Date last published: July 2025
This clinical guideline is written for health care professionals who provide care to children with life-limiting diagnoses. It is intended to inform clinical practice through concise best practice advice. Please contact your Paediatric Palliative Care Service for further advice.
This guideline has been adapted with approval from the PSNZ New Zealand Paediatric Palliative Care Clinical Network Clinical Guidelines.
Definition 1
“Agitation or irritability is used to describe unpleasant psychological and physical arousal, often in circumstances in which the underlying etiology remains unclear. It refers to a complex set of symptoms and signs that are distressing to the patient, their family and caregivers. Agitation/ irritability may consist of psychological symptoms, physical symptoms and autonomic changes.”
In this clinical guideline the word “child” is used for brevity but refers to neonate, baby, child and/or adolescent. There are developmentally appropriate considerations for each. The word “parent” is used interchangeably to represent the legal guardian of the child.
Be SURE you practice these key actions;
 |
Seek the voice of the child |
 |
Understand the family’s current goals of care and expectations |
 |
Recognise parent/carer role and expertise about their child |
 |
Explore shared decision making and care partnership |
This document is only valid for the day on which it is accessed. Please read our disclaimer.
Goals of management
Causes and provoking factors 1-5
Clinical features 1-4
Recommendations 1-7
Non-pharmacological management
Work with the child and family to;
Pharmacological management
Work with the child and family about their expectations and preferences keeping in mind that there is often a balance between alertness and complete control over agitation.
Where the symptom persists and is a significant burden, consider consultation with the specialist Palliative Care Services and/or the Psychiatry team for evaluation and guidance whether other psychotropic medications may be helpful. For longer term management, consider Gabapentin.
Principles of Prescribing 3
In neonates, start at the lower end of the dose ranges and consider lower end of dosing interval.
Table 1. Dosing information 2
Note: intranasal (IN), intravenous (IV), per oral (PO), per rectum (PR), subcutaneous (SC), sublingual (SL), when required (PRN)Doses recommended are for opioid and benzodiazepine naive patients.
| Drug | Dosing | Notes |
|---|---|---|
| First Line | ||
| Midazolam |
Buccal/IN: 0.3 mg/kg stat (max dose 10 mg) Neonates; 0.1-0.3 mg/kg stat IV/SC: 0.025-0.05 mg/kg/dose Q1h prn |
More immediate acting sedation Suitable in neonates Plastic ampoules can be used buccally and intranasally |
|
Midazolam continuous infusion (dosing for Agitation) |
0.25-1.5 mg/kg/24hrs SC |
Consider continuous infusion if frequent stat doses have been used Breakthrough (stat) doses can also be given as above Note; Agitation dose is lower than Seizure dosing |
|
Clonazepam (alternative to Midazolam) |
PO/SL <10yrs: 0.01mg-0.05 mg/kg/day divided in 2 or 3 doses >10yrs:0.5 mg/dose q8h-12h |
Longer duration than Midazolam Prescribe oral liquid as number of drops and mg to reduce errors (1 drop contains 0.1 mg) |
|
Clonidine (alternative first line or in addition to Midazolam/Clonazepam |
PO/IV/SC: 0.5-4 microg/kg/dose Q6-8h |
Suitable for neonates Can lower blood pressure, consider impact on cardiac conditions |
| Second Line | ||
| Haloperidol |
PO/IV/SC: 0.01-0.02 mg/kg/dose Q8-12h (max dose 0.5 mg) Can be administered as a continuous infusion |
Children and adolescents may be at greater risk of acute dystonic reactions than adults |
| Chloral Hydrate | PO/PR: 10–20 mg/kg/dose Q6h prn |
Suitable for neonates Can have a more prolonged effect |
| Phenobarbital |
PO/IV/SC: 2.5-5 mg/kg/dose Q12-daily |
Suitable for neonates Note; Agitation dose is lower than Seizure dosing |
Note: Units for dosing are given as mg (milligrams) or micrograms (microg). Please check doses and units carefully before administering medication. Please check your local legislation and requirements for conditions related to prescriptions of medications. This information is designed to be a dose guide only. Each patient’s dose requirements may vary and should be adjusted based on the clinical situation. Readers should also refer to more comprehensive texts on palliative care for further information on drugs, indications, and side effects. (A Practical Guide to Palliative Care in Paediatrics)
In the literature search for this guideline there were seven guidelines discovered, including two neonatal guidelines. There are many causes of agitation, each with its own management. Each guideline differs in some aspects of management and the concordant recommendations are included in this guideline.
No references to supportive research evidence are given in source guidelines, and as such, the advice is likely to be recommended best practice based on clinical experience.
The methodology for these guidelines can be read here.
We recognise and acknowledge those who are working through Sorry Business, Sad News, grief and bereavement and offer our condolences and support.
Aboriginal and Torres Strait Islander peoples are advised that this website may contain images, videos and voices of people who have passed on. Some of the content and topics covered might also cause distress. You are welcome here, and we want you to feel safe and take care.
If you find that you need support please reach out to 13YARN on 13 92 76, Grief Australia, Grief Line on 1300 845 745, or Lifeline on 13 11 14.
Palliative Care Australia is located in Canberra. We acknowledge the traditional custodians of the surrounding land and waters, the Ngunnawal and Ngambri Peoples and pay our respects to Elders past and present. We extend that same respect and acknowledge the continuing cultures and contribution of Aboriginal and Torres Strait Islander Peoples across Australia.
Close
