Table 2.

Dosing of pain medications for acute vaso-occlusive episodes in children with SCD

Medication	Dosing	Daily dose limit	Notes
Acetaminophen	10 to 15 mg/kg/dose (maximum 650 mg to 1 g/dose) by mouth every 4–6 h	75 mg/kg/day or 4 g/day (whichever is less)	Administer ‘round the clock’. Contraindicated in severe hepatic impairment.
NSAID by mouth: Ibuprofen or naproxen	Ibuprofen: 10 mg/kg/dose (maximum 400 mg to 600 mg/dose) by mouth every 6–8 h Naproxen: 5 to 7 mg/kg/dose (maximum 250 mg to 500 mg/dose) by mouth every 8–12 h	Ibuprofen: 40 mg/kg/day or 2400 mg/day Naproxen: 1 g/day	Administer “round the clock”. Contraindicated with impaired renal function or GI bleeding. Choose oral or IV NSAID, not both.
NSAID IV: Ketorolac	0.5 mg/kg/dose IV every 6–8 h	<16 years: 15 mg/dose ≥16 years: 30 mg/dose	Administer “round the clock”. Caution with impaired renal function or GI bleeding. Limit therapy to 48 h Choose oral or IV NSAID, not both.
Fentanyl	1 to 2 mcg/kg/dose intranasal (maximum 100 mcg/dose)	Use x 1 to 2 doses (maximum 100 mcg total) until alternative mode of analgesia is administered. Use fentanyl 50 mcg/mL for a maximum of 1 mL/nostril.	Use for patients above 1 year of age. Divide dose between both nostrils to maximize absorption.
Morphine by mouth	0.2 to 0.5 mg/kg/dose by mouth every 4–6 h (maximum 15 mg/dose)		Start at lower end in opioid-naive patients
Morphine IV (intermittent dosing)	0.1 mg/kg/dose IV (maximum 7.5 mg/dose) over 5 minutes, repeat up to every 3 h	May add 0.05 mg/kg (maximum 5 mg) hourly as needed	Consider lower doses in opioid-naive patients If pain is insufficiently controlled with intermittent morphine dosing, consider initiating a morphine infusion or patient-controlled analgesia (PCA). Consultation with paediatric hematology is recommended. If patient is intolerant or allergic to morphine, liaise with paediatric hematology for alternative analgesia options.

GI Gastrointestinal; IV Intravenous; NSAID Non-steroidal anti-inflammatory drug.

Adapted from reference (15).