Meropenem (Meronem®)50 mg/ml40 mg/kg x 3 (2 g x 3) alt. 20 mg/kg x 3-4 (2 g x 3-4) alt. 10-20 mg/kg x 3 (0,5-1 g x 3)Diluted with sterile water. Given for 3-5 min.
Tobramycin (Nebcin®)10 mg/ml7.5 mg/kg x 1. Higher dose 8-10-(12) mg/kg x1
can be used in CF and neutropenic fever.
Nebcina 40 mg/ml is diluted with NaCl 9 mg/ml alt. Glucose 50 mg/ml. Infusion for 20-60 min.
Vancomycin (Vancocin®)5 mg/ml20 mg/kg x 2 (-3) (1 g x 2) ev x 3Diluted in two steps. First stock solution with sterile water to 50 mg/ml. Then dilute with sodium chloride 9 mg/ml or glucose 50 mg/ml to 5 mg/ml. Infusion for at least 60 minutes.
Piperacillin/Tazobactam80 mg/kg x 3-4 alt. 100 mg/kg x 3-4 (4 g x 3-4)
Ceftriaxone (Rocephalin®)100 mg/kg x 1. (2 g x 1)
Linezolid (Zyvoxid®)10 mg/kg x 2 (600 mg x 2)(max 28 days)

Pain Assessment Scales for Children 0-7 years.

FLACC – Face, Legs, Activity, Cry, Consolability

For pain estimation of children 0-7 years, a behavioral scale for pain estimation is used, it can also be used for children with multiple disabilities.

  • Note the child for a few minutes and then look at face /legs/activity/cry/comfortability and decide whether the scoring graduation 0, 1 or 2 suits the child.
  • Then add the score, to a maximum of 10 points.
  • A value of <3 is sought. At values ​​<4, nursing measures may be sufficient, at values > 4, pain relief should be considered.
  • When any pain is suspected and nursing measures do not help the child, a test of analgesic delivery is done.
  • Evaluate the result with a new pain estimation.

FLACC Behavioral Scale Children

Try to observe the child for at least
2 minutes
0 points1 points2 points
FaceNeutral facial expressions or smilesBister eyesight, wrinkles the forehead occasionally, withdrawn, uninterestedFrequent or constantly wrinkled brow, trembling chin, bumpy jaws
LegsNormal position or relaxedWorried, restless or tense legsKicking or legs drawn
ActivityStands calm, normal position, moves unobstructedScrews, often changes position, tenseArc, raises or stems
CryingNo crying (awake or sleeping)Gnaws or smells, complains off and onCrying persistently, screaming or sneaking, complaining often
Ability to comfortSatisfied, relaxedCan be calm with touch, hugs or chatting. Distractable.Hard to comfort or calm

AS – Facial Expression Scale

AS is a modified VAS scale for children 5-18 years. It consists of six faces, 1st face counting as 0 points and 6th face as 10 points. At 4 points and above, consideration should be given to pain relief. Keep in mind that some children may confuse state of mind with pain. Do not ask “Does it hurt” ask instead “Do you feel anything from the wound. If the answer becomes “Yes”, then ask “How does it feel “? If the child replies pain ask “How bad are you?” “Can you show on this scale?”


MAC-values for Children

Age effect on MAC for children

Age of Patient (Years)Sevoflurane in oxygen (%)Sevoflurane in 65% N2O/35% O2
0 - 1 months*3.3%Undetermined
1 - <6 months3.0%Undetermined
6 months - <3 years2.8%2,0 %**
3 to 12 years2.5%Undetermined
* Newborns after the end of pregnancy. MAC in prematures has not yet been established.
** In pediatric patients 1 - <3 years old, 60% N2O/40% O2 was used.

Product Information on Medicines for Children.

The presence or absence of information in the product information specific for children are seen here. For nasal use, information is not available for all medicines. The information may differ between different preparations with the same active substance.

Pharmaceutical Information for Children
Substance / substance groupDosage for children in product informationAge of dosage or other relevant information in product information
Lidocaine/prilocaine YesCream / patches. Premature children or children with increased risk of methemoglobinemia.
Lidocaine/tetracain YesPlaster: Children > 3 years.
LidocaineYesInjection solution: Children >1 year.
Glucose 300 mg/mL NoIndications for the treatment of pain are missing
Paracetamol YesFullterm newborns
Ibuprofen YesChildren >3 months or >5 kg
Diclofenac YesChildren > 6 years. Gel: Contraindicated to children <14 years
MorphineNo
Ketobemidone No
Oxicodone YesTablets for children > 12 years. Oral solution: Not approved for children
Fentanyl YesDosage for children > 2 years is available for i.v. use
Dexmedetomidin NoApproved for sedation of adults in the intensive care department
Ketamine Yes
Nitrous OxideYes
Clonidine NoPain / sedation is not accepted indications for any age group
Midazolam YesChildren < 5 years may require higher doses (mg/kg) than older children
Diazepam YesChildren > 1 year rectally. Children may require higher doses (mg/kg) than adults.
NaloxoneYes
* Product information (Summary of Products Characteristics) for all authorized drug substances is available at www.lakemedelsverket.se

Optiflow for children

Flow in Highflow Grid (Optiflow) for children.

WeightFlow (l/min)
2-6 kgChild's weight + 1 l up to 2 l/kg
7-9 kgChild's weight + 1-2 l
10-14 kgStart at 10 l / min increase as required to 15 l / min
15-19 kgStart at 15 l / min increase as required to 20 l / min
20-49 kg20-25 l/min
>50 kg25 l/min up to 40 l/min


Steroid Substitution for Children

Children’s steroid substitution schedule is recommended for children < 30 kg. For children weighing 30-60 kg, the half-adult schedule is recommended. Children over 60 kg are counted as adults and recommended adult schedule.

Injection betametason 1 mg/mlDose (ml)Dose (mg)
Day 12 ml x 22 mg x 2
Day 22 ml x 22 mg x 2
Day 31 ml x 21 mg x 2
Day 41 ml x 21 mg x 2
Day 50,5 ml x 10,5 mg x 1
Day 60,5 ml x 10,5 mg x 1
OrallyTablet 0,5 mgDose (mg)
Day 14 st x 22 mg x 2
Day 24 st x 22 mg x 2
Day 32 st x 21 mg x 2
Day 42 st x 21 mg x 2
Day 51 st x 10,5 mg x 1
Day 61 st x 10,5 mg x 1