Pediatric Amiodarone Dosing
For pediatric cardiac arrest, administer 5 mg/kg IV/IO as a rapid bolus, which may be repeated up to 2-3 times for refractory ventricular fibrillation or pulseless ventricular tachycardia. 1
Cardiac Arrest Dosing (IV/IO)
- Bolus dose: 5 mg/kg administered rapidly during cardiac arrest 1, 2
- May repeat up to 2 times (per 2010 guidelines) 1 or 3 total doses (per 2020 guidelines) 1 for refractory VF/pulseless VT
- Administer immediately after defibrillation attempts in shockable rhythms 1
- Resume CPR immediately after each dose with minimal interruptions 1
Clinical context: The 2020 AHA guidelines updated the maximum number of doses from 2 to 3 total doses, reflecting evolving evidence for refractory arrest situations. 1 Both guidelines maintain the same 5 mg/kg bolus dose, which has remained consistent across pediatric resuscitation protocols.
Non-Arrest Arrhythmia Dosing (IV/IO)
Acute Treatment (Intravenous)
- Loading dose: 5 mg/kg administered over 20-60 minutes for hemodynamically stable tachyarrhythmias 1
- Maintenance infusion: 10 mg/kg/day as continuous infusion after loading 3, 4
- Monitor continuously for bradycardia and hypotension during infusion 1, 4
Oral Loading Regimen
- Loading: 10-15 mg/kg/day for 4-10 days 3, 5, 6
- Maintenance: 5-7 mg/kg/day for 5 days per week 3, 6
- Alternative maintenance: 5 mg/kg daily continuously 5
Efficacy data: Oral amiodarone demonstrates complete effectiveness in 77% of pediatric patients, with partial response in 5% and failure in only 18%. 2, 3 For Wolff-Parkinson-White syndrome specifically, 90% of patients become asymptomatic within 5 days of therapy. 2, 5
Critical Monitoring Requirements
During IV Administration
- Continuous ECG monitoring for heart rate, AV conduction abnormalities, and QT prolongation 7, 4
- Monitor for bradycardia (occurs in 4.9% of patients) and hypotension (occurs in 16%) 7, 8
- If heart rate decreases by 10 beats per minute, reduce infusion rate immediately 7
- Watch for second- or third-degree heart block, which requires immediate discontinuation 7
During Oral Therapy
- Thyroid function tests every 6 months during maintenance 7, 8
- Liver function tests every 6 months 7
- Ophthalmologic examination every 6 months for corneal deposits 3
- Chest x-ray and echocardiography annually to screen for pulmonary toxicity 3
Important Drug Interactions and Adjustments
- Reduce digoxin dose by 30-50% when initiating amiodarone, as amiodarone predictably doubles digoxin levels 2, 7, 8
- Reduce warfarin dose by one-third to one-half and monitor INR weekly for first 6 weeks 7, 8
- Avoid combining with other AV nodal blocking agents (beta-blockers, calcium channel blockers) due to additive bradycardia risk 2, 7
- Prohibit grapefruit juice consumption as it inhibits metabolism and increases plasma levels 7
Age-Specific Considerations
- Infants under 1 year: More pronounced reduction in sinus automatism; monitor heart rate closely 3
- Neonates and young infants: Can safely use as first-choice drug for life-threatening arrhythmias 3
- Amiodarone metabolism is faster in children than adults, resulting in more rapid onset (mean 4.1 days) and earlier relapses after discontinuation (3.3 weeks) 6
Common Adverse Effects in Pediatric Patients
- Photosensitivity: Occurs in 22% of children; counsel sun protection 3
- Thyroid dysfunction: Blood level fluctuations of T3/T4 in 86%, but usually remain within normal ranges 3
- Corneal deposits: Rare in children; do not typically impair visual acuity 3
- First-degree AV block: May develop during therapy 3
- Overall side effect rate requiring discontinuation: approximately 19% 9
Pharmacokinetic Properties
- Half-life: 15-100 days (average 58 days), meaning therapeutic effects persist long after dose adjustments 2, 8
- Significant overlap exists between IV and oral dosing due to prolonged half-life 7, 8
- Full antiarrhythmic effect may take days to weeks despite adequate serum levels 8
- Target serum concentrations during maintenance: 1.30-2.06 µM/L (effective range in adults) 4