What is the recommended dose of Narcan (naloxone) for a pediatric patient?

Pediatric Naloxone Dosing

For pediatric opioid overdose with respiratory depression, administer naloxone 0.1 mg/kg IV/IM/IO, with lower doses of 0.01-0.05 mg/kg for therapeutic opioid reversal to avoid complete analgesia loss. 1

Standard Dosing by Age and Weight

Children Under 5 Years or Less Than 20 kg

• 0.1 mg/kg IV/IO/IM/SC for opioid-induced apnea or respiratory depression 1
• Doses may be repeated every 2 minutes as needed to maintain reversal 1

Children 5 Years or Older or 20 kg or Greater

• 2 mg IV/IO/IM/SC as standard dose 1
• This represents the weight-based equivalent that transitions to a fixed adult-like dose 1

Intranasal Route (Alternative)

• 2-4 mg intranasally for opioid overdose 1
• Repeat every 2-3 minutes as needed 1
• This route is particularly useful when IV access is unavailable in emergency settings 1

Critical Dosing Considerations

Lower Doses for Therapeutic Reversal

Use 0.01-0.05 mg/kg (or 1-15 mcg/kg) when reversing respiratory depression from therapeutic opioid administration rather than overdose. 1 This prevents complete reversal of analgesia while restoring adequate respiratory drive and protective airway reflexes. 1 The goal is titration to reversal of respiratory depression, not complete opioid antagonism. 1

Repeat Dosing Strategy

• Naloxone's duration of action (30-45 minutes to 1 hour) is shorter than most opioids 1
• Repeat doses every 2-3 minutes until desired respiratory response 1
• Patients require continuous monitoring for at least 2 hours after the last naloxone dose for recurrence of respiratory depression 1

Continuous Infusion for Prolonged Effect

For long-acting opioid ingestions or inadequate response to bolus dosing:

• Initial bolus: 0.01 mg/kg IV 2
• Continuous infusion: 0.4 mg/hr (approximately 0.027 mg/kg/hr for average-sized child) 2
• This approach has been safely used for up to 9 hours with total doses reaching 280 mcg/kg without toxicity 2
• Alternative calculation: two-thirds of the initial waking dose per hour 1

Route-Specific Administration

Intravenous/Intraosseous (Preferred)

• Onset: 1-2 minutes 1
• Most reliable and fastest route for critically ill patients 1

Intramuscular/Subcutaneous

• Acceptable when IV/IO access unavailable 1
• Slightly delayed onset compared to IV route 1

Endotracheal (Not Recommended in Newborns)

• ET route specifically not recommended for newborn infants 1
• Less predictable absorption 1

Critical Safety Warnings

Neonates with Maternal Opioid Use

Do not administer naloxone to newborns whose mothers have suspected long-term opioid use due to risk of acute withdrawal syndrome and seizures. 1 This represents a life-threatening complication that outweighs the benefits of naloxone in this specific population.

Opioid-Dependent Patients

• May precipitate acute withdrawal syndrome in any opioid-dependent pediatric patient 1
• Withdrawal symptoms can include agitation, vomiting (with aspiration risk), and in severe cases, seizures 3
• Use lowest effective dose and titrate carefully 1

Cardiovascular Effects and Monitoring

Naloxone administration in children causes predictable cardiorespiratory changes:

• Respiratory rate increases by 4.7-6.8 breaths/min 4
• Heart rate increases by approximately 5 beats/min 4
• Blood pressure increases by 6 mmHg systolic and 4 mmHg diastolic 4
• Systolic hypertension occurs in 17% of patients, diastolic hypertension in 7% 4
• These changes typically resolve spontaneously without intervention 4

Rare but Serious Complications

Pulmonary edema has been reported in approximately 0.5% of pediatric cases, particularly with rapid or high-dose administration. 4 This risk is higher in patients receiving naloxone for severe pain management reversal rather than overdose. 3

Special Clinical Scenarios

Combined Opioid-Benzodiazepine Poisoning

Administer naloxone first (before flumazenil) when combined opioid and benzodiazepine poisoning is suspected. 1 This prioritizes reversal of respiratory depression from the opioid component, which poses the more immediate life threat.

Maximum Documented Safe Doses

• Pediatric patients have safely received up to 11 doses of 0.2 mg (total 2.2 mg) 5
• A single case report documents a 2.5-year-old receiving 20 mg without adverse sequelae 5
• A 4.5-year-old received 11 doses over 12 hours without complications 5
• However, standard dosing should not exceed what is necessary for clinical effect 1

Monitoring Requirements

All patients receiving naloxone require:

• Continuous cardiorespiratory monitoring for minimum 2 hours after last dose 1
• Extended monitoring if long-acting opioid involved 1
• Oxygen saturation monitoring 1
• Blood pressure monitoring, especially with doses exceeding 0.1 mg/kg 4