Maintenance Dose of Amiodarone in Pediatric Patients
The recommended maintenance dose of oral amiodarone in pediatric patients is 5 mg/kg/day, typically administered 5 days per week after an initial loading period. 1, 2
Dosing Algorithm for Pediatric Amiodarone
Loading Phase
- Oral loading: Administer 10 mg/kg/day for 10 days 1
- Alternative loading regimens of 10-15 mg/kg/day have been used successfully in some studies 3
- IV loading (for acute situations): 5 mg/kg bolus followed by 10 mg/kg/day continuous infusion 1, 4
Maintenance Phase
- Standard maintenance dose: 5-7 mg/kg/day administered 5 days per week 1
- This intermittent dosing schedule (5 days on, 2 days off) helps minimize cumulative toxicity while maintaining therapeutic efficacy 1
- Some protocols use continuous daily dosing at 5 mg/kg/day, though the intermittent schedule is more commonly reported 2
Dose Adjustments
- The maintenance dose should be titrated to the lowest effective level to minimize side effects 2
- In cases where side effects develop (particularly corneal deposits), dose reduction rather than discontinuation may be sufficient 2
- Mean effective maintenance doses in clinical practice typically settle around 5 mg/kg/day 2
Critical Monitoring Requirements
Mandatory Surveillance
Thyroid function tests: Check quarterly during therapy 1
Holter monitoring: Perform quarterly to assess arrhythmia control and detect bradycardia 1
Ophthalmologic examination: Every 6 months to detect corneal deposits 1
- Corneal deposits occur but rarely impair visual acuity in children 1
Chest radiography and echocardiography: Annually to screen for pulmonary fibrosis 1
Common Pitfalls and Adverse Effects
High incidence of side effects (24% in long-term pediatric use) necessitates vigilant monitoring 2:
- Photosensitivity: Occurs in 22% of children—counsel families about sun protection 1
- Bradycardia: More pronounced in infants less than 1 year old; reduction in sinus automatism is expected 1
- AV conduction delays: First-degree AV block may develop; monitor ECG regularly 1
- Pulmonary toxicity: Rare but serious; any new respiratory symptoms require immediate evaluation 2
- Thyroid dysfunction: Requires laboratory and clinical monitoring; may necessitate treatment discontinuation in 8% of cases 1
Efficacy Data
Oral amiodarone demonstrates exceptional efficacy in pediatric arrhythmias:
- Complete effectiveness in 77% of children with oral therapy 1
- Partial response in 5%, ineffective in only 18% 1
- Success maintained over mean follow-up of 13 months 1
- Particularly effective for supraventricular tachycardia associated with Wolff-Parkinson-White syndrome, with 90% of patients becoming asymptomatic within 5 days 3
Special Considerations for Cardiac Arrest
For shock-refractory VF/pulseless VT during cardiac arrest, the dosing differs significantly from maintenance therapy:
- Bolus dose: 5 mg/kg IV/IO during cardiac arrest 5
- May repeat up to 2 times for refractory rhythms 5
- This acute dosing is distinct from chronic maintenance therapy and applies only to resuscitation scenarios 5
Drug Interactions in Pediatric Patients
When initiating amiodarone maintenance therapy, adjust concomitant medications 5:
- Digoxin: Reduce dose by 30-50% as amiodarone increases digoxin levels 5
- Monitor for bradycardia when combining with other AV nodal blocking agents 5
Practical Implementation
The typical pediatric maintenance regimen follows this pattern:
- Complete 10-day loading at 10 mg/kg/day 1
- Transition to 5-7 mg/kg/day for 5 days weekly 1
- Assess response at 5 days (most patients become asymptomatic) 3
- Continue maintenance dosing with quarterly monitoring 1
- Adjust dose downward if side effects emerge, rather than discontinuing immediately 2
The extremely long half-life of amiodarone (15-100 days, average 58 days) means therapeutic effects persist long after dose adjustments, requiring patience when titrating 6, 7