What is the recommended starting dose of noradrenaline (norepinephrine) for neonates and pediatric patients?

Noradrenaline (Norepinephrine) Dosing in Neonates and Pediatric Patients

The recommended starting dose of noradrenaline (norepinephrine) for neonates is 0.1-1.0 μg/kg/min, and for pediatric patients is 0.1-1.0 μg/kg/min, titrated to desired clinical effect. 1

Dosing Guidelines by Age Group

Neonates

• Starting dose: 0.1-0.5 μg/kg/min 2, 3
• Titration range: Up to 1.0 μg/kg/min 1
• Maximum dose: Up to 5.0 μg/kg/min in severe cases 1

Infants and Children

• Starting dose: 0.1-0.5 μg/kg/min 1
• Titration range: 0.1-2.5 μg/kg/min 4
• Maximum dose: Up to 2.5 μg/kg/min (mean maximum dose in clinical practice) 4

Clinical Indications

1. Continued shock after volume resuscitation 1

   • Start at the lowest dose (0.1 μg/kg/min)
   • Titrate to desired clinical effect
   • Monitor blood pressure response every 5-15 minutes during initial titration

2. Septic shock 4

   • May require higher doses (up to 2.5 μg/kg/min)
   • Ensure adequate volume resuscitation before initiation (median 50 mL/kg) 4

3. Pulmonary hypertension of the newborn 2, 3

   • Effective in both term and preterm infants
   • May be used as first or second-line agent

Administration Guidelines

Route of Administration

• Preferred route: Central venous access
• Alternative routes in emergencies:
  • Peripheral venous access (safe for short-term use up to 3-4 hours) 4
  • Intraosseous route (safe for emergency administration) 4

Preparation and Administration

• Standard concentration: 1 mg in 100 mL (10 μg/mL)
• Administration: Always use an infusion pump for accurate dosing
• Monitoring: Continuous heart rate, blood pressure, and perfusion monitoring

Expected Clinical Response

Most neonates and children respond with:

• Increased mean blood pressure within 1 hour of initiation 3
• Improved tissue perfusion 2
• Decreased vasoactive inotrope score within 24 hours 5
• Improved urine output within 24 hours 5

Potential Adverse Effects

• Common: Tachycardia (occurs in approximately 31% of patients) 2, 3
• Less common: Transient hypertension 2
• Rare: Arrhythmias 4
• Local complications: Tissue necrosis with extravasation

Management of Extravasation

If extravasation occurs:

• Immediately stop the infusion
• Consider phentolamine (0.1-0.2 mg/kg up to 10 mg diluted in 10 mL of 0.9% sodium chloride) injected intradermally at extravasation site 1

Important Clinical Considerations

1. Volume status: Always ensure adequate volume resuscitation before starting noradrenaline
2. Monitoring: Continuous cardiovascular monitoring is essential
3. Titration: Titrate to clinical effect rather than a predetermined dose
4. Weaning: Wean gradually to avoid rebound hypotension

Special Populations

Preterm Infants

• Generally tolerate noradrenaline well at lower doses (median 0.5 μg/kg/min) 3
• Normotension typically achieved within 1 hour of initiation 3
• Higher mortality associated with younger gestational age and worse cardiovascular function at initiation 3

Septic Shock

• May require higher doses than other indications 4
• Ensure adequate fluid resuscitation before initiation

Common Pitfalls to Avoid

1. Inadequate volume resuscitation before starting noradrenaline
2. Failure to monitor for extravasation when administering through peripheral access
3. Rapid discontinuation without appropriate weaning
4. Delayed initiation in cases of fluid-refractory shock
5. Inadequate dose titration based on clinical response

Noradrenaline appears to be effective and safe in the pediatric population when administered appropriately, with careful monitoring and dose titration based on clinical response.