Pediatric Drug Dosing Guidelines

1/5/24, 12:22 PM Print – IWK Drug Information Resource
Pediatric Drug Dosing Guidelines

January 05, 2024 12:21 PM
abatacept - [Orencia]
Juvenile Idiopathic Arthritis
Intravenous (6-17 years )
Less than 75 kg
10 mg/kg/dose IV at weeks 0, 2, 4 then monthly thereafter.
75 to 100 kg
750 mg IV at weeks 0, 2, 4 then monthly thereafter.
Greater than 100 kg
1000 mg IV at weeks 0, 2, 4 then monthly thereafter.
Subcutaneous (2-17 years)

10 kg to less than 25 kg
50 mg subcutaneous weekly
87.5 mg subcutaneous weekly
50 kg and greater
Uveitis
10 mg/kg/dose IV at weeks 0, 2, 4 then monthly thereafter.

Maximum: 750 mg/dose
Supplied: Injection: 250 mg, 125 mg/mL
acetaminophen - [Tylenol]
November 2022: For printable patient information on managing pediatric pain and fever at home during acetaminophen
shortage please click here
Refer to 6 Steps to Success in Pill Swallowing and Tips on Success in Pill Swallowing to support patients during the shortage.
Intravenous acetaminophen must be ordered by a staff prescriber with Anesthesia / General Surgery / Hematology-Oncology/
Neurosurgery /NICU/ PICU
Injection is restricted to patients who meet one or more of the following:
Unable to take oral meds for strict NPO or mucositis and rectal route not an option
Developmental delay and lack of cooperative with oral medications
Surgery lasting longer than 6 hours (one dose)
Maximum number of doses before reassess is described in the order set linked below.
General
Oral
10-15 mg/kg/dose PO every 4 to 6 hours PRN

Maximum: 75 mg/kg/24h OR 4 grams/24h
https://www.dir.iwk.nshealth.ca/DrugDosingGuidelines/Print?PatientPopulation=Ped 1/182
Rectal
*Prescribers: see important information below about ordering rectal doses
15-20 mg/kg/dose PR every 6 hours PRN

Maximum: 80 mg/kg/24h OR 4 grams/24h
Intravenous
Prescribers: see important information regarding restricted use above and in order set
Must use clinical order set IWKACET "Intravenous Acetaminophen For Analgesia"
Comments
* Although weight based RECTAL dosing is provided above, doses MUST be rounded to and ordered as one of the doses listed
below to accommodate the available strengths in the care area:
30 mg
45 mg (1 x 30 mg + 1/2 x 30 mg)
60 mg
90 mg (1 x 60 mg + 1 x 30 mg)
120 mg
162.5 mg (1/2 x 325 mg)
180 mg (120 mg + 60 mg)
240 mg (2 x 120 mg)
325 mg
445 mg (1 x 325 mg + 1 x 120 mg)
487.5 mg (1 x 325 mg + 1/2 x 325 mg)
650 mg
Not all suppository strengths in "Supplied" below are in all care areas at the IWK. 30 mg and 60 mg strengths are not likely
available in community pharmacies.
Supplied: Injection: 10 mg/mL

Solution: 32 mg/mL
Suppository: 30 mg IWK Compounded, 60 mg IWK Compounded, 120 mg, 325 mg, 650 mg
Suspension: 32 mg/mL
Tablet: 325 mg, 500 mg
Tablet, Chewable: 160 mg
acetaZOLAMIDE
Renal Adjustment
Diuretic
5 mg/kg/dose PO once daily OR every second day
Increased intracranial pressure
6-8 mg/kg/dose PO TID - Dose may be titrated up to:

Maximum: 100 mg/kg/24h OR 2000 mg/24h
Urinary Alkalinization
5 mg/kg/dose PO BID to TID
Glaucoma
2.6-10 mg/kg/dose PO TID

Maximum: 1000 mg/24h
Supplied: Suspension: 25 mg/mL IWK Compounded

Tablet: 250 mg
acetylcysteine - [N-acetylcysteine, NAC]

Renal Adjustment
Antidote
Go to Atlantic Canada Poison Centre Antidote Kit for information on antidote dosing and use SINGLE CONCENTRATION protocol.
OR
Go to clinical order set IWK INNAC “Intravenous N-Acetylcysteine Protocol for Acute Acetaminophen Ingestion”

Solution: 50 mg/mL IWK Compounded
acetylsalicylic acid - [ASA, Aspirin]

Although weight based dosing is provided below, doses MUST be rounded when ordered to accommodate these available
strengths:
20 mg
40 mg
60 mg
80 mg
Do not use in patients less than 16 years of age who have chicken pox, influenza or flu-like illness due to risk of Reye's
syndrome. Not recommended for antipyresis in children.
Renal Adjustment
Kawasaki's Disease
Febrile
7.5-12.5 mg/kg/dose PO every 6 hours until fever resolves
Once patient is afebrile for 24-48 hours
3-5 mg/kg/dose PO daily

Maximum: 80 mg/dose
Antiplatelet (Cardiology patients)

Note: Adequate pediatric studies have not been done
Usual 3-5 mg/kg/dose PO daily . Doses may range between 1-5 mg/kg/dose PO daily.
Maximum: 80 mg/dose
Supplied: Tablet, Chewable: 80 mg

Tablet, Enteric Coated: 81 mg
acyclovir
Acyclovir may precipitate in kidneys if the patient is dehydrated.
Ensure adequate hydration during and for at least 2 hours following administration.
Manufacturer suggests 1 litre of fluid/24 hours/gram of acyclovir and recommends a minimum urine output of 500 mL/24
hours/gram of acyclovir
Ideal Body Weight (IBW) should be used for obese patients requiring intravenous therapy. Go to IBW calculator
Various Indications
Go to Firstline
Genital Herpes Simplex Virus Infection

First Episode
Less than 12 years
Consult Infectious Diseases
Greater than 12 years
Go to Canadian Guidelines on Sexually Transmitted Infections
Herpes Simplex and Zoster Prophylaxis, Immunocompromised Patient
25 mg/kg/dose PO BID
Maximum: 800 mg/24h
Frequent Recurrences
26 mg/kg/dose PO TID

Tablet: 200 mg
adalimumab - [Humira]
Crohn's Disease
17 to 39 kg AND Greater than 6 years of age
Day 1
80 mg subcutaneous once followed by:
Day 15
Day 29
20 mg subcutaneous every 2 weeks
Greater than or equal to 40 kg

Day 1 (or Day 1 and 2- i.e. may be given over 2 days)
Day 15
Day 29
40 mg subcutaneous every 2 weeks . After 12 weeks may increase to weekly dosing to manage flares.
Ulcerative Colitis
Less than 40 kg
Day 1
Go to Body Surface Area (BSA) Calculator
100 mg/m*2/dose subcutaneous once followed by:

Day 15
50 mg/m*2/dose subcutaneous once followed by:

Maximum: 80 mg/dose
Day 29
25 mg/m*2/dose subcutaneous every 2 weeks

Maximum: 40 mg/dose

Day 1
Day 15
Day 29

(Weight-based)
2 to 3 years
10 to 14 kg
15 to 29 kg
Greater than 4 years of age

15 to 29 kg
Greater than 30 kg
(Body-Surface Area Based)

2 to 3 years of age

Maximum: 20 mg/dose
4 to 17 years of age

Maximum: 40 mg/dose
adenosine
Pediatric Advanced Life Support
Go to PALS Calculator
Supraventricular Tachycardia (SVT)

Initial Dose
0.1 mg/kg/dose IV once

Maximum: 6 mg/dose
Repeat dose

Maximum: 12 mg/dose
Comments
The effects of adenosine may be decreased by methylxanthines (such as caffeine and theophylline) and larger doses may be
required.
alfacalcidol - [Vitamin D analog|One-Alpha]

Note: 2 microgram/mL solution contains 0.1 microgram/drop
Renal Osteodystrophy
Less than 20 kg
0.01-0.03 microgram/kg/dose PO daily

Maximum: 0.5 microgram/dose
0.25-1 microgram(s) PO daily
Supplied: Capsule: 0.25 microgram(s), 1 microgram(s)

Solution: 2 micrograms/mL
allopurinol
Renal Adjustment
Prevention or Treatment of Tumor Lysis Syndrome (TLS)
Go to clinical order set IWK ORTU "Prevention and Treatment of Tumor Lysis Syndrome (TLS)"

Tablet: 100 mg
alteplase (CVAD occlusion/parapneumonic effusion) - [Cathflo]

CVAD Occlusion
Go to Medication Management Policy 30.52 (CVAD: Management of Partial and Total Occulsions)
Go to clinical order set IWK CVADUN "Management of Partial or Total CVAD Occulsions with Altelplase (Cathflo*)
Parapneumonic Effusion
Go to clinical order set IWK PAEF "Parapneumonic Effusions Admission Orders"
Instillation in peritoneal dialysis catheter

Go to Policy 1520.10 (Instillation of Alteplase into a Peritoneal Dialysis Catheter)
Catheter length Total priming volume (equivalent mg)
57 cm 3.5 mL (3.5 mg)

42 cm 3 mL (3 mg)
39 cm 2.5 mL (2.5 mg)
32 cm 2.5 mL (2.5 mg)
31 cm 2.5 mL (2.5 mg)
Supplied: Injection: 2 mg
alteplase (Systemic) - [tPA]

Renal Adjustment
Systemic Thromboses
Usual*
0.5 mg/kg/hour IV continuous infusion for up to 6 hours

Maximum: 100 mg/24h
*Doses may range from 0.1-0.6 mg/kg/hour. Some patients may require shorter or longer duration.
amino acids (Primene) - [parenteral nutrition, Primene]

Go to IWK Compatibility Chart for:
TPN
SMOF Lipid
Intralipid
Go to IWK Policy 30.70 "Parenteral Nutrition"
Go to clinical order set IWK NEPANU "PRIMENE (10 kg and less) PARENTERAL NUTRITION (PN) ORDER"
Comments
Calcium/Phosphate Solubility Charts
Note: Calcium = mEq / 100 mL Phosphate = mmol / 100 mL

Charts are guides only. Please contact Pharmacy, Sterile Service @ 470- 8661 for further solubility information.
Amino Acid (Primene®)
1% 1.5% 2% 2.5% 3% 3.5% 4%
Calcium Phosphate Calcium Phosphate Calcium Phosphate Calcium Phosphate Calcium Phosphate Calcium Phosphate Calcium Phosphate
0.5 2.3 0.5 2.6 0.5 4.0 0.5 4.2 0.5 4.5 0.5 5.0 0.5 5.4
1.0 1.7 1.0 2.3 1.0 3.4 1.0 3.6 1.0 3.8 1.0 4.6 1.0 4.6
1.5 1.3 1.5 2.2 1.5 2.6 1.5 3.0 1.5 3.5 1.5 3.5 1.5 4.2
2.0 1.1 2.0 1.8 2.0 2.3 2.0 2.6 2.0 3.3 2.0 3.3 2.0 3.8
3.0 0.85 3.0 1.2 3.0 1.8 3.0 2.2 3.0 2.5 3.0 2.5 3.0 3.2
4.0 0.72 4.0 1.0 4.0 1.25 4.0 1.9 4.0 2.3 4.0 2.3 4.0 2.6
5.1 0.35 5.0 0.75 5.0 1.25 5.0 1.6 5.0 2.1 5.0 2.1 5.0 2.6
Supplied: Injection: 10 %
amino acids (Travasol) - [parenteral nutrition, Travasol]

TPN
SMOF Lipid
Intralipid
Go to clinical order set IWK PEPA "Travasol Pediatric Parenteral Nutrition Order"
Comments
Calcium/Phosphate Solubility Charts
Note: Calcium = mEq / 100 mL Phosphate = mmol / 100 mL

Charts are guides only. Please contact Pharmacy, Sterile Service @ 470- 8661 for further solubility information.
Amino Acid (Travasol®)
less than 1% 1– 2% 2.1 – 3% 3.1 – 4.4% 4.5% and higher
Calcium Phosphate Calcium Phosphate Calcium Phosphate Calcium Phosphate Calcium Phosphate
0.0 0.0 0.25 2.75 0.5 2.75 0.5 2.75 1.0 3.5
0.0 0.0 0.75 1.75 0.75 2.25 0.75 2.25 1.25 2.75
0.0 0.0 1.0 1.5 1.0 1.75 1.0 1.75 1.5 2.5
0.0 0.0 1.25 1.25 1.25 1.5 1.25 1.5 1.75 2.25
0.0 0.0 1.5 1.0 1.75 1.25 1.75 1.25 2.0 2.0
0.0 0.0 2.0 0.75 2.25 1.0 2.25 1.0 2.5 1.75
Supplied: Injection: 10 %
aminophylline
Renal Adjustment
Severe Asthma Exacerbation (in patients who have failed to improve despite maximized therapy in PICU)
Continuous
Ordered as: mg/kg/hour
Loading Dose
6 mg/kg/dose IV once
Maintenance
6 weeks to 6 months
0.5 mg/kg/hour IV continuous infusion
Greater than 6 months to 1 year
0.6-0.7 mg/kg/hour IV continuous infusion
Greater than 1 year to 9 years
1-1.2 mg/kg/hour IV continuous infusion
Greater than 9 years to 12 years
Diuresis (PICU)
Continuous
Loading Dose
None
Initial Dosing
0.2 – 0.4 mg/kg/hour
Suggested Titration
0.1 mg/kg/hour
Usual Range
0.1 – 0.4 mg/kg/hour
amiodarone
Go to PALS calculator
Intravenous
Continuous
Ordered as: microgram/kg/minute
Loading Dose
5 mg/kg/dose IV once. May repeat PRN up to a maximum total dose of 15 mg/kg OR 300 mg.
Initial Dosing
5 microgram/kg/min
Suggested Titration
2.5-5 microgram/kg/min
Usual Range
5-15 microgram/kg/min
Maximum:
25 microgram/kg/min
Oral
Loading Dose, Body Surface Area (BSA)-Based
(More accurate dosing is achieved with BSA based dosing in patients 1 to 12 months old)
350-460 mg/m*2/dose PO daily for 4-14 days or until control achieved
or
175-230 mg/m*2/dose PO BID for 4-14 days or until control achieved
Maintenance, BSA-Based
(More accurate dosing is achieved with BSA based dosing in patients 1 to 12 months old)
115-230 mg/m*2/dose PO daily
OR
Loading Dose, Weight Based
10-20 mg/kg/dose PO daily for 4-14 days or until control achieved

Maximum: 800 mg/24h
or
5-10 mg/kg/dose PO BID for 4-14 days or until control achieved

Maximum: 800 mg/24h
Maintenance, Weight Based

Higher maintenance doses may be required in infants (up to 20 mg/kg/24 hours)

Maximum: 200 mg/24h
or
2.5-5 mg/kg/dose PO BID

Maximum: 200 mg/24h
Comments
If arrhythmia does not recur, decrease dose to lowest effective dose. Usual minimum dose: 2.5 mg/kg/24h PO given 5 days/week.

Suspension: 5 mg/mL IWK Compounded
Tablet: 200 mg
amitriptyline
Antidepressant
Go to Clinical Handbook of Psychotropic Drugs: Children and Adolescents (only accessible through IWK)
Chronic Pain
0.1 mg/kg/dose PO at bedtime titrated to 0.5-2 mg/kg/dose over 2 to 3 weeks as tolerated
Migraine Prophylaxis
0.25 mg/kg/dose PO at bedtime . Dose may be increased in 0.25 mg/kg increments every 2 weeks. Doses greater than 1 mg/kg/dose
should be divided BID
Maximum: 2 mg/kg/dose OR 75 mg/dose
Supplied: Tablet: 10 mg, 25 mg
amLODIPine
Hypertension
Less than 6 years
0.1-0.2 mg/kg/dose PO daily

Maximum: 0.4 mg/kg/dose AND 5 mg/24h
6 years to 17 years
2.5-5 mg PO daily
Maximum: 10 mg/24h
Comments
Doses greater than 5 mg have not been evaluated in pediatrics.
Some younger children may require q12h to achieve BP control. (Younger children have a higher clearance)
Drug has along half-life resulting in a more gradual onset and prolonged duration of action. Dose changes should not be made
sooner than 1-2 weeks after initiation or previous change in dose
Supplied: Solution: 1 mg/mL

Tablet: 5 mg
amoxicillin
Renal Adjustment
Various Indications
Go to Firstline
Penicillin Allergy De-Labelling
Go to clinical order set IWKORAC "Oral Amoxicillin Challenge for Penicillin Allergy De-Labelling in Low Risk Patients"
Pneumococcal infection prophylaxis, anatomic or functional asplenia (e.g, sickle cell disease)
*Amoxicillin is preferred for less than 3 months. 3 months and greater, Penicillin V is the first line agent, go to Penicillin V
Less than or equal to 5 years

Use of prophylaxis over the age of 5 should be considered on a case by case basis
250 mg PO BID
Cystic Fibrosis
Less than 3 months
10-15 mg/kg/dose PO BID
Greater than 3 months
16-30 mg/kg/dose PO TID

Maximum: 4 grams/24h
Supplied: Capsule: 250 mg, 500 mg

amoxicillin|clavulanate - [Clavulin]
All doses expressed in terms of amoxicillin component. All orders must be written in terms of amoxicillin component.
Maximum total dose of amoxicillin is 4000 mg regardless of weight.
October 2022: shortage of amoxicillin clavulanate oral suspensions - Please try to conserve the use of these formulations. Only
choose if it is optimal therapy for the syndrome being treated and if tablets or part tablets are not feasible. For alternative therapy,
please refer to Firstline for further guidance.
Renal Adjustment
Various Indications
Oral
Go to Firstline
Parenteral
Go to Firstline
Supplied: Injection: 2000|200 mg

Suspension: 25|6.25 mg/mL, 80|11.4 mg/mL
Tablet: 875 |125 mg, 500|125 mg
amphetamine mixed salts - [Adderall XR]

Go to CADDRA ADHD Medication Chart for information on dosage forms etc
Attention Deficit and Hyperactivity Disorder (ADHD)
Go to Clinical Handbook of Psychotropic Drugs: Children and Adolescents (only accessible via IWK networked computer)
Comments
Do not crew/crush. Capsules can be opened and sprinkled on apple sauce, if taken immediately without chewing OR given via
tube.
Go to SwitchRx for information on tapering, switching or combining psychotropic medications (registration/login required)
Supplied: Capsule, Extended Release: 5 mg, 10 mg, 15 mg, 20 mg, 25 mg, 30 mg
amphotericin B deoxycholate (conventional) - [Fungizone]

Medication errors, including deaths, have resulted from confusion between lipid-based forms of amphotericin (Abelcet®,
AmBisone®) and amphotericin B deoxycholate (conventional) (Fungizone®) for Injection.
Given the potential for infusion related reactions, prescribers should consider completing order set IWK PRHY DRUG
HYPERSENSITIVITY OR TRANSFUSION REACTION TREATMENT or ordering additional medications required for as needed
management of rigors.
Renal Adjustment
Antifungal
Go to Firstline
amphotericin B liposomal - [AmBisome]

Medication errors, including deaths, have resulted from confusion between lipid-based forms of amphotericin (Abelcet®,
AmBisome®) and amphotericin B deoxycholate (conventional, Fungizone®) for Injection
Given the potential for infusion related reactions, prescribers should consider completing order set IWK PRHY DRUG
HYPERSENSITIVITY OR TRANSFUSION REACTION TREATMENT or ordering additional medications required for as needed
management of rigors.
Antifungal
Go to Firstline
ampicillin
May be suitable for IV to PO conversion. Go to Guidelines
Renal Adjustment
Various Indications
Go to Firstline
Peritonitis
Intraperitoneally
Go to 2012 ISPD Consensus Guidelines for the Prevention and Treatment of Catheter-Related Infections an Peritonitis in Pediatrics
Receiving PD
Supplied: Injection: 250 mg, 1 gram(s)
anakinra - [Kineret]
As a specialty refrigerated biologic product, anakinra has a unique supply chain, it is very important that clinical
pharmacists/pharmacy practice assistants are engaged with IWK pharmacy purchasers to ensure availability of medication. For
example, orders for this medication can only be placed Mon-Wed to ensure cold chain maintenance. Drug is provided in packages
of 7 syringes.
Renal Adjustment
Macrophage activation syndrome
Note: In consultation with rheumatology, higher doses up to 20 mg/kg/24 hours have been used in refractory cases.
Less than 40 kg
1-5 mg/kg/dose IV/Subcutaneous every 12 hours
or
0.67-3.3 mg/kg/dose IV/Subcutaneous every 8 hours
or
0.5-2.5 mg/kg/dose IV/Subcutaneous every 6 hours
100 mg IV/Subcutaneous every 6 hours
antithymocyte globulin (equine) - [ATGAM, Thymoglobulin]

Go to IWK Chemotherapy Administration Standards document
Aplastic Anemia
Go to clinical order set IWK ATGAA Aplastic Anemia Orders Hematology -Oncology
antithymocyte globulin (rabbit) - [ATG rabbit, Thymoglobulin]

Renal Transplantation
Go to clinical order set IWK RETR "Renal Transplant Post-Operative Orders for Induction Protocol"
aprepitant
Go to APPHON Nausea and Vomiting Guidelines - for Moderate/High Emetogenic Antineoplastic Therapy
Antiemetic with Antineoplastic Therapy

Greater than or equal to 6 months
Day 1
3 mg/kg/dose PO once
Day 2 and 3
2 mg/kg/dose PO daily for 2 doses

Maximum: 80 mg/dose
Post-op Nausea and Vomiting

30 kg and less
1 mg/kg/dose PO once pre-operatively . May be repeat x 1 dose post-op as ordered by anesthesia.
Greater than 30 kg
40 mg PO once pre-operatively . May be repeat x 1 dose post-op as ordered by anesthesia.

arginine
Management of hyperammonemia
Urea Cycle Disorder (UCD) Treatment
Go to clinical order set IWK EMMA "Emergency Management of Hyperammonemia"
Growth Hormone Stimulation Test
0.5 grams/kg IV once

Maximum: 30 grams/dose
Comments
For Growth Hormone Stimulation Test, please refer to product label from pharmacy for more information.

Powder: 0
aripiprazole
Various Indications
Oral
Long Acting Injection
Comments
Supplied: Injection: 300 mg, 400 mg

Tablet: 2 mg, 5 mg, 10 mg, 15 mg
arsenic trioxide
Go to IWK Hazardous Drug Classification
As per Children's Oncology Group (COG) Protocol
Go to COG login page
artesunate
Refer to page 2 on clinical order set(s) for procurement details.
Go to clinical order set IWK MAMA "Initial Management of Malaria"
Go to clinical order set IWK REMAMA "Severe Falciparum Malaria 24 hour Reassessment"
Supplied: Injection: 120 mg Special Access
ascorbic acid - [Vitamin C]

Severe Septic Shock (HAT - Hydrocortisone, Ascorbic Acid, Thiamine Therapy)
25 mg/kg/dose IV every 6 hours for 4 days

Comments
Go to other HAT therapy meds:
Hydrocortisone
Thiamine

asparaginase (Erwinia)
Supplied: Injection: 10000 units
atenolol
0.5-1 mg/kg PO daily
OR
0.25-0.5 mg/kg PO BID

Supplied: Tablet: 25 mg
atomoxetine
Attention-Deficit/Hyperactivity Disorder
Comments
Supplied: Capsule: 10 mg, 18 mg, 25 mg, 40 mg, 60 mg
atorvastatin
HMG-CoA Reductase Inhibitors (Statins) Dose Equivalency
atovaquone|proguanil - [Malarone]
Malaria
5 to 8 kg: Malarone® Pediatric (62.5 mg atovaquone/25 mg proguanil): 2 tablets PO once daily X 3 doses
9 to 10 kg: Malarone® Pediatric (62.5 mg atovaquone/25 mg proguanil): 3 tablets PO once daily X 3 doses
11 to 20 kg: Malarone® Adult (250 mg atovaquone/100 mg proguanil): 1 tablet PO once daily X 3 doses
21 to 30 kg: Malarone® Adult (250 mg atovaquone/100 mg proguanil): 2 tablets PO once daily X 3 doses
31 to 40 kg: Malarone® Adult (250 mg atovaquone/100 mg proguanil): 3 tablets PO once daily X 3 doses
Greater than 40 kg: Malarone® Adult (250 mg atovaquone/100 mg proguanil): 4 tablets PO once daily X 3 doses
Go to clinical order set IWK MAMA "Initial Management of Malaria"
Go to clinical order set IWK REMAMA "Severe Falciparum Malaria 24 hour Reassessment"
Supplied: Tablet: 62.5|25 mg, 250|100 mg
atropine
Go to Atlantic Canada Poison Centre Antidote kit for information on antidote administration
Antidote
Go to Atlantic Canada Poison Centre Antidote Kit for information on antidote dosing.
Sialorrhea
12 kg or less
Use injectable form (0.4 mg/mL) by mouth (PO/SL)
0.02-0.04 mg/kg/dose PO/Sublingual TID PRN Start at low end of dosing range. Titrate to effect while monitoring for systemic effects
(e.g. mydriasis and tachycardia)
Maximum: Increased frequency (up to q2h) may be considered for end-of-life care
Greater than 12 kg
Use 1% ophthalmic drops
1-2 drops sublingual every 4 to 6 hours PRN Start at low end of dosing range. Titrate to effect while monitoring for systemic effects (e.g.
mydriasis and tachycardia)
Maximum: Increased frequency (up to q2h) may be considered for end-of-life care
Refractory or Recurrent Pyloric Stenosis (restricted to General Surgery)

Infants
Intravenous
0.01 mg/kg/dose IV six times daily, 5 minutes before each feed
Oral (May switch to oral once vomiting has ceased and tolerating feeds)
Use injectable form (0.4 mg/mL) by mouth (PO)
0.02 mg/kg/dose PO six times daily, 5 minutes before each feed
Ophthalmic
Manufacturer recommended
1 drops in affected eye(s) TID
Comments
Patient/Family Resource: AboutKidsHealth Atropine for drooling
Supplied: Drops, Ophthalmic: 1 %

Injection: 0.2 mg/mL, 0.4 mg/mL, 0.6 mg/mL, 0.1 mg/mL
azacitidine
azaTHIOprine - [Imuran]
When prescribing azaTHIOprine:
use order set IWK IMDI for outpatient prescriptions (available in e-Access)
Renal Adjustment
Renal Transplantation
Lupus Nephritis/Autoimmune Hepatitis
0.5-3 mg/kg/dose PO daily
Inflammatory Bowel Disease
1-2.5 mg/kg/dose PO daily
Comments
If using tablets, round dose to nearest 12.5 mg increment

Tablet: 50 mg
azithromycin
May be suitable for IV to PO conversion. Go to Guidelines
Renal Adjustment
Various Indications
Go to Firstline
Sexually Transmitted Infection
Cystic Fibrosis as an Anti-Inflammatory Agent

25 to 40 kg
250 mg PO three times weekly (Mon, Wed, Fri)
Greater than 40 kg
500 mg PO three times weekly (Mon, Wed, Fri)

Tablet: 250 mg
baclofen
Tone Management
Oral
Initial
2.5-5 mg PO TID then may increase by 5-15 mg/24 hours every 3-7 days to age specific maximums below
Intrathecal
Initial/Test Dosing
25-100 microgram(s) via lumbar puncture once
Maintenance
Reservoir for pump filled with 2 mg/mL (20- 40 mL)
Rate managed by rehab clinic. Dose provided in microgram/hour via intrathecal pump
Comments
Oral Maximums
Less than 2 years: 40 mg/24h
2 to 7 years: 60 mg/24h
Greater than 8 years: 80 mg/24h
Taper dose gradually over 1-2 weeks to avoid abrupt withdrawal.

