What is the maximum dosing of furosemide (Lasix) for pediatric edema?

Maximum Dosing of Furosemide for Pediatric Edema

For pediatric edema, the maximum recommended dose of furosemide is 10 mg/kg per day, with doses exceeding 6 mg/kg/day not to be given for periods longer than one week to avoid ototoxicity. 1

Dosing Guidelines for Furosemide in Pediatric Edema

Initial Dosing

• For initial treatment, furosemide can be administered at 0.5-2 mg/kg per dose intravenously or orally 1
• When given with albumin infusions, consider an intravenous bolus of furosemide (0.5-2 mg/kg) at the end of each albumin infusion in the absence of marked hypovolaemia or hyponatraemia 1
• For oral maintenance therapy in pediatric patients, the FDA recommends starting at 2 mg/kg body weight as a single dose 2

Dose Escalation and Maximum Dosing

• Dosing frequency can be increased up to six times daily based on the degree of edema and diuresis achieved 1
• If diuretic response is not satisfactory after initial dose, dosage may be increased by 1-2 mg/kg no sooner than 6-8 hours after the previous dose 2
• The maximum recommended dose is 10 mg/kg per day for severe edema 1
• Doses greater than 6 mg/kg body weight are not recommended for maintenance therapy according to FDA labeling 2
• High doses of furosemide (>6 mg/kg/day) should not be given for periods longer than 1 week to avoid hearing loss 1

Administration Considerations

• Infusions should be administered over 5-30 minutes to minimize the risk of ototoxicity 1
• For maintenance therapy, the dose should be adjusted to the minimum effective level 2
• In stable patients, furosemide can be given orally at doses of 2-5 mg/kg per day, potentially in combination with a thiazide or potassium-sparing diuretic 1

Monitoring and Safety Considerations

Required Monitoring

• Adequate monitoring should include assessment of fluid status, electrolytes (particularly for hypokalaemia or hyponatraemia), blood pressure, and kidney function (diuresis and estimated glomerular filtration rate) 1
• Electrolyte disturbances are the most frequent side effects of high-dose furosemide therapy, especially in patients with gastroenteritis 3

Contraindications and Precautions

• Furosemide must be stopped in the case of anuria 1
• Diuretics should be used with caution and only in cases of intravascular fluid overload (evidenced by good peripheral perfusion and high blood pressure) 1
• Avoid furosemide in patients with marked hypovolaemia, as it could induce or increase hypovolaemia and promote thrombosis 1

Special Considerations for Different Clinical Scenarios

Congenital Nephrotic Syndrome

• In patients with congenital nephrotic syndrome, diuretics improve edema and fluid control, especially when given with albumin infusions 1
• If potassium-sparing diuretics are needed, epithelial sodium channel (ENaC) inhibitors like amiloride are preferable to spironolactone 1

Acute Renal Failure

• In children with acute renal failure, a broad relationship has been observed between single IV dose and diuretic response with furosemide doses ranging from 1.2 to 30.8 mg/kg 3
• For acute renal failure, it is suggested that the total daily dose should not exceed 100 mg in children 3

Continuous vs. Intermittent Infusion

• Continuous infusion yields comparable urinary output with a lower total dose of furosemide compared to intermittent administration 4
• Intermittent administration is associated with greater fluctuations in urinary output and increased fluid replacement needs 4

By following these dosing guidelines and monitoring parameters, furosemide can be safely and effectively used to manage pediatric edema while minimizing the risk of adverse effects.