Restlessness and agitation are not uncommon during the terminal phase. Nursing the child in a calm, peaceful, and preferably familiar environment is helpful, as is having a parent or other trusted adult present; many children settle when held by parents or family. It is important to exclude pain or inadequate positioning as a cause of distress. Hypoxia may also be a factor.

Management

Medication

Midazolam

Form

Injection: 1mg/mL, 2mg/mL, 5mg/mL
Injection may be diluted if required, in sodium chloride 0.9% or glucose 5%. Injection can be used for buccal, intranasal, oral or rectal administration.
Oral solution: 2.5mg/mL
Buccal liquid: 5mg/mL).

Other oral and buccal liquids (e.g. Epistatus® 10mg/mL) are also available from ‘specials’ manufacturers or specialist importing companies (unlicensed). NOTE The buccal and oral formulations available may differ in strength – take care with prescribing.

Single doses

Oral

>1month -18yr: 500µg/kg (maximum 20mg) as a single dose.

Intravenous/subcutaneous

>1month -18yr: 100µg/kg

Buccal

>1month -18yr: 100µg/kg (max. 5mg)

Intranasal

>1month -18yr: 200-300µg/kg

Intranasal route may be unpleasant but has a fast onset of action (5-15 minutes).

Dose (Continuous intravenous/subcutaneous infusion)

Your starting point will depend on the child’s previous medication and need for symptom control. If in doubt start at a lower dose and be prepared to titrate up over a short period until symptoms are controlled. Seek specialist advice if uncertain.

Well absorbed subcutaneously. Titrate dose up according to need.

Midazolam is compatible in a syringe driver with diamorphine, cyclizine and other commonly used drugs.

Contraindications and warnings: caution with pulmonary disease, hepatic and renal dysfunction (reduce dose), severe fluid /electrolyte imbalance and congestive cardiac failure. Avoid rapid withdrawal after prolonged treatment.

Licence: Not licensed for this indication in children.

Levomepromazine

Form

Tablets: 25mg (6mg available as ‘special’)
Injection: 25mg in 1mL, 1ml ampoule

An extemporaneous oral solution may be prepared.

Dose (SC/IV )

1–12 years: 350µg/kg/24 hours (maximum initial dose 12.5 mg), increasing as necessary up to 3mg/kg/24hr
12–18 years: 12.5mg/24 hours increasing as necessary up to 200mg/24hr

Titrate according to need.
Also acts as antiemetic.
May lower seizure threshold.
Can be used in conjunction with midazolam.

Licence: Licensed for use in children with terminal illness for the relief of pain and accompanying anxiety and distress.