13.4 Palliative Care & Pediatric Pharmacotherapy

Palliative Care & Pediatric Pharmacotherapy

Palliative care and pediatrics sit at opposite ends of life. Both reward the same skill: matching drug choice, dose and formulation to physiology and to what matters to the patient and family.

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Part A: Palliative Care

1. Goals of Care Drive the Medication List

When the goal shifts from prolonging life to comfort, preventive medications lose their purpose. Examples are low-dose ASA for primary or secondary prevention, statins, osteoporosis drugs, tight glycemic control and most vitamins. Deprescribing them reduces pill burden, interactions and adverse effects. Medications that relieve symptoms (pain, anxiety, insomnia, neuropathic pain, depression) are kept or adjusted. PEBC sample items have tested exactly this: a patient who wants only quality-of-life medications should stop preventive ASA, not their analgesics or anxiolytics.

2. Pain

• Strong opioids are central. Give regular doses for constant pain, plus breakthrough doses of about 10% of the total daily opioid dose, available every 1 to 2 hours orally as needed.
• Renal failure: morphine and codeine metabolites accumulate (myoclonus, sedation). Hydromorphone is used cautiously. Fentanyl and methadone are preferred in severe renal impairment.
• Adjuvants: dexamethasone for bone pain, nerve compression and liver capsule pain; gabapentinoids or antidepressants for neuropathic pain; NSAIDs for bone pain when renal function and bleeding risk allow.
• Routes: the subcutaneous route (intermittent doses via a butterfly or continuous infusion) is preferred when patients cannot swallow. Subcutaneous hydromorphone or morphine is roughly twice as potent as the oral form.
• Every patient on a regular opioid needs a scheduled laxative.

3. Other Symptoms

4. Medical Assistance in Dying (MAID)

Under the Criminal Code, the physician or nurse practitioner who prescribes a substance for MAID must inform the pharmacist that it is intended for MAID before it is dispensed. Pharmacists who object on conscience grounds must still ensure that care is not abandoned: they follow provincial college policies on effective referral or transfer of care, without delay or obstruction.

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Part B: Pediatric Pharmacotherapy

5. Why Children Are Different

• Neonates: immature glucuronidation and renal function. Chloramphenicol causes the gray baby syndrome. Sulfonamides and ceftriaxone can displace bilirubin (kernicterus risk). Ceftriaxone must not be given with IV calcium solutions in neonates.
• Body water: higher total body water gives a larger volume of distribution for water-soluble drugs (aminoglycosides need higher mg/kg doses).
• Drugs to avoid:
  • Tetracyclines under 8 years (tooth staining).
  • ASA in children and teenagers with viral illness (Reye syndrome).
  • Codeine and tramadol under 12 years. Health Canada advises against them because ultrarapid CYP2D6 metabolizers can develop fatal respiratory depression. They are also avoided after tonsillectomy or adenoidectomy in anyone under 18.
  • Honey under 1 year (infant botulism).
  • Non-prescription cough and cold products under 6 years (Health Canada labelling).
• Dosing is usually mg/kg (or BSA), capped at the adult dose. Always verify the concentration of the liquid product. Most pediatric dosing errors are tenfold errors with liquids.

6. Fever and Pain in Children

• Acetaminophen: 10 to 15 mg/kg every 4 to 6 hours. Maximum 5 doses (75 mg/kg) a day, not to exceed the adult maximum.
• Ibuprofen: 5 to 10 mg/kg every 6 to 8 hours (maximum 40 mg/kg/day) for infants 6 months and older. Give with fluids, and avoid it in dehydration.
• The goal is the child's comfort, not a normal temperature. The Canadian Paediatric Society does not recommend routinely alternating or combining the two drugs for fever, because of dosing confusion.
• Refer urgently:
  • any fever in an infant under 3 months;
  • lethargy, a non-blanching rash or neck stiffness;
  • signs of dehydration;
  • fever lasting more than 72 hours.

7. Formulation and Adherence

• Choose the formulation: concentrated suspensions, chewable tablets, or small capsules that can be opened or swallowed. Mixing a full dose into a large volume of juice risks an incomplete dose.
• Use an oral syringe, never a household spoon. Write doses in mL only.
• Taste: chilling the suspension or giving a cold item first can help. Flavouring services are available in many pharmacies.

8. Dehydration and Common Parent Questions

• Mild to moderate dehydration from vomiting or diarrhea is treated with an oral rehydration solution given in small, frequent amounts (for example, 5 mL every 1 to 2 minutes with a syringe or spoon). Continue breastfeeding and the usual diet as tolerated. Juices and sports drinks contain too much sugar and too little sodium.
• Refer a child with few wet diapers, no tears, sunken eyes, lethargy, bloody diarrhea, or persistent vomiting.
• Antidiarrheals: loperamide is not used for self-care in young children.
• Teething: discomfort is managed with chilled teething rings and age-appropriate acetaminophen or ibuprofen, rather than topical anesthetic gels.