Maximum effect not seen for 5-7 days.
Dose related side effects (i.e. sedation) may be minimized by slow titration or lower initial doses.
Patient/Family Resource: AboutKidsHealth Baclofen (Oral)
Supplied: Injection: 2 mg/mL HIGH ALERT, 50 micrograms/mL HIGH ALERT

Tablet: 10 mg
basiliximab
Renal Transplant
Pre-op
Go to clinical order set IWK TRPR " Renal Transplant Pre-Operative Orders for Induction Protocol"
Intra-op
Go to clinical order set IWK RETR "Renal Transplant Intra-Operative Orders for Induction Protocol"
Post-op
Beclomethasone - [Qvar]
Click here for dose equivalencies of various inhaled corticosteroids
Oral Inhalation (MDI)

Asthma:
50-100 microgram(s) inhalation BID

Maximum: 200 microgram/24h
Comments
Use with Aerochamber® recommended.
Rinse mouth after use to decrease risk of thrush.
Metered dose inhalers should be primed before first use or after one week without use.
Health Canada approved age of use is > 5 years old.
Supplied: Inhalation, Metered Dose: 50 micrograms/puff
bendamustine
benztropine
Managament of Extrapyramidal Adverse Effects
Go to clinical order set IWK CHRE “Emergency Management of Anxiety and Agitation”
Dystonic reactions (e.g. secondary to metoclopramide)
1-2 mg IV/IM once . In patients greater than 12 years of age a second dose may be administered after 30 minutes PRN

Tablet: 1 mg
betamethasone
*NEW - September 2023: shortage of betamethasone injection (until Jan 2024). Please refer to dexamethasone for dosing and
administration information during this shortage
Topical
Refer to Topical Corticosteroid Equivalency and IWK Product Selection Chart
Supplied: Cream, Topical: 0.05 % (as valerate), 0.1 % (as valerate), 0.05 % (as dipropionate)
Injection: 6 mg/mL
Ointment, Topical: 0.05 % (as dipropionate), 0.05 % (as valerate), 0.1 % (as valerate)
Scalp, Topical: 0.1 % (as valerate)
bevacizumab - [Avastin, or biosimilars]

Recurrent respiratory papillomas
Go to clinical order set IWK BEVA Bevacizumab for Recurrent Respiratory Papilloma
Comments
Dose modifications
Proteinuria
Laboratory urinalysis for protein should be performed at baseline and then prior to each cycle as per order set.
If 24 Hour Urine Total Protein (gram/24 hours) is:
Less than or equal to 2 : Give usual dose (100%)

Greater than 2 to 4: Hold dose and recheck 24 hour urine every 2 weeks, resume therapy when less than or equal to 2 g/24 hr
Greater than 4: Hold dose, consider discontinuation of therapy
Hypertension
See order set for management of hypertension during the infusion.
If blood pressure (mm Hg) is:
Less than or equal to 160/100: Give usual dose (100%)

Greater than 160/100 asymptomatic: Notify prescriber and consider initiation or modification of antihypertensive therapy
Greater than 160/100 symptomatic: Hold dose, consider discontinuation of therapy
biotin
Biotinidase Deficiency
5 mg PO daily
or
5 mg PO BID
Partial Biotinidase Deficiency
5 mg PO daily
Leigh Syndrome

Maximum: 10 mg/kg/24h
Comments
Doses must be rounded to 5 mg increments
Capsules may be opened for administration
Supplied: Capsule: 5 mg
bisacodyl
Constipation
Oral
5-10 mg PO once
5-15 mg PO once
Rectal
Less than 2 years of age
5 mg PR once
2 years to 11 years of age
5-10 mg PR once
Greater than 12 years of age
10 mg PR once
Bowel preparation for colonoscopy
Go to clinical order set "IWKCOBO Colonoscopy for Bowel Prep Orders for Admitted Patients"
Comments
Do not crush or chew tablets. Swallow whole.
Supplied: Suppository: 10 mg
Tablet, Enteric Coated: 5 mg
bivalirudin
Renal Adjustment
Anticoagulant
Continuous
Loading Dose
NONE
Initial Dosing
0.3 mg/kg/hour
CrCl less than 60 mL/min: 0.2 mg/kg/hour
CrCl less than 30 mL/min: 0.05 mg/kg/hour
Suggested Titration
0.05-0.1 mg/kg/hour based on PTT [target 1.5-2.5 times normal (60-90 seconds)]
Usual Range
0.3-1 mg/kg/hour
Comments
Monitor PTT 2 hours after initiating infusion and 2 hours after dose adjustments.
Monitor PTT once daily when stable.
Anticoagulant effect is immediate. It is not reversible. Coagulation times return to baseline 1 hour after stopping infusion. In cases of
severe bleeding, low dose rFVIIa has decreased PTT and slowed bleeding.
Transition from heparin to bivalirudin:

1. Discontinue heparin and start bivalirudin at the same time
2. Draw PTT after 2 hours (this will still reflect heparin)
3. If PTT is less than 80 seconds, consider increasing bivalirudin
4. Repeat PTT in 2 hours. Titrate bivalirudin to achieve PTT of 60-90 seconds
black widow spider antivenin

Antidote
Go to Atlantic Canada Poison Centre Antidote Kit for information dosing and administration.
bleomycin
blinatumomab
Supplied: Injection: 12.5 micrograms/mL
bortezomib
Supplied: Injection: 3.5 mg
bosentan
Pulmonary Hypertension
Initial Dosing
4 to 8 kg
15.6 mg PO BID
8.1-16 kg
31.25 mg PO BID
16.1 to 24 kg
46.85 mg PO BID
Greater than 24 kg
62.5 mg PO BID
Supplied: Tablet: 15.6 mg IWK Compounded, 31.25 mg IWK Compounded, 62.5 mg
botulinium toxin type a - [Botox]

The botulinum toxin products are not interchangeable, and dosing units of one product cannot be converted or compared with
dosing units of another botulinum toxin product.
Drooling
Parotid Gland
20-40 units/gland may be repeated every 4 months PRN
Submandibular Gland
15-25 units/gland may be repeated every 4 months PRN
Spasticity
2-17 years
Upper Extremity
Note: When treating both upper and lower limb spasticity, the total dose in a 3 month period should not exceed 10 units/kg or 340
units in patients less than 18 years of age OR 400 units in patients greater than 18 years of age
3-6 units/kg total divided among affected muscles IM

Maximum: 50 units/site AND 6 units/kg or 200 units, whichever is less, maximum total dose per session
Lower extremity
4-8 units/kg total divided among affected muscles IM

Maximum: 50 units/site AND 8 units/kg or 300 units, whichever is less, maximum total dose per session
Strabismus
Less than 12 years
1-2.5 units/muscle IM
12 years and greater
1.25-5 units/muscle IM
brentuximab vedotin
budesonide
Click here for Aerosol Medication Compatibility Guide
Click here for dose equivalencies for various inhaled corticosteroids
3 months to 12 years
0.25-0.5 mg inhalation BID

Maximum: 2 mg/24h
Adolescents
1-2 mg inhalation BID
Comments
Rinse mouth after use
Supplied: Inhalation, Dry Powder: 400 micrograms/puff

Inhalation, Nebule: 0.25 mg/mL, 0.5 mg/mL
bupivacaine|EPINEPHRine
Updated: December 2023 SHORTAGE: Bupivacaine 0.25% and 0.5% with EPINEPHrine 1:200,000 (20 mL vials) are short from
available manufacturers. Refer to comment section below for instructions to prepare during shortage
Comments
Preparation of bupivacaine 0.25% with EPINEPHrine
Use: 20 mL vial – bupivacaine 0.25% solution
1 mL amp – EPINEPHrine 1 mg/mL solution
Prepare immediately before use and discard after completion of the procedure
Bupivacaine 0.25% with EPINEPHrine 1:200,000 (0.005 mg/mL)

1. Withdraw 0.1 mL (0.1 mg) from EPINEPHrine 1 mg/mL ampoule
2. Add 0.1 mL EPINEPHrine 1 mg/mL to bupivacaine 0.25%, 20 mL vial
3. Shake gently to mix
4. Label vial appropriately
5. Discard after procedure
Preparation of bupivacaine 0.5% with EPINEPHrine

Use: 20 mL vial- bupivacaine 0.5% solution
1 mL amp – EPINEPHrine 1 mg/mL solution
Bupivacaine 0.5% with EPINEPHrine 1:200,000 (0.005 mg/mL)

2. Add 0.1 mL EPINEPHrine 1 mg/mL to bupivacaine 0.5%, 20 mL vial
Supplied: Injection: 0|0
buPRENorphine|naloxone - [Suboxone]
All dosing is based on buPRENorphine component.
Opioid Use Disorder (OUD)

Dosing is individualized. For additional information refer to "CAMH Opioid Agonist Therapy: A Synthesis of Canadian Guidelines for
Treating Opioid Use Disorder"
Go to clinical order set IWKOAT "Opioid Agonist Treatment (OAT) [methadone, buPRENorphine/ naloxone (Suboxone®)] for Opioid Use
Disorder High Alert
IWK - 4.07 - Care of Patients on Opioid Agonist Treatment (OAT) [methadone, buPRENorphine/naloxone (Suboxone®)] for Opioid Use
Disorder
Induction Phase
2−4 mg as an initial supervised dose when the patient is in moderate to severe withdrawal (Clinical Opiate Withdrawal Scale (COWS)
greater than 13). Up to 6 mg is acceptable in clinically required situations, but may increase the risk of precipitating withdrawal.
Reassess the patient after one to three hours and prescribe additional observed doses if necessary (e.g., COWS greater than 8,
symptoms of withdrawal).
Avoid prescribing more than 12 mg total on the first day.
Be careful not to precipitate withdrawal by giving too high a dose or by medicating in the absence of observable withdrawal.
One or two 2 mg tablets to take home may be provided if repeated observation is not feasible in the clinical setting, with clear
instructions on timing the dose to avoid precipitating withdrawal.
Consider alternative induction approaches such as:
“microdosing,” starting with 0.5 mg twice per day, with increasing doses to a total daily dosage of 12 mg over 5–7 days for patients
who cannot tolerate the significant period of abstinence needed to start with a conventional induction
“rapid microdosing,” administering 0.5–1 mg at shorter intervals, up to 12 mg total in a 24-hour period.
Titration and Stabilization Phase
Add up the dose given on day 1 and administer it as the first dose of day 2, followed by additional doses based on the re-emergence of
withdrawal symptoms. On day 3, add up the doses administered on day 2 and provide additional doses as necessary. Repeat daily until
the patient is stable (no withdrawal, or COWS scores < 8 for 24 hours) or until a maximum of 24 mg per day is achieved.
Maintenance
Use clinical judgment to maintain an optimal individualized daily dose, which is up to a maximum of 24 mg per day.
If exceeding 24 mg in exceptional circumstances, inform the patient that this is a departure from approved doses and that there is
limited evidence of a benefit with doses higher than 24 mg (and possibly an increased risk of adverse events).
Review the case with an experienced colleague before trialing a dose higher than 24 mg per day and attempt to reduce the dose
to approved levels (as tolerated) once the OUD has stabilized.
Comments
Separate daily doses by at least 15 hours.
Oral route ineffective, swallowed doses are not readily absorbed.
If patient vomits, do not replace dose.
Additional Resources
Nova Scotia College of Pharmacists:
Opioid Agonist Maintenance Treatment Services

Opioid Agonist Maintenance Treatment Services During the COVID-19 Pandemic
Supplied: Tablet, Sublingual: 2|0.5 mg, 8|2 mg
buPROPion
Antidepressant
Comments
Supplied: Tablet, Sustained Release: 100 mg

Tablet, XL: 150 mg
calcitriol - [Vitamin D, Rocaltrol]

Hypoparathyroidism
Less than 1 year
1 to 5 years
0.25-0.75 microgram(s) PO daily
Greater than or equal to 6 years
0.5-2 microgram(s) PO daily
Supplied: Capsule: 0.25 microgram(s)
calcium (oral)
All doses expressed in terms of mg of elemental calcium. All orders must be written in terms of mg of elemental calcium
Equivalencies
500 mg calcium carbonate =200 mg elemental calcium = 10 mEq elemental calcium = 5 mmol elemental calcium
Hypocalcemia
11.25-16.25 mg/kg/dose PO QID
Phosphate Binding (IWK Nephrology)
100-300 mg PO BID to TID then adjust dose according to bloodwork to a usual:

Maximum: 2000 mg/24h (from diet and medications)
Comments
Take prior to or with meals.
Separate administration by at least 2 hours from phosphate or iron containing supplements.
Calcium supplement doses greater than 500 mg elemental calcium should be given in divided doses
Supplied: Liquid (as lactogluconate): 20 mg (as elemental)/mL

Tablet (as carbonate): 500 mg (as elemental)
Tablet, Chewable (as carbonate): 200 mg (as elemental), 400 mg (as elemental)
calcium chloride
Dose expressed in terms of mg of calcium chloride. All orders must be written in terms of mg of calcium chloride
NOTE: 100 mg calcium chloride = 27.3 mg elemental calcium = 1.4 mEq elemental calcium = 0.7 mmol elemental calcium
Pediatric Advanced Life Support (PALS)
Antidote
Hypocalcemia
Go to clinical order set IWK ELREP "PICU Electrolyte replacement Orders"
Supplied: Injection: 100 mg/mL (10 mL Vial) , 100 mg/mL (10 mL Prefilled Syringe)
calcium gluconate
Dose expressed in terms of mg of calcium gluconate. All orders must be written in terms of mg of calcium gluconate
Equivalencies
100 mg calcium gluconate = 9.3 mg elemental calcium = 0.465 mEq elemental calcium = 0.23 mmol elemental calcium
Go to Atlantic Canada Poison Centre Antidote Kit for information on antidote administration
Renal Adjustment
Antidote
Hypocalcemia
Intermittent
50-125 mg/kg/dose IV every 6 hours

Maximum: 2 grams/dose
Continuous Infusion
8-20 mg/kg/hour IV continuous infusion
Hyperkalemia Management of Emergency Department Patients
Go to clinical order set IWK EDMH "Management of Hyperkalemia Emergency Department (Patients Greater than 6 Months of Age)"
capsaicin
Cannabinoid Hyperemesis Syndrome
5 grams topically once to abdomen, back or arms*
Comments
* To visualize 5 grams of capsaicin, click here.
Supplied: Cream, Topical: 0.075 %
captopril
IWK recommends:
Monitor blood pressure every 30 minutes x 2 hours with initial dose and with each increase in dose
Contact prescriber for a 20% or greater decrease in systolic blood pressure
For information on administration of liquid via Dissolve-A-Dose, go to Policy 20.09
Test dose: 0.1 mg/kg/dose Usual maximum initial dose 6.25 mg.
Titrate dose based on response
Renal Adjustment
Hypertension
Infants
0.15-0.3 mg/kg/dose PO every 8 to 12 hours titrated to desired clinical effect to a:

Children
0.3-0.5 mg/kg/dose PO every 8 hours titrated to desired clinical effect to a:

Adolescent
6.25-12.5 mg/dose PO every 8 to 12 hours titrated to desired clinical effect to a:

Maximum: 150 mg/24h
Heart Failure
Infant
0.1-0.8 mg/kg/dose PO every 8 hours
or
Children and Adolescents
0.1-2 mg/kg/dose PO every 8 hours

or
0.15-3 mg/kg/dose PO every 12 hours

Maximum: 6 mg/kg/dose OR 150 mg/24h
Comments
Cardiology or Nephrology should be consulted for doses greater than 2 mg/kg/day. Doses exceeding this may require additional
monitoring.
For patient information on Dissolve-A-Dose , click here
Relevant Article: Angiotensin-Converting Enzyme Inhibitor Initiation and Dose Uptitration in Children With Cardiovascular Disease:
A Retrospective Review of Standard Clinical Practice and a Prospective Randomized Clinical Trial
Supplied: Solution, Dissolve A Dose: 1 mg/mL IWK Compounded

Tablet: 12.5 mg, 50 mg
carBAMazepine
Note: Dosage interval is based on dosage form selected. Please refer to comments for further guidance
Renal Adjustment
Anticonvulsant
Less than 6 years
10-20 mg/kg/24h divided PO every 6 to 12 hours - Dose may be titrated up to:

6 to 12 years
200 mg/24h divided PO every 6 to 12 hours May increase dose by 100 mg/24 hours at weekly intervals to a usual range of 400 to 800
mg/24 hours
400 mg/24h divided PO every 6 to 12 hours May increase dose by 200 mg/24 hours at weekly intervals to a usual range of 800 to 1200
mg/24 hours
Comments
Maximum:
12 to 15 years: 1000 mg/24 hour
Greater than 15 years: 1200 mg/ 24 hour
Suggested dosing intervals based on dosage form
controlled release tablet: every 12 hours (or BID)
chewable and immediate release tablets: every 8-12 hours (or BID to TID)
suspension: every 6 hours (or QID)
Supplied: Suspension: 20 mg/mL

Tablet: 200 mg
carbomer|sorbitol - [Eye Lubricant Gel]

Current contract brand: Tear-Gel
Ordered as: "Eye lubricant gel"
Gel form is typically reserved for use by ophthalmology as a preferred lubricant with specific eye examinations.
Ophthalmic
1 drops in affected eye(s) TID to QID PRN
Supplied: Gel, Ophthalmic: 0|0
CARBOplatin
carmustine
carvedilol
Heart failure
Initial
0.05 mg/kg/dose PO every 12 hours

Maximum: 3.125 mg/dose
or

Titration
0.2-0.5 mg/kg/dose PO every 12 hours May double dose every 2 weeks to highest dose tolerated by patient
Maximum: 50 mg/24h
or
0.13-0.33 mg/kg/dose PO every 8 hours May double dose every 2 weeks to highest dose tolerated by patient
Maximum: 50 mg/24h
Comments
Infants and children less than 4 years: consider dividing daily dose every 8 hours in as they have a faster clearance and may
require higher daily doses.
Supplied: Suspension: 1.25 mg/mL IWK Compounded

Tablet: 3.125 mg, 12.5 mg
caspofungin
Antifungal for patients who are refractory to or intolerant of liposomal amphotericin B
Go to Firstline
ceFAZolin
There is a small risk of cross-reactivity in patients with a true penicillin allergy; use caution in patients with previous
anaphylactic reactions to penicillins. Go to IWK Beta Lactam Allergy Information
Renal Adjustment
Various Indications
Go to Firstline
Surgical Prophylaxis
Go to Firstline
Ophthalmic
Keratitis (with vision threatening ulcer)
Go to Firstline
Peritonitis
Intraperitoneally
Go to order set IWK PERPR Peritonitis Protocol Order
Supplied: Drops, Ophthalmic: 50 mg/mL IWK Compounded

Injection: 2 gram(s) (10 mL Prefilled Syringe) IWK Compounded, 1 gram(s)
cefepime
Febrile Neutropenia
Intravenous
Go to Firstline
Go to clinical order set IWK FENEOR Febrile Neutropenia Empiric Management Pediatrics
Intramuscular - For urgent use when IV access is not readily available (to prevent delay in treatment)
(Note: this route is not typically used at the IWK)
50 mg/kg/dose IM every 8 hours

Supplied: Injection: 2 gram(s), 1 gram(s)
ceFIXime - [Suprax]
Renal Adjustment
Various Indications
Go to Firstline
Asplenia Prophylaxis
Go to Atlantic Provinces Pediatric Hematology Oncology Network
Irinotecan-Induced Diarrhea Prophylaxis
8 mg/kg/dose PO daily beginning 2 days prior to start of irinotecan, continuing during treatment and for 3 days post last dose, for a
total of 10 days.

Tablet: 400 mg
cefoTAXime
Renal Adjustment
Various Indications
Go to Firstline
Peritonitis
Intraperitoneally
Receiving PD
Comments
IV doses may be given as frequently as every 4 hours if warranted by the severity of the infection
Supplied: Injection: 1 gram(s)
ceFOXitin
Renal Adjustment
Various Indications
Go to Firstline
Go to Firstline
cefPROZil
Renal Adjustment
Various Indications
Go to Firstline

Tablet: 250 mg
ceftAZIDime
Renal Adjustment
Various Indications
Go to Firstline
Peritonitis
Intraperitoneally
Go to order set IWKPERPR Peritonitis Protocol Orders
cefTRIAXone
Renal Adjustment
Various Indications
Go to Firstline
Fever or Acute Illness in Sickle Cell Disease and/or Asplenia
Go to Firstline
Go to clinical order set IWK SCFEIN "Sickle Cell Disease and/or Asplenia with Fever or Acute Illness Greater than 1 month old Pediatric
Admission Orders"
Go to clinical order set IWK SCFEED "Sickle Cell Disease and/or Asplenia with Fever or Acute Illness ED/Clinic Management Greater than
1 month old"
Go to clinical order set IWK SCFEOP "Sickle Cell Disease and/or Asplenia with Fever or Acute Illness Greater than 1 month old Outpatient
Follow Up"
Meningitis Prophylaxis
Go to Nova Scotia Communicable Diseases Manual
cefUROXime
Renal Adjustment
Various Indications
Go to Firstline
Supplied: Injection: 1.5 gram(s)
celecoxib
Renal Adjustment
Analgesia
Pre-operative
Go to clinical order set IWK ORSU "Pediatric Perioperative Anaesthesia Orders"
Post-operative
Less than 25 kg
3 mg/kg PO BID
25 kg to 50 kg
100 mg PO BID
Greater than 50 kg
200 mg PO BID to TID
Juvenile Rheumatoid Arthritis

10 to 25 kg
50 mg PO BID
Greater than 25 kg
100 mg PO BID

cephALEXin
Cephalexin suspension (liquid) is very expensive and may be cost prohibitive for families upon discharge. In this scenario
and if appropriate, please consider ordering doses in increments of 62.5 mg (1/4 tablet) to allow use of portion of tablets
to provide the dose while in hospital.
Renal Adjustment
Various Indications
Go to Firstline
Cystic Fibrosis
12.5-25 mg/kg/dose PO QID
Comments
For discharge or outpatient prescriptions, if cephalexin suspension is not affordable, please prescribe tablets. If part tablets are
required, please indicate on the prescription for the pharmacy to split the tablets for patient if required for accurate dosing and for
the pharmacy to counsel the family on how to crush tablets or part tablets and to administer with a small amount of juice, jam,
apple sauce, crushed bananas or chocolate pudding. See Firstline for more information.

Tablet: 250 mg
cetirizine
For doses outside of the recommended ranges and care areas, please consult Allergy specialists
March 2023: oral syrup is temporarily unavailable:
Please round doses to nearest portion of a tablet (increments of 2.5 mg) when appropriate
Refer to desloratadine for doses not accommodated by a tablet or portion of
Renal Adjustment
Antihistamine
Weight Based Dose
0.25 mg/kg/dose PO
Maximum: 10 mg/dose
Age based dosing

6 to 12 months
2.5 mg PO daily
12 to 23 months
2.5 mg PO once to twice daily
2 to 5 years
2.5 mg PO BID
or
5 mg PO daily
6 years or greater
5-10 mg PO daily
Management of Infusion-Related Reactions with Oncology/Hematology Medications
0.25-0.5 mg/kg/dose PO
Maximum: 20 mg/dose AND 40 mg/24h
Comments
Risk of drowsiness increases as dose increases.
Supplied: Syrup: 1 mg/mL

Tablet: 10 mg
charcoal, activated - [Activated charcoal]

Not routinely administered in the management of poisoned patients. Consult Atlantic Canada Poison Centre for more information.
Antidote
Go to Atlantic Canada Poison Centre Antidote Kit for information on antidote dosing and administration.
chloral hydrate
Chloral hydrate has sedative properties only and does not provide any analgesia
Renal Adjustment
Procedural Sedation
50-75 mg/kg/dose PO/PR 30-60 minutes prior to procedure. May repeat in 30 minutes
Maximum: 120 mg/kg TOTAL DOSE
Sedation
6.25-12.5 mg/kg/dose PO/PR every 6 hours

or

Sedation, mechanically ventilated patients

(very limited data available)
8-25 mg/kg/dose PO every 6 to 8 hours titrate to desired clinical effect

Comments
Maximum total dose: 120 mg/kg or 1 gram total for infants, 2 grams total for children for PROCEDURAL sedation.
Limited data available, however diluted oral liquid has been administered rectally. Use rectal route only if oral route not available
(irritating to mucous membranes).
Minimize unpleasant taste and gastric irritation by administering with water or infant formula.
chlorambucil
chlorhexidine gluconate
Go to APPHON Mucositis Guidelines
Mouth Care
Less than 6 years
5 mL swab/swish and spit BID
10 mL swab/swish and spit BID
Comments
Wait at least 30 minutes after brushing teeth before using chlorhexidine mouth rinse
Rinse for 60 seconds or may rinse twice over 30 seconds each time then spit out.
If unable to use as a rinse. it may also be applied to teeth, gums and inside of mouth with a gauze pad
Avoid rinsing mouth, brushing teeth or eating or drinking for 30 minutes after using
May cause staining or taste changes
Do not swallow. Not harmful if swallowed in small amounts
Supplied: Rinse, Oral: 0.12 %
cholecalciferol - [Vitamin D]
Doses MUST be rounded when ordered, to accommodate the available strengths (shown below)
Supplementation
Breastfed, full term infants
Supplementation should continue for ALL infants until they are consuming 1000 mL/24 hours or more of vitamin D fortified infant formula or whole milk
400 unit(s) PO daily
Single high dose "Stoss Therapy"

Usually reserved for 25-OH vitamin D levels less than 50 nmol/L with deficiency secondary to malabsorption or non-adherence to a daily regimen.
May be considered for 25-OH vitamin D levels less than 75 nmol/L to a usual maximum of 300,000 units/dose.
Note: if the below doses present an administration or patient acceptance issue, weekly dosing regimens may be used.
3 to 12 months
100,000-150,000 unit(s) PO once . May repeat every 3 months as needed to maintain optimal 25-OH vitamin D levels.
1 to 3 years
200,000 unit(s) PO once . May repeat every 3 months as needed to maintain optimal 25-OH vitamin D levels.
3 to 12 years
12 years and older
Supplied: Drops, Oral: 400 units/drop

Tablet: 400 units, 1000 units, 10000 units
ciclesonide
Not recommended in the patients aged 1 to 5 years- Consult Respirology

Low Dose
100-200 microgram(s) inhalation daily
Medium Dose
200-400 microgram(s) inhalation daily
High Dose
400 microgram(s) inhalation once to twice daily

Comments
Rinse mouth after use.
Prime MDI before first use or if after one week without use
Supplied: Inhalation, Metered Dose: 200 micrograms/puff, 100 micrograms/puff
ciprofloxacin
Ciprofloxacin suspension should NOT be given via an enteral feeding tube (e.g. g-tube) route. Crushed whole or portioned
ciprofloxacin (regular) tablets can be given via tube, but should not be administered concurrently with enteral feedings.
Discontinue feed for 1 to 2 hours prior to and after ciprofloxacin administration. Doses may be need to be adjusted to allow for
the use of tablets (e.g. 1/4 of 250 mg tab = 62.5 mg)
Renal Adjustment
Various Indications
Go to Firstline
Meningitis Prophylaxis
Go to Nova Scotia Communicable Diseases Manual
Peritonitis
Intraperitoneally
Receiving PD

ciprofloxacin|dexamethasone - [Ciprodex]
Acute Otitis Media (with tympanostomy tubes)
6 months and greater
4 drops in affected ear(s) BID for 2 days
Acute Otitis Externa

6 months and greater:
4 drops in affected ear(s) BID for 7 days
Airway reconstruction surgery (to control granulation tissue and airway edema)
Nebulization/ Instillation: Limited evidence
Dosing and frequency outside of these guidelines may occasionally occur at physician's discretion based on patient factors and clinical
situation
Dose is based on dexamethasone component (Ciprodex* contains 1 mg/mL dexamethasone)

0.17 mL/kg/DOSE nebulized or instilled TID for 3-5 days (Usual: 0.5 mL/kg/DAY)
Usual maximum: 3 mL/dose
Supplied: Suspension, Otic: 3|1 mg/mL
cisapride
Prokinetic
0.2 mg/kg/dose PO TID to QID

Maximum: 0.8 mg/kg/24h OR 40 mg/24h
Comments
Patient/Family Resource: Cisapride Information Handout
Recommended monitoring:
ECG with QTc at baseline
ECG with QTc 3 to 5 days after initiating cisapride

Tablet: 10 mg
cisatracurium
Ideal Body Weight (IBW) should be used for obese patients requiring intravenous therapy. Go to IBW calculator
IV Continuous
Ordered as: microgram/kg/min
Initial Dosing
2 microgram/kg/min
Suggested Titration
0.5-1 microgram/kg/min every 30 minutes
Usual Range
Maximum
10 microgram/kg/min (not well established)
IV Intermittent (when administered using bolus function with continuous infusion)
100-150 microgram/kg/dose IV may be repeated PRN
CISplatin
citalopram
Renal Adjustment
Antidepressant
Comments
clarithromycin
Renal Adjustment
Various Indications
Go to Firstline

Tablet: 250 mg
clindamycin
February 2023: shortage of all forms of parenteral clindamycin
Use is reserved to treatment of necrotizing fasciitis and STSS (Streptococcal Toxic Shock Syndrome)
Refer to IWK Firstline for guidance on most appropriate - clindamycin is not first line therapy for most infectious syndromes
If clindamycin is being ordered due to allergy, ensure allergy has been thoroughly assessed. Refer to IWK Firstline - De-labelling
Penicillin Allergy
Renal Adjustment
Various Indications
Go to Firstline
Peritonitis
Intraperitoneally
Receiving PD

Injection: 18 mg/mL, 150 mg/mL
Solution: 15 mg/mL
cloBAZam
Renal Adjustment
Anticonvulsant
Less than 2 years
0.125-0.5 mg/kg/dose PO BID

Maximum: 30 mg/dose
2 to 16 years
5 mg PO daily may increase every 5-7 days to a usual range of 5-10 mg/dose PO BID
Maximum: 40 mg/24h OR 30 mg/dose
Comments
Adolescent Maximum: 80 mg/24h
If daily doses are not divided equally, give larger dose at bedtime

Tablet: 10 mg
clobetasol
Topical
Supplied: Cream, Topical: 0.05 %

Ointment, Topical: 0.05 %
Scalp, Topical: 0.05 %
clofarabine
clomiPRAMINE
Antidepressant
Comments
clonazePAM
Anticonvulsant
Less than 10 years OR 30 kg and less
Initial
or

Maximum: 0.05 mg/kg/24 hours
Maintenance
Increase by 0.25-0.5 mg/24 hours every 3 days to usual maintenance of

10 years and greater OR weighing more than 30 kg and Adolescents

Initial
0.5 mg PO every 8 hours increase by 0.5-1 mg/24 hours every 3 days up to

Maximum: 20 mg/24h
Various Indications
• Go to Clinical Handbook of Psychotropic Drugs: Children and Adolescents (only accessible through IWK)
Comments
Supplied: Suspension: 0.1 mg/mL IWK Compounded

cloNIDine
Renal Adjustment
Pre-Op
ADHD/Tourette's Syndrome
Withdrawal Management (PICU)
Go to PICU Withdrawal Guidelines
Opioid Withdrawal
Infants
1-2 microgram/kg/dose PO every 6 hours
Tone Management
Initial
Day 1-3
1 microgram/kg/dose PO at bedtime
Days 4-6
1 microgram/kg/dose PO BID
Days 7-9
1 microgram/kg/dose PO TID
Usual Maintenance
20 microgram/kg/24h divided PO every 3 to 8 hours . May be titrated up to maximum 75 microgram/kg/24h divided every 3 hours
Hypertension
2.5-5 microgram/kg/dose PO every 12 hours may increase gradually up to 6.25 micrograms/kg/dose every 6 hours
or
1.67-3.3 microgram/kg/dose PO every 8 hours may increase gradually up to 6.25 micrograms/kg/dose every 6 hours
EEG Sedation for Children with Autism

Children less than 10 kg
50 microgram(s) PO once
Children 10 to 30 kg
100 microgram(s) PO once
Children greater than 30 kg
150-200 microgram(s) PO once
Comments
Do not abruptly discontinue as a rapid increase in blood pressure and symptoms of sympathetic overactivity may occur. Gradually
taper dose over at least one week.
Consider ECG monitoring in patients receiving stimulants like methylphenidate for ADHD.
Supplied: Suspension: 10 micrograms/mL IWK Compounded

Tablet: 100 microgram(s), 25 microgram(s)
clotrimazole - [Canesten]
Antifungal
Topical (Cream)
Topically to affected area BID
Vaginal (Cream)
1 applicatorful PV/Topical daily for 6 doses
Supplied: Cream, Topical: 1 %

