What is the recommended pediatric atropine dose (mg/kg, minimum and maximum single dose, repeat interval) for systemic indications such as symptomatic bradycardia or organophosphate poisoning?

Pediatric Atropine Dosing

For symptomatic bradycardia in children, administer atropine 0.02 mg/kg IV/IO with a minimum single dose of 0.1 mg and maximum single dose of 0.5 mg (1.0 mg for adolescents), repeatable every 5 minutes up to a total dose of 1 mg in children or 2 mg in adolescents. 1, 2

Dosing by Clinical Indication

Symptomatic Bradycardia or AV Block

• Initial dose: 0.02 mg/kg IV/IO 1, 2, 3
• Minimum single dose: 0.1 mg (prevents paradoxical bradycardia from very low doses) 1, 2, 3
• Maximum single dose: 0.5 mg for children; 1.0 mg for adolescents 1, 2, 3
• Repeat interval: Every 5 minutes as needed 1, 2, 3
• Maximum total dose: 1 mg for children; 2 mg for adolescents 1, 2, 3

Critical first step: Oxygenation and ventilation are essential initial maneuvers before atropine administration, as hypoxia-induced bradycardia typically responds to these interventions alone. 1, 2 Epinephrine is the drug of choice if oxygen and adequate ventilation fail to correct hypoxia-induced bradycardia. 1, 3

Organophosphate or Carbamate Poisoning

For severe poisoning with bronchospasm, bronchorrhea, seizures, or significant bradycardia, atropine must be given immediately. 1

• Initial dose: 0.02-0.05 mg/kg IV (up to initial adult dose of 2-5 mg) 1, 2
• Titration strategy: If response to initial dose is inadequate, double the dose and repeat every 10-20 minutes as needed to achieve full atropinization 1, 2
• Endpoint of therapy: Dry pulmonary secretions, clear chest on auscultation, heart rate >80/min, systolic blood pressure >80 mm Hg 1
• Maintenance: Atropine infusion can maintain atropinization after initial boluses 1

Organophosphate poisonings may require extraordinarily large cumulative doses (adult patients may need 10-20 mg in the first 2-3 hours, up to 50 mg in 24 hours). 2 Do not withhold adequate atropine doses due to fear of overdose, as inadequate dosing can be fatal. 2

Essential adjunctive therapy: Atropine must be combined with pralidoxime (oximes) to address nicotinic receptor dysfunction and respiratory muscle paralysis, as atropine alone has minimal effect on these symptoms. 1, 2 Benzodiazepines (diazepam first-line or midazolam) are required to treat seizures and agitation. 1

Rapid Sequence Intubation (RSI) Premedication

• Dose: 0.01-0.02 mg/kg IV/IO 1, 2, 4
• Minimum dose: 0.1 mg 1, 4
• Maximum dose: 1 mg 1, 4
• Timing: Administer before sedative/anesthetic and paralytic agents 1, 2

Important caveat: Do not routinely use atropine for RSI premedication in all pediatric patients, as it may be unnecessary for many patients. 2

Neonatal Dosing Considerations

• Neonatal dose: 0.01-0.03 mg/kg IV/IO 1, 3
• No minimum dose required: Recent American Heart Association guidelines (2015) eliminated the previous 0.1 mg minimum dose requirement for neonates after evidence demonstrated efficacy and safety with 0.02 mg/kg without a minimum dose. 3

Alternative Routes When IV/IO Access Unavailable

Endotracheal Administration

• Neonates: 0.01-0.03 mg/kg 1, 2, 3
• Children and adolescents: 0.03-0.06 mg/kg 1, 2, 3
• Technique: Follow with or dilute in saline flush (1-5 mL) based on patient size 1, 2

Intramuscular Route

• Dose: 0.02-0.04 mg/kg IM 1

Critical Safety Considerations and Common Pitfalls

Concentration errors are common and potentially fatal. Atropine sulfate comes in different concentrations (typically 0.1 mg/mL and 0.4 mg/mL); calculate dosage carefully to avoid 10-fold errors. 1, 2

Administration technique matters: For cardiac arrest, administer atropine by slow IV push to avoid paradoxical bradycardia. 2, 3

Monitor continuously: Watch heart rate and blood pressure during and after administration; observe for reversal of bradycardia within 3 minutes (peak action time). 2

Tachycardia warning: Atropine may cause tachycardia, which could worsen ischemia in patients with underlying cardiac conditions or acute coronary syndrome. 2, 3

Contraindications in specific heart blocks: Do not use atropine for type II second-degree AV block or third-degree AV block with wide-complex escape rhythm, as it is ineffective and potentially harmful in these conditions. 2

Organophosphate poisoning pitfall: In young children with organophosphate or carbamate poisoning, absence of classic muscarinic effects (miosis, salivation, diarrhea) does not exclude the diagnosis—central nervous system depression and severe hypotonia may be the predominant presentation. 5 Tachycardia is not a contraindication to atropine treatment in organophosphate toxicity. 6