What is a recommended intravenous (IV) analgesic for a 3-year-old child?

Recommended IV Analgesics for a 3-Year-Old Child

Intravenous fentanyl is the recommended first-line IV analgesic for a 3-year-old child, administered at a dose of 1-2 micrograms/kg, titrated to effect. 1

Primary IV Analgesic Options

Opioid Options

• Fentanyl:

  • Dosage: 1-2 micrograms/kg IV for initial pain management
  • For breakthrough pain in PACU: 0.5-1.0 micrograms/kg, titrated to effect 1
  • Advantages: Rapid onset, short duration, hemodynamic stability

• Alternative opioids (if fentanyl unavailable):

  • Morphine: 25-100 micrograms/kg depending on age, titrated to effect
  • Nalbuphine: 0.1-0.2 mg/kg for children >3 months

Non-Opioid IV Options

• IV Paracetamol (Acetaminophen):

  • Loading dose: 15-20 mg/kg
  • Maintenance: 10-15 mg/kg every 6-8 hours 1
  • Can be used alone for mild pain or as adjunct to reduce opioid requirements

• IV NSAIDs (e.g., ibuprofen):

  • Dosage: 10 mg/kg every 8 hours 1
  • Particularly useful when combined with paracetamol

Stepwise Approach Based on Pain Severity

For Mild Pain

1. IV paracetamol (15-20 mg/kg loading dose)
2. Consider IV NSAID if no contraindications

For Moderate Pain

1. IV paracetamol + IV NSAID (combination reduces opioid requirements) 1
2. Add IV tramadol (1-1.5 mg/kg) if additional analgesia needed 2

For Severe Pain

1. IV fentanyl (1-2 micrograms/kg) or alternative opioid
2. Add IV paracetamol and/or IV NSAID as adjuncts
3. Consider regional anesthesia techniques if appropriate for the clinical situation

Special Considerations for Tramadol

Tramadol may be considered as an intermediate option between non-opioids and full opioids:

• Dosage: 1-1.5 mg/kg IV, titrated to effect 2
• Maximum daily dose: 8 mg/kg/day, not exceeding 400 mg 2
• Advantages: Less respiratory depression than traditional opioids
• Cautions: Monitor for nausea, vomiting, dizziness, and potential for seizures 2

Important Safety Considerations

• Dosing precision: Weight-based dosing is critical in pediatric patients
• Monitoring: All children receiving IV opioids require appropriate cardiorespiratory monitoring
• Respiratory depression: The primary risk with opioid administration; have reversal agents available
• Contraindications:
  • Avoid NSAIDs in dehydrated children or those with renal impairment 3
  • Use tramadol with caution in children with seizure history 2

Breakthrough Pain Management

For breakthrough pain in the post-anesthesia care unit (PACU):

• IV fentanyl: 0.5-1.0 micrograms/kg, titrated to effect 1
• Alternative: IV tramadol 1-1.5 mg/kg if opioid-sparing approach desired 2

The choice of IV analgesic should be guided by the severity of pain, underlying condition, and potential for adverse effects, with fentanyl being the first-line option for moderate to severe pain in this age group.