Cream, Vaginal: 1 %
cloxacillin
Oral cloxacillin is not usually recommended as absorption is poor
Various Indications
IV
Go to Firstline
clozapine
Go to Medication Management Policy 4.31 Clozapine Management for important information on the use of clozapine
Antipsychotic
Initiation of Therapy
Approvals through CSAN and Nova Scotia Clozapine Program should be obtained prior to initiation (refer to policy above)
Go to clinical order set IWK CLIN "Clozapine Initiation Orders"
Additional Information
Comments
Monitor vital signs as per recommendations in the clozapine clinical order set.
Doses up to 200 mg daily may be taken as single dose at bedtime. Doses greater than 200 mg may be divided unevenly with the larger portion
given at bedtime.
Avoid abrupt discontinuation, wean over 1-2 weeks. If abrupt discontinuation is required, closely monitor patient for symptoms of withdrawal.
cosyntropin
ACTH Stimulation Test
Low Dose
1 microgram(s) IV once
Standard Dose
Less than 2 years
125 microgram(s) IV/IM once
250 microgram(s) IV/IM once
Supplied: Injection: 250 microgram(s)
crisantaspase recombinant - [Rylaze]

Every 48 hour schedule
25 mg/m*2 IM every other day (every 48 hours)
Monday ,Wednesday, Friday schedule
25 mg/m² IM on Monday and Wednesday morning

50 mg/m² IM on Friday afternoon (53-58 hours after Wednesday's dose)
cyanocobalamin - [Vitamin B12]

Transcobalamin deficiency
1000 microgram(s) PO/IM daily initally, then twice weekly
Supplied: Injection: 1000 micrograms/mL

Tablet: 1000 microgram(s)
cyclophosphamide
Renal Adjustment

Tablet: 25 mg
cycloSPORINE
When prescribing cycloSPORINE for outpatients, use order set IWK IMDI (available in e-Access)
Renal Adjustment
Renal Transplant
Induction
Go to clinical order set IWK RETRBA "Renal Transplant Post−Op Induction Protocol Basiliximab (Simulect®)"
Go to order set IWK RETRRA "Renal Transplant Post−Op Orders for Induction Protocol Rabbit Anti−thymocyte Globulin
(Thymoglobulin®)"
Maintenance
3-7.5 mg/kg/dose PO every 12 hours
or
2-5 mg/kg/dose PO every 8 hours
Erythema Multiforme
[Mycoplasma pneumoniae-associated rash and mucositis, Stevens-Johnson syndrome (SJS), and toxic epidermal necrolysis (TEN)]
Oral
1.5-2.5 mg/kg/dose PO/NG BID for 7-10 days
Intravenous
0.5-0.8 mg/kg/dose IV every 12 hours
Aplastic Anemia
Go to clinical order set IWK ATGAA Aplastic Anemia Orders Hematology-Oncology
Comments
Target pre (trough) level for aplastic anemia: 200-400 micrograms/L
IWK Nephrology target trough level ranges - time post renal transplant (months):
Month 1: 250-500 ug/L
Months 2 & 3: 200-300 ug/L
Months 4, 5 & 6: 150-250 ug/L
Months 7 to 12: 100-200 ug/L
greater than 1 year: 75-150 ug/L
NOTE: If confirmed nephrotoxicity or EBV mismatch, target ranges may be lower
If confirmed rejection, target ranges may be higher
Supplied: Capsule: 10 mg, 25 mg, 100 mg

Injection: 50 mg/mL
Solution: 100 mg/mL
cytarabine
Comments
Please refer to dexamethasone dosing guidelines, for information on use of ophthalmic drops in patients receiving greater than or
equal to 1000 mg/m2 of cytarabine.
dacarbazine
DACTINomycin
Supplied: Injection: 500 microgram(s)
dalteparin
For patients less than 16 years AND less than 50 kg: Hematology, PICU*
For patients 16 years and greater AND 50 kg and greater: Hematology, PICU*, Orthopedics, General Surgery
*NOTE: all PICU patients require a consult to Hematology (as per restriction criteria) upon transfer
Renal Adjustment
Venous Thromboembolism
Prophylaxis
16 years and greater AND 50 kg and greater
5000 unit(s) subcutaneous daily
Supplied: Injection: 2500 units/0.2 mL (Prefilled Syringe), 5000 units/0.2 mL (Prefilled Syringe), 7500 units/0.3 mL (Prefilled Syringe),
10000 units/0.4 mL (Prefilled Syringe), 12500 units/0.5 mL (Prefilled Syringe), 15000 units/0.6 mL (Prefilled Syringe), 18000 units/0.72 mL
(Prefilled Syringe)
dantrolene
For the management of malignant hyperthermia see Medication Management Policy 30.21 or see most current guidelines from Malignant
Hyperthermia Association of the US (MHAUS)
Malignant Hyperthermia
Treatment - MHAUS protocol
2.5 mg/kg/dose IV may be repeated PRN up to

Maximum: 10 mg/kg TOTAL DOSE
Post Crisis Follow-up
1 mg/kg/dose IV every 4 to 6 hours
OR
0.25 mg/kg/hour IV continuous infusion for 1 day
DAPTOmycin
Various Indications
Go to Firstline
DAUNOrubicin
deferoxamine
Renal Adjustment
Antidote
desloratadine - [Aerius]
March 2023: Brought in temporarily as replacement product during cetirizine shortage.
Renal Adjustment
Antihistamine
2 to 5 months
NOTE: no published guidelines to support dosing in this age group. Dosing provided based on expert opinion
0.5 - 1 mg PO daily
6 to 11 months
1 mg PO daily
1 to 5 years
1.25 mg PO daily
6 to 11 years
2.5 mg PO daily
5 mg PO daily
Comments
Doses greater than 5 mg provide no additional benefit but may increase the risk of adverse effects.
Occasionally, higher doses may be used in chronic urticaria.
Supplied: Syrup: 0.5 mg/mL
desmopressin - [DDAVP]
All inpatients with diabetes insipidus should have Endocrinology involved in fluid/electrolyte/desmopressin management.
Go to Health Canada Warning (2008): Desmopressin nasal sprays are associated with an increased risk of serious side
effects involving water retention and decreased blood sodium levels (hyponatremia)
Diabetes Insipidus (DI)

All inpatients with (DI) should have Endocrinology involved in fluid/ electrolyte/ desmopressin management. Restrict fluid intake. Allow the
patient free access to water to drink to own thirst. Use IV fluids conservatively and monitor serum sodium levels, fluid intake and urine
output as per Endocrinology.
Intranasal
5-30 microgram/24h divided intranasal once to twice daily
5-40 microgram/24h divided intranasal once to three times daily
IV/Subcutaneous
Less than 12 years
0.4 microgram(s) IV/Subcutaneous daily
1-4 microgram(s) IV/Subcutaneous daily
Oral, Tablet**
1 to 3 years Note: Less than 1 year. Consult Endocrinology
Initial
0.025 mg/dose PO . Subsequent doses and interval based on patient’s response. Usual dose titration 0.05 mg to 0.1 mg per dose.

Initial
0.05 mg/dose PO . Subsequent doses and interval based on patient’s response. Usual dose titration 0.05 mg to 0.1 mg per dose.
Usual maintenance
0.05-0.4 mg/dose PO BID to TID

Maximum: 1.2 mg/24h
Bleeding Disorder
Dosing Under Review May 2021
Comments
**Dosing for the tablet and the oral disintegrating tablet dosage forms is NOT equivalent. IWK only stocks the tablet dosage
form.
**Dose conversion: 100 microgram oral tablet is equivalent to 60 microgram oral disintegrating tablet
Supplied: Injection: 4 micrograms/mL, 15 micrograms/mL

Spray, Nasal: 10 micrograms/spray
Tablet: 0.1 mg, 0.2 mg
dexamethasone
Airway Edema or Extubation
0.125-0.5 mg/kg/dose PO/IV/IM every 6 hours begin 6-24 hours before extubation and continue for 4-6 doses after extubation
Maximum: 10 mg/dose
Antiemetic with Antineoplastic therapy
Go to APPHON Guidelines
Asthma Exacerbation
Emergency Department
Go to clinical order set IWK PEASCA "Asthma Care Path Orders- Emergency Department"
Inpatient
Go to clinical order set IWK PEINAS "Pediatric Inpatient Asthma Care Map"
Note: Maximum of 12-16 mg/dose. The higher maximum dose (16 mg) applies to inpatients based on their severity of illness (i.e.
requirement for hospitalization) and the available inpatient literature.
Cerebral Edema
Loading Dose
1-2 mg/kg/dose IV/IM once

Maximum: Usual: 10 mg/dose
Maintenance
0.25-0.375 mg/kg/dose PO/IV/IM every 6 hours

Maximum: Usual: 4 mg/dose
or
0.17-0.25 mg/kg/dose PO/IV/IM every 4 hours

Maximum: 4 mg/dose
Croup
Go to Care Pathway and Care Directive for the Treatment of Croup in the ED
0.6 mg/kg/dose PO once
Maximum: 12 mg/dose
Bacterial Meningitis
0.15 mg/kg/dose IV every 6 hours Start dexamethasone 10-20 minutes before OR at the same time as the first dose of antibiotic
Ophthalmic
Drops (Suspension)
With cytarabine doses greater than or equal to 1000 mg/m2
2 drops in each eye QID beginning immediately before 1st dose of cytarabine and continuing for 24 hours after the last dose of
cytarabine
Manufacturer Recommendation
1-2 drops in affected eye(s) every 4 to 6 hours
Ointment
Thin strip in affected eye(s) three to four times daily
Comments
If the oral suspension is unavailable or dose is immeasurable, the injectable product may be given orally.
Discontinuation of long-term therapy requires gradual withdrawal by tapering of dose.
Refer to Comparative Dosage Table: Corticosteroids Properties and Potencies

Ointment, Ophthalmic: 0.1 %
Solution: 0.05 mg/mL IWK Compounded
Suspension, Ophthalmic: 0.1 %
dexmedetomidine
Analgesia/Sedation
Continuous Infusion
Ordered as: microgram/kg/hour
Loading Dose
Not usually required
0.5 microgram/kg/dose IV once
Initial Dosing
0.2-0.4 microgram/kg/hour
Suggested Titration
0.1-0.2 microgram/kg/hour every 2 hours
Usual Range
Maximum:
2 microgram/kg/hour
Go to clinical order set IWK DEAPS “Dexmedetomidine Continuous Infusion Pediatric Acute Pain Service and Advanced Care Team ONLY"
(for use outside of PICU, OR/PACU)
PICU Weaning/Withdrawal Guidelines
Pre-Operative/Procedural Sedation
Oral
Restricted to specific acute/critical care areas: OR, PACU/DS, PICU, NICU, ED and for Anaesthetists in remote locations providing sedation services (e.g. MRI and
Radiotherapy)

1-4 microgram/kg/dose PO once
Maximum: 200 microgram/dose
Intranasal
*Use the 100 microgram/mL vial*
Restricted to specific acute/critical care areas: OR, PACU/DS, PICU, NICU, ED and for Anaesthetists in remote locations providing sedation services (e.g. MRI and
Radiotherapy

1-4 microgram/kg/dose intranasal once
dexrazoxane
Ratios of Dexrazoxane to Chemotherapeutic Agent

Dexrazoxane: DOXOrubicin
10:1
Dexrazoxane: DAUNOrubicin
10:1
Dexrazoxane: IDArubicin
50:1
Dexrazoxane: mitaXANTRONE
40:1
dextran 70|hydroxypropyl methylcellulose - [Eye Lubricant Drop]

Current contract brand: Tears Naturale Free (preservative free) minims
Order as: "Eye lubricant drop"
Ophthalmic
1 to 2 drops in affected eye(s) as needed
Supplied: Drops, Ophthalmic: 0.1|0.3 %
dextroamphetamine
Attention Deficit/ Hyperactivity Disorder
Supplied: Capsule, Sustained Release: 10 mg, 15 mg

Tablet: 5 mg
dextromethorphan
Fatty Acid Oxidation Defects/Organic Acidemias
4-5 mg/kg/24h divided
dextrose - [Glucose]
The term glucose and dextrose are often used interchangeably.
Note: Each 31 gram tube of InstaGlucose* contains 10 grams of dextrose equivalent to 24 grams of carbohydrate
Available dextrose containing IV solutions at IWK Supply and Distribution
Antidote
Hypoglycemia in Diabetes
Go to clinical order set IWK TRHY "Treatment of Hypoglycemia in Children & Youth with Diabetes"
Supplied: Gel: 40 % (31 G Tube) , 40 % (2.5 mL Syringe)

Injection: 0.1 gram/mL, 0.125 gram/mL (250 mL Bag) IWK Compounded, 0.15 gram/mL (250 mL Bag) IWK Compounded, 0.2 gram/mL
(250 mL Bag) IWK Compounded, 0.5 gram/mL (50 mL Prefilled Syringe) , 0.5 gram/mL (50 mL Vial)
Tablet: 4 gram(s)
diazepam
Renal Adjustment
Spasticity/Muscle Relaxant
Oral
Greater than 6 months and less than 12 years
0.04-0.27 mg/kg/dose PO TID

Maximum: 10 mg/dose
or

Maximum: 10 mg/dose
2-10 mg/dose PO BID to QID
Intravenous
Greater than 6 months and less than 12 years
0.04-0.2 mg/kg/dose IV every 2 to 4 hours PRN to a maximum of 0.6 mg/kg within an 8 hour period
Procedural Sedation (IWK Nephrology)

Children and Adolescents
0.04-0.2 mg/kg/dose IV
Maximum: 10 mg/dose
Anticonvulsant
Greater than 1 month
0.2-0.5 mg/kg/dose IV every 5 to 10 minutes PRN

Maximum: 5 mg TOTAL DOSE (less than 5 years) OR 10 mg TOTAL DOSE (greater than 5 years)
OR
0.5 mg/kg/dose PR and may repeat 0.25 mg/kg/dose in 10 minutes if needed

Maximum: 20 mg/dose
Alcohol Withdrawal Management
Go to clinical order set IWK AWLI "Alcohol Withdrawal Management Adults and Pediatrics"
Comments
Injection may be administered rectally (undiluted)

Tablet: 2 mg, 5 mg
digoxin
Ideal Body Weight (IBW) should be used for dosing. Go to IBW calculator
Renal Adjustment
"Digitalizing"/Loading Dose *rarely indicated -consult cardiology*
IV
Less than 2 years
15-25 microgram/kg/dose IV once followed by 7.5-12.5 microgram/kg/dose IV every 6 to 8 hours for 2 doses
2 to 5 years
12.5-17.5 microgram/kg/dose IV once followed by 6.25-8.75 microgram/kg/dose IV every 6 to 8 hours for 2 doses
5 to 10 years
7.5-15 microgram/kg/dose IV once followed by 3.75-7.5 microgram/kg/dose IV every 6 to 8 hours for 2 doses
4-6 microgram/kg/dose IV once followed by 2-3 microgram/kg/dose IV every 6 to 8 hours for 2 doses
Oral
Less than 2 years
17.5-30 microgram/kg/dose PO once followed by 8.75-15 microgram/kg/dose PO every 6 to 8 hours for 2 doses
2 to 5 years
15-20 microgram/kg/dose PO once followed by 7.5-10 microgram/kg/dose PO every 6 to 8 hours for 2 doses
5 to 10 years
10-17.5 microgram/kg/dose PO once followed by 5-8.75 microgram/kg/dose PO every 6 to 8 hours for 2 doses
5-7.5 microgram/kg/dose PO once followed by 2.5-3.75 microgram/kg/dose PO every 6 to 8 hours for 2 doses
Maintenance Dose
IV
Less than 2 years
3.75-6 microgram/kg/dose IV every 12 hours
2 to 5 years
3-4.5 microgram/kg/dose IV every 12 hours
5 to 10 years
2-4 microgram/kg/dose IV every 12 hours
1-1.5 microgram/kg/dose IV every 24 hours
Oral
Less than 2 years
5-7.5 microgram/kg/dose PO BID
2 to 5 years
3.75-5 microgram/kg/dose PO BID
5 to 10 years
2.5-5 microgram/kg/dose PO BID
Supplied: Injection: 250 micrograms/mL HIGH ALERT

Solution: 50 micrograms/mL
Tablet: 125 microgram(s)
digoxin immune fab (ovine)

Antidote
dimaval - [DMPS,Unithiol]
Antidote
Go to Atlantic Canada Poison Centre Antidote Kit for information on antidote dosing and administration
dimenhyDRINATE
Prevention or Treatment of Post-op Nausea/Vomiting (PONV)
Ideally treatment of PONV should include an anti-emetic from a different class other than the drug(s) used for prophylaxis
0.5 mg/kg/dose IV/IM every 6 to 8 hours PRN

Maximum: 25 mg/dose
0.5 mg/kg/dose PO every 6 to 8 hours PRN

Maximum: 25 mg/dose
General Anti-Emetic
2 to 12 years
0.5-1.25 mg/kg/dose PO every 6 to 8 hours PRN

Maximum: 25 mg/dose
OR
2 to 6 years
12.5-25 mg PO every 6 to 8 hours PRN

Maximum: 75 mg/24h
12.5-25 mg PR once may repeat after consultation with physician
6 to 12 years
25-50 mg PO every 6 to 8 hours PRN

Maximum: 150 mg/24h
12.5-25 mg PR every 8 to 12 hours PRN
Adolescents
12.5-25 mg IV/IM every 4 to 6 hours PRN
25-50 mg PR every 8 to 12 hours PRN

Maximum: 100 mg/dose OR 300 mg/24h
Chemotherapy Induced Nausea and Vomiting

Less than 1 year
Go to APPHON guidelines
0.5 mg/kg/dose IV/PO every 4 hours PRN for breakthrough
Maximum: 25 mg/dose OR 1 mg/kg/dose
Greater than or equal to 1 year
Go to APPHON guidelines
1 mg/kg/dose IV/PO every 4 hours PRN for breakthrough
Maximum: 50 mg/dose
Comments
May cause paradoxical excitation in young children.
Dosing recommendations have been made based on the references sited here. However adjustments to dosing (often lower recommendation) have
been made after extensive consultation within the IWK.

Liquid: 3 mg/mL
Suppository: 25 mg, 50 mg
Tablet: 50 mg
dinutuximab
As a specialty refrigerated biologic product, dinutuximab has a unique supply chain, it is very important that clinical
pharmacists/pharmacy practice assistants are engaged with IWK pharmacy purchasers to ensure availability of medication. For
example, orders for this medication can only be placed Mon-Wed to ensure cold chain maintenance.
Supplied: Injection: 3.5 mg/mL
diphenhydrAMINE
Non-sedating antihistamine is preferred when using via the oral route. Go to cetirizine
See more information: CSACI position statement: Newer generation H1-antihistamines are safer than first-generation H1-antihistamines
and should be the first-line antihistamines for the treatment of allergic rhinitis and urticaria
Renal Adjustment
Antihistamine in vomiting patients
1 mg/kg/dose IV/IM every 6 hours PRN

Maximum: 50 mg/dose
Anxiety (Emergency Department)

Revised clinical order set for Emergency Management of Anxiety and Agitation coming soon (Fall 2022)
1 mg/kg/dose PO once
Maximum: 50 mg/dose
Comments
Avoid use in delirium
Elixir: 2.5 mg/mL
Injection: 50 mg/mL
DOBUTamine
For administration guidelines outside of PICU or NICU, go to Policy 25.40 Inotrope Infusions on Cardiology Inpatient Unit
IV Continuous
Loading Dose
None
Initial Dosing
5 microgram/kg/min
Suggested Titration
2.5 - 5 microgram/kg/min every 10 minutes
Usual Range
5 - 15 microgram/kg/min
Maximum: 20 microgram/kg/min
dolutegravir
Antiretroviral Agent
Consult Infectious Diseases for dosing
Tablet, Dispersible: 5 mg
domperidone
Go to Health Canada warning (2015) Domperidone- Association with Serious Abnormal Heart Rhythms and Sudden Death (Cardiac
Arrest)
Renal Adjustment
GERD
Greater than or equal to 1 month
0.4-0.8 mg/kg/dose PO TID . Give 15-30 minutes before feeds/meals/bedtime (as applicable)
Maximum: 30 mg/24h
OR
0.3-0.6 mg/kg/dose PO QID . Give 15-30 minutes before feeds/meals/bedtime (as applicable)
Maximum: 30 mg/24h
Older Children and Adolescents
10 mg/dose PO TID . Give 15-30 minutes before feeds/meals/bedtime (as applicable)

Maximum: 30 mg/24h
Comments
Discontinue domperidone if after 4 – 6 weeks there is no clinical response
Recommend ECG pre initiation and repeat 3-5 days post initiation of domperidone in:
All Neonates
Patients:
with a history of heart rate or rhythm disorders, structural heart abnormalities, hypokalemia
with Family history of significant cardiac disease or long QT syndrome
on concomitant QT-prolonging drugs or CYP 3A4 inhibitors

Tablet: 10 mg
DOPamine
IV Continuous
Loading Dose
None
Initial Dosing
5 microgram/kg/min
Suggested Titration
2.5 - 5 microgram/kg/min every 10 minutes
Usual Range
2.5 - 20 microgram/kg/min
Comments
Low dose (1 - 5 microgram/kg/min): dopaminergic receptor agonism
Intermediate dose (5 - 10 microgram/kg/min): beta-1 adrenergic receptor agonism
High dose (10 - 20 microgram/kg/min): alpha-1 adrenergic receptor agonism
DOXOrubicin
Renal Adjustment
DOXOrubicin PEG liposomal

Renal Adjustment
doxycycline
Various Indications
Go to Firstline
duloxetine
Antidepressant
Comments
Supplied: Capsule, Delayed Release: 30 mg
eltrombopag - [Revolade]
Chronic Immune Thrombocytopenia
Less than 6 years
25 mg PO daily may be titrated up to

Maximum: 75 mg/24h
6 years or greater
50 mg PO daily may be titrated up to

Maximum: 75 mg/24h
Severe Aplastic Anemia

15 years or greater
150 mg PO daily
Comments
Do not crush or split tablets. If patient is unable to swallow tablets whole, please discuss with Hematology.
Dose in increments of 25 mg.
Consider reducing doses in East Asian decent populations.
enalapril
Renal Adjustment
Hypertension
Infants and Children
Initial
0.08 mg/kg/dose PO daily

Maximum: 5 mg/dose
Maintenance
titrate dose upward over 10-14 days to maximum of
0.58 mg/kg/dose PO daily

Maximum: 40 mg/dose
Adolescents
Initial
2.5-5 mg/dose PO daily
or
1.25-2.5 mg/dose PO BID
Maintenance
10-40 mg/dose PO daily

Maximum: 40 mg/24h
or
5-20 mg/dose PO BID

Maximum: 40 mg/24h

Tablet: 5 mg, 10 mg
enalaprilat
Renal Adjustment
Hypertension
Infants and Children
0.005-0.01 mg/kg/dose IV every 8 to 24 hours

Adolescents
0.625-1.25 mg/dose IV every 6 hours . Doses up to 5 mg/dose IV q6h have been tolerated for up to 36 hours
enoxaparin
June 2023 - Current product provided by IWK Pharmacy: Redesca®
Dose Rounding Guidelines:

Note: these are guidelines only, and variations from this guidance may be warranted as is clinically appropriate.
Doses greater than 5 mg--> round to the nearest whole milligram.
Doses less than 5 mg--> round to the 0.5 mg increments as follows:
Total Calculated Dose (mg) Dose to order (mg)
1 - 1.25 1
1.26 -1.74 1.5
1.75 - 2.25 2
2.26 - 2.74 2.5
2.75 - 3.25 3
3.26 - 3.74 3.5
3.75 - 4.25 4
4.26 - 4.74 4.5
4.75 - 5 5
Renal Adjustment
Venous Thromboembolism
Prophylaxis
Go to order set IWKPREN "Enoxaparin Prophylactic Orders"
Therapeutic
Initial Dosing
Go to order set IWKTHEN "Enoxaparin Therapeutic Orders"
Subsequent Dosing
Refer to page 2 of IWKTHEN (above) for information on monitoring and subsequent dosing
Supplied: Injection: 30 mg/0.3 mL (Prefilled Syringe), 40 mg/0.4 mL (Prefilled Syringe), 60 mg/0.6 mL (Prefilled Syringe), 80 mg/0.8 mL
(Prefilled Syringe), 100 mg/mL (Prefilled Syringe), 100 mg/mL (3 mL Vial)
EPINEPHrine
Pediatric Advanced Life Support/Anaphylaxis
Go to Calculator
Hypotension/Shock/Inotropic Support
IV Continuous
Loading Dose
None
Initial Dosing
0.02 microgram/kg/min
Suggested Titration
0.01 microgram/kg/min every 10 minutes
Usual Range
0.01 - 1 microgram/kg/min
Sepsis Management in Emergency Department

IV Continuous
Greater than 28 days
Go to order set IWKSESE "Sepsis Management in Children Greater than 28 Days of Age, Emergency Department"
Anaphylaxis
General Dosing
Go to PALS/Anaphylaxis Calculator
0.01 mg/kg/dose IM
Go to clinical order set IWK ANED "Anaphylaxis in the Emergency Department"
Outside of the Emergency Department for Known Anaphylactic Allergy
Go to clinical order set IWK ANRT "Anaphylaxis: Recognition and Initial Treatment"
Medication Infusion Reactions, Transfusion Related Adverse Events and Anaphylaxis Initial Treatment
Go to clinical order set IWK PRHY "Medication Infusion Reactions, Transfusion Related Adverse Events and Anaphylaxis Initial Treatment"
Croup
Inhalation *Use 1 mg/mL (30 mL)*
Usual practice/ED care directive includes racemic EPINEPHrine, however there is a national shortage of racemic EPINEPHrine (as of August 2019)
Go to Care Pathway and Care Directive for the Treatment of Croup in the ED
0.5 mg/kg/dose inhalation every hour PRN Mix dose (as needed) with 0.9% sodium chloride to provide a total volume of 2.5 mL for
nebulization
Maximum: 5 mg/dose
ETT Instills (PICU)

0.5 mg in 250 mL 0.9% NaCl with suctioning PRN
Supplied: Injection: 1 mg/mL (1 mL Ampoule) , 0.1 mg/mL (10 mL Prefilled Syringe) , 0.5 mg/mL (0.3 mL Auto-Injector) , 1 mg/mL (0.3
mL Auto-Injector) , 1 mg/mL (30 mL Vial)
Solution, Topical: 1 mg/mL
EPINEPHrine, Racemic - [Racemic EPINEPHrine]

Racemic EPINEPHrine is currently short from the manufacturer.
Go to IWK Drug Shortages page for more information on alternatives
See EPINEPHrine for information on dosing via inhalation:
Go to Neonatal
Go to Pediatrics
For information on the use of nebulized medications and COVID, click here
Supplied: Inhalation, Nebule: 22.5 mg/mL
epoprostenol - [prostacyclin]
NOTE: 1 NANOgram = 0.001 microgram
IV Continuous
Ordered as: NANOgram/kg/min
Loading Dose
None
Initial Dosing
2 NANOgram/kg/min
Suggested Titration
1-2 NANOgram/kg/min every 15-30 minutes to effect or until side effects develop and tolerance limit is observed
Usual Range
20-40 NANOgram/kg/min
Maximum: 80 NANOgram/kg/min
Comments
Do not withdraw treatment abruptly. Decrease dose by 2 NANOgrams/kg/minute every 15 minutes
ertapenem
Renal Adjustment
Various Indications
Go to Firstline
erythromycin
Renal Adjustment
Prokinetic Agent
2-3 mg/kg/dose IV every 8 hours

Various Indications (Infectious Diseases)

Consider other macrolides as appropriate
Go to Firstline

erythropoietin alfa - [Epo, Epoetin Alfa]

Anemia of Chronic Renal Failure
50 units/kg/dose IV/Subcutaneous three times weekly
Comments
Dose adjusted based on hemoglobin. Once weekly doses may be given
Supplied: Injection: 1000 units, 2000 units, 3000 units, 4000 units, 5000 units, 10000 units
EScitalopram - [Cipralex]
Antidepressant
Comments
esmolol
Supraventricular Tachycardia/Hypertension
IV Continuous
Loading Dose
100-500 microgram/kg/dose IV once
Initial Dosing
Suggested Titration
25-50 microgram/kg/min every 10-20 minutes
Usual Range
Maximum
1000 microgram/kg/min
Supplied: Injection: 10 mg/mL (10 mL Vial) , 10 mg/mL (250 mL Bag)
etanercept - [Enbrel, Erelzi]

Juvenile idiopathic arthritis
2 years and greater
0.8 mg/kg/dose subcutaneous weekly

Maximum: 50 mg/dose
Comments
Dose may be divided twice weekly.
Supplied: Injection: 50 mg/mL, 25 mg
ethambutol
Renal Adjustment
Tuberculosis Treatment

OR
50 mg/kg/dose PO twice weekly

etoposide
etoposide phosphate
Go to Chemotherapy Administration Standards document
Supplied: Injection: 100 mg Special Access
famotidine
Famotidine is associated with QT interval prolongation, caution with other drugs or conditions associated with QT interval
prolongation.
GERD
Oral
0.5 - 1 mg/kg/dose PO once to twice daily

Maximum: 40 mg/24h
Intravenous
Less than 1 year
0.25 - 0.5 mg/kg/dose IV every 24 hours
Greater than 1 year
0.25 mg/kg/dose IV every 12 hours

Maximum: 20 mg/dose
Stress Ulcer Prophylaxis
0.5 - 1 mg/kg/dose IV every 12 hours

Maximum: 20 mg/dose
or
0.33 - 0.67 mg/kg/dose IV every 8 hours

Comments
Patients receiving parenteral nutrition may have the total daily dose (mg/kg/24h) added to the solution

Tablet: 20 mg
fat emulsion (Intralipid) - [Intralipid]

TPN
SMOF Lipid
Intralipid
Do not use in patients with a history of severe egg, peanut or legume (soy bean) allergy
Antidote
Parenteral Nutrition
Go to Clinical Order Set IWK FALI "Fat/Lipid Emulsion Order"
Supplied: Injection: 0.2 gram/mL
fat emulsion (SMOF) - [SMOF]

TPN
SMOF Lipid
Intralipid
Do not use in patients with a history of severe egg, peanut or legume (soy bean) or fish allergy
Go to Clinical Order Set IWK FALI "Fat / Lipid Emulsion Orders"
fentaNYL
These dosing guidelines are intended for opioid-naive, acute pain situations.
Practitioners should consider whether the patient is opioid naive and other underlying medical conditions when choosing
an initial dose.
The Children’s Health Program is supported by an Acute Pain Service which is available for medical consultation in
complex dosing situations.
Patients already receiving regular opioids or with cancer or chronic pain may require significantly higher or more frequent
doses.
Renal Adjustment
IV Intermittent
Critical Care Areas - PICU/OR/PACU/ED
1-2 microgram/kg/dose IV once

