Knowledge Bank

Purpose and Background/Significance: Thousands of children under age two are admitted to intensive care units each year in the United States. Many are treated for pain and other symptoms they experience as a result of lifethreatening/life-limiting illness (LT/LL). Limited evidence is available for this vulnerable population which can lead to substantial variation in treatment and the potential for increased suffering. The purpose of this study was to explore the literature for information about those medications used to treat children under the age of two who may receive palliative or end-of-life care.

Theoretical/Conceptual Framework: The PRISMA-S Checklist for Scoping Reviews was used to guide this review.

Methods: A search of CINAHL (1190 articles), PubMed (3527 articles), Embase (101 articles), and Cochrane (2396 articles) databases was conducted using keywords: children, neonatal and pediatric intensive care units, medications, palliative, and end-of-life care. Peer-reviewed articles written in English from 2000- present that discussed the pharmacological symptom management of children aged two and under in illnesses that may receive palliative or end-of-life care were included. Excluded articles included neonatal abstinence syndrome, nonpharmacological treatments, drugs used for prophylaxis or procedural pain, and those used routinely, such as antibiotics, that are not managed by the palliative care team.

Results: The last search on April 6th, 2021 yielded 7,216 articles, of which 27 were included in the final review. Articles were screened using the online platform Covidence. A level of evidence analysis is not required for a scoping review. A total of 80 medications were mentioned in treating12 different symptoms. Opioids (morphine and fentanyl) were the most commonly used medications, followed by benzodiazepines (lorazepam and midazolam). Pain and agitation were the main symptoms being managed. A majority of articles outlined the need for further research in this area, as there is no consensus for use and many medications used in this population are off-label and not FDA approved.

Conclusion: Symptom assessment and management is an important component of pediatric care. This review highlights the exclusion of children under age two in research and inconsistencies around medication use in this vulnerable population. Future research must include children under two and should focus on palliative and end-of-life care protocol development as these guidelines have been shown to decrease variability and increase the use of pharmacological symptom management.