What is the recommended dose of Naloxone (Narcan) for pediatric patients?

From the Guidelines

The recommended dose of naloxone (Narcan) for pediatric patients with suspected opioid overdose is 0.1 mg/kg per dose, as indicated by the most recent guidelines 1.

Key Considerations

• For children under 5 years or weighing less than 20 kg, the initial dose is typically 0.1 mg/kg.
• For older children and adolescents, a starting dose of 2 mg is appropriate, which can be administered intranasally, intramuscularly, intravenously, or subcutaneously.
• If there is no response after 2-3 minutes, the dose should be repeated, with multiple doses potentially required due to naloxone's shorter duration of action compared to many opioids.

Administration and Monitoring

• For intranasal administration, the concentrated 4 mg/0.1 mL formulation is preferred.
• When administering naloxone, be prepared for potential withdrawal symptoms, including agitation, vomiting, and tachycardia.
• Supportive care, including airway management and ventilation, should be provided alongside naloxone administration.

Mechanism of Action

• Naloxone works by competitively binding to opioid receptors, displacing the opioid and temporarily reversing respiratory depression and other opioid effects, as supported by the guidelines 1.

Important Notes

• The ideal dose of naloxone may vary, and it is often necessary to titrate the dose to achieve control of critical signs and symptoms.
• Consultation with a medical or clinical toxicologist, regional poison center, or topic-specific reference may be necessary for detailed dosing and administration instructions, especially in complex cases.

From the FDA Drug Label

Pediatric Patients Up to 11 doses of 0.2 mg naloxone (2. 2 mg) have been administered to children following overdose of diphenoxylate hydrochloride with atropine sulfate. Pediatric reports include a 2½ year-old child who inadvertently received a dose of 20 mg naloxone for treatment of respiratory depression following overdose with diphenoxylate hydrochloride with atropine sulfate. The child responded well and recovered without adverse sequelae There is also a report of a 4½ year-old child who received 11 doses during a 12-hour period, with no adverse sequelae.

The pediatric dose of Narcan is not explicitly stated in the label, but based on the reports, 0.2 mg of naloxone has been administered to children. However, the label does mention a case of a 2½ year-old child who received a dose of 20 mg naloxone without adverse sequelae.

• The information provided is based on case reports and not on a systematic study.
• Dosing should be individualized and based on close monitoring of the patient's response.
• It is essential to consult a poison control center for the most up-to-date patient management information 2.

From the Research

Pediatric Narcan Dose

• The optimal dose of naloxone for pediatric patients is not explicitly stated in the provided studies, but a study from 3 found that a continuous low-dose naloxone infusion of 0.25 μg/kg/h was effective in ameliorating opioid-induced side effects in children receiving intravenous patient-controlled analgesia morphine.
• However, the same study found that the minimum naloxone dose at which patients were successfully treated with a <10% side effect/failure rate was 1 μg/kg/h.
• Another study from 4 investigated the effect of low-dose naloxone infusion on fentanyl requirements in critically ill children and found that a low-dose naloxone infusion of 0.25 microg/kg per hour did not decrease fentanyl requirements.
• It's worth noting that the studies provided do not specifically address the use of Narcan (naloxone) for opioid overdose reversal in pediatric patients, but rather its use in ameliorating opioid-induced side effects or its effectiveness in cardiac arrest situations.

Naloxone Administration

• A study from 5 discusses the safety of naloxone in a prehospital setting and notes that naloxone dose and route of administration can produce variable intensity of potential adverse reactions and opioid withdrawal symptoms.
• The same study mentions that intravenous administration and higher doses of naloxone produce more adverse events and more severe withdrawal symptoms in those individuals who are opioid dependent.
• A study from 6 found that naloxone administration during cardiac arrest in suspected opioid overdosed patients was associated with a change in cardiac rhythm in 42% of patients.

Limitations of Naloxone

• A study from 7 examines the pharmacology of naloxone and its safety and limitations in reversing opioid-induced respiratory depression, noting that long-acting opioids and those with a high affinity at the µ-opioid receptor and/or slow receptor dissociation kinetics are particularly resistant to the effects of naloxone.