• Excessive respiratory secretions can often cause distress to the child and carers in the terminal phase
• Drug treatment is more effective if started before or immediately the secretions are evident
• Anti-secretory agents may cause drowsiness and anti-cholinergic side-effects: glycopyrronium has less CNS side effects than hyoscine hydrobromide because it does not cross the blood brain barrier

Management

General measures

• Positioning the child carefully can often reduce noisy breathing considerably
• Suction may be helpful in a few children, but is only recommended in the oral cavity unless the child is used to and tolerant of suction further down
• Gentle physiotherapy can also help if it is available.
• Explanation and reassurance is sometimes all that is needed at the end of life

Medication

Hyoscine hydrobromide

Form

Tablets: 150µg, 300µg
Patch: 1mg/72hr
Injection: 400µg in 1mL, 1mL ampoule. 600µg in 1mL, 1mL ampoule.

Dose: (Oral or SL)

2–12yr: 10µg/kg, (max. 300µg q.d.s.)
12–18yr: 300µg q.d.s.

Dose (transdermal)

1 month–3 years: quarter of a patch every 72h
3–10 years: half of a patch every 72h
10–18 years: one patch every 72h

Dose (SC, IV)

Single dose:

1 month-18yr: 10µg/kg (max 600µg) every 4-8h

Subcutaneous/intravenous continuous infusion

All ages: 40-60µg/kg/24h (max. dose 2400µg/24h) Can cause delirium or sedation with repeated dosing

Licence: transdermal preparation licensed for use in children >10yr for motion sickness.

Glycopyrronium Bromide

Form

Injection: 200µg in 1mL, 1mL ampoules

(Also available as tablets: 1mg, 2mg; named patient basis only)

Dose (oral)

1 month -18yr: 40-100µg/kg t.d.s.-q.d.s (max 2mg/dose tds)

Dose (SC)

1 month -12yr: 4-10µg/kg (max. 200µg/dose) t.d.s.-q.d.s.
12-18yrs: 200µg every 4hours as required

Dose (continuous SC infusion)

1 month -12yr: 10-40µg/kg/24hr (max: 1200µg/24h).
12-18yr: 600µg/24hr (max: 2400µg/24h)

Oral administration injection solution may be given or tablets may be crushed and suspended in water.