Maximum: Usual 100 microgram/dose
IV Continuous
Outside of NICU/PICU
Note: restricted to Acute Pain Service and Pediatric Advanced Care Team for Use Outside NICU/PICU
Go to order set IWK FECOIN "fentaNYL Continuous Infusion Restricted to Acute Pain Service and Pediatric Advanced Care Team for Use
Outside NICU/PICU
Loading Dose
None
Initial Dosing
1-2 microgram/kg/hour
Suggested Titration
0.5-1 microgram/kg/hour every hour
Usual Range
Maximum: 5 microgram/kg/hour
Patient Controlled Analgesia
Go to IWK IVPA "ACUTE PAIN SERVICE (APS) PATIENT CONTROLLED ANALGESIA (PCA) ORDERS − PEDIATRICS""
Intranasal
*Use the 50 microgram/mL amp*
1-2 microgram/kg/dose intranasal once

Comments
IWK Opioid Dose Conversion and Equianalgesic Guidelines
Supplied: Injection: 50 micrograms/mL, 10 micrograms/mL IWK Compounded, 2 micrograms/mL IWK Compounded

Transdermal Patch: 25 micrograms/hour, 50 micrograms/hour, 75 micrograms/hour, 100 micrograms/hour
ferric derisomaltose - [Monoferric, formerly known by generic name iron isomaltoside]

Prescribing is restricted to Pediatric Hematology for use in patients greater than or equal to 50 kg who:
have failed a trial of oral iron AND require rapid replacement based on symptoms (e.g. uncontrolled headache and
fatigue), decreased quality of life and family concerns/expenses
OR
would likely be non-adherent with an iron sucrose regimen
All doses expressed in terms of elemental iron. All orders must be written in terms of elemental iron.
Oral iron therapy should be stopped during parenteral iron therapy. Oral iron may be restarted 5 days after completion of
parenteral iron.
Iron Deficiency Anemia
Go to clinical order set IWK IRSU "Intravenous Iron Therapy Pediatric"
filgrastim - [G-CSF, Grastofil, Neupogen]

Current product selection: Nivestym (a biosimilar to Neupogen)
In general, doses greater than or equal to 200 micrograms are rounded up to 300 micrograms.
Orders for 300 micrograms/dose subQ should be written as filgrastim (biosimilar) and dispensed and administered as Nivestym
prefilled syringes.
Neutropenia, Secondary to Chemotherapy
5 microgram/kg/dose subcutaneous daily Refer to individual protocols for treatment endpoint.
fish oil emulsion - [Omegaven]

Go to Clinical Order Set IWK FALI "Fat / Lipid Emulsion Orders"
flecainide
Antiarrhythmic
Body Surface Area Based Dosing
Less than 6 months
Initial: 25 mg/m*2/dose PO every 12 hours

Maximum: 200 mg/m*2/24h
or
16.7 mg/m*2/dose PO every 8 hours

Initial: 50 mg/m*2/dose PO every 12 hours

or
33.3 mg/m*2/dose PO every 8 hours

Weight based dosing

Limited data- BSA dosing preferred
Initial: 0.3-1 mg/kg/dose PO every 8 hours

Maximum: 8 mg/kg/24 hours
Comments
Daily ECG for 3 days on initiation and then ECG with change of dose.
In infants receiving milk or formula, avoid concurrent administration with feedings, milk may inhibit absorption.
Target drug levels can be used to monitor flecainide for efficacy and toxicity although it is processed off site and turnaround time
is 1 to 2 weeks
Flecainide may increase serum drug levels of digoxin, when used in combination monitor closely.

fluconazole
Renal Adjustment
Various Indications
Go to Firstline
Peritonitis
Intraperitoneally
Receiving PD
Prophylaxis in Immunocompromised Patients (Hematology/Oncology Service)
6-12 mg/kg/dose IV/PO daily

Maximum: 400 mg/24h

fludarabine
flumazenil
Antidote
Benzodiazepine reversal in procedural sedation
Go to clinical order set IWK MIPRSE "Midazolam for Procedural Sedation in Pediatric Patients Outside of PICU, NICU and ED"
fluorometholone - [FML]
Ophthalmic
1-2 drops in affected eye(s) BID to QID
Comments
Can increase to 2 drops every hour x 24-48 hours initially
Supplied: Drops, Ophthalmic: 0.1 %
fluorouracil
FLUoxetine
Antidepressant
Comments

Liquid: 4 mg/mL
flupenTHIXol
Antipsychotic
Comments
Supplied: Tablet: 0.5 mg
fluticasone
October 2023: Fluticasone 50 microgram/puff MDI short from manufacturer. Please use patient's own supply if possible.
Consult pharmacy/clinical pharmacist for alternate therapy options.
Click here for information on an alternative inhaled corticosteroid
Oral Inhalation (MDI)

1 to 5 years
Low Dose
50 microgram(s) inhalation BID
Medium Dose
100-125 microgram(s) inhalation BID
6 to 11 years
Low Dose
Medium Dose
High Dose

Low Dose
Medium Dose
High Dose

Rhinitis- Nasal Spray

4 to 11 years
1 to 2 sprays (50 to 100 micrograms) in each nostril daily
Maximum: 2 sprays (100 micrograms) in each nostril per day

2 sprays (100 micrograms) in each nostril once daily OR 1 spray (50 micrograms) in each nostril BID
May increase to 2 sprays (100 micrograms) in each nostril BID for severe rhinitis
Comments
Doses greater than 500 micrograms inhaled BID should only be prescribed by a respirologist
Patients previously on inhaled or oral corticosteroids may require higher doses.
Adjust dose to minimum effective dose based on individual response.
Long term therapy requires monitoring for corticosteroid systemic effects/adrenal insufficiency (i.e., doses greater than 500 micrograms/24h)
Metered dose inhalers should be primed before first use or after one week without use.
Supplied: Inhalation, Metered Dose: 50 micrograms/puff, 125 micrograms/puff

Spray, Nasal: 50 micrograms/spray
fluvoxamine
Antidepressant
Comments
folic acid - [folate]

Deficiency
1 mg PO/IV/IM/Subcutaneous daily
Maintenance
Infants
0.1 mg PO daily
Less than 4 years
0.3 mg PO daily
0.4 mg PO daily
Prevention of methotrexate side effects (Rheumatologic indications)
5 mg PO weekly
OR
1 mg PO daily

Tablet: 0.4 mg, 1 mg, 5 mg
fomepizole
Antidote
Supplied: Injection: 1 gram/mL
fosaprepitant
Go to APPHON Guidelines for the Management of Chemotherapy Induced Nausea and Vomiting in Children with Cancer for more
information

6 months and greater to less than 2 years AND 6 kg and greater
Single day regime
5 mg/kg IV once
3 day regime
3 mg/kg IV once on day 1 followed by oral aprepitant on day 2 and 3.

2 years to less than 12 years

Single day regime
4 mg/kg IV once
3 day regime
3 mg/kg IV once on day 1 followed by oral aprepitant on day 2 and 3.


Single day regime
150 mg/dose IV once
3 day regime
115 mg/dose IV once on day 1 followed by oral aprepitant on day 2 and 3.
fosphenytoin - [Cerebyx]
**CONTENT UNDER DEVELOPMENT: DO NOT USE THIS AS REFERENCE (DEC 8, 2023)**
Fosphenytoin labelling expresses concentration and amount of fosphenytoin as phenytoin sodium equivalents (PE)
All doses are expressed as phenytoin sodium equivalents (PE)
All orders must be written as dose followed by PE i.e fosphenytoin 500 mg PE
NOTE: fosphenytoin is not typically used at the IWK
Status Epilepticus
Loading Dose [all doses expressed as phenytoin sodium equivalents (PE)]
15-20 mg PE/kg/dose IV/IM

Maximum: 1000 mg PE/dose
Maintenance
2 to 4 mg PE/kg/dose IV/IM every 12 hours
OR
1.33 to 2.66 mg PE/kg/dose IV/IM every 8 hours

Maximum: 300 mg PE/24 hours
Comments
1.5 mg fosphenytoin = 1 mg phenytoin sodium = 1 mg PE phenytoin
If patient is receiving maintenance phenytoin, consider using a partial loading dose of 10 mg PE/kg
fosphenytoin has been given intraosseously (IO)
Each 1 mg of PE contains 0.0037 mmol of phosphate
Supplied: Injection: 50 mg PE/mL
furosemide
Diuretic
Intermittent
0.5-2 mg/kg/dose PO/IV/IM every 6 to 24 hours
IV Continuous (ICU)
Loading Dose
None
Initial Dosing
0.2 mg/kg/hour
Suggested Titration
0.1 mg/kg/hour every 6 to 12 hours
Usual Range
0.05 - 0.4 mg/kg/hour
Maximum: 0.5 mg/kg/hour
Comments
Older children and adolescents usually respond to lower doses (10-20 mg/dose)

Solution: 10 mg/mL
Tablet: 20 mg
fusidic acid - [Fucidin]

Topical (cream or ointment)
Topically to affected area three to four times daily
Supplied: Cream, Topical: 2 %

Ointment, Topical: 2 %
gabapentin
Renal Adjustment
Pre-Operative
Children 3 to 12 years
Anticonvulsant
Initial
3 to 12 years
3.3-5 mg/kg/dose PO TID titrated up to usual aged based doses below
Adolescents
300 mg PO TID titrated up to usual aged based doses below
Usual
3 to 4 years
13.3 mg/kg/dose PO TID
5 to 12 years
Adolescents
300-600 mg PO TID
Neuropathic Pain
3 to 12 years
Day 1
5 mg/kg/dose PO at bedtime
Day 2
5 mg/kg/dose PO BID
Day 3
5 mg/kg/dose PO TID
Maintenance

Adolescents
Initial
100-300 mg PO once to three times daily may increase dose by 300 mg/24 hours at weekly intervals to:
Usual
600-800 mg PO TID
Idiopathic Scoliosis (IWK Orthopedics and Pain Team)

Adolescents
Post-Op Day 1
5 mg/kg/dose PO BID
Post-Herpetic Neuralgia
Adolescents
Day 1
300 mg PO at bedtime
Day 2
300 mg PO BID
Day 3
300 mg PO TID - Dose may be titrated up to:

Comments
Do not exceed 12 hours between doses with TID schedule
Patient/Family Resource: AboutKidsHeath Gabapentin

galsulfase
Mucopolysaccharidosis (MPS) VI
Go to clinical order set IWK GANA "Galsulfase (Naglazyme) Orders"
ganciclovir
Renal Adjustment
Cytomegalovirus Prophylaxis, Post-kidney transplant
5 mg/kg/dose IV every 12 hours for 7 to 14 days then 5 mg/kg/dose IV once daily
Other CMV infections
5 mg/kg/dose IV every 12 hours for 14 to 21 days
gemtuzumab ozogamicin
gentamicin
Renal Adjustment
Extended Interval Dosing
Initial
Go to Firstline
Subsequent Dosing/Monitoring
Indication for Monitoring Levels
For anticipated duration of therapy more than 2 days
Timing of Serum Samples
23 hr level: 60 minutes prior to 2nd dose
Careful documentation of infusion and serum sample collection time is required. When interpreting levels,
ensure timing of serum samples is appropriate.
Target Serum Concentrations
less than 1 microgram/mL
Suggested Regimen Adjustments based on Serum Concentration Results
If desired trough, continue current dose and repeat pre (trough) every 7 days
Traditional/Conventional Dosing
Initial
Traditional dosing needs to be adjusted based upon analysis of drug levels (e.g. reduced renal function or treatment for synergy). It is preferable to use an
alternative agent in renal failure.
Go to Firstline
Subsequent Dosing/Monitoring
Indication for Monitoring Levels
For anticipated duration of therapy more than 2 days monitor serum gentamicin levels as follows.
Timing of Serum Samples
Serum concentrations should be measured at steady state, usually with the 3rd or 4th dose.
Pre (trough): 0-30 minutes prior to dose
Post (peak): 30 minutes after the end of a 30 minute IV infusion or 1 hour following IM injection
NOTE: Careful documentation of infusion and serum sample collection time is required. When interpreting levels, ensure timing of serum samples
is appropriate.
Target Serum Concentrations

Desired (micrograms/mL)
Indication Pre (trough) | Post (Peak)
Synergy for Gram Positive Infections Less than 2 | 3-5
Urinary Tract Infection & Mild-Moderate Infections Less than 2 | 4-8
Severe Infections (Pneumonia, Sepsis, CF) Less than 2 | 8-12
Suggested Regimen Adjustments based on Serum Concentration Results

Result Adjustment
High Pre ↑ Interval
High Post ↓ Dose*
Low Post ↑ Dose*
*Aminoglycosides exhibit linear kinetics. Decreasing or increasing the dose by a specified percentage will result in an equal decrease/increase in
percentage of peak levels.
Repeat levels with 3rd or 4th dose after regimen adjustments to ensure the desired results have been achieved and approximately every 7 days or
sooner if changing renal function or clinical status.
Peritonitis
Intraperitoneally
Receiving PD
Supplied: Injection: 1 mg/mL, 40 mg/mL
glucagon
NOTE: 1000 micrograms = 1 mg = 1 unit
Antidote
Go to Atlantic Canada Poison Centre Antidote Kit for information on antidote dosing
Severe hypoglycemia
Go to clinical order set IWK_TRHY “Treatment for Hypoglycemia in Children and Youth with Diabetes"
Anaphylaxis in Emergency Department
Go to clinical order set IWK ANED
glycerin
Constipation
less than 6 years:
One infant suppository PR daily PRN
6 years and greater:
One adult suppository PR daily PRN
Supplied: Suppository: 1.8 gram/suppository, 2.34 gram/suppository
glycopyrrolate
Note: 1 microgram = 0.001 mg
Renal Adjustment
Reduction of respiratory and salivary secretions

Parenteral
4-10 microgram/kg/dose IV/IM every 3 to 4 hours

Maximum: 200 microgram/dose OR 800 microgram/24h
Oral
40-100 microgram/kg/dose PO TID to QID

Comments
Injection may be given orally
Supplied: Injection: 0.2 mg/mL, 200 micrograms/mL

Suspension: 0.5 mg/mL IWK Compounded
golimumab
Ulcerative Colitis (2 years and older) and Crohns' Disease
Less than 45 kg
Week 0
115 mg/m*2/dose subcutaneous once
Week 2
60 mg/m*2/dose subcutaneous once
Maintenance
60 mg/m*2/dose subcutaneous at week 6 and every 4 weeks thereafter.
45 kg and greater
Week 0
200 mg subcutaneous once
Week 2
Maintenance
100 mg subcutaneous at week 6 and every 4 weeks thereafter.
Juvenile Idiopathic Arthritis (Polyarticular)

40 kg and greater
50 mg subcutaneous monthly
Ankylosing Spondylitis, Psoriatic Arthritis, Rheumatoid Arthritis

Adolescents
50 mg subcutaneous monthly
OR
2 mg/kg/dose IV at weeks 0, 4 and every 8 weeks thereafter.
Comments
The safety of switching between IV and subcutaneous formulations has not been studied
Supplied: Injection: 12.5 mg/mL (4 mL Vial) , 100 mg/mL (0.5 mL Prefilled Syringe) , 100 mg/mL (1 mL Prefilled Syringe)
granisetron
information
Antiemetic- Refractory
Intravenous
0.04 mg/kg IV daily

Maximum: 3 mg/dose
Oral
Round all calculated doses to nearest 1/2 tablet portion (0.5 mg increments)
0.04 mg/kg PO BID

Maximum: 2 mg/dose
Comments
Avoid administering crushed tablets by mouth due to bitter taste.

Tablet: 1 mg
guanFACINE - [Intuniv XR]

Attention-Deficit/Hyperactivity Disorder
Comments
Swallow tablets whole. Do not chew, crush or break. Do NOT administer with high fat meal
Supplied: Tablet, Extended Release: 1 mg, 2 mg, 4 mg
haemophilus B conjugate vaccine - [ACT-HiB]
Go to clinical order set IWK IMOR "Immunization Orders"
Go to Health Canada "Canadian Immunization Guidelines"
haloperidol
Renal Adjustment
Anxiety and Agitation in Emergency department
Intramuscular Route
Go to clinical order set IWK CHRE "Emergency Management of Anxiety and Agitation Emergency Department Patients greater than 6
years old "
Antipsychotic
Comments
Supplied: Injection: 5 mg (as base)/mL

heparin
CVAD Patency
Go to Policy 735 "Central Venous Access Device (CVAD) Care & Maintenance" for more information
Go to Clinical Order Set IWK_HELO "CVAD Heparin Locking Pediatric and Neonatal"
Systemic Anticoagulant, Therapeutic
Go to clinical order set IWK THUN "Therapeutic Unfractionated Heparin Infusion Orders Neonatal & Pediatric High Alert"
PICU/Cardiology Patients
Go to clinical order set IWK THUNHE "Therapeutic Unfractionated Heparin Infusion Orders for PICU/Cardiology Patients (excludes ECMO
patients)"
Post Cardiac Catheterization/Surgery/CVAD Patency in PICU patients less than 10 kg

Prophylaxis
Note: No routine monitoring of coagulation required
10-15 unit(s)/kg/hour IV continuous infusion
Supplied: Injection: 10000 units/mL, 50 units/mL in D5W, 2 units/mL, 10 units/mL, 100 units/mL, 1000 units/mL
hepatitis A and B vaccine - [Twinrix]
Go to clinical order set IWK IMORAD "Immunization Orders Adolescents at High Risk"
Supplied: Injection: 0
hepatitis A vaccine - [Havrix, VAQTA]
hepatitis B vaccine - [Recombivax]

Go to clinical order set IWK HEIM "HEPATITIS B (HB) IMMUNIZATION ORDERS"
Go to Nova Scotia Routine Immunization Schedules for Children, Youth & Adults
human papillomavirus vaccine - [HPV, Gardasil-9]
hyaluronidase
Management of Extravasation
Most effective if used within 1 hour of injury; may be used up to 12 hours after injury. Duration of action is 24-48 hours
Go to Medication Management Policy 30.60 "Management of Extravasation" for more information *policy under review*
5 x 30 unit (0.2 mL) subcutaneous injections around the circumference of infiltrate (one injection may be given via interstitial cannula if
remains in situ) every 30 minutes PRN
Maximum: 450 unit(s) OR 3 doses
hydrALAZINE
Renal Adjustment
Hypertensive Crisis
0.1-0.2 mg/kg/dose IV/IM every 4 to 6 hours PRN

Maximum: 20 mg/dose AND 3.5 mg/kg/24h
Chronic Hypertension
Initial

Maximum: 25 mg/dose
or

Maximum: 25 mg/dose
or

Maximum: 25 mg/dose
Dose may be titrated up to:

Maximum for Infants: 5 mg/kg/24 hours
Maximum for Children: 7.5 mg/kg/24 hours OR 200 mg/24 hours
Supplied: Injection: 20 mg/mL HIGH ALERT

hydrochloric acid
CVAD Occlusion
Secondary to drug precipitate or mineral e.g. calcium-phosphorous
PICC, Non-Tunneled (e.g. Cook, Arrow), Tunneled (e.g. Broviac, Hickman)
Go to Medication Management Policy 30.52 (CVAD: Management of Partial and Total Occlusions)
1 mL instillation for 60 minutes, check and repeat dose for another 60 minutes if necessary
Implanted (e.g. Port-a-Cath)

1.5 mL for 60 minutes, check and repeat dose for another 60 minutes if necessary
Supplied: Injection: 0.1 N IWK Compounded
hydrochlorothiazide
Renal Adjustment
Diuretic
Less than 6 months

Maximum: 37.5 mg/24h
1 mg/kg/dose PO BID
Maximum: 100 mg/24h

Tablet: 25 mg
hydrocortisone
Physiologic Replacement
Go to Body Surface Area Calculator

3-5 mg/m*2/dose PO BID
or
2-3.3 mg/m*2/dose PO TID
Moderate Stress Dosing

If BSA is not available, give THREE times the usual total daily (home) physiologic dose PO divided TID. Reassess after 3 days.

10 mg/m*2/dose PO TID Reassess after 3 days
Severe Stress Dosing or Surgery

50-100 mg/m*2/dose IV once followed by 25 mg/m2/dose IV every 6 hours for 1-2 days then reassess.
Significant Illness /Adrenal Crisis

Emergency Management (If BSA is not available)
Less than 6 months: 25 mg IV/IM once

6 months to 2 years: 50 mg IV/IM once
Greater than 2 years: 100 mg IV/IM once
followed by 25 mg/m2/dose IV every 6 hours for 1-2 days then reassess.
Congenital Adrenal Hyperplasia

3.3-5 mg/m*2/dose PO TID
Anti-Inflammatory/Immunosuppressive
Oral
Weight Based
or
BSA based
18.75-75 mg/m*2/dose PO every 6 hours
or
25-100 mg/m*2/dose PO every 8 hours
Parenteral
Weight Based
0.28-4 mg/kg/dose IV/IM every 12 hours or
0.56-8 mg/kg/dose IV/IM every 24 hours
BSA Based
8-120 mg/m2/dose IV/IM every 12 hours or
16-240 mg/m*2/dose IV/IM every 24 hours
Asthma
Inpatient
Go to clinical order set IWK PEINAS "Pediatric Inpatient Asthma Care Map Orders"
Go to Clinical Order Set "Asthma Care Path Order- Emergency Department"

Hypersensitivity
Go to Clinical Order Set IWK PRHY "Drug Hypersensitivity or Transfusion Reaction Treatment
Severe Sepsis and Shock (HAT- Hydrocortisone, Ascorbic Acid and Thiamine Therapy)

Maximum: 50 mg/dose
Sepsis Management in Children greater than 28 days of age– “Catecholamine resistant shock"
Go to Clinical Order Set IWK SESE "Sepsis Management in Children Greater than 28 Days of Age"
Topical
Comments
Thiamine
Ascorbic Acid
Supplied: Cream, Topical: 0.5 %, 1 %

Injection: 100 mg, 250 mg, 500 mg
Ointment, Topical: 0.5 %, 1 %
Tablet: 10 mg
HYDROmorphone
These dosing guidelines for HYDROmorphone are intended for opioid-naive, acute pain situations.
Practitioners should consider whether the patient is opioid-naive and other underlying medical conditions when choosing
an initial dose.
doses.
*NEW concentration February 14, 2023: ALL pediatric care areas will now stock HYDROmorphone 1 mg/mL vials for intermittent use
Renal Adjustment
Analgesia
Oral
Initial dosing

Maximum: (usual initial maximum) 2 mg/dose
Usual dosing range:
Intravenous - Intermittent
Initial dosing
0.015 mg/kg/dose IV every 3 to 4 hours PRN

Maximum: (usual initial maximum) 0.5 mg/dose
Continuous Infusion- Greater than 1 month MSNU, PMU, 6 Link

(Note: for infants less than 6 months, HYDROmorphone continuous infusion MUST be prescribed by Acute Pain Service or
Pediatric Advanced Care Team)
Go to IWK HYCO " Hydromorphone Continuous Infusion MSNU, PMU, 6 Link"
Loading Dose
None
Initial Dosing
2 microgram/kg/hour
Suggested Titration
1-2 microgram/kg/hour every 1 to 2 hours
Usual Range
Usual* Maximum: 8 microgram/kg/hour

*may require higher doses in certain clinical situations in a critical care setting
Go to IWK IVPA "ACUTE PAIN SERVICE (APS) PATIENT CONTROLLED ANALGESIA (PCA) ORDERS − PEDIATRICS"
Comments
Supplied: Capsule, Controlled Release: 3 mg

Injection: 1 mg/mL, 2 mg/mL, 10 mg/mL, 0.2 mg/mL (50 mL Prefilled Syringe) IWK Compounded, 0.2 mg/mL (100 mL Bag) IWK
Compounded, 0.05 mg/mL (25 mL Syringe) IWK Compounded
Liquid: 1 mg/mL
Tablet: 1 mg, 2 mg, 4 mg
hydroxocobalamin - [Cyanokit*]
Antidote
hydroxyurea
Renal Adjustment
Sickle Cell Anemia
20 mg/kg/dose PO daily increase by 5 mg/kg/24 hours every 8 weeks, up to

hydrOXYzine
Pruritus
0.5 mg/kg/dose PO every 6 hours PRN

Maximum: 25 mg/dose
or

Maximum: 25 mg/dose
Syrup: 2 mg/mL
hyoscine BUTYLbromide - [Buscopan]

Do not confuse with hyoscine HYDRObromide (scoplamine). Doses are NOT equivalent.
Antispasmodic
Less than 6 years
0.3-0.6 mg/kg/dose IV TID PRN

Maximum: 5 mg/dose
6 to less than 12 years
5-10 mg/dose IV TID to QID PRN

Maximum: 30 mg/24h
10-20 mg/dose IV TID to QID PRN

Maximum: 80 mg/24h
ibuprofen - [Advil, Motrin, NeoProfen]

November 2022: For printable patient information on managing pediatric pain and fever at home during ibuprofen shortage
please click here
Refer to 6 Steps to Succuss in Pill Swallowing and Tips on Success in Pill Swallowing to support patients during the shortage.
Limited data in infants less than 6 months.

Ensure patients have adequate hydration prior to using
Renal Adjustment
Analgesic/Antipyretic
Infants 1 to 3 months or less than 5 kg
5 mg/kg/dose PO every 6 to 8 hours PRN
Infants over 3 months and greater than 5 kg
5-10 mg/kg/dose PO every 6 to 8 hours PRN Reassess after 3 days

Maximum: 30-40 mg/kg/24h
5-10 mg/kg/dose PO every 6 to 8 hours PRN

Adolescents
Anti-Inflammatory, Juvenile Rheumatoid Arthritis


or
10-16 mg/kg/dose PO every 8 hours

Anti-Inflammatory
Adolescents
400-800 mg PO every 6 to 8 hours

Comments
Patient/Family Resource: NSAIDs Information (Division of GI and Rheumatology)
Supplied: Injection: 10 mg/mL Special Access

Tablet: 200 mg
IDArubicin
Renal Adjustment
ifosfamide
imatinib mesylate
Renal Adjustment
indomethacin
Renal Adjustment
Anti-inflammatory

Maximum: 4 mg/kg/24 hours OR 200 mg/24h
or

or

Comments
Take with food to reduce GI irritation
Injection: 1 mg Special Access
Suppository: 100 mg
inFLIXimab
Current product provided by IWK Pharmacy: Remicade®
Crohns' Disease, Ulcerative Colitis, Juvenile Idiopathic Arthritis, Uveitis
Go to Clinical Order Set IWK INPERE "inFLIXimab Pediatric Infusion"
influenza vaccine
Go to clinical order set IWK INIM "Influenza Immunization Orders"
insulin aspart - [NovoRapid, Trurapi, Fiasp. Refer to IWK Insulin Equivalencies]

Go to IWK Insulin Equivalencies
Current IWK insulin equivalant:
Go to Insulin Lispro
Go to Insulin Products Available in Canada

Info on various insulins including availability, administration, mixing information, onset/duration etc
Continuous Subcutaneous Insulin Infusion (CSII)

For additional information on CSII, go to Insulin Pumps: Safe Management of Patients with Continuous Subcutaneous Insulin Infusion (CSII) Pumps at the IWK
Health Centre
Go to clinical order set IWK MACOSU "Management of Patients with Continuous Subcutaneous Insulin Infusion (CSII) Pumps in Hospital
(Non−Pregnant Adults, Youth & Children)"
Supplied: Injection: 100 units/mL
insulin degludec - [Tresiba]

Current IWK product selection:
Tresiba (100 unit/mL AND 200 unit/mL)

Supplied: Injection: 100 units/mL, 200 units/mL
insulin detemir - [Levemir]

Levemir (100 unit/mL)

insulin glargine - [Basaglar, Lantus, Toujeo (300 unit/mL). Refer to IWK product selections
for currently stocked brand(s)]
Current IWK equivalency/product selection(s):
Lantus (100 unit/mL)

Supplied: Injection: 100 units/mL, 300 units/mL
insulin glulisine - [Apidra]

Apidra (100 unit/mL)


Health Centre
insulin lispro - [Humalog, Admelog]

Humalog (100 unit/mL)


Health Centre
Supplied: Injection: 100 units/mL (3 mL Vial) , 100 units/mL (3 mL Prefilled Disposable Pen)
insulin, human NPH - [Humulin N]

Humulin N (100 unit/mL)

insulin, human regular - [Humulin R]

Renal Adjustment
Humulin R (100 unit/mL)

Antidote
Diabetic Ketoacidosis
Go to clinical order set IWK DIKE " Diabetic Ketoacidosis (DKA) in Children and Youth 0 to 19 years"
Hyperglycemia Management of Non-Diabetic PICU Patients
Go to clinical order set IWK HYMA "IV Insulin Infusion for Hyperglycemia Management of Non-Diabetic PICU Patients"
Perioperative Management of Diabetic Patients
Go to clinical order set IWK PEFL "Perioperative Management of Diabetic Patients − Procedures greater than 2 hours"
Go to clinical order set IWK PEFLSH "Perioperative Management of Diabetic Patient Procedures up to 2 Hours Duration"
Supplied: Injection: 100 units/mL (3 mL Vial) , 100 units/mL (3 mL Prefilled Disposable Pen)
insulin, NPH - [Novolin ge NPH. Refer to IWK Equivalencies]

Current IWK insulin equivalent:
Go to Humulin N

ipratropium
Go to Aerosol Medication Compatibility Guide
Severe Acute Asthma
Go to clinical order set IWK PEASCA "Asthma Care Path Order- Emergency Department"
Comments
Spacers/aerochamber devices available from Supply and Distribution
Suggested Dose equivalencies:
Medication (nebulization) Conversion to MDI (administered with spacer and mask)
Ipratropium Nebulization Ipratropium MDI (20 micrograms/puff)

(250 micrograms/mL)
for severe, acute exacerbation
250 micrograms INH via nebulization 4 puffs INH via MDI

500 micrograms INH via nebulization 8 puffs INH via MDI
At same prescribed frequency

Inhalation, Nebule: 0.25 mg/mL
irinotecan
iron (oral) - [ferrous salts]

Doses are a reflection of the total daily intake – consider iron content of oral feeds if receiving

Prophylaxis
Note: For infants born less than 37 weeks continue treatment until 12 months corrected gestational age - refer to Neonatal dosing for
complete dosing information.
Not recommended in healthy term babies until at least 4-6 months old.
4-6 months and greater
OR
Treatment
OR
OR

Maximum: 200 mg/24h
Comments
For information on iron dose equivalencies/therapeutic interchange, click here
Supplements should be continued for a minimum of three months, and then reassessed.
Absorption improves when iron is ingested with a source of vitamin C
Separate administration by at least 2 hours from phosphate or calcium containing supplements.
For further information on iron supplementation in the first 2 years of life, click here
Supplied: Drops (as ferrous sulfate): 15 mg (as elemental)/mL

Tablet (as ferrous gluconate): 35 mg (as elemental)
Tablet (as ferrous sulfate): 60 mg (as elemental)
iron sucrose - [Venofer]

Oral iron therapy should be stopped during parenteral iron therapy. Oral iron may be restarted 5 days after completion of
parenteral iron.

