BNF for Children 2011-2012

BNFC 2011–2012 Prescribing in palliative care 19anxiety. Sublingual lorazepam or subcutaneous orbuccal midazolam are alternatives. A nebulised shortactingbeta 2agonist (section 3.1.1.1) or a corticosteroid(section 3.2), such as dexamethasone or prednisolone,may also be helpful for bronchospasm or partialobstruction.Excessive respiratory secretion Excessive respiratorysecretion (death rattle) may be reduced by hyoscinehydrobromide patches (p. 198) or by subcutaneousor intravenous injection of hyoscinehydrobromide 10 micrograms/kg (max. 600 micrograms)every 4 to 8 hours; however, care must betaken to avoid the discomfort of dry mouth. Alternatively,glycopyrronium (p. 636) may be given.For the administration of hyoscine hydrobromide bysubcutaneous or intravenous infusion using a continuousinfusion device, see p. 20.Fungating tumours Fungating tumours can be treatedby regular dressing and antibacterial drugs; systemictreatment with metronidazole (p. 296) is often requiredto reduce malodour, but topical metronidazole (p. 587)is also used.Hiccup Hiccup due to gastric distension may be helpedby a preparation incorporating an antacid with an antiflatulent(p. 37).Hypercalcaemia See section 9.5.1.2.Insomnia Children with advanced cancer may notsleep because of discomfort, cramps, night sweats, jointstiffness, or fear. There should be appropriate treatmentof these problems before hypnotics (p. 169) are used.Benzodiazepines, such as temazepam, may be useful.Metoclopramide has a prokinetic action and is used bymouth for nausea and vomiting associated with gastritis,gastric stasis, and functional bowel obstruction. Drugswith antimuscarinic effects antagonise prokinetic drugsand, if possible, should not therefore be used concurrently.Haloperidol (p. 174) is used by mouth or by continuousintravenous or subcutaneous infusion for most metaboliccauses of vomiting (e.g. hypercalcaemia, renal failure).Cyclizine (p. 193) is used for nausea and vomiting due tomechanical bowel obstruction, raised intracranial pressure,and motion sickness.Ondansetron (p. 197) is most effective when the vomitingis due to damaged or irritated gut mucosa (e.g. afterchemotherapy or radiotherapy).Antiemetic therapy should be reviewed every 24 hours;it may be necessary to substitute the antiemetic or toadd another one.Levomepromazine (p. 175) can be used if first-line antiemeticsare inadequate. Dexamethasone by mouth canbe used as an adjunct.For the administration of antiemetics by subcutaneousinfusion using a continuous infusion device, see below.For the treatment of nausea and vomiting associatedwith cancer chemotherapy, see section 8.1.Pruritus Pruritus, even when associated with obstructivejaundice, often responds to simple measures suchas application of emollients (p. 552). Ondansetron maybe effective in some children. Where opioid analgesicscause pruritus it may be appropriate to review the doseor to switch to an alternative opioid analgesic. In thecase of obstructive jaundice, further measures includeadministration of colestyramine (p. 70).Prescribing in palliative careIntractable cough Intractable cough may be relievedby moist inhalations or by regular administration of oralmorphine every 4 hours. Methadone linctus should beavoided because it has a long duration of action andtends to accumulate.Mucosal bleeding Mucosal bleeding from the mouthand nose occurs commonly in the terminal phase,particularly in a child suffering from haemopoeiticmalignancy. Bleeding from the nose caused by a singlebleeding point can be arrested by cauterisation or bydressing it. Tranexamic acid (p. 123) may be effectiveapplied topically or given systemically.Nausea and vomiting Nausea and vomiting arecommon in children with advanced cancer. Ideally, thecause should be determined before treatment with anantiemetic (section 4.6) is started.Nausea and vomiting with opioid therapy are less commonin children than in adults but may occur particularlyin the initial stages and can be prevented by givingan antiemetic. An antiemetic is usually necessary onlyfor the first 4 or 5 days and therefore combined preparationscontaining an opioid with an antiemetic arenot recommended because they lead to unnecessaryantiemetic therapy (and associated side-effects whenused long-term).Raised intracranial pressure Headache due toraised intracranial pressure often responds to a highdose of a corticosteroid, such as dexamethasone, for 4to 5 days, subsequently reduced if possible; dexamethasoneshould be given before 6 p.m. to reduce therisk of insomnia. Treatment of headache and of associatednausea and vomiting should also be considered.Restlessness and confusion Restlessness and confusionmay require treatment with haloperidol (p. 174)10–20 micrograms/kg by mouth every 8–12 hours.Levomepromazine (p. 175) is also used occasionallyfor restlessness. See also p. 20.Continuous infusion devicesAlthough drugs can usually be administered by mouthto control symptoms in palliative care, the parenteralroute may sometimes be necessary. Repeated administrationof intramuscular injections should be avoided inchildren, particularly if cachectic. This has led to the useof portable continuous infusion devices such as syringedrivers to give a continuous subcutaneous infusion,