What is the starting dose of oral oxycodone (opioid analgesic) for a 5-year-old pediatric patient weighing 12 kg?

Starting Dose of Oral Oxycodone for a 5-Year-Old Weighing 12 kg

For this 5-year-old child weighing 12 kg, start with oral oxycodone 0.6-1.8 mg (0.05-0.15 mg/kg) every 4-6 hours as needed for moderate to severe pain. 1

Weight-Based Dosing Calculation

• The American Thoracic Society guideline provides the pediatric oral oxycodone starting dose range of 0.05-0.15 mg/kg for opioid-naive patients with moderate to severe pain 1
• For a 12 kg child, this translates to:
  • Low end: 0.6 mg (12 kg × 0.05 mg/kg)
  • High end: 1.8 mg (12 kg × 0.15 mg/kg)
• Start at the lower end of this range (0.6-1.0 mg) and titrate upward based on pain response and tolerability 1, 2

Critical Dosing Considerations

• The pediatric dose should never exceed the corresponding adult starting dose (5-10 mg), which is not a concern for this 12 kg patient 1
• Population pharmacokinetic studies confirm that weight-based dosing without age adjustment is appropriate for children 6 months to 7 years old 3
• Duration of effect is 4-6 hours, so dosing intervals should be every 4-6 hours as needed 1

Formulation and Administration

• Liquid formulation is strongly preferred for a 5-year-old child, as 98% of children under 6 years receive liquid opioid formulations in clinical practice 4
• Liquid oxycodone is typically available as 1 mg/mL or 5 mg/5 mL concentration 4
• For a starting dose of 0.6-1.0 mg, this would be 0.6-1.0 mL of the 1 mg/mL concentration 4

Multimodal Approach Requirement

• Opioids should NOT be prescribed as monotherapy—they must be combined with nonpharmacologic therapies and nonopioid analgesics (acetaminophen and/or ibuprofen) 2
• The American Academy of Pediatrics 2024 guideline emphasizes that opioids are indicated only when pain is not adequately controlled with nonopioid approaches 2

Prescribing Limitations and Safety

• Prescribe immediate-release formulations only (never extended-release for acute pain) 2
• Initial supply should be 5 days or fewer unless pain is related to trauma or surgery with expected duration longer than 5 days 2
• Start with the lowest age- and weight-appropriate dose and titrate based on clinical response 5, 2

Absolute Contraindications

• Never prescribe codeine or tramadol for patients younger than 12 years due to risk of respiratory depression and death 2
• Exercise extreme caution if the child is taking other sedating medications (benzodiazepines, antihistamines) due to increased risk of respiratory depression 1, 2

Essential Safety Measures

• Provide naloxone to caregivers along with instructions on recognition of overdose and naloxone administration 2
• Counsel on safe storage (locked location, out of reach of children) and proper disposal of unused medication 2
• Direct observation of medication administration by caregivers is recommended to prevent accidental ingestion by siblings or the patient taking extra doses 2
• Monitor closely for respiratory depression, especially within the first 24-72 hours of initiating therapy 5

Common Pitfalls to Avoid

• Do not round doses to convenient volumes that exceed weight-based calculations—this is a common source of dosing errors in young children 6
• Verify the child's current weight rather than relying on historical weights, as weight discrepancies occur in 3.6% of prescriptions and can lead to significant dosing errors 4
• Do not prescribe tablets for a 5-year-old—liquid formulations are appropriate and safer for this age group 4
• Avoid prescribing large quantities—the average liquid opioid prescription is 106 mL, but most is unused and becomes a source of diversion 4

Monitoring and Titration

• Reassess pain and side effects within 24 hours of initiating therapy 5, 2
• Titrate dose upward by 25-50% if pain control is inadequate and no concerning side effects are present 5
• Common side effects include nausea, constipation, drowsiness, and pruritus—these tend to decrease over time but may require symptomatic management 7
• Be prepared to provide respiratory support and have naloxone immediately available, as respiratory depression is the most serious adverse effect 1, 2