Chronic Kidney Disease
Supplied: Injection: 20 mg (as elemental)/mL
isoniazid
Renal Adjustment
Tuberculosis Treatment

OR
20-30 mg/kg/dose PO three times weekly

Comments
Concomitant therapy with pyridoxine to prevent peripheral neuropathy is recommended. Go to Pyridoxine
Used as part of a multi-drug regimen

Tablet: 300 mg
isoproterenol
Very limited use in pediatrics. Go to Up To date or Micromedex for further information
isotretinoin
ivabradine
Although weight based dosing is provided below:
Calculated doses less than 1.25 mg must be rounded to increments of 0.15 mg (e.g. 0.15, 0.3, 0.45 mg, etc.)
Calculated doses greater than 1.25 mg must be rounded to increments of 1.25 mg (e.g. 1.25, 2.5, 3.75 mg, etc.)
Junctional Ectopic Tachycardia

Initial

Maximum: 5 mg/INITIAL dose
Subsequent
Doses can be titrated to the following maximums:
Less than 1 year: 0.2 mg/kg/dose
Greater than 1 year: 0.3 mg/kg/dose OR 7.5 mg/dose
Supplied: Powder papers: 0.15 mg IWK Compounded

Tablet: 5 mg
ketamine
Pain
Continuous Infusion
Prescribing/management of ketamine via continuous infusion in non-critical care areas is restricted to Pain Team/PACT (see order set below)
Loading Dose
None
Initial Dosing
0.05 mg/kg/hour
Suggested Titration
Usual Range
0.05 - 0.2 mg/kg/hour
Maximum
0.2 mg/kg/hour
Go to clinical order set IWK KECOIN Ketamine Continuous Infusion Acute Pain Service, Pediatric Advanced Care Team ONLY
Intubated
Continuous Infusion
Loading Dose
None
Initial Dosing
0.1 mg/kg/hour
Suggested Titration
0.2-0.5 mg/kg/hour every hour
Usual Range
0.1 - 1 mg/kg/hour
Maximum
2 mg/kg/hour
Procedural Sedation
Intravenous
Go to clinical order set IWKPRSEED "Procedural Sedation in the Emergency Department"
Oral
Injection can be administered orally. Mask bitter taste in cola or other beverage
Go to Clinical Order Set IWK ORSU "Pediatric Perioperative Anaesthesia Orders"
Intranasal
(Pediatric Perioperative Anesthesia ONLY)
Go to Medication Management Policy 20.11 "Administration of Intranasal Medications via a Mucosal Atomization Device (MAD)"
2-4 mg/kg/dose intranasal once
Comments
Use 50 mg/mL injection for intranasal administration
ketorolac
Use of IV ketorolac should be restricted to patients unable to receive enteral ibuprofen, naproxen or celecoxib
*All IV orders must be reassessed at 48 hours and medication must be re-ordered if deemed appropriate to continue therapy.
Lowest effective dose and shortest duration of administration minimizes risk of adverse effects.
Ketorolac may increase risk for GI bleed especially in patients with multiple risk factors. Concurrent therapy with a PPI may decrease, but
not eliminate, the risk for GI bleed.
Renal Adjustment
Pain
Loading dose (Pain Team/Anaesthesia only)
0.2-0.5 mg/kg/dose IV/IM once

Maximum: 30 mg/dose
1 month and greater
0.2-0.3 mg/kg/dose IV/IM every 6 hours for up to 48 hours*

Maximum: 15 mg/dose
15 mg IV/IM every 6 hours for up to 48 hours*
labetalol
Hypertension
Round doses to nearest 25 mg to allow for portion of 100 mg tablet to be administered (crushed or swallowed)

Hypertensive Emergency
Intermittent
0.2-1 mg/kg/dose IV every 10 minutes PRN

Maximum: 40 mg/dose
Continuous Infusion
Loading Dose
None
Initial Dosing
0.25-0.5 mg/kg/hour
Suggested Titration
0.25-0.5 mg/kg/hour every 15 minutes
Usual Range
0.25 - 1 mg/kg/hour
Maximum
3 mg/kg/hour

Tablet: 100 mg
lactulose
Constipation
5-10 mL PO daily May double dose daily until stool is produced to a:

Maximum: 60 mL/24h
Hepatic Encephalopathy
Infants
2.5-10 mL/24h divided PO TID to QID adjust dose to produce 2 to 3 soft stools per day
Children
40-90 mL/24h divided PO TID to QID adjust dose to produce 2 to 3 soft stools per day
Comments
May administer with juice, milk, or water.
lamoTRIgine
Round calculated dose down to the nearest whole tablet
Renal Adjustment
WITHOUT valproate/enzyme inducers*
2 to 12 years
Week 1 and 2
0.3 mg/kg/24h divided PO once to twice daily
Week 3 and 4
0.6 mg/kg/24h divided PO BID THEN after week 4, increase dose every 1 to 2 weeks by 0.6 mg/kg/24 hours to a usual dose of 4.5-7.5
mg/kg/24 hours
Maximum: 300 mg/24h

Week 1 and 2
25 mg PO daily
Week 3 and 4
50 mg PO daily THEN after week 4, increase dose every 1 to 2 weeks by 50 mg/24 hour to a usual dose of 225-375 mg/24 hours divided
BID
WITH valproate
2 to 12 years
Week 1 and 2
0.15 mg/kg/24h divided PO once to twice daily
Week 3 and 4
0.3 mg/kg/24h divided PO once to twice daily THEN after week 4, increase dose by no more than 0.3 mg/kg/24 hour each week to a
usual dose of 1-5 mg/kg/24 hours
Maximum: 200 mg/24h

Week 1 and 2
25 mg PO every other day (every 48 hours)
Week 3 and 4
25 mg PO daily THEN after week 4, increase dose every 1 to 2 weeks by 25 to 50 mg/24 hours to a usual dose of 100-400 mg/24 hours
With enzyme inducer* WITHOUT valproate:

2 to 12 years
Week 1 and 2
0.3 mg/kg/dose PO BID
Week 3 and 4
0.6 mg/kg/dose PO BID THEN after week 4, increase dose by no more than 1.2 mg/kg/24 hour each week to a usual dose of 5-15
mg/kg/24 hours
Maximum: 400 mg/24h

Week 1 and 2
50 mg PO daily
Week 3 and 4
50 mg PO BID THEN after week 4, increase dose every 1 to 2 weeks by 100 mg/24 hours to a usual dose of 300-700 mg/24 hours
Comments
*Enzyme-inducers = carbamazepine, phenyTOIN, pHENobarbital and primidone
Monitor for skin rash and HLH- see Health Product InfoWatch

lansoprazole
GERD (short term treatment)*
28 days to less than 1 year
or
1 to 11 years
Less than or equal to 30 kg
15 mg PO daily
Greater than 30 kg
30 mg PO daily
15-30 mg PO daily
Comments
For information on proton pump inhibitor dose equivalencies, click here
Some patients may need increased doses up to 30 mg po BID if they remain symptomatic. Higher doses may be ordered in
consultation with GI services.
Prevacid FasTab® cannot be split: tablets are not scored and dose is not distributed evenly through the tablet.
Do not chew or crush capsules or FasTab®. Capsules can be opened and mixed in 60 mL of an acidic beverage (juice) or granules
can be sprinkled over soft food (i.e applesauce, yogurt, cottage cheese or pudding)
For administration via oral syringe, or NG tube greater than or equal to 8 French, Prevacid FasTab® can be administered as
follows:
Place a 15 mg tablet in oral syringe and draw up approximately 4 mL of water, or place a 30 mg tablet in oral syringe and
draw up approximately 10 mL of water.
Shake gently to allow for a quick dispersal.
After the tablet has dispersed, administer the contents within 15 minutes.
Refill the syringe with approximately 2 mL (5 mL for the 30 mg tablet) of water, shake gently, and administer any remaining
contents.
Supplied: Capsule, Delayed Release: 15 mg, 30 mg

Tablet, Disintegrating Delayed Release (FasTab): 15 mg, 30 mg
leucovorin - [folinic acid]

Post Methotrexate "Leucovorin rescue"

Refer to individual protocol. Leucovorin dose, duration and timing are based on chemotherapy protocols and plasma methotrexate level
Comments
IV route is preferred for doses greater than 25 mg or if nausea or vomiting.
Leucovorin therapy should not be administered concurrently with high-dose methotrexate infusion. It is commonly initiated 24-36 hours after the
start of methotrexate (varies by treatment protocol).
May be given as a single dose after intrathecal methotrexate (should not be given within 24 hours of intrathecal dose) Do not administer leucovorin
intrathecally.

Tablet: 5 mg
leuprolide - [Lupron Depot]

Menstrual Suppression
Hematology Oncology Patients
For additional information refer to Policy 80.65
Go to clinical order set IWK MESU "Menstrual Suppression for Oncology Patients"
Supplied: Injection: 3.75 mg, 7.5 mg, 11.25 mg
levetiracetam - [Keppra]
When switching between oral and IV formulations, the total daily dose should be the same.
Renal Adjustment
Refractory Status Epilepticus

If patient is already receiving oral levetiracetam, consider a lower range for loading IV dose.
20-60 mg/kg/dose IV
Partial Onset Seizures, adjunct

1 to 6 months
7 mg/kg/dose PO/IV BID increase every 2 weeks by 7 mg/kg/dose BID, up to

Anticonvulsant
6 months to 4 years
10 mg/kg/dose PO/IV BID increase every 1 to 2 weeks by 10-20 mg/kg/dose BID, up to

4 to 15 years OR less than 50 kg
10 mg/kg/dose PO/IV BID increase every 1 to 2 weeks by 10-20 mg/kg/dose BID, up to

Greater than or equal to 16 years OR greater than 50 kg
500 mg PO/IV BID increase every 2 weeks by 500 mg/dose BID, up to


Solution: 100 mg/mL
levocarnitine
Renal Adjustment
Carnitine Deficiency/Metabolic Disorders
Oral
Initial
16.7-33.3 mg/kg/dose PO every 8 hours - Dose may be titrated up to:

or
25-50 mg/kg/dose PO every 12 hours - Dose may be titrated up to:

Intravenous

or

IV Continuous Infusion
Loading Dose
Followed by
2 mg/kg/hour
End Stage Renal Disease, on hemodialysis

Maintenance doses are based on plasma levocarnitine levels
10-20 mg/kg/dose IV after dialysis

Solution: 100 mg/mL
Tablet: 330 mg
levofloxacin
Renal Adjustment
Various Indications
Go to Firstline

Tablet: 250 mg
levonorgestrel - [Mirena*]
Go to Practice Guideline for IWK Inpatients Contraception
Supplied: Intrauterine System: 52 mg
levonorgestrel 0.15mg|ethinyl estradiol 0.03mg - [Oral Contraceptive, MinOvral, Ovima,

Portia]
Go to Comparison of available contraceptives in Canada
Current IWK contract brand: Ovima 21 and 28 pack
Oral Contraception
(use 28 tablet package- contains 21 active tablets and 7 "reminder" tablets)
1 tablet PO daily
Menstrual Suppression
(use 21 tablet package)
1 tablet PO daily
Hematology Oncology Patients

For additional information refer to Policy 80.65
Go to clinical order set IWK MESU "Menstrual Suppression for Oncology Patients"
Supplied: Tablet: 0.15|0.03 mg (21 Tablet Package) , 0.15|0.03 mg (28 Tablet Package)
levonorgestrel 0.1mg|ethinyl estradiol 0.02mg - [Oral Contraceptive, Alysena, Alesse,

Aviane, Lutera]
Current IWK contract brand: Alysena 28 pack
Oral Contraception
(use 28 tablet package -contains 21 active tablets and 7 "reminder" tablets )
1 tablet PO daily
Supplied: Tablet: 0.1|0.02 mg
levosimendan
Go to manufacturer provided dosing information
Comments
Levosimendan is a drug that is supplied for compassionate use by Tenax Therapeutics.
If a PICU patient is a candidate for levosimendan, the PICU intensivist must contact Tenax Therapeutics to review the patient case and receive approval for
compassionate release:
Douglas Hay, PhD
Executive VP, Regulatory Affairs
Tenax Therapeutics, Inc.
One Copley Parkway, Suite 490, Morrisville, NC 27560
(919) 855-2110 (Office)
(267) 733-5278 (Mobile)
d.hay@tenaxthera.com
Following approval from Tenax Therapeutics, a Special Access Request form must be submitted to Health Canada. Special Access request must note that
approval for compassionate release has been granted by Tenax Therapeutics.
Levosimendan is not routinely stocked at the IWK and drug delivery may take 3-4 business days after approval.
levothyroxine
Round dose upward to the nearest tablet or portion of tablet.
For oral administration, use tablet or part tablet and dissolve with a small amount of sterile water, breast milk or non-soy
formula. Use immediately
Hypothyroidism
1 to 3 months
10-15 microgram/kg/dose PO daily
3 to 6 months
6 to 12 months
1 to 5 years
6 to 12 years
Adolescents, Growth and Puberty Complete

Initial
1.7 microgram/kg/dose PO daily
OR
12.5-25 microgram(s) PO daily Adjust dose by 12.5 to 25 microgram increments at 4-6 week intervals PRN
Maintenance
100-200 microgram(s) PO daily
T4 Replacement for Organ Donor Management

Less than 60 kg
100 microgram(s) IV once followed by 50 micrograms IV every 12 hours
Comments
Lower doses may be needed in those at risk for or with active cardiac disease.
Levothyroxine is best taken on an empty stomach but this can be difficult to achieve; adherence and consistency in regard to time
of day and presence of food is important.

Tablet: 25 microgram(s), 75 microgram(s), 88 microgram(s), 100 microgram(s), 112 microgram(s)
lidocaine
Updated: September 2023; SHORTAGE: lidocaine 1% with EPINEPHrine (1:100,000 and 1:200,000) AND lidocaine 2% with
EPINEPHrine (1:100,000 and 1:200,000). Refer to comment section below for instructions to prepare during shortage
Antiarrhythmic
Continuous Infusion
Loading Dose
1 mg/kg/dose IV X 1. May repeat every 10-15 minutes x 2 doses to a maximum TOTAL DOSE of 100 mg OR 5 mg/kg.
Initial Dosing
20 microgram/kg/min
Suggested Titration
10 microgram/kg/min every 10 minutes
Usual Range
Maximum
50 microgram/kg/min
Local Anesthetic
Injectable - without EPINEPHrine
4.5 mg/kg/dose Do not repeat within 2 hours,

Maximum: 300 mg
Injectable - with EPINEPHrine

(see comment section below to prepare - product may be short)
7 mg/kg/dose Do not repeat within 2 hours,

Maximum: 500 mg
Topical
4.5 mg/kg/dose once to four times daily PRN

Maximum: 300 mg
Viscous Solution
Refer to dosing information provided by manufacturer
Comments
Preparation of Lidocaine 1% with EPINEPHrine solutions
Use:
• 20 mL vial - Lidocaine 1% solution
• 1 mL amp – EPINEPHrine 1 mg/mL solution
Lidocaine 1% with EPINEPHrine 1:100,000 (0.01 mg/mL):
2. Add 0.2 mL EPINEPHrine 1 mg/mL to Lidocaine 1%, 20 mL vial
Lidocaine 1% with EPINEPHrine 1:200,000 (0.005 mg/mL)
Preparation of Lidocaine 2% with EPINEPHrine solutions

Use:
• 20 mL vial - Lidocaine 2% solution
• 1 mL amp – EPINEPHrine 1 mg/mL solution
Lidocaine 2% with EPINEPHrine 1:100,000 (0.01 mg/mL):
Lidocaine 2% with EPINEPHrine 1:200,000 (0.005 mg/mL)
Supplied: Gel: 2 %
Injection: 20 mg/mL, 20 mg/mL (5 mL Prefilled Syringe) HIGH ALERT, 4 mg/mL in D5W (500 mL Bag) HIGH ALERT
Solution, Viscous: 2 %
Spray, Endotracheal: 10 mg/spray
lidocaine|EPINEPHrine|tetracaine - [LET]
Simple skin lacerations, approximately 5 cm or less
See Care Directive 1355 - for the Application of Lidocaine, EPINEPHrine and Tetracaine Gel by Registered Nurses on Patients Requiring
Laceration Repair in the Emergency Department Description
Maximum: 3 mL
Comments
LET gel should remain in situ for 20 to 30 minutes prior to suturing.
The duration of action following removal of LET gel is 45 to 60 minutes.
Supplied: Gel: 4|0.05|0.5 % IWK Compounded
lidocaine|prilocaine - [EMLA]
Go to Medication Management Policy 20.77 - Application of Topical Anesthetics
Usual dose (single site)
1-1.5 grams (marble sized amount spread to size of loonie) over the injection site 60 minutes prior to procedure
Alternate dosing (e.g. multiple sites/smaller area in smaller infants)
0.5 grams over the injection site 60 minutes prior to procedure
Maximums
Greater than 37 weeks to 3 months OR Less than 5 kg
No more than 1 gram (marble sized amount spread to size of loonie)

Maximum: 1 hours maximum application time AND 1 application/24 hours
3 to 12 months OR Less than 10 kg
No more than 4.5 grams (approx. 1 x 5 gram tube) applied to a maximum skin area of 20 cm*2 (size of a credit card)
1 to 6 years OR Less than 20 kg
No more than 10 grams (2 x 5 gram tube) applied to a maximum skin area of 100 cm*2 (size of two credit cards)
Greater than 7 years AND Greater than 20 kg
No more than 20 grams (4 x 5 gram tube) applied to a maximum skin area of 200 cm*2 (size of standard post card)
Comments
Optimal anesthesia requires a minimum of 60 minutes of contact time and persists for 1-2 hours after removal
Patient/Family Resource: Numbing Cream: Topical Anesthetic
Supplied: Cream, Topical: 2.5|2.5 %
linezolid
Methicillin-Resistant Staph Aureus and Cystic Fibrosis
Go to Firstline
Comments
Go to Firstline for additional information on monitoring and drug interactions

Tablet: 600 mg
lipase|amylase|protease (Cotazym) - [Cotazym, pancrealipase]

Occluded Feeding Tube
Open one capsule of Cotazym and mix contents with one crushed 500 mg tablet of sodium bicarbonate (to activate the Cotazym*). Add 5 mL of warm water
to the powder. Instill the suspension into the feeding tube and clamp for 5 minutes and then flush with up to 30 mL of water.
Go to AboutKidsHealth "G/GJ tubes: What to do if your child's feeding tube is blocked"
Pancreatic Insuf ficiency (Actual requirements are patient-specific. Adjust dose based on response to therapy)
Initial
Less than 1 year
16.6-41.6 lipase units/mL of formula/breast milk PO with feeds
1 to 4 years
1000 lipase units/kg PO with each meal. Dose titrations are patient specific and based on response.
Maximum: 10000 lipase units/kg/24h
Comments
Total daily dose should be divided into 3 meals and 2-3 snacks per day. Snack doses are approximately half of meal doses.
Do not mix capsule contents directly into formula or breastmilk.
When used for pancreatic insufficiency, do not crush or chew microspheres. May open capsule and spread beads over acidic foods. Administer
immediately and follow with sufficient fluid. Sweep mouth with finger after administration as beads are irritating to oral mucosa.
Supplied: Capsule: 10000|40000|35000 units
lipase|amylase|protease (Creon 10) - [pancrealipase, Creon 10]

Pancreatic Insuf ficiency
Initial
Less than 1 year
1 to 4 years
Comments
Do not crush or chew microspheres. May open capsule and spread beads over acidic foods. Administer immediately and follow with sufficient fluid.
Sweep mouth with finger after administration as beads are irritating to oral mucosa.
lipase|amylase|protease (Creon 25) - [pancrealipase, Creon 25]

Pancreatic Insuf ficiency
Initial
Less than 1 year
1 to 4 years
Comments
Do not crush or chew microspheres. May open capsule and spread beads over acidic foods. Administer immediately and follow with sufficient fluid.
Sweep mouth with finger after administration as beads are irritating to oral mucosa.
lisdexamfetamine - [Vyvanse]
Supplied: Capsule: 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg, 70 mg
lisinopril
Renal Adjustment
Hypertension, Proteinuria
0.07-0.1 mg/kg/dose PO daily . Initial maximum 5 mg/dose. Titrate to effect up to

Maximum: 0.6 mg/kg/24h OR 40 mg/24h

Tablet: 5 mg, 10 mg
lithium
Renal Adjustment
Mood Stabilizer
Initial
Go to clinical order set IWK LITH “LITHIUM ORDERS Patients over 12 Years of Age AND/OR Patients 25 kg or Greater Child and
Adolescent Psychiatry"”
General
Comments
May require serum therapeutic drug monitoring

Go to clinical order set IWK LIINLA “Lithium Lab Work-up” for monitoring info

Tablet, Sustained Release: 300 mg
lomustine
loperamide
Chronic diarrhea*
secondary to intestinal failure, short-bowel syndrome, or other non-infectious causes
2 months to 2 years

Maximum: 2 mg/dose
or
0.03-0.08 mg/kg/dose PO TID titrate to effect with a usual range of 0.125-0.25 mg/kg/dose BID
Maximum: 2 mg/dose
Acute Diarrhea
First 24 hours (Avoid use in children less than 2 years old for acute diarrhea)
2 to 5 years (13 to 20 kg)
1 mg PO TID
6 to 8 years (21 to 30 kg)
2 mg PO BID
9 to 12 years (Greater than 30 kg)
2 mg PO TID
After initial dosing
0.1 mg/kg/dose PO after each loose stool but not exceeding initial dosing above
4 mg PO once followed by 2 mg after each loose stool

Maximum: 16 mg/24h
Comments
*Chronic diarrhea: secondary to intestinal failure, short-bowel syndrome, or other non-infectious causes:
Initiate at a lower dose and titrate to effect
Due to sorbital in oral solution, recommend using tablets for administration.
Slows intestinal transit but does not directly improve functional absorption
Decreases pancreatic/biliary secretion
Risk of paralytic ileus
Use with caution in young children; dehydration enhances the variability of response to loperamide.
Discontinue if clinical improvement of acute diarrhea is not observed within 48 hours.
Do not use for infectious diarrhea resulting from organisms such as Shigella, Salmonella, Campylobacter, C.difficile, etc.
Supplied: Caplet: 2 mg
Solution: 0.2 mg/mL
LORazepam
Intramuscular OLANZapine and any benzodiazepine should not be given concurrently due to severe drug interactions however if
deemed absolutely clinically necessary. Space intramuscular OLANZapine and intramuscular LORazepam by at least 2 hours.
Renal Adjustment
Anticipatory Nausea and Vomiting Associated with Chemotherapy
Go to APPHON Nausea and Vomiting Guidelines - for Moderate/High Emetogenic Antineoplastic Therapy
0.04-0.08 mg/kg/dose PO/Sublingual/IV night before and just prior to chemotherapy
Maximum: 2 mg/dose
Anticonvulsant
Go to Status Epilepticus Calculator

0.1 mg/kg/dose IV once and may repeat 0.05 mg/kg/dose in 10 to 15 minutes as needed.
Maximum: 4 mg/dose
Buccal
(Note: dose must be ordered in increments of 0.5 mg to accommodate tablets strengths of 0.5 mg and 1 mg)
0.1 mg/kg buccal

Maximum: 4 mg/dose

years old "
Anxiety
Alcohol Withdrawal Management
Go to clinical order set IWK AWLI "Alcohol Withdrawal Management Adults and Pediatrics"
Muscle Spasms, Post-op orthopedic surgery
Go to order set IWK ORPO "Orthopaedic Post-Operative for Children Over 6 Months of Age"
Comments
When written PO, sublingual tab formulation can be given orally.

Tablet, Sublingual: 0.5 mg, 1 mg
loxapine
General

years old "
Comments

lurasidone
Comments
magnesium (oral)
All doses expressed in terms of elemental magnesium. All orders must be written in terms of mg of elemental magnesium
Equivalencies
12 mg elemental magnesium= 1 mEq elemental magnesium= 0.5 mmol elemental magnesium
Hypomagnesemia

or
10-20 mg/kg/dose PO QID

Prevention of Hypomagnesemia/Dietary Supplementation
Comments
Oral magnesium replacement is limited by diarrhea. Replacement with IV magnesium sulfate is recommended for severe
(magnesium level less than 0.45 mmol/L) or symptomatic hypomagnesemia.
Magnesium equivalencies:
magnesium oxide 420 mg = 250 mg elemental magnesium
magnesium hydroxide 80 mg = 33 mg elemental magnesium
magnesium glucoheptonate 100 mg = 5 mg elemental magnesium
Supplied: Capsule (as citrate): 150 mg (as elemental)

Solution (as glucoheptonate): 5 mg (as elemental)/mL
Suspension (as hydroxide): 33 mg (as elemental)/mL
Tablet (as oxide): 250 mg (as elemental)
magnesium sulfate
All doses expressed in terms of mg of magnesium sulfate. All orders must be written in terms of mg of magnesium sulfate
1 gram magesium sulfate = 8.12 mEq elemental magnesium = 98.6 mg elemental magnesium.
Renal Adjustment
Hypomagnesemia
Intermittent
25-50 mg/kg/dose IV every 4 to 6 hours PRN
Continuous Infusion (PICU)
Go to clinical order set IWK ELREP “PICU Electrolyte Replacement Orders High Alert"
Severe Acute Asthma

Consultation with PICU or Respirologist is recommended
Go to clinical order set IWK PEASCA "Asthma Care Path Order- Emergency Department"
25-50 mg/kg/dose IV once
Torsades With Pulses
25-50 mg/kg/dose IV once

Supplied: Injection: 40 mg/mL (100 mL Bag) IWK Compounded, 40 mg/mL (500 mL Bag) IWK Compounded, 200 mg/mL
magnesium|aluminum - [Almagel, Maalox, or equivalent]

2020 contract brand: Almagel Suspension
Antacid
5-15 mL PO TID to QID PRN

Maximum: 80 mL/24h
Supplied: Suspension: 40|40 mg/mL
mannitol
20 % = 0.2 gram/mL= 200 mg/mL
Renal Adjustment
Increased Intracranial/Intraocular Pressure
0.25-1 grams/kg/dose IV every 4 to 8 hours PRN

Maximum: 2 grams/kg/dose
Cerebral Edema in Diabetic Ketoacidosis
Go to clinical order set IWK DIKE "Diabetic Ketoacidosis Management 0 to 19 years- Pediatrics"
measles, mumps, rubella vaccine - [MMR]

Live vaccine
measles, mumps, rubella, varicella vaccine - [MMRV]

Live vaccine
mebendazole
Pinworms
Go to Firstline
medroxyPROGESTERone - [Provera, Depo-Provera]

Contraception
150 mg IM every 3 months

Tablet: 5 mg
melatonin
To facilitate use of the tablets (or portions of), consider dosing melatonin in the following dose increments:
0.75 mg, 1.5 mg, 2.25 mg or 3 mg, (using the 3 mg tablets) OR
1.25 mg, 2.5 mg, 3.75 mg or 5 mg (using the 5 mg tablets)
Less than 1 year
0.75-1.25 mg PO at bedtime
1 to 12 years
0.05-0.15 mg/kg/dose
OR
2.25-3 mg PO at bedtime
Maximum: 10 mg/24h
5 mg PO at bedtime titrate to desired clinical effect

Maximum: 10 mg/24h
Comments
Tablets readily dissolve in small amount of water for administration via enteral feeding tubes or for patient who can not swallow the dissolvable
tablets.
Give dose 30-120 minutes before bedtime.
Dose is variable and may need to be titrated for each patient. Consider tablet strengths and incremental dosing when ordering.
Supplied: Tablet, Oral Disintegrating: 3 mg, 5 mg
meningococcal group A,C,Y,W-135 vaccine - [Menveo, Menactra, MenAWCY]
meningococcal group B vaccine - [Bexsero, 4C Men B]
Go to IWK IMOR "Immunization Orders"
meningococcal group C conjugate vaccine - [Menjugate, Neisvac-C, Men-C]
mercaptopurine - [6-mercaptopurine]
meropenem
Renal Adjustment
Various Indications
Go to Firstline
mesna
Prevention of Hemorrhagic Cystitis

Refer to individual protocols for dose and administration schedule.
Mesna dosage depends on dosage of antineoplastic agent used, but is usually equal to 60 to 120% w/w total daily ifosfamide or
cyclophosphamide dose
Go to clinical order set IWKCYPR Cyclophosphamide PROTOCOL Rheumatology
Go to clinical order set IWKNEIV Nephrology IV Cyclophosphamide PULSE
Go to Children's Oncology Group (COG) Protocol
Comments
Injection may be given orally
metformin
Atypical antipsychotic- induced weight gain/insulin resistance/hypergylcemia
500-1000 mg PO BID
methadone
Opioid use disorder (OUD)
For additional information refer to "CAMH Opioid Agonist Therapy: A Synthesis of Canadian Guidelines for Treating Opioid Use Disorder"
Must use clinical order set IWKOAT "Opioid Agonist Treatment (OAT) [methadone, buPRENorphine/ naloxone (Suboxone®)] for Opioid
Use Disorder High Alert
IWK - 4.07 - Care of Patients on Opioid Agonist Treatment (OAT) [methadone, buPRENorphine/naloxone (Suboxone®)] for Opioid Use
Disorder
Initiation*
Patients who meet any one of the following criteria: 1) Recently abstinent or only use intermittently 2) Have unknown tolerance to opioids
3) Use low potency opioids (e.g. codeine)
Initial Dose: 10 mg or less

Increase by: 5 mg or less every 5 days
Patients who have established tolerance via patient history or collateral information AND have risk factors such as: 1) Multiple CNS
depressant use 2) Medical illness involving respiratory compromise 3) Changes in drug metabolism (e.g. age over 65, taking medications
that inhibit CYP 3A4)

Increase by: 5-10 mg every 3-5 days
Patients who have a high tolerance of high-potency opioids from daily use with urine drug test confirmation of recent opioid use AND who
do not have risk factors for excessive CNS depression (as listed above)

Increase by: 5-15 mg every 3-5 days
Maintenance Phase
Use clinical judgment to determine an appropriate maintenance dose, with treatment objectives generally being to provide 24 hours
without opioid withdrawal and to reduce opioid cravings while not causing sedation or toxicity.
Pain
Dosing is individualized. For additional information refer to: Advanced Care/Pain Resources
Must use clinical order set IWKMETH Methadone for PAIN
Comments
*Reassess patients frequently during the first two weeks of treatment because they are at the highest risk of fatal overdose during this
period. Discuss this risk and strategies to reduce it (e.g., use only small amounts of additional opioids; do not use alone; have a naloxone
kit available). Reassess the patient with every subsequent dose increase.
Additional Resources
Nova Scotia College of Pharmacists:
Opioid Agonist Maintenance Treatment Services

Opioid Agonist Maintenance Treatment Services During the COVID-19 Pandemic
Supplied: Powder: 0
Solution: 10 mg/mL
Tablet: 1 mg, 5 mg, 10 mg, 25 mg
methotrexate
Folic acid is often given concurrently with methotrexate when used for rheumatologic indications to minimize side effects. Go to Folic
Acid dosing
Crohn's Disease
Weight based
20 to 29 kg
10 mg PO/subcutaneous weekly
30 to 39 kg
40 to 49 kg
Greater than 50 kg
Body Surface Area Based

15 mg/m*2/dose PO/subcutaneous weekly

Maximum: 25 mg/dose

Weight Based
Initial
0.5 mg/kg/dose PO/subcutaneous weekly

Maximum: 15 mg/dose
Maintenance
1 mg/kg/dose PO/subcutaneous weekly

Maximum: 30 mg/dose
As per Children's Oncology Group (COG) protocol

Comments
For information on high-dose methotrexate drug interactions, please click here.
Where coverage and access allows, weight based doses may be rounded to accommodate outpatient subcutaneous administration
using pre-filled syringe. For more information on prefilled syringes, click here.

