REVIEW   Free access

Minerva Pediatrics 2023 Sep 06

DOI: 10.23736/S2724-5276.23.07275-0

Copyright © 2023 EDIZIONI MINERVA MEDICA

language: English

Morphine versus hydromorphone in pediatrics: a narrative review of latest indications and optimal use in neonates and children

Sarah SPÉNARD ¹, Marie-Elaine METRAS ^{2, 3}, Charles GÉLINAS ⁴, Vibhuti SHAH ^{5, 6}, Marie-Joëlle DORÉ-BERGERON ^{7, 8}, Kathryn DEKOVEN ⁹, Marc-Antoine MARQUIS ^{7, 10}, Evelyne D. TROTTIER ^{11, 12, 13}, Céline THIBAULT ^{2, 13, 14}, Niina KLEIBER ^{7, 13, 14} ✉

¹ Division of Neonatology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada; ² Division of Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, University of Montreal, Montreal, QC, Canada; ³ Faculty of Pharmacy, University of Montreal, Montreal, QC, Canada; ⁴ Department of Anesthesia, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada; ⁵ Division of Neonatology, Department of Pediatrics, University of Toronto, Toronto, ON, Canada; ⁶ Department of Pediatrics, Sinai Health, Toronto, ON, Canada; ⁷ Division of General Pediatrics, Department of Pediatrics, CHU Sainte-Justine, University of Montreal, Montreal, QC, Canada; ⁸ Multidisciplinary Chronic Pain Clinic, CHU Sainte-Justine, University of Montreal, Montreal, QC, Canada; ⁹ Department of Anesthesia, CHU Sainte-Justine, University of Montreal, Montreal, QC, Canada; ¹⁰ Pediatric Palliative Care, CHU Sainte-Justine, University of Montreal, Montreal, QC, Canada; ¹¹ Pediatric Emergency Department, CHU Sainte-Justine, Montreal, QC, Canada; ¹² Department of Pediatrics, University of Montreal, Montreal, QC, Canada; ¹³ Research Center, CHU Sainte-Justine, University of Montreal, Montreal, QC, Canada; ¹⁴ Department of Pharmacology and Physiology, University of Montreal, Montreal, QC, Canada

The management of pain in pediatrics is multimodal and includes non-pharmacologic and pharmacologic approaches. Opioids, and particularly morphine and hydromorphone, are frequently used to treat moderate-to-severe pain. The goals of this review are to describe the pharmacological characteristics of both drugs, to cover the latest evidence of their respective indications, and to promote their safe use in pediatrics. Morphine is the most studied opioid in children and is known to be safe and effective. Morphine and hydromorphone can be used to manage acute pain and are usually avoided when treating chronic non-cancer pain. Current evidence suggests that both opioids have a similar efficacy and adverse effect profile. Hydromorphone has not been studied in neonates but in some centers, it has been used instead of morphine for certain patients. In palliative care, the use of opioids is often indicated and their benefits extend beyond analgesia; indications include treatment of central neuropathic pain in children with severe neurologic impairment and treatment of respiratory distress in the imminently dying patients. The longstanding belief that the use of well-titrated opioids hastens death should be abandoned as robust evidence has shown the opposite. With the current opioid crisis, a responsible use of opioids should be promoted, including limiting the opioid prescription to the patient’s anticipated needs, optimizing a multimodal analgesic plan including the use of non-pharmacological measures and non-opioid medications, and providing information on safe storage and disposal to patients and families. More data is needed to better guide the use of morphine and hydromorphone in children.

KEY WORDS: Pediatrics; Pharmacology; Analgesics, opioid; Morphine; Hydromorphone