Neonatal Drug Therapy Manual

Morphine

Disclaimer: Official controlled document is the CHEO and Ottawa Hospital online copy. It is the responsibility of user to ensure that any paper copy version is the same as the online version before use.

Classification: 
Opiate Agonist
Original Date: 
March 1992
Revised Date: 
April 2022
Indications: 
  • Analgesia
  • Sedation
  • Treatment of neonatal abstinence syndrome (NAS)
Administration: 
  • IV direct: over 5 minutes
  • IV intermittent infusion: over 15-30 minutes
  • IV continuous infusion
  • PO
  • Buccal (see Palliative Care Symptom Management Protocol below)
Dosage: 
  • IV direct: 50 - 100 mcg/kg/dose (0.05 - 0.1 mg/kg/dose) Q4-6h PRN or as directed

Morphine Equivalents

1 mg

1000 mcg

0.1 mg/mL

100 mcg/mL

Dose check:

 Dose _____ mg multiplied by 1000 = Dose _____ mcg

 Divide dose (mcg) by pt weight (kg) for ____ mcg/kg (50 - 100 mcg/kg/dose)

 Volume to be administered: Divide dose (mcg) by concentration (mcg/mL) = ___ mL required for dose 

 

  • IV continuous infusion: 10 - 20 mcg/kg/hour. Titrate dose according to effect/side effects
  • PO: 0.15 to 0.3 mg/kg/dose Q4-6H PRN   

 

 

  • For the treatment of narcotic withdrawal syndrome, the following doses have been used, based on Finnigan's score.

Finnigan's score

Oral Morphine Dose (mg/kg/dose q6h)

Oral Morphine Dose in combination with Phenobarbital (mg/kg/dose q6h)

8-10

11-13

14-16

>17

0.08 mg/kg

0.12 mg/kg

0.16 mg/kg

0.2 mg/kg

0.04 mg/kg

0.08 mg/kg

0.12 mg/kg

0.16 mg/kg

 *If cannot use oral, give IV at ½ to 1/3 of the recommended oral dose

 

 

  • Palliative Care Symptom Management Protocol
Birthweight Buccal Morphine Dose* Comments
< 500 g 0.05 mg q2h prn Increase dose by 0.05 mg/dose if previous dose ineffective** 
> 500 g - < 2000 g 0.1 mg q2h prn Increase dose by 0.1 mg/dose if previous dose ineffective**
> 2000 g - < 4000 g 0.2 mg q2h prn Increase dose by 0.1 mg/dose if previous dose ineffective**
> 4000 g 0.3 mg q2h prn Increase by 0.15 mg/dose if previous dose was ineffective**

* Morphine dose should be administered buccal (inside the cheeks).  Administration via NG/OG tube should be considered if unable to provide through buccal route. Morphine 1 mg/mL syrup or morphine 2 mg/mL injection may be used bucally, depending on the volume of the dose. 

**Titrate to effect with no maximum dose for opioids.

Side Effects: 
  • CNS: respiratory depression, lethargy
  • CVS: hypotension
  • GI: ileus
  • Other: tolerance and physical dependency with prolonged use
Parameters to Monitor: 
  • BP, HR,
  • RR, oxygen saturation
  • Bowel sounds, abdominal distension
Reconstitution and Stability: 

CHEO:

IV direct:

- Use morphine 0.2 mg/mL (200 mcg/mL) - 3 mL prefilled syringe prepared by pharmacy

- If patient receiving morphine by continuous infusion, use appropriate setting on pump to administer bolus dose

IV continuous infusion:

- Use morphine 0.2 mg/mL (200 mcg/mL) 25 mL prefilled syringe prepared by pharmacy

 

** Morphine 1 mg/mL (1000 mcg/mL) prefilled syringe can also be dispensed by pharmacy or obtained from the PICU medication cabinet if required urgently.

 

TOH:

IV direct:

  • Morphine 2 mg/mL
    • Take 0.5 mL (1000 mcg) and add to 9.5 mL 0.9% NaCl
    • Final concentration: 100 mcg/mL

IV continuous infusion:

  • Morphine 2 mg/mL
    • Take 0.1 mL (200 mcg) and add to 19.9 mL D5W
    • Final concentration: 10 mcg/mL
  • Morphine 2 mg/mL
    • Take 0.2 mL (400 mcg) and add to 19.8 mL D5W
    • Final concentration: 20 mcg/mL
  • Morphine 2 mg/mL
    • Take 0.4 mL (800 mcg) and add to 19.6 mL D5W
    • Final concentration: 40 mcg/mL
  • Morphine 2 mg/mL
    • Take 1 mL (2000 mcg) and add to 19 mL D5W
    • Final concentration: 100 mcg/mL
Compatibility: 

- Solutions Compatible: D5W, D10W, 0.9% NaCl, dextrose-saline combinations

- Y-site Compatible: ampicillin, cefotaxime, dobutamine, dopamine, epinephrine, furosemide, heparin, KCl, midazolam, pancuronium, SMOF, TPN

Incompatible: acyclovir, cloxacillin, furosemide, phenytoin

References: 

- Taketomo CK, Hodding JH, Kraus DM. Pediatric Dosage Handbook 23th Edition. Hudson: Lexi-Comp Inc.; 2015

- American Society of Health-System Pharmacists (ASHP). Handbook on Injectable Drugs. 19th Edition. Bethesda: ASHP 2017

- Harlos MS, Stenekes S, Lambert D, Hohl C, Chochinov HM (2013). Intranasal fentanyl in the palliative care of newborns and infants. Journal of Pain and Symptom Management, 46 (2), 265-274

- Milesi C, Baleine J, Mura T, Benito-Castro F, ferragu F, Thiriez G, Thevenot P, Combes C, Carbajal R, Cambonie G. (2018). Nasal midazolam vs ketamine for neonatal intubation in the delivery room: a randomized trial. Arch Dis Child: Fetal & Neonatal Edition 103, 221-226

- Moore Hepburn C, Booth M, Ontario's Provincial Council for Maternal and Child Health. Healthcare Quaterly Vol.15 Special issue. July 2012

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