Tablet: 2.5 mg
methotrimeprazine
information
Renal Adjustment
Antiemetic
Intravenous

Maximum: 2 mg/dose
or

Maximum: 2 mg/dose
or

Maximum: 2 mg/dose
Oral
or
0.083 mg/kg/dose PO TID
Continuous Infusion
In consultation with Pediatric Advanced care Team (PACT)

Tablet: 5 mg
methylene blue
Antidote
methylphenidate
Comments
Evaluate patient for cardiac disease prior to starting therapy.
Discontinue if no improvement after one month of treatment.
Sustained release preparations may be given in place of the immediate-release tablets once the daily dose is titrated.
Extended-release preparations are considered first line as they are more effective, increase patient compliance and are less likely to be diverted.
However, reimbursement may be an issue without a trial of IR or SR preparations.
Supplied: Capsule, Controlled Release: 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg, 80 mg
Tablet: 20 mg, 5 mg, 10 mg
Tablet, Extended Release: 18 mg, 27 mg, 36 mg, 54 mg
Tablet, Sustained Release: 20 mg
methylPREDNISolone ACETATE - [Depo-Medrol]

Various Indications
Variable dosing via Intramuscular Injection, Intra-synovial Injection, Intralesional Injection ONLY
methylPREDNISolone sodium succinate - [Solu-MEDROL]

Anti-Inflammatory, Immunosuppressive:
or
or
Pulse Therapy
10-30 mg/kg/dose IV daily for 1-3 days (up to 5 days for neurologic conditions)
Acute Peri-Operative Spinal Cord Injury
30 mg/kg/dose IV followed in 45 minutes by a continuous infusion of 5.4 mg/kg/hour
Asthma (PICU)
*Hydrocortisone IV is preferred for this indication: Go to clinical order set IWK PEINAS "Pediatric Inpatient Asthma Care Map
Orders"
1 mg/kg/dose IV every 6 hours transition to PO when clinically appropriate
Comments
Supplied: Injection: 125 mg, 500 mg, 1 gram(s)
metoclopramide
Go to Health Canada warning (2015) Metoclopramide - Abnormal Involunatary Movements (Extrapyramial Symptoms) in Chldren
Go to APPHON Guidelines for the Management of Chemotherapy Induced Nausea and Vomiting in Children with Cancer for more information
Renal Adjustment
Postoperative Nausea and Vomiting
Less than 14 years
0.1-0.2 mg/kg/dose IV every 6 to 8 hours PRN

Maximum: 0.5 mg/kg/24h
10 mg IV every 6 to 8 hours PRN
Intubation of Small Intestine to Facilitate Radiographic Exam of Upper GI

Less than 6 years
6 to 14 years
2.5-5 mg IV once
10 mg IV once
Antineoplastic Emesis Prophylaxis

Greater than 1 year
DiphenhydrAMINE should be administered concurrently. Go to diphenhydrAMINE
Maximum: 40 mg/dose
Gastroesophageal Reflux
Domperidone has similar mechanism but fewer adverse effects than metoclopramide. No benefit in using metoclopramide in treatment failure after
domperidone. Metoclopramide is not recommended for treatment of GERD or upper GI symptoms
Comments
Risk of developing tardive dyskinesia with long-term use (greater than 3 months) and higher doses. These symptoms are often irreversible.

Liquid: 1 mg/mL
Tablet: 5 mg
metolazone
Renal Adjustment
Diuretic

Maximum: 10 mg/dose
or

Maximum: 10 mg/dose

Tablet: 2.5 mg
metoprolol
Hypertension
0.5-1 mg/kg/dose PO BID titrated to desired clinical effect to a:


Tablet: 50 mg
metroNIDAZOLE - [Flagyl]
Renal Adjustment
Various Indications
Go to Firstline
Go to Firstline
Go to Canadian Guidelines on Sexually Transmitted Infection
Antibacterial
Vaginal (cream)
500 mg (1 applicatorful) PV/Topical once to twice daily for 10-20 days.
Supplied: Cream, Vaginal: 10 %

Injection: 5 mg/mL
Tablet: 250 mg
midazolam
Renal Adjustment
Status Epilepticus
Loading Dose
Intravenous, Intramuscular, Intranasal*
Go to IWK Policy 20.11 "Administration of Intranasal Medications via a Mucosal Atomization Device (MAD)" for more information
Continuous IV Infusion
see dosing below
Buccal
0.2 mg/kg/dose buccal

Maximum: 10 mg/dose
Sedation/Mechanical Ventilation/Status Epilepticus

Continuous IV Infusion
Loading Dose
0.05-0.1 mg/kg/dose
Initial Dosing
0.05 - 0.1 mg/kg/hour
Suggested Titration
0.05-0.1 mg/kg/hour every hour. Bolus dose may be desirable due to longer half-life and time to reach steady state.
Usual Range
0.05-0.5 mg/kg/hour
Maximum
2 mg/kg/hour
Procedural Sedation*
Go to IWK Policy 50002 "Sedation Outside of the Pediatric Operating Room, excluding PICU, NICU, and Emergency" for more information
Outside PICU, OR and ED
Go to clinical order set IWKMIPRSE "IWK MIPRSE Midazolam for Procedural Sedation in Pediatric Patients Outside of PICU, NICU, OR and
ED"
PICU, OR and ED
Oral
0.25-0.5 mg/kg/dose PO once

Maximum: 20 mg/dose
Intranasal
Go to IWK Policy 20.11 "Administration of Intranasal Medications via a Mucosal Atomization Device (MAD)" for more information
0.2-0.3 mg/kg/dose intranasal once
Maximum: 10 mg/dose AND 5 mg/nostril
Intramuscular
0.1-0.15 mg/kg/dose IM once

Maximum: 10 mg/dose
Intravenous
Less than 6 years of age
0.05-0.1 mg/kg/dose IV once titrated every 2 to 3 minutes to a:

Maximum: 0.6 mg/kg TOTAL DOSE OR 6 mg TOTAL DOSE
0.025-0.05 mg/kg/dose IV titrated every 2 to 3 minutes to a:

0.5-2.5 mg IV
Maximum: 10 mg TOTAL DOSE
Comments
*Onset of effects
Route Time to Onset
IV 2 to 3 minutes
PO 15 to 30 minutes
Intranasal 10 minutes
Usual duration of sedation after a single dose: 30 to 60 minutes
Supplied: Injection: 1 mg/mL (10 mL Vial) , 5 mg/mL (restricted to oral, buccal and intranasal routes of admin), 1 mg/mL (100 mL Bag) ,
1 mg/mL (2 mL Vial)
milrinone
For administration guidelines outside of PICU or NICU, go to Policy 25.40 Inotrope Infusions on Cardiology Inpatient Unit
Renal Adjustment
Continuous Infusion
Loading Dose
Very rarely given
Initial Dosing
Suggested Titration
0.25 microgram/kg/min as required
Usual Range
0.25 - 0.75 microgram/kg/min
Maximum
1 microgram/kg/min
mirtazapine
Antidepressant
Comments
mitomycin
Dosing under review
mitoXANTRONE
mometasone
Rhinitis- Nasal Spray
3 to 11 years
1 spray (50 micrograms) in each nostril daily

2 sprays (100 micrograms) in each nostril daily. May reduce to 1 spray (50 micrograms) in each nostril daily
Supplied: Spray, Nasal: 50 micrograms/spray
montelukast
Asthma
4 mg PO daily
5 mg PO daily
10 mg PO daily
Tablet, Chewable: 4 mg, 5 mg
morphine
These dosing guidelines are intended for opioid-naive, acute pain situations.
Practitioners should consider whether the patient is opioid naive and other underlying medical conditions when choosing
an initial dose.
doses.
Renal Adjustment
Analgesia
Intermittent- Oral
Initial dosing
Less than 6 months

Usual dosing range:

Intermittent- Parenteral
Initial dosing
Less than 6 months
0.05 mg/kg/dose IV every 4 hours PRN
0.05-0.1 mg/kg/dose IV/IM/Subcutaneous every 3 to 4 hours PRN

Usual dosing range:

0.05-0.2 mg/kg/dose IV every 3 to 4 hours PRN
Continuous Infusion - Greater than 1 month

MSNU, PMU, 6 Link
(Note: for infants less than 6 months, morphine continuous infusion MUST be prescribed by Acute Pain Service or
Pediatric Advanced Care Team)
Go to order set IWK MOCO "Morphine Continuous Infusion MSNU, PMU, 6 Link"

Ordered as : mg/kg/hour
Loading Dose
0.1 mg/kg/dose IV x 1
Initial Dosing
0.02 mg/kg/hour
Suggested Titration
Usual Range
0.01-0.04 mg/kg/hour
Usual* Maximum:
0.04 mg/kg/hour *May require higher doses for sedation or if switching between opioids (e.g. converting from fentaNYL to morphine)
Go to IWK IVPA "ACUTE PAIN SERVICE (APS) PATIENT CONTROLLED ANALGESIA (PCA) ORDERS − PEDIATRICS""
Post-Tonsillectomy
Go to order set IWK TOADPO "Post Tonsillectomy and/or Adenoidectomy Surgery Orders"
Comments
Supplied: Capsule, Extended Release: 10 mg, 15 mg, 30 mg

Injection: 1 mg/mL (50 mL Prefilled Syringe) IWK Compounded, 1 mg/mL (100 mL Bag) , 2 mg/mL, 10 mg/mL, 0.5 mg/mL
Syrup: 1 mg/mL
Tablet: 5 mg
moxifloxacin
1 drops in affected eye(s) TID to QID

(Short term alternate - for use after hours)
Go to Firstline
multivitamin (renal)
Contact main pharmacy dispensary for current contract brand and for specific ingredients
Supplementation in patients with renal disease
1 tablet PO daily
Supplied: Tablet: 0
multivitamin with minerals (adult)

1 tablet PO daily
Supplied: Tablet: 0
multivitamin with minerals (pediatric)

Chewable tablet
4 to 18 years
1 tablet PO daily
Liquid
1 to 13 years
15 mL PO daily
Supplied: Liquid: 0
Tablet, Chewable: 0
mupirocin
Topically to affected area TID
Supplied: Ointment, Topical: 2 %
mycophenolate mofetil - [Cellcept]

There are two different formulations/salts of mycophenolate: [mycophenolate mofetil (Cellcept®) and mycophenolate
sodium (Myfortic® or equivalent)] each with different dosing. See equivalences below or:
Go to mycophenolate sodium (Myfortic® or equivalent)
Go to Body Surface Calculator
Renal Adjustment
Renal Transplant
Liver Transplant
Initial
Comments
Dosing Equivalence
CellCept®(mofetil) Myfortic®(sodium)or equivalent

2000 mg 1440 mg
1500 mg 1080 mg
1000 mg 720 mg
500 mg 360 mg
250 mg 180 mg
Patient/Family Resource: Mycophenolate Information (Division of GI and Rheumatology)

Liquid: 200 mg/mL
Tablet: 500 mg
mycophenolate sodium - [Myfortic]

There are two different formulations/salts of mycophenolate: [mycophenolate mofetil (Cellcept®) and mycophenolate sodium
(Myfortic® or equivalent)] each with different dosing. See equivalences below or:
Go to mycophenolate mofetil (Cellcept®)
Renal Adjustment
Renal Transplant
Comments
Dosing Equivalence
CellCept®(mofetil) Myfortic®(sodium) or equivalent

2000 mg 1440 mg
1500 mg 1080 mg
1000 mg 720 mg
500 mg 360 mg
250 mg 180 mg
Patient/Family Resource: Mycophenolate Information (Division of GI and Rheumatology)
Supplied: Tablet, Enteric Coated: 180 mg, 360 mg
nabilone
information
Antiemetic with Moderately Emetogenic Antineoplastic Therapy

Less than 18 kg
0.5 mg PO BID
18 to 30 kg
1 mg PO BID
Greater than 30 kg
1 mg PO BID to TID
Comments
The first dose of nabilone should be given the evening before the start of chemotherapy and continued for the duration of
chemotherapy
Caution in patients with history of psychiatric disorder; hypertension; heart disease.
Mood and behavioural changes may occur. Adverse effects on mental state can persist for 48-72 hours after stopping.
Supplied: Capsule: 0.25 mg, 0.5 mg, 1 mg
nadolol
Prescribing of nadolol for the indication of infantile hemangioma is reserved/restricted to: Dermatology, ENT, or Plastics
Renal Adjustment
Supraventricular Tachycardia
0.5-1 mg/kg/dose PO daily titrated to desired clinical effect to a:

Maximum: 2.5 mg/kg/24h
Infantile Hemangioma
Prescribing of nadolol for the indication of infantile hemangioma is reserved/restricted to: Dermatology, ENT, or Plastics
May consider TID dosing interval in suspected PHACES syndrome prior to MRI
Week 1
Week 2
Week 3 and thereafter
1 mg/kg/dose PO BID
Maximum: 2 mg/kg/dose
Comments
Infantile hemangioma: Nadolol is only considered in patients who have previously received propranolol and have experienced
sleep disturbances, irritability or another intolerance (e.g. bradycardia, hypotension) OR a lack of efficacy of propranolol. Given
elimination of nadolol, ensure no history of constipation, regular stooling.

Tablet: 40 mg
naloxone
The duration of action of some opioids may exceed that of naloxone, therefore repeat doses may be required. Monitor patient
closely.
Antidote
Partial reversal
*See "Comments" for additional info regarding route of administration options
See example of partial reversal dosing in IWKMETH "Methadone for PAIN"

0.001 mg/kg/dose IV every 2-3 minutes as needed
Full reversal
*See "Comments" for additional info regarding route of administration options
See example of full reversal dosing in IWKMOCO "Morphine Continuous Infusion MSNU, PMU, 6Link"
0.01 mg/kg/dose IV every 2-3 minutes as needed
Opioid Induced Pruritus

IV Continuous
Loading dose
None
Initial Dosing
0.25 microgram/kg/hour
Suggested Titration
0.25 microgram/kg/hour
Usual Range
Maximum
0.5 microgram/kg/hour. Must consult APS if exceeding this dose.
Go to clinical order set IWK ANAPS Acute Pain Service- Anesthesia Analgesic, Antiemetic, Antipruritic
Comments
*If IV route not available, may administer same dose subcutaneous, intramuscular. Consideration of maximum volumes/injection via
each route may need to be considered.
naltrexone
Patients must be opioid-free prior to initiation of naltrexone.
Short-acting opioids must be discontinued 7-10 days prior to naltrexone initiation. 14 days may be needed for long-acting opioids.
If opioid pain management is anticipated during treatment with naltrexone, discontinue oral naltrexone at least 3 days prior to initiating
opioid pain management.
Alcohol Use Disorder

Initial
25-50 mg PO daily
Maintenance
50-100 mg PO daily
naproxen
Renal Adjustment
Analgesic

Anti-inflammatory
Comments
Patient/Family Resource: NSAIDs Information (Division of GI and Rheumatology)

Tablet: 500 mg
nelarabine
neostigmine
Renal Adjustment
Reversal of Neuromuscular Blockade
0.03-0.07 mg/kg/dose IV
Comments
Atropine or glycopyrrolate should be given prior to or with neostigmine.
Supplied: Injection: 0.5 mg/mL, 1 mg/mL
nicotine
Smoking Cessation
Go to Clinical Order Set "Nicotine Replacement Therapy Orders"
For additional information on dosing nicotine products

Go to RxTx
or:
Go to Nicoderm Patch manufacturer website
Go Nicorette gum/inhaler manufacturer website
Supplied: Gum: 2 mg, 4 mg

Inhalation, Cartridge: 10 mg
Transdermal Patch: 7 mg, 14 mg, 21 mg
NIFEdipine
Hypertension
Acute
Immediate release
0.1-0.25 mg/kg/dose PO/Sublingual every 4 to 6 hours PRN Dose may be titrated up to 0.5 mg/kg/dose.
Maximum: 10 mg/dose OR 2 mg/kg/24h
Chronic
Extended release
0.125-0.25 mg/kg/dose PO every 12 hours . Maximum initial dose: 30-60 mg/24 hours
or
0.25-0.5 mg/kg/dose PO every 24 hours . Maximum initial dose: 30-60 mg/24 hours
Comments
For rapid onset sublingual administration when dose is less than a full capsule: withdraw appropriate volume from capsule by
puncturing with a large bore needle attached to a 1 mL syringe. Withdraw dose and remove needle. Administer immediately as
NIFEdipine is light sensitive.
If the dose is:
a full capsule, the patient may bite and swallow.
less than a full capsule the concentration of the liquid in the 10 mg capsule (brand AAP DIN00755907) is 33.3 mg/mL, which
can be used to calculate the volume to withdraw. Note, concentration may vary by brand.
To convert from immediate release to extended release formulation, use the same total daily mg dose and adjust interval
accordingly. When switching to extended release formulation, the initial dose should not exceed 30 mg.

Tablet, Extended Release: 30 mg
nitrazepam
Renal Adjustment
Anticonvulsant
Comments
May cause bronchial hypersecretion in infants with epilepsy; ensure upper airways are clear before beginning treatment.

Tablet: 5 mg
nitrofurantoin
Renal Adjustment
Various Indications
Pediatric dosing is specific to nitrofurantoin tablets or suspension , NOT monohydrate macrocrystals (MacroBID®)
Go to Firstline
Supplied: Capsule: 100 mg (as monohydrate macrocrystals) Macrobid

Tablet: 50 mg
nitroglycerin
Renal Adjustment
0.25-0.5 microgram/kg/min IV continuous infusion titrate to effect with a usual range of 1-5 micrograms/kg/min
Comments
Tolerance may develop within 24-48 hours of continuous use.
Supplied: Injection: 5 mg/mL, 0.4 mg/mL in D5W

Spray, Sublingual: 0.4 mg
nitroprusside
IV Continuous
Loading Dose
None
Initial Dosing
0.3-0.5 microgram/kg/min
Suggested Titration
0.25-0.5 microgram/kg/min every 5-10 minutes
Usual Range
Maximum
10 microgram/kg/min
Comments
Maximum: 4 micrograms/kg/minute if use exceeds 24 hours.
Infusion should be discontinued if blood pressure not adequately controlled within 10 minutes at a maximum dose of 10
microgram/kg/min
norepinephrine
All doses expressed in terms of norepinephrine base
IV Continuous
Loading Dose
None
Initial Dosing
Suggested Titration
0.01 microgram/kg/min every 10 minutes
Usual Range
Maximum
2 microgram/kg/min
Intravenous, Sepsis Management in Emergency Department

Greater than 28 days
Go to order set IWKSESE "Sepsis Management in Children Greater than 28 Days of Age, Emergency Department"
norethindrone - [Oral Contraceptive, Jencycla, or equivalent]

Current IWK contract brand: Jencycla 28 pack
Oral Contraception
(28 tablet package - contains all active tablets)
1 tablet PO daily
Supplied: Tablet: 0.35 mg
nystatin
January 2020- Nystatin in cream and ointment form are no longer on IWK Formulary (click here for memo or click here for
alternatives)
Oral Candidiasis
Less than 1 year
200,000 unit(s) PO QID for 7-10 days or until control is achieved
Greater than 1 year
400,000-600,000 unit(s) PO QID for 7-14 days or until control is achieved
Comments
Administer half of the dose to each side of mouth, and if possible swish in the mouth and retain as long as possible before
swallowing.
Do not use within 30 minutes of chlorhexidine mouthrinse.
Continue treatment for 3 days after symptoms have resolved.
Supplied: Suspension: 100000 units/mL
octreotide
Renal Adjustment
Antidote
Chylothorax (IWK Cardiology)

Intermittent
5 microgram/kg/dose IV every 8 hours for 5 days. Increase by 5 microgram/kg/dose every 24 hours. Titrate to response
Maximum: 40 microgram/kg/24h
Continuous Infusion
0.5-4 microgram/kg/hour
Maximum: 4 microgram/kg/hour
Esophageal Varices/GI Bleed

Loading Dose
1-2 micrograms/kg/dose x 1
Initial Dosing
Maximum: 50 microgram/hour
When no active bleeding for 24 hours, decrease dose by 50% every 12 hours then discontinue.
Secretory Diarrhea
Intermittent
1 microgram/kg/dose IV/Subcutaneous every 8 to 12 hours titrate to desired clinical effect. Doses may be increased by 0.3
microgram/kg/dose every 3 days.
Maximum: 10 microgram/kg/dose OR 500 microgram/dose
Continuous Infusion
Ordered as: micrograms/kg/hour
1 microgram/kg/hour IV continuous infusion
OLANZapine
Intramuscular OLANZapine and any benzodiazepine should not be given concurrently due to severe drug interactions however if
deemed absolutely clinically necessary. Space intramuscular OLANZapine and intramuscular LORazepam by at least 2 hours.
Renal Adjustment
Antipsychotic

Go to clinical order set IWK CHRE “Emergency Management of Anxiety and Agitation Emergency Department Patients greater than 6
years old ”

information
3 years or greater
Round doses to nearest whole or portion of tablet strength on formulary
0.1 mg/kg/dose PO once to twice daily

Maximum: 10 mg/dose
Tablet, Oral Disintegrating: 5 mg, 10 mg, 20 mg
onasemnogene abeparvovec-xioi - [Zolgensma]

5q spinal muscular atrophy (SMA) with bi-allelic mutations in the survival motor neuron 1 (SMN1) gene
Order set coming soon. Clinical use pending funding /agreements
Supplied: Injection: 20000000000000 vector genomes/mL
ondansetron
information
Additional Resource: Go to About Kids Health: Ondansetron
Nausea/Vomiting/Pruritis (eg. opioid-induced pruritis)
0.1-0.15 mg/kg/dose IV/PO every 8 hours PRN

Maximum: 8 mg/dose
Post-Operative
1 month to 12 years
Less than 40 kg
Give at induction of anaesthesia for prevention or post-operatively if patient is symptomatic*
Maximum: 4 mg/dose
Greater than 40 kg
4 mg IV once
Acute Gastroenteritis
Maximum: 8 mg/dose
8 to 15 kg
2 mg PO once
15.1 to 30 kg
4 mg PO once
Greater than 30 kg
8 mg PO once
Antineoplastic therapy
Low emetogenic
0.1-0.2 mg/kg/dose IV/PO once pre-therapy, then up to q8h PRN
Maximum: 8 mg/dose
Moderately and highly emetogenic
0.1-0.2 mg/kg/dose IV/PO once pre-therapy, then q8h

Maximum: 8 mg/dose
Comments
*Additional postoperative doses to control nausea and vomiting may not provide any benefit in patients who did not achieve adequate
control with a single perioperative dose.

Liquid: 0.8 mg/mL
Tablet: 4 mg
Tablet, Oral Disintegrating: 4 mg
oseltamivir - [Tamiflu]
Renal Adjustment
Influenza
Treatment/Prophylaxis
Go to Firstline

Suspension: 6 mg/mL
OXcarbazepine
Renal Adjustment
Partial Seizures, Adjunctive treatment
Initial
Maximum: 600 mg/24h
2 to 4 years
Less than 20 kg

Maximum: 600 mg/24h
Titration and Maintenance

2 to 4 years
Increase slowly over 2-4 weeks to:
4 to 16 years
Less than 29 kg
Increase dose over 2 weeks to:
450 mg PO BID
29 to 39 kg
600 mg PO BID
Greater than 39 kg
900 mg PO BID
Partial Seizures, Monotherapy

Initial
4 to 16 years
4-5 mg/kg/dose PO BID Increase dose by 5 mg/kg/24 hour every 3 days up to the recommended dose:
Maintenance
Less than 25 kg
300-450 mg PO BID
25 to 34.9 kg
450-600 mg PO BID
35 to 44.9 kg
450-750 mg PO BID
45 to 49.9 kg
600-750 mg PO BID
50 to 59.9 kg
600-900 mg PO BID
60 to 69.9 kg
600-1050 mg PO BID
Greater than 70 kg
750-1050 mg PO BID

Tablet: 300 mg
oxybutynin
Renal Adjustment
Neurogenic Bladder
0.2 mg/kg/dose PO BID to TID

Maximum: 15 mg/24h
5 mg PO BID to TID
Maximum: 15 mg/24h

Tablet: 5 mg
paliperidone
Antipsychotic
Oral

Note: There are two long acting injectable formats a monthly injection (Invega Sustenna as 50, 75, 100 and 150 mg) and an every 3 month
injection (Invega Trinza as 175, 263, 350 and 525 mg)
Comments
Supplied: Injection: 50 mg, 75 mg, 100 mg, 150 mg, 175 mg, 263 mg, 350 mg, 525 mg
Tablet, Extended Release: 3 mg, 6 mg
palivizumab - [Synagis]
Go to IWK Policy 10.37 "Care Directive for the Administration of Palivizumab (Synagis®) Intramuscular by Registered Nurses at the
IWK Working in the RSV Prevention Clinic"
Go to IWK External Website "About Palivizumab" for more information
Go to NACI Statement "Recommended use of Palivizumab to Reduce Complications of RSV Infection in Infants"
RSV Prophylaxis
Go to clinical order set IWKRSPR "Palivizumab for RSV Prophylaxis"
Supplied: Injection: 50 mg, 100 mg
palonosetron
information
Antiemetic
MODERATE/HIGH emetogenic antineoplastic therapy
1 month to 17 years
0.02 mg/kg/dose IV once pre-therapy . May be repeated once in 48 hours for multi-day chemotherapy
0.25 mg IV once pre-therapy . May be repeated once in 48 hours for multi-day chemotherapy
OR
0.5 mg PO once pre-therapy . May be repeated once in 48 hours for multi-day chemotherapy
Supplied: Capsule: 0.5 mg

Injection: 0.05 mg/mL
pamidronate
Go to clinical order set IWK PAIN “IV Bisphosphonate Pediatric Order "
pantoprazole
IV therapy should be discontinued as soon as patient tolerates oral therapy.
Renal Adjustment
Acid Suppression (if unable to take oral)

5 to less than 20 kg
2 mg/kg/dose IV daily
Maximum: 40 mg/dose
1-1.5 mg/kg/dose IV daily

Maximum: 40 mg/dose
Upper GI Bleed
IV Continuous Infusion
5 to 40 kg
2 mg/kg/dose IV once followed by 0.2 mg/kg/hour IV infusion, for up to a maximum of 72 hours
Greater than 40 kg
80 mg IV once followed by 8 mg/hour IV infusion, for up to a maximum of 72 hours

Maximum: 8 mg/hour
PARoxetine
Various Indications
Go to SwitchRx for information on tapering, switching or combining psychotropic medications
pegaspargase
pegfilgastrim - [Neulasta]
Biosimilar products are available such as LaPelga, Fulphilia
Neutropenia, Secondary to Chemotherapy

less than 10 kg:
0.1 mg/kg subcutaneous once
10 to 20 kg
1.5 mg subcutaneous once
21 to 30 kg
2.5 mg subcutaneous once
31 to less than 45 kg
45 kg and greater
penicillin G
0.1 million units= 0.1 MU (note : displayed in infusion pumps as MU)= 100,000 units/mL
Renal Adjustment
Various Indications
Go to Firstline
Supplied: Injection: 1 million units (MU), 5 million units (MU)
penicillin V - [Pen VK]

Renal Adjustment
Various Indications
Go to Firstline
Pneumococcal infection prophylaxis, anatomic or functional asplenia (e.g, sickle cell disease)
*While penicillin V is the first line agent, see also amoxicillin
3 months to 5 years
150 mg PO BID
Over 5 years
Use of prophylaxis over the age of 5 should be considered on a case by case basis
300 mg PO BID
Comments
Tablets/Part-tablets can be crushed for patients who can't swallow tablets.
pentamidine
Renal Adjustment
Pneumocystis Pneumonia (PCP)
Prophylaxis
Inhalation - Intravenous formulation is used via nebulizer for inhalation. Refer to parenteral information for information on
reconstitution of vial for use via inhaled route.
Less than 5 years
9 mg/kg/dose inhalation monthly

300 mg inhalation monthly
Intravenous (as an alternative to inhalation)

All ages
4 mg/kg/dose IV monthly
Pneumocystis Pneumonia (PCP)

Treatment
Intravenous
All ages
4 mg/kg/dose IV every 24 hours for 2 to 3 weeks

permethrin
Go to NS Public Health Head Lice brochure
Go to Canadian Pediatric Society Practice Point: Head lice infestations: A clinical update
Head Lice
Go to Nix Cream Rinse website for more information
Scabies
Go to Canadian Public Health information
Supplied: Cream, Rinse: 1 %

Cream, Topical: 5 %
PHENobarbital
Renal Adjustment
Anticonvulsant
Loading Dose
15-20 mg/kg/dose IV May repeat after 20 minutes to a TOTAL of 40 mg/kg

Maintenance Dose - Start 12 hour after loading dose

Less than 1 year
2.5-3 mg/kg/dose IV/PO every 12 hours
or
5-6 mg/kg/dose IV/PO every 24 hours
1 to 5 years
or
6 to 12 years
or
Over 12 years
0.5-1.5 mg/kg/dose IV/PO every 12 hours
or
Supplied: Elixir: 5 mg/mL

Injection: 30 mg/mL, 120 mg/mL
Tablet: 15 mg
phentolamine - [Rogitine]
Vasodilation
0.5-1 microgram/kg/min IV continuous infusion titrated to desired clinical effect to a:

Most effective if given within 1 hour of injury but may be used up to 12 hours after.
Go to Medication Management Policy 30.60 "Management of Extravasation" for more information *policy under review*
5 x 0.1 mg (0.2 mL) subcutaneous injections around the circumference of infiltrate (one injection may be given via interstitial cannula if
remains in situ) every 30 minutes PRN for persistent or recurrent blanching
Maximum: 5 mg TOTAL DOSE OR 0.2 mg/kg TOTAL DOSE
phenyLEPHrine
Hypotension/Shock
IV Direct
Round dose to 25 microgram increments to align with pre-filled syringe volume increments
5-20 microgram/kg/dose IV every 10 minutes PRN
Continuous Infusion
0.1-0.5 microgram/kg/min IV continuous infusion titrate to desired clinical effect
Ophthalmic
Manufacturer Recommended
1 drops in affected eye(s) once
Supplied: Drops, Ophthalmic: 2.5 %, 10 %

Injection: 50 micrograms/mL, 10 mg/mL
phenyTOIN
If suspension must be administered through a tube, first dilute 2 to 3-fold with a compatible diluent (e.g. sterile water).
Hold tube feeds for 1-2 hours prior to and 1-2 hours after phenyTOIN administration
Renal Adjustment
Anticonvulsant
Loading Dose

15-20 mg/kg/dose IV
Maintenance - Initial
Starting 12 hours after loading dose
2.5 mg/kg/dose IV/PO BID
or
1.7 mg/kg/dose IV/PO TID . Dose may be titrated based on clinical response and/or serum drug monitoring
Maximum: 300 mg/24h OR 10 mg/kg/24h

Injection: 50 mg/mL
phosphorus (Oral) - [Phosphate ]

All doses expressed in terms of elemental phosphorus.
All orders must be written in terms of mmol of elemental phosphorus.
1 mmol phosphorus = 1 mmol phosphate
Solution (Phoslax®) contains: 4 mmol phosphate and 4.8 mmol sodium/mL
Each Tablet, Effervescent contains: 500 mg phosphorus = 16.1 mmol of phosphorus
Renal Adjustment
Mild hypophosphatemia or Maintenance

(serum phosphate 0.5 - 0.8 mmol/L)
0.5-1.5 mmol/kg/dose PO BID

Maximum: 48 mmol/24h (less than 4 years old) OR 97 mmol/24h (5 to 17 years)
or
0.33-1 mmol/kg/dose PO TID

or
0.25-0.75 mmol/kg/dose PO QID

Moderate hypophosphatemia
(serum phosphate 0.4 - 0.5 mmol/L)
1-1.5 mmol/kg/dose PO BID

or
0.67-1 mmol/kg/dose PO TID

or

Comments
Oral phosphate supplementation is preferred. Separate oral administration by at least 2 hours from calcium, iron, aluminum or
magnesium containing supplements.
Dissolve oral effervescent tablet in 125-250 mL water and allow to completely dissolve prior to administration. Water is the
preferred fluid but juice has been use.
Supplied: Solution: 4 mmol/mL

Tablet, Effervescent: 16.1 mmol
phosphorus|potassium (Parenteral) - [potassium phosphate (intravenous)]

The most reliable method of ordering IV phosphorus is in mmol then specifying the salt (i.e. potassium or sodium)
e.g. 5 mmol phosphorus as potassium phosphate
When IV is required, sodium phosphate is preferred in the absence of concomitant hypokalemia.
1 mmol phosphorus = 31 mg phosphorus
Renal Adjustment
Mild Hypophosphatemia
serum phosphate 0.5-0.8 mmol/L
Oral (Preferred)
Go to phosphorus (Oral)
Intravenous (for those unable to tolerate oral)
0.08 mmol/kg/dose IV once

Maximum: 80 mmol/24h
Moderate Hypophosphatemia
Oral (Preferred)
0.16-0.24 mmol/kg/dose IV once . Repeat serum phosphate level in 12 to 24 hours

Severe hypophosphatemia OR if symptomatic

serum phosphate less than 0.4 mmol/L
0.32 mmol/kg/dose IV once and may repeat in 6 hours PRN. Repeat serum phosphate level 1 hour after the infusion is complete
Maintenance
Oral
Intravenous
0.5-1.5 mmol/kg/24h divided IV in maintenance fluids

Comments
Standard concentration provides phosphate 0.05 mmol/mL AND potassium 0.073 mmol/mL
Supplied: Injection: 0.05|0.073 mmol/mL IWK Compounded
phosphorus|sodium (Parenteral) - [sodium phosphate (intravenous)]

The most reliable method of ordering IV phosphorus is in mmol then specifying the salt (i.e. potassium or sodium)
e.g. 5 mmol phosphorus as sodium phosphate
When IV is required, sodium phosphate is preferred in the absence of concomitant hypokalemia.
1 mmol phosphorus = 31 mg phosphorus
Renal Adjustment
Mild Hypophosphatemia
Oral (Preferred)
0.08 mmol/kg/dose IV once

Moderate Hypophosphatemia
Oral (Preferred)
0.16-0.24 mmol/kg/dose IV once . Repeat serum phosphate level in 12 to 24 hours

Severe hypophosphatemia OR if symptomatic

serum phosphate less than 0.4 mmol/L
0.32 mmol/kg/dose IV once and may repeat in 6 hours PRN. Repeat serum phosphate level 1 hour after the infusion is complete
Maintenance
Oral
Intravenous
0.5-1.5 mmol/kg/24h divided IV in maintenance fluids

Comments
Standard concentration provides phosphate 0.05 mmol/mL AND sodium 0.066 mmol/mL
Supplied: Injection: 0.05|0.066 mmol/mL IWK Compounded, 3|4 mmol/mL
physostigmine
Go to Atlantic Canada Poison Centre Antidote Kit for Information on antidote dosing and administration
phytonadione - [Vitamin K ]
Vitamin K Deficiency
Initial
Oral
Injectable form may be given orally either undiluted or diluted in juice/water just prior to administration
2.5-5 mg PO once
Parenteral
If parenteral route is required, the subcutaneous route is preferred.
1-2 mg IV/IM/Subcutaneous once
Subsequent
Dose, route and frequency dependent upon severity of condition
Vitamin K Supplementation in patients greater than 11 years of age on parenteral nutrition (TPN)
Go to clinical order set IWK PEPA "Travasol Pediatric Parenteral Nutrition Order" (see multivitamin section)
Anticoagulant- Induced Hypoprothrombinemia

Patients with no bleeding requiring reversal
WILL require further anticoagulation
0.5-2 mg PO once
Will NOT require further anticoagulation
2-5 mg PO once
Bleeding
NON life-threatening
2-5 mg IV/PO once
Life-threatening
5 mg IV once
Comments
Anticoagulant-Induced Hypoprothrombinemia: As per American College of Chest Physicians (ACCP) subQ route not
recommended. IM route not mentioned because of erratic absorption. For no major bleeding with mild/moderately elevated INR,
may be given orally.

Tablet: 5 mg (as elemental) Special Access
picosulfate sodium|magnesium oxide|citric acid - [Pico-Salax]

Bowel preparation for colonoscopy
Go to clinical order set "IWKCOBO Colonoscopy for Bowel Prep Orders for Admitted Patients"
Comments
Each 16.1 grams of powder/sachet contains: picosulfate sodium 10 mg, magnesium oxide 3.5 grams and citric acid 12 grams
Supplied: Powder for Solution: 0|0|0
piperacillin|tazobactam - [Pip-Taz]
Renal Adjustment
Various Indications
Go to Firstline
Febrile Neutropenia (Oncology)

Empiric
Supplied: Injection: 3|0.375 gram(s), 4|0.5 gram(s)
pneumococcal 13-valent conjugate vaccine - [Prevnar-13]
pneumococcal 23-valent polysaccharide vaccine - [Pneumovax-23]
polio vaccine - [IVP, Imovax]
polyethylene glycol (PEG 3350 NF) - [PEG 3350 NF Granular]

Although weight based dosing is provided below, doses should be rounded to one of these doses to accommodate available
formats/volume equivalencies:
Dose Approximate equivalency ( 1 gram = 1.3 mL if measure in an oral syringe)
2.1 grams 2.7 mL
4.25 grams 5.5 mL
8.5 grams 11 mL
12.75 grams 16.6 mL
17 grams (fill line on bulk container OR contents of 17 g packet)
Less than or equal to 15 kg

In clinical practice, doses may need to be titrated up beyond maximum recommended dose (IWK GI Service)
0.4-1 grams/kg/dose PO daily

or
0.2-0.5 grams/kg/dose PO BID

Greater than 15 kg
17 grams PO daily
Disimpaction
1-1.5 grams/kg/24h divided PO can be used for up to 3-6 consecutive days. Maintenance treatment should begin after disimpaction for
at least 2 months to prevent relapse.
Comments
Powder should be stirred in an appropriate volume of clear fluid to allow for dissolution of the dose.
It is important that patient consumes the entire volume/dose and maintains adequate hydration status for optimal effectiveness.
Supplied: Powder: 0 (17 Gram Packet) , 0 (510 Gram Bottle)
polymyxin B sulfate|bacitracin zinc - [Polysporin equivalent]

January 2020- Polysporin (equivalent) in cream form is no longer on IWK Formulary. Use ointment form (click here for memo).
Antimicrobial
Topical (Ointment)
Topically to affected area BID to TID
Supplied: Ointment, Topical: 10000|500 units/g
polymyxin B sulfate|gramicidin - [Polysporin Eye Drop ]

Topical (Ophthalmic and Otic)
1-2 drops in affected eye/ear QID
Supplied: Drops, Ophthalmic: 10000|0.025 units/mg/mL
potassium chloride
All dosage guidelines based on mmol of potassium. 1 mmol potassium= 1 mEq potassium
Note: 10 mmol/litre = 10 mEq/litre = 1 mEq/100 mL = 1 mEq%
Starting dose should be determined by considering maintenance, losses and desired replacement
CLICK HERE for additional important information on potassium chloride containing solutions, please refer to September 2019
parenteral monograph (currently being reviewed).
Available potassium chloride containing IV solutions at IWK Supply and Distribution
Information on preparing potassium chloride IV solution after hours
Hypokalemia
Prophylaxis (with diuretic therapy)
Oral
1-2 mmol/kg/dose PO daily

Maximum: Usual: 20 mmol/dose
or
0.5-1 mmol/kg/dose PO BID

Treatment
Oral
1-2.5 mmol/kg/dose PO BID

or
0.67-1.7 mmol/kg/dose PO TID

or

Intravenous
Supplied in maintenance IV solution or TPN
Go to clinical order set IWK_ELREP "PICU Electrolyte Replacement Orders"
Intermittent Infusion
If oral route is not feasible and patient has a central line
0.5-1 mmol/kg/dose IV
Maximum: 10 mmol/dose
Peritoneal Dialysis
1-5 mmol/litre of dialysate
Comments
Dilute oral solution in water or fruit juice prior to administration
Supplied: Capsule, Extended Release: 8 mmol

Injection: 2 mmol/mL HIGH ALERT, 0.1 mmol/mL, 1 mmol/mL HIGH ALERT IWK Compounded
Solution: 1.33 mmol/mL
Tablet, Sustained Release: 20 mmol
potassium citrate
Urinary Alkalization
0.25-2 mEq/kg/dose PO BID

Maximum: 100 mEq/24h
or
0.17-1.33 mEq/kg/dose PO TID

Maximum: 100 mEq/24h
Comments
One tablet dissolves in 85-115 mL of cold or ice water. Patients can drink an appropriate volume of liquid to get desired dose. Sip
slowly over 5-10 minutes.
For administration via feeding tube, allow tablet to completely effervesce in 50 mL water (a smaller volume may be used in fluid
restricted patients). Do not dissolve in a syringe due to gas production.
See website for more information: https://k-lyte.ca/
Supplied: Tablet, Effervescent: 25 mEq
potassium iodide - [RadBlock]

Less than 1 month
16.25 mg PO once daily for 4 days (the day before, the day of and 2 days post MIBG injection)
1 month to 3 years
32.5 mg PO once daily for 4 days (the day before, the day of and 2 days post MIBG injection)
3 to 18 years
65 mg PO once daily for 4 days (the day before, the day of and 2 days post MIBG injection)
130 mg PO once daily for 4 days (the day before, the day of and 2 days post MIBG injection)
Comments
Tablets may be crushed and dissolved in water
pralidoxime - [2-PAM]
Antidote
prazosin
Post Traumatic Stress Disorder
predniSONE/prednisoLONE
Go to methylPREDNISolone sodium succinate for information on dosing via parenteral route
As per IWK Drugs and Therapeutics, oral predniSONE and prednisoLONE are considered equivalent on a mg per mg basis.
Acute Asthma Exacerbation
Go to clinical order set IWK PEINAS "Pediatric Inpatient Asthma Care Map Orders"
Maximum: 50 mg/24h
Anti-inflammatory/Immunosuppressive
0.5-2 mg/kg/24h divided PO once to four times daily
Infantile Spasm
Go to clinical order set IWKMAIN "Management of Infantile Spasm"
Nephrotic Syndrome
Initial
Weight based
2 mg/kg/24h divided PO once to four times daily

Maximum: 80 mg/24h

60 mg/m*2/24h divided PO once to four times daily

Maximum: 80 mg/24h
Maintenance
Weight Based
2 mg/kg/dose PO every other day (every 48 hours) then gradually taper and discontinue after 4 to 6 weeks

40 mg/m*2/dose PO every other day (every 48 hours) then gradually taper and discontinue after 4 to 6 weeks
Ophthalmic
Drops (Suspension)
1-2 drops in affected eye(s) BID to QID

Maximum: Frequency can be increased in the initial 24-48 hours
Comments
Patient/Family Resource: Prednisone Information (Division of GI and Rheumatology)
Supplied: Liquid: 1 (as prednisoLONE) mg/mL

Suspension, Ophthalmic: 1 (as prednisoLONE) %
Tablet: 5 mg, 50 mg
pregabalin - [Lyrica]
Renal Adjustment
Pain
Initial
Greater than 4 years and less than 30 kg
1.75 mg/kg/dose PO BID - Dose may be titrated up to:

OR
75 mg PO BID (whichever is less). Dose may be titrated up to:

Maximum: 10 mg/kg/24h OR 600 mg/24h , whichever is less.
Comments
Dose must be prescribed in minimum increments of 25 mg
Initial doses may be lower to avoid CNS adverse effects
probenecid
Probenecid with intravenous ceFAZolin for outpatient treatment of non-facial cellulitis, lymphangitis, and lymphadenitis in
patients 2 years of age and older
Refer To ED Binder
Supplied: Capsule: 125 mg IWK Compounded
procainamide
Renal Adjustment
IV Continuous
Loading Dose
10 – 15 mg/kg/dose x 1, Max: 1000 mg/dose
Initial Dosing
20 microgram/kg/min
Suggested Titration
10 - 20 microgram/kg/min every 20 minutes
Usual Range
20 - 80 microgram/kg/min
Maximum
80 microgram/kg/min to maximum of 2000 mg/24h
procarbazine
propofol
Sedation
1-3 mg/kg/hour IV continuous infusion for up to 12 hours

Maximum: 4 mg/kg/hour
Procedural Sedation (Emergency Department)

Go to clinical order set IWK PRSEED "Procedural Sedation in the Emergency Department"
Induction
6 months to 2 years
1-2 mg/kg/dose IV
0.5-1 mg/kg/dose IV
Comments
Duration of infusion greater than 48 hours and doses greater than 5 mg/kg/hour have been associated with increased risk of
propofol related infusion syndrome (PRIS). Consider PRIS in any patient who develops unexplained metabolic acidosis,
hyperkalemia, lipemia, rhabdomyolysis, myoglobinuria, hepatomegaly, or cardiac/renal failure.
propranolol
Prescribing of propranolol for the indication of infantile hemangioma is reserved/restricted to: Dermatology, ENT, or Plastics
Renal Adjustment
Hypertension
Initial: 0.5 to 1 mg/kg/24h divided PO every 6 to 12 hours increase gradually every 3 to 7 days to a usual range of 1 to 5 mg/kg/24
hours.
Arrhythmias
Intravenous
Infants
0.01 to 0.15 mg/kg/dose IV every 6 to 8 hours PRN

Maximum: 1 mg/dose
Children
0.01 to 0.15 mg/kg/dose IV every 6 to 8 hours PRN

Maximum: 3 mg/dose
Oral
Initial: 0.5 to 1 mg/kg/24h divided PO every 6 to 8 hours increase gradually every 3 to 5 days to a usual range of 2 to 4 mg/kg/24 hours.
Tetralogy of Fallot
0.25 mg/kg/dose PO every 6 hours titrated to desired clinical effect to a:

Infantile Hemangioma
Prescribing of propranolol for the indication of infantile hemangioma is reserved/restricted to: Dermatology, ENT, or Plastics
May consider TID dosing interval in suspected PHACES syndrome prior to MRI
Week 1
Go to clinical order set IWK_HEINMA "Infantile Hemangioma - Initial Management"

Week 2
1 mg/kg/dose PO BID
Week 3 and thereafter
Comments
A withdrawal syndrome (tachycardia, sweating, hypertension) has been associated with sudden discontinuation of therapy. Taper
dose over 1-2 weeks.
Hypoglycemia may occur, particularly in infants and children.

protamine
Heparin Infusion Antidote
If anticoagulation needs to be terminated, discontinuation of heparin infusion will usually suffice. If an immediate effect is required,
consider administering protamine. Following IV administration, neutralization occurs within 5 minutes
Time Since End of IV Heparin Infusion Dose of Protamine (mg) to Neutralize 100 units of Heparin*
(min)
less than 30 1
30-60 0.5-0.75
61-120 0.375-0.5
greater than 120 0.25-0.375
*Heparin received within previous 2 hours
Maximum: 50 mg/dose
Subcutaneous Heparin Antidote

1 mg protamine neutralizes ~100 units of heparin. Give a portion of the total dose by slow IV injection then give the remainder of the
dose by IV infusion over 8-16 hours
Maximum: 50 mg TOTAL DOSE
Low Molecular Weight Heparin (LMWH) antidote

If anticoagulation needs to be terminated, discontinuation of LMWH injections will usually suffice. If an immediate reversal of effect is
required, protamine reverses some (60-75%) of the anti-Factor Xa activity of LMWH. Haematology Service must be consulted for
recommendations.
If LMWH dose has been administered within the last 8 hours

Use 1 mg protamine per 1 mg (or 100 units) LMWH. If PTT (activated) remains prolonged 2-4 hours after first dose, a second dose of 0.5
mg protamine per 1 mg (or 100 units) LMWH may be given.
Maximum: 50 mg/dose
Comments
Patients with known hypersensitivity reaction to fish or those who have had previous protamine therapy, may be at risk for
hypersensitivity reaction to protamine.
Heparin rebound with bleeding may occur 8-18 hours after protamine administration.
pyrantel pamoate
Pinworms
Go to Firstline
pyrazinamide
Renal Adjustment
Tuberculosis

or


Tablet: 500 mg
pyridoxine - [Vitamin B6]

Go to Atlantic Canada Poison Centre Provincial Antidote Kit for information on antidote administration
Antidote
Pyridoxine-dependent Seizures
Diagnostic
50-100 mg IV/IM once
Maintenance
50-100 mg PO daily
Maximum: 200 mg/24h
Pyridoxine Deficiency
1 month to 12 years
Initial
5-25 mg PO/IV/IM daily for 3 weeks
Maintenance
2.5-5 mg PO daily

Initial
10-20 mg PO/IV/IM daily for 3 weeks
Maintenance
2-5 mg PO daily
Drug-Related Neuropathy (e.g. isoniazid)

Prophylaxis
1 month to 12 years
1 mg/kg/dose PO daily
Maximum: 25 mg/dose
25-50 mg PO daily
Comments
If administered for pyridoxine-dependent seizures, concurrent EEG monitoring is recommended

Tablet: 25 mg
QUEtiapine
Renal Adjustment
Antipsychotic
Delirium in ICU
*Round dose to a portion of a tablet. In infants, consider dividing dose BID to allow dose adjustment to a portion of a tablet.
Minimum monitoring recommendation for prolonged QTc: ECG at baseline and 48 hours after initiation.
Comments
Supplied: Tablet: 25 mg, 100 mg, 200 mg

Tablet, Extended Release: 50 mg, 200 mg
rasburicase
Go to APPHON Clinical Practice Guidelines for the Management of Tumor Lysis Syndrome for more information
Prevention and Treatment of Tumour Lysis Syndrome
Go to clinical order set IWK ORTU “Prevention and Treatment of Tumour Lysis Syndrome”
Comments
Should give rasburicase at least 4 hours prior to giving first dose of chemotherapy. Begin chemotherapy within 24 hours of first
dose.
remdesivir - [Veklury]
Consultation and approval with a designated prescriber are required to initiate these therapies. If referral criteria
for remdesivir is met, email COVIDTreatment@nshealth.ca to initiate prescribing

Positive COVID-19 test
Symptomatic, non-severe COVID-19
At high risk for progression to severe disease
Management of non-severe COVID-19 in select patients
Go to clinical order set IWK REMD "Remdesivir for Non-Severe COVID-19 PEDIATRICS (12 years and over)"
Management of COVID-19 in select patients

Loading Dose- Day 1
200 mg IV once
Subsequent Doses- Day 2-3 (up to 5 days for severe, inpatient therapy)
100 mg IV daily
rifampin
Renal Adjustment
Various Indications
Go to Firstline

Injection: 600 mg Special Access
rifapentine
Latent TB infection: combination regimen with isoniazid
10 to 14 kg
300 mg PO once weekly for 12 weeks
14.1 to 25 kg
25.1 to 32 kg
32.1 to 49.9 kg
50 kg and greater
Comments
Take with food to prevent GI upset
Tablet(s) may be crushed and added to small amount of semi-solid food (e.g pudding ,apple sauce)
risperidone
Renal Adjustment
Antipsychotic
Oral

years old "
Comments
Use with caution in children less than 15 kg.
Supplied: Injection: 12.5 mg, 25 mg, 37.5 mg, 50 mg

Solution: 1 mg/mL
Tablet: 0.25 mg, 0.5 mg, 1 mg
riTUXimab
Current product selection: Ruxience (a biosimilar to Rituxan) Effective April 29th, 2021
Go to clinical order set IWK RIOR “riTUXimab Order "
rivaroxaban - [Xarelto]
Prevention of VTE Post Orthopedic Surgery

10 mg PO daily until post-op day 5.
Treatment of VTE and Prevention of VTE Recurrence

2.6 kg to less than 3 kg
0.8 mg PO TID
0.9 mg PO TID
1.4 mg PO TID
1.6 mg PO TID
1.8 mg PO TID
2.4 mg PO TID
2.8 mg PO TID
3 mg PO TID
5 mg PO BID
15 mg PO daily
50 kg and greater
20 mg PO daily

rizatriptan
Triptans are intended for patients experiencing a migraine that are unresponsive to oral analgesics.
Do not use within 24 hours of a different triptan or ergotamine preparation.
Repeat doses are only indicated if partial response is achieved with first dose.
Repeat dosing has not been established in pediatric patients.

If a second dose is deemed appropriate, wait at least 2 hours before administering a second dose AND do not exceed 2
doses/24h.
Migraine
6 years and greater
Less than 40 kg
5 mg PO once
Maximum: 5 mg/24h
40 kg and greater
10 mg PO once
Maximum: 10 mg/24h
Supplied: Tablet, Oral Disintegrating: 5 mg, 10 mg
rocuronium
Intermittent
1 mg/kg/dose IV every 30-60 minutes PRN titrate to desired clinical effect
Continuous Infusion
Loading Dose
1 mg/kg/dose x 1
Initial Dosing
0.5 mg/kg/hour
Suggested Titration
0.25 mg/kg/hour every 30-60 minutes
Usual Range
0.25 – 1 mg/kg/hour
ropivacaine
Continuous Peripheral Nerve Block
Go to clinical order set IWK CPNB Acute Pain Service Continuous Peripheral Nerve Block Pediatric
Epidural
Go to clinical order set IWK PECOEP Acute Pain Service Epidural Pediatric 2 months and older
Supplied: Injection: 5 mg/mL, 10 mg/mL, 2 mg/mL, 1 mg/mL IWK Compounded, 1.5 mg/mL IWK Compounded
rotavirus vaccine
LIVE vaccine
Immunization
Go to IWK IMOR "Immunization Orders"
For administration guidance
Go to Nova Scotia Rotavirus Vaccine Program Information for Health Care Professionals (FAQ) November 2019
Supplied: Solution: 0
ruxolitinib - [Jakavi]
Graf t-versus-host disease (GVHD): acute/steroid-refractory treatment OR Refractory hemophagocytic
lymphohistiocytosis (HLH)
less than 25 kg
Initial
2.5 mg PO BID . If tolerated, may double the dose on a weekly basis to a maximum of 10 mg twice daily.
25 kg and greater
Initial
5 mg PO BID . If tolerated, may double the dose on a weekly basis to a maximum of 10 mg twice daily.
salbutamol
For information on Continuous Nebulization in ICU please refer to salbutamol via Aerogen*
Go to Aerosol Medication Compatibility Guide
Acute Asthma Exacerbation

Go to clinical order set IWK PEASCA “Asthma Care Path orders- Emergency Department "
Pediatric Inpatient
Go to clinical order set IWK PEINAS "Pediatric Inpatient Asthmacare Map Order"
Parenteral
1 microgram/kg/min IV continuous infusion

Asthma Maintenance (Reliever) Therapy

Metered Dose Inhaler
100-200 microgram(s) inhalation every 4 to 6 hours PRN
Nebulization
less than 20 kg
2.5 mg inhalation every 4 to 6 hours PRN
20 kg or greater
5 mg inhalation every 4 to 6 hours PRN
Comments
Acute exacerbations may require more frequent administration times and higher doses
Spacer/aerochamber devices are available from Supply and Distribution
Suggested Dose equivalencies:
Medication (nebulization) Conversion to MDI (administered with spacer and mask)
Salbutamol Nebulization Salbutamol MDI 100 micrograms/puff

(resp solution 5 mg/mL, 2 mg/mL, 1 mg/mL
and 0.5 mg/mL)
2.5 mg INH via nebulization 5 puffs INH via MDI

5 mg INH via nebulization 10 puffs INH via MDI
At same prescribed frequency

Inhalation, Nebule: 0.5 mg/mL, 2.5 mg/mL, 1 mg/mL
Inhalation, Solution: 5 mg/mL
Injection: 1 mg/mL
salbutamol (via Aerogen*)

Optimal dose has not been established.
The effect of high flow on dose delivery has not been established.
Refer to salbutamol for information on all other routes of administration
Continuous Nebulization via Aerogen* ICU and ED only

Prescribe dose in mg/hr
0.5 mg/kg/hour . Usual maximum: 24 mg/hour
OR
Less than 20 kg
10 mg/hour
20 mg/hour
Comments
No dilution required. Use 5 mg (2.5 mL) nebuamps.
Administer via syringe pump
Maximum rate is 12 mL/hour
In rare circumstances, PICU may increase dose beyond 24 mg/hour. This requires use of respiratory solution (5 mg/mL) which
contains preservative
Preservative contained in respiratory solution may lead to bronchoconstriction
Supplied: Inhalation, Nebule: 2 mg/mL
senna
Syrup
1 month to 2 years
2.125-4.25 mg PO daily
Maximum: 8.5 mg/24h
2 to 5 years
4.25-6.375 mg PO once to twice daily

6 to 12 years
8.5-17 mg PO once to twice daily

Maximum: 34 mg/24h
Tablet
6 to 12 years


Supplied: Syrup: 1.7 mg/mL

Tablet: 8.6 mg
sertraline
Renal Adjustment
Antidepressant
Comments
sevelamer carbonate - [Renvela]

Hyperphosphatemia in Chronic Kidney Disease
BSA 0.75 to less than 1.2 m2
800 mg PO with each meal/feed. Titrate based on serum phosphorus.
BSA 1.2 m2 and greater
1600 mg PO with each meal/feed. Titrate based on serum phosphorus.
Patients on Continuous Feeds
Mix 2.4-4.8 grams (1-2 sachets) in total daily feeds. After sitting for 10 minutes, decant liquid from the precipitate at the bottom
Comments
Swallow tablets whole. Do not chew, crush or break.
Supplied: Powder: 2.4 gram/sachet

Tablet: 800 mg
sildenafil
Renal Adjustment
Pulmonary Hypertension
Oral
Less than or equal to 1 year of age
0.25-0.5 mg/kg/dose PO TID to QID

Maximum: 2 mg/kg/dose
Greater than 1 year of age
0.25-0.5 mg/kg/dose PO TID to QID

Continuous Infusion
Loading Dose
0.04 - 0.4 mg/kg/dose
Followed By
0.015 - 0.08 mg/kg/hour
Maximum
0.4 mg/kg/hour
Intermittent
Adolescent
10 mg IV every 8 hours
Comments
Hypotension is dose limiting side effect. Monitor blood pressure especially with first or increased dose
Oral dose may be given as frequently as every 4 hours in some situations
An intravenous rate of 0.4 mg/kg/hour is approximately equivalent to an oral dose of 20 mg/kg/24 hour
Note: No dosing information available for intermittent doses IV in pediatrics, however if patient is receiving enteral sildenafil and
requires a transition to oral (eg: postop, NPO), IV dose is 50% of oral dose
Supplied: Injection: 0.8 mg/mL HIGH ALERT

Suspension: 2.5 mg/mL IWK Compounded
simethicone
Less than 2 years AND less than 11 kg
20 mg PO QID PRN
Maximum: 240 mg/24h
2 to 12 years AND greater than 11 kg
40 mg PO QID PRN
Maximum: 480 mg/24h
80-240 mg PO QID PRN

Maximum: 500 mg/24h
Comments
Drops may be mixed with water, infant formula or other suitable liquids.
Supplied: Drops, Oral: 40 mg/mL
sirolimus - [Rapamune]
When prescribing sirolimus:
Conversion from calcineurin-inhibitor

2-3 mg/m*2/dose PO every 24 hours . Adjust dose according to serum drug levels
or
1-1.5 mg/m*2/dose PO every 12 hours . Adjust dose according to serum drug levels
Comments
Younger children divide dose every 12 hours

Tablet: 1 mg
sodium benzoate|sodium phenylacetate - [Ammonul]

IMPORTANT: IF A PATIENT REQUIRES USE OF THIS DRUG, SPECIAL ACCESS PAPERWORK (SAP) (click here to access) MUST BE
FILLED OUT AND SENT TO SAP IMMEDIATELY FOR URGENT CONSIDERATION
Management of hyperammonemia
Urea Cycle Disorder (UCD) Treatment
Go to clinical order set IWK EMMA "Emergency Management of Hyperammonemia"
Comments
If after hours, pharmacy to:
follow-up with a phone call to SAP (see number in SAP paperwork above).
scan the SAP paperwork and email to the email listed (see email in SAP paperwork above).
The Letter of Authorization doesn’t get sent to the company or us, until the SAP staff return to work after the weekend. They
give verbal authorization in the meantime, so the company can send the drug.
Contact the manufacturer (Valeant/Bausch Health, 514-886-6052/514-214-4799 ) to arrange urgent processing of SAP request/PO
for drug. The Bausch Health staff arranged for to pick up, take it to the airport and deliver it right to the IWK. Ask which website
to check for tracking. If after pharmacy hours, make arrangement with Emergency Department to receive the package. Provide
written information to the Emergency Dept and your contact information so the information doesn’t get missed at shift change.
As of 2022, Halifax Infirmary also stocks this medication.
Supplied: Injection: 100|100 mg/mL
sodium bicarbonate
1 mmol sodium bicarbonate = 1 mEq sodium bicarbonate
1 mmol sodium bicarbonate (NaHCO3) is equivalent to 84 mg and provides 1 mmol each of sodium AND bicarbonate
500 mg tablet contains 6 mmol each of sodium and bicarbonate
Renal Adjustment
Antidote
Metabolic Acidosis
Intermittent
0.5-1 mmol/kg/dose IV
Continuous Infusion
0.5-1 mmol/kg/hour IV continuous infusion
Urinary Alkalinization
0.25-2.5 mmol/kg/dose PO QID titrate to desired clinical effect
Occluded feeding tube

Open one capsule of Cotazym and mix contents with one crushed 500 mg tablet of sodium bicarbonate (to activate the Cotazym*).
Add 5 mL of warm sterile water to the powder. Instill the suspension into the feeding tube and clamp for 5 minutes and then flush with
up to 30 mL of sterile water.
Go to AboutKidsHealth "G/GJ tubes: What to do if your child's feeding tube is blocked"
Occluded CVAD
Secondary to drug precipitate /high pH drugs
PICC, Non-tunelled (e.g. Cook, Arrow), Tunelled (e.g. Broviac, Hickman)
1 mL for 60 minutes, check and repeat dose for another 60 minutes if necessary
Implanted (e.g. Port-a-Cath)

1.5 mL for 60 minutes, check and repeat dose for another 60 minutes if necessary
Supplied: Injection: 1 mmol/mL (50 mL Vial) , 1 mmol/mL (50 mL Prefilled Syringe) , 0.5 mmol/mL (5 mL Vial)
Solution: 1 mmol/mL IWK Compounded
Tablet: 500 mg
sodium chloride (hypertonic) - [hypertonic saline]

1 mmol of 3% sodium chloride = 2 mL of 3% sodium chloride
3% injection = 0.513 mmol/mL
*For doses ordered as mL or mL/kg, parenteral manual calculator is NOT required. Refer to parenteral manual for
administration and monitoring guidelines.
Increased ICP
Intermittent*
3-5 mL/kg/dose IV. May repeat dose if initial dose effective but ICP remains elevated.
NOTE:
3 mL/kg/dose = 1.5 mmol/kg/dose
4 mL/kg/dose = 2 mmol/kg/dose
5 ml/kg/dose = 2.5 mmol/kg/dose
Symptomatic Hyponatremia
Continuous Infusion
usually reserved for patients with cerebral salt wasting and difficulty maintaining serum sodium
0.1-1 mL/kg/hour (0.05 -0.5 mmol/kg/hr)
Suspected Cerebral Edema in Diabetic Ketoacidosis

Intravenous
Go to clinical order set IWKDIKE Diabetic Ketoacidosis (DKA) Management 0 to 19 years
Hyponatremic Seizure*
Too rapid correction of sodium deficit can result in osmotic demyelination syndromes with severe brain injury and potentially death.
3-5 mL/kg/dose (1.5-2.5 mmol/kg/dose) IV
Note 1 mL/kg typically raises serum sodium by 1 mmol/L
Cystic Fibrosis
Inhalation (7 % nebule)
4 mL inhalation once to twice daily (usually prior to physiotherapy)
Supplied: Inhalation, Nebule: 3 %, 7 %

Injection: 0.513 mmol/mL HIGH ALERT
sodium chloride (oral)

1 mEq sodium chloride = 1 mmol sodium chloride
1-5 mmol/kg/dose PO daily
or
0.5-2.5 mmol/kg/dose PO BID
or
0.33-1.66 mmol/kg/dose PO TID
or
Comments
Note: Each 1 gram sodium chloride capsule contains 17 mEq sodium (= 17 mmol sodium)
Supplied: Capsule: 1 gram(s)

Solution: 2.5 mmol/mL IWK Compounded
sodium polystyrene - [Kayexalate]

Renal Adjustment
Hyperkalemia
1 grams/kg/dose PO every 6 hours PRN

Maximum: 15 grams/dose* OR 60 grams/24h
1 grams/kg/dose PR every 2 to 6 hours PRN

Maximum: 60 grams/dose OR 100 grams/24h
Pre-treatment of Formula
0.5 - 2.6 grams resin/100 mL formula. (or 1 gram of resin for each mEq of potassium)
Shake for 1 minute and let settle in the refrigerator for 30-60 minutes. Pour off the formula without disturbing precipitate on the
bottom.
Comments
* Single doses greater than 15 grams have been used, but are not recommended and are unlikely to increase potassium removal
(Source: Moffett, Lee 2016) . Excessive dosage or inadequate dilution could result in impaction of the resin.
Dosing may also be based on 1 gram of resin binding with ~ 1 mEq potassium. Releases 1 mEq sodium per gram for each 1 mEq
potassium removed.
Powder: each 1 gram of powder equals 1.3 mL when measured in an oral syringe. Mix each gram of powder with 3-4 mL water for
oral administration.
Suspension: may be given PO, NG, PR. After rectal administration, irrigate colon thoroughly to ensure adequate removal of resin.
Supplied: Powder: 1 gram of sodium polystyrene sulfonate/gram of powder

sotalol
Dosing based on mg/m2 is available in many references but may require an age related dose adjustment in infants and children less
than 2 years of age. Refer to Up-to-Date for further information.
Renal Adjustment
Arrhythmias
1 mg/kg/dose PO BID If needed increase dose by 1-2 mg/kg/24 hours. Allow 3 days between dose increments to reach steady state and
monitor clinical response
or
0.67 mg/kg/dose PO TID If needed increase dose by 1-2 mg/kg/24 hours. Allow 3 days between dose increments to reach steady state
and monitor clinical response
Maximum: 2.67 mg/kg/dose OR 106.7 mg/dose

Tablet: 80 mg
spironolactone
Renal Adjustment
Diuretic
1-3.3 mg/kg/dose PO daily

Maximum: 100 mg/24h
or

Maximum: 100 mg/24h

Tablet: 25 mg
succinylcholine
Pre-Intubation
Less than 6 months
2 mg/kg/dose IV/IM
6 to 12 months
1-2 mg/kg/dose IV
OR if IV route is not available:
3-4 mg/kg/dose IM
Maximum: 150 mg/dose (IM)
1 mg/kg/dose IV
OR if IV route is not available:
3-4 mg/kg/dose IM
Maximum: 150 mg/dose (IM)
Comments
IM use only if IV route not available
Supplied: Injection: 20 mg/mL, 2 mg/mL IWK Compounded
sucralfate
Button battery ingestion
From the time of identification in the esophagus until sedation for endoscopy is given:
1000 mg PO every 10 minutes for 3 doses

Tablet: 1 gram(s)
sulfamethoxazole|trimethoprim - [Co-trimoxazole, Septra]

The only manufacturer product available for co-trimoxazole suspension available in Canada is through the special access
program; therefore:
An alternate choice of antimicrobial may be considered if liquid formulation is required (when clinically appropriate)
OR
Doses may need to be rounded to portions or whole tablet strengths to allow patients to crush for administration.
Renal Adjustment
Various Indications
Go to Firstline
Supplied: Injection: 80|16 mg/mL

Suspension: 40|8 mg/mL Special Access
Tablet: 100|20 mg, 400|80 mg, 800|160 mg
sumatriptan - [Imitrex]
Triptans are intended for patients experiencing a migraine that are unresponsive to oral analgesics.
Do not use within 24 hours of a different triptan or ergotamine preparation.
Repeat doses are only indicated if partial response is achieved with first dose.
Sumatriptan evidence is limited in pediatrics. Use in select patients who cannot tolerate oral rizatriptan.
Repeat dosing has not been established in pediatric patients.
If a second dose is deemed appropriate, wait at least 2 hours before administering a second dose AND do not exceed 2
doses/24h.
Migraine
12 years and greater AND 40 kg and greater
20 mg intranasal once
Maximum: 20 mg/24h
Comments
Sumatriptan 20 mg dose is to be administered in one nostril.
Supplied: Spray, Nasal: 20 mg
tacrolimus
When prescribing tacrolimus, please:

include the brand name and formulation [immediate-release (Prograf®) or extended-release (Advagraf®)]
Renal Adjustment
Solid Organ Transplant (e.g. kidney, liver)
Immediate release
0.1-0.15 mg/kg/dose PO every 12 hours . Adjust dose according to serum drug levels
Intravenous
1.25-2.5 microgram/kg/hour IV continuous infusion . Adjust dose according to serum drug levels
Extended release
(de novo: start within 24 hours of reperfusion)
0.3 mg/kg/dose PO daily . Adjust dose according to serum drug levels
Comments
Younger children typically require higher mg/kg doses than older children and adults
IV to PO conversion: total daily IV dose x 4 then divided every 12 hours PO
Extended release dosage form:
Monitor daily AM trough and adjust dose every ~2-3 days until target range
Crossover may be considered for stable patients on immediate release formulation with no rejection for 3-6 months.
Crossover ratio is 1:1. Single daily dose of extended release formulation equivalent to the patient's previous stable daily dose of immediate
release formulation.
Recommended to increase extended release formulation dose by 10-30% at time of conversion based on anticipated drop in AUC seen in
clinical practice.
IWK Nephrology target trough level ranges (time from renal transplant):
less than 1 month: 10-12 ng/mL
1 to 2 months: 8-12 ng/mL
greater than 12 months: 4-8 ng/mL (ideally 5-7 ng/mL)
NOTE: If confirmed nephrotoxicity or EBV mismatch, target ranges may be lower
If confirmed rejection, target ranges may be higher
Supplied: Capsule, Extended Release: 0.5 mg, 1 mg, 5 mg

Capsule, Immediate Release: 0.5 mg, 1 mg, 5 mg
Injection: 5 mg/mL
tamsulosin - [Flomax]
Urolithiasis
0.2-0.4 mg PO daily
0.4 mg PO daily
Comments
For a 0.2 mg dose, approximate half the contents of a capsule. Discard remaining half.
Administration via enteral feeding tubes is typically not recommended, but limited evidence suggests capsule contents can be
used if no alternative route is available. Avoid use with small bore feeding tubes (less than 8 French).
Do not chew or crush sustained release capsule contents.
Supplied: Capsule, Sustained Release: 0.4 mg
temozolomide
IWK Chemotherapy Administration Standards document
Supplied: Capsule: 5 mg, 20 mg, 100 mg, 140 mg
temsirolimus
tetanus, diphtheria vaccine - [Td, Td adsorbed]
Go to Nova Scotia "Tetanus Prophylaxis in Wound Management"
tetanus, diphtheria, acellular pertussis vaccine - [Tdap, Adacel, Boostrix]
tetanus, diphtheria, acellular pertussis, polio vaccine - [Tdap_IPV, TDap-Polio, Boostrix-

Polio]
tetanus, diphtheria, acellular pertussis, polio, haemophilus B vaccine - [DTap-IPV-Hib]
tetracaine - [Ametop (gel)]

Go to Medication Management Policy 20.77 - Application of Topical Anesthetics
1 tube of gel contains 1.5 grams
Topical gel
Usual dosing (single site)
0 grams (contents of 1 tube) over the injection site 30-45 minutes prior to procedure
Alternate dosing (e.g. multiple sites/smaller area in smaller infants)
0.5 grams (contents of half a tube) over the injection site 30-45 minutes prior to procedure
Comments
Maximums
1 month to 5 years of age: 2 tubes/24 hours
Greater than 5 years of age: 7 tubes/24 hours
Optimal anesthesia requires a minimum of 30 minutes of contact time (45 minutes for IV cannulation) and persists for 4-6 hours after
removal
Patient/Family Resource: Numbing Cream: Topical Anesthetic

Gel: 4 %
thiamine - [Vitamin B1]

Severe Sepsis and Shock (HAT- Hydrocortisone, Ascorbic Acid, Thiamine Therapy)

Comments
Ascorbic Acid
Hydrocortisone

Tablet: 100 mg
thioguanine - [6-thioguanine]
thiosulfate sodium - [sodium thiosulfate]

Antidote
Prevention of cisplatin induced ototoxicity
CISplatin
Go to Medication Management Policy to 30.60 "Extravasation Management"

95 mg per 100 mg of CISplatin IV/Subcutaneous
tobramycin
Renal Adjustment
Various Indications
Go to Firstline
Febrile Neutropenia (Oncology)
Ophthalmic
Manufacturer recommendation
Drops 0.3%
1 drops in affected eye(s) QID
Ointment 0.3%
Thin strip in affected eye(s) BID to TID

Drops 14 mg/mL
Go to Firstline
Cystic Fibrosis
Inhalation
*Use the 40 mg/mL injection vial *
80 mg inhalation BID to TID
Peritonitis
Intraperitoneally
Comments
*For summary of available inhaled tobramycin products click here
Supplied: Drops, Ophthalmic: 0.3 %, 14 mg/mL IWK Compounded

Injection: 40 mg/mL
tobramycin|dexamethasone - [Tobradex]
Ophthalmic
Manufacturer Recommendation
Drops (Suspension)
1-2 drops in affected eye(s) every 2 hours for 24-48 hours then reduce to every 4 hours
Ointment
Thin strip in affected eye(s) TID to QID
Supplied: Drops, Ophthalmic: 0.3|0.1 %

Ointment, Ophthalmic: 0.3|0.1 %
tocilizumab
Rheumatology
Various Indications
Go to clinical order set IWK TOPE "Tocilizumab Orders Pediatric"
Cytokine Release Syndrome (CRS) (during blinatumomab therapy)

Initial
Less than 30 kg
12 mg/kg/dose IV once and consider a second dose (or dexamethasone) if patient does not improve or stabilize within 24 hours of
initial dose as per protocol
30 kg or greater
8 mg/kg/dose IV once and consider a second dose (or dexamethasone) if patient does not improve or stabilize within 24 hours of initial
dose as per protocol
topiramate
Renal Adjustment
Anticonvulsant
2 to 16 years
Initial
1-3 mg/kg/dose PO daily Increase at 2 week intervals by 0.5-1.5 mg/kg/dose BID (Maximum increase 50 mg/24 hours) to a usual
maintenance dosing below
Maximum: 25 mg/dose
or
0.5-1.5 mg/kg/dose PO BID Increase at 2 week intervals by 0.5-1.5 mg/kg/dose BID (Maximum increase 50 mg/24 hours) to a usual
maintenance dosing below
Maximum: 25 mg/24h
Maintenance

Maximum: 400 mg/24h

Initial
25-50 mg PO at bedtime Increase at 2 week intervals by 25-50 mg/24 hours to a usual:
Maintenance
100-200 mg PO BID
Comments
Doses greater than 50 mg/24h should be divided BID

topotecan
tranexamic acid
Renal Adjustment
Inhibition of fibrinolysis
1 month to 18 years
Doses must be rounded to accommodate portions of (500 mg) tablets, whole tablets and multiples of tablets
25 mg/kg/dose PO BID to TID
OR
10 mg/kg/dose IV every 6 to 8 hours

Menorrhagia
Adolescents
1000 mg PO TID to QID for 4 days

Trauma-associated hemorrhage (known or suspected; ONLY if within 3 hours of injury)

Go to Policy 630 (Massive Transfusion Protocol) for more information
Less than 12 years
Loading
15 mg/kg/dose IV
followed by
2 mg/kg/hour IV continuous infusion for 8 hours or until bleeding stops

Maximum: 125 mg/hour
1000 mg IV
followed by
125 mg/hour IV continuous infusion for 8 hours or until bleeding stops

Tablet: 500 mg
traZODone
Comments
tretinoin - [ATRA]
trihexyphenidyl
Round doses to nearest 1/4 tablet (0.5 mg)
Tone Management
Initial:
1-2 mg/24h divided PO once to twice daily .May increase by 1 mg/24 h every 3 to 7 days to a
trimethoprim
Renal Adjustment
Urinary Tract Infection
Prophylaxis
Go to Firstline

Tablet: 100 mg
tuberculin purified protein derivative - [PPD (Mantoux)]

Tuberculin Skin Testing
5 TU intradermal once
Supplied: Solution, Intradermal: 50 TU/mL
ulipristal
Emergency Contraception
30 mg PO as soon as possible within 5 days (120 hours) after unprotected intercourse or a known or suspected contraceptive failure.
Comments
If vomiting occurs within 3 hours of administration, another tablet should be taken
May be taken at any time during the menstrual cycle
unithiol - [Dimaval]
Go to Atlantic Canada Poison Centre Antidote Kit for information dosing, administration and location of medication
ursodiol
Go to Health Canada warning (2011) Ursodiol- Association of High-Dose with Serious Liver Side Effects
Cholestasis
Secondary to biliary atresia/intestinal failure/post Kasai

or

Maximum: 45 mg/kg/24 hours
or

Secondary to Parenteral Nutrition
10 mg/kg/dose PO TID

Tablet: 250 mg
ustekinumab - [Stelara]
Crohn's Disease
Induction (Week 0)
55 kg and less
260 mg IV once
55.1 to 85 kg
390 mg IV once
Greater than 85 kg
520 mg IV once
Maintenance (Week 8 onward)
Psoriatic Arthritis
Adolescents
100 kg or less
45 mg subcutaneous at weeks 0, 4 and every 12 weeks thereafter.
Greater than 100 kg
Plaque Psoriasis
12-17 years
less than 60 kg
0.75 mg/kg subcutaneous at weeks 0, 4 and every 12 weeks thereafter.
60 to 100 kg
Greater than 100 kg:
valACYclovir
*Oral acyclovir is preferred as the safety and efficacy of valACYclovir have not been established in infants younger than 2 years of age.
Renal Adjustment
3 months to 11 years*
Mucocutaneous Herpes Simplex Virus
Adolescents
Sexually Transmitted Infections
Genital herpes - Suppressive therapy in Pregnancy
Go To Women's Health Drug Dosing Guidelines
Herpes Labialis (Cold Sores)

Begin at earliest symptoms
2000 mg PO every 12 hours for 2 doses
Herpes Zoster
To begin within 72 hours of rash onset
1000 mg PO TID
valGANciclovir
Renal Adjustment
Congenital Cytomegalovirus,Treatment
Infants
Cytomegalovirus, Immunocompromised Patients

Prophylaxis
Go to Schwartz Creatinine Clearance Calculator
*Note that the Schwartz calculator utilizes serum creatinine values and may overestimate the degree of renal function. It is suggested to
cap the CrCl at 100 mL/min/1.73m2
7 mg/m*2/dose X Creatinine Clearance* PO daily
Treatment
Go to Schwartz Creatinine Clearance Calculator
*Note that the Schwartz calculator utilizes serum creatinine values and may overestimate the degree of renal function. It is suggested to
cap the CrCl at 100 mL/min/1.73m2
7 mg/m*2/dose X Creatinine Clearance* PO BID


Tablet: 450 mg
valproic acid - [divalproex]

Seizure Disorder
Initial
5-7.5 mg/kg/dose PO BID then as needed increase by 5-10 mg/kg/24h at weekly intervals to the maintenance dosing below
or
3.3-5 mg/kg/dose PO TID then as needed increase by 5-10 mg/kg/24h at weekly intervals to the maintenance dosing below
Maintenance
or
Comments
Contraindicated in hepatic disease and in urea cycle disorders and mitochondrial disorders
Hepatic failure and pancreatitis may occur; increased risk of fatal hepatotoxicity in children less than 2 years
Abrupt discontinuation may precipitate life-threatening status epilepticus

Capsule, Sprinkle Cap-Delayed Release: 125 mg Special Access
Syrup: 50 mg/mL
Tablet, Enteric Coated (as Divalproex): 125 mg, 250 mg, 500 mg
vancomycin
For more information on therapeutic drug level monitoring for parenteral vancomycin, refer to "Monitoring" section in Firstline
Renal Adjustment
Various Indications
Go to Firstline
Go to Firstline
Clostridium Dif ficile Infection, Oral Route
Go to Firstline
Febrile Neutropenia (Oncology), Empiric
Fever or Acute Illness in Sickle Cell Disease and/or Asplenia, Suspected Meningitis
See various order sets IWK SCFEED, SCFEIN, SCFEOP
Go to Firstline
Peritonitis
If Vancomycin is also being given IV, reduce IV loading dose to 10 mg/kg/dose IV daily, based on levels (per IWK Nephrology)
Ophthalmic
Go to Firstline
Comments
Note: If a liquid formulation is required for PO/NG administration when pharmacy is closed, the injectable, reconstituted from
powder according to parenteral information, may be used until pharmacy can prepare compounded solution.

Drops, Ophthalmic: 25 mg/mL IWK Compounded
Injection: 1 gram(s)
varicella vaccine - [Varivax III, Varilrix]
vasopressin
1 unit = 1000 milliunits
There are different dosing units depending on the indication
Do not abruptly discontinue continuous infusion. Taper dose.
Vasodilatory Shock, Adjunct

IV Continuous
Ordered as: milliunits/kg/min
Loading Dose
None
Initial Dosing
0.1 – 0.2 milliunits/kg/min
Suggested Titration
0.1 milliunits/kg/min every 30-60 minutes
Usual Range
0.2 – 1 milliunits/kg/min
Maximum
10 milliunits/kg/min
Gastrointestinal Hemorrhage
IV Continuous
Ordered as: milliunits/kg/min
Loading Dose
None
Initial Dosing
2 – 5 milliunits/kg/min
Suggested Titration
Every 60 minutes
Maximum
10 milliunits/kg/min
Diabetes Insipidus
IV Continuous
Ordered as: milliunits/kg/HOUR
Loading Dose
None
Initial Dosing
0.5 milliunits/kg/hour
Suggested Titration
0.5 milliunits/kg/hour every 30 minutes
Maximum
10 milliunits/kg/hour
vedolizumab - [Entyvio]
This medication is accessible to IWK inpatients or outpatients ONLY when approved by the OnePath program offered by Takeda. As
such, IWK Pharmacy can not stock or procure this without the involvement of this program. No stock is kept on hand.
Crohn's Disease/Ulcerative Colitis

2 years and greater
Given at week 0, 2 and week 6 then repeat every 4 to 8 weeks.
Go to clinical order set IWK VEDO Vedolizumab Pediatric Orders
venlafaxine
Antidepressant
Comments
Supplied: Capsule, Extended Release: 37.5 mg, 75 mg
verapamil
Renal Adjustment
Hypertension

Maximum: 480 mg/24h
Dysrythmias
Greater than 1 year
0.1-0.3 mg/kg/dose IV once May repeat in 30 minutes

Maximum: 5 mg (1st dose) OR 10 mg (2nd dose)
Supplied: Injection: 2.5 mg/mL HIGH ALERT

Suspension: 8 mg/mL
Tablet: 80 mg
vigabatrin
For information on administration of liquid via Dissolve-A-Dose, go to Policy 20.09
Do not stop abruptly taper dose over a 2-4 week period by decreasing by 25-50 mg/kg every 3-4 days
Renal Adjustment
Infantile Spasm
Initial
25 mg/kg/dose PO BID May increase every 3 days by 25-50 mg/kg/24h to maintenance dosing below
Maintenance

Partial Seizures, Adjunctive Therapy

Initial
Greater than 10 kg
40 mg/kg/dose PO daily
or
Maintenance
10 to 15 kg
250-500 mg PO BID
16 to 30 kg
500-750 mg PO BID
31 to 50 kg
750-1500 mg PO BID
Greater than 50 kg
1000-1500 mg PO BID
Supplied: Powder for Suspension: 500 mg

Tablet: 500 mg
vinBLAStine
vinCRIStine
vinORELbine
voriconazole
Dosing in infants and children younger than two is not well established. Small pharmacokinetic studies show that the
same mg/kg dosing may be used if there is no alternative treatment.
Renal Adjustment
Various Indications
Go to Firstline

warfarin
Renal Adjustment
Anticoagulant
0.2 mg/kg/dose PO daily subsequent doses should be adjusted to maintain INR within desired range.
Maximum: 5 mg/24 hours (prior to levels)
Fontan procedure/Liver dysfunction/Hemodialysis
0.1 mg/kg/dose PO daily subsequent doses should be adjusted to maintain INR within desired range.
Maximum: 5 mg/24 hours (prior to levels)
white petrolatum|mineral oil - [Eye Lubricant Ointment]

Current contract brand Soothe* Night Time
Ordered as: "Eye lubricant ointment"
Ophthalmic
Apply 0.5 cm to inside of lower lid in affected eye(s) as needed
Supplied: Ointment, Ophthalmic: 80|20 %
zinc
All doses expressed in terms of elemental zinc. All orders must be written in terms of elemental zinc
Although weight based dosing is provided below, doses MUST be rounded and ordered to accommodate the available
tablet strengths.
Zinc deficiency
0.5-1 mg/kg/dose PO daily
or
or
Supplied: Tablet: 10 mg (as elemental), 25 mg (as elemental)
zoledronic acid
Go to clinical order set IWK PAIN "IV Bisphosphonate"
Supplied: Injection: 0.05 mg/mL, 0.8 mg/mL
zopiclone
Go to Health Canada Warning(2014): New dosage Recommendations to Minimize the Risk of Next Day Impairment
Renal Adjustment
Insomnia
Supplied: Tablet: 5 mg, 7.5 mg
zuclopenthixol - [Clopixol-Acuphase]
Antipsychotic
Comments
Supplied: Injection: 50 mg (as acetate)/mL
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Pediatric Drug Dosing Guidelines

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1/5/24, 12:22 PM Print – IWK Drug Information Resource

Pediatric Drug Dosing Guidelines

10 mg/kg/dose IV at weeks 0, 2, 4 then monthly thereafter.

750 mg IV at weeks 0, 2, 4 then monthly thereafter.

Greater than 100 kg

1000 mg IV at weeks 0, 2, 4 then monthly thereafter.

Subcutaneous (2-17 years)

87.5 mg subcutaneous weekly

125 mg subcutaneous weekly

10 mg/kg/dose IV at weeks 0, 2, 4 then monthly thereafter.

Supplied: Injection: 250 mg, 125 mg/mL

Injection is restricted to patients who meet one or more of the following:

10-15 mg/kg/dose PO every 4 to 6 hours PRN

15-20 mg/kg/dose PR every 6 hours PRN

Supplied: Injection: 10 mg/mL

5 mg/kg/dose PO once daily OR every second day

Increased intracranial pressure

6-8 mg/kg/dose PO TID - Dose may be titrated up to:

5 mg/kg/dose PO BID to TID

2.6-10 mg/kg/dose PO TID

Supplied: Suspension: 25 mg/mL IWK Compounded

acetylcysteine - [N-acetylcysteine, NAC]

Supplied: Injection: 200 mg/mL

acetylsalicylic acid - [ASA, Aspirin]

7.5-12.5 mg/kg/dose PO every 6 hours until fever resolves

Once patient is afebrile for 24-48 hours

3-5 mg/kg/dose PO daily

Antiplatelet (Cardiology patients)

Supplied: Tablet, Chewable: 80 mg

Genital Herpes Simplex Virus Infection

Greater than 12 years

Go to Canadian Guidelines on Sexually Transmitted Infections

Herpes Simplex and Zoster Prophylaxis, Immunocompromised Patient

Supplied: Injection: 50 mg/mL

80 mg subcutaneous once followed by:

40 mg subcutaneous once followed by:

20 mg subcutaneous every 2 weeks

Greater than or equal to 40 kg

160 mg subcutaneous once followed by:

80 mg subcutaneous once followed by:

100 mg/m*2/dose subcutaneous once followed by:

50 mg/m*2/dose subcutaneous once followed by:

25 mg/m*2/dose subcutaneous every 2 weeks

Greater than or equal to 40 kg

160 mg subcutaneous once followed by:

80 mg subcutaneous once followed by:

40 mg subcutaneous every 2 weeks

Juvenile Idiopathic Arthritis

10 mg subcutaneous every 2 weeks

20 mg subcutaneous every 2 weeks

Greater than 4 years of age

40 mg subcutaneous every 2 weeks

(Body-Surface Area Based)

24 mg/m*2/dose subcutaneous every 2 weeks

24 mg/m*2/dose subcutaneous every 2 weeks

Supplied: Injection: 50 mg/mL

Supraventricular Tachycardia (SVT)

0.1 mg/kg/dose IV once

0.2 mg/kg/dose IV once