Canuck Place is here to guide you and help you with Perinatal anticipatory symptom management

Pain and irritability

The source of discomfort can be difficult to discern in a neonate. If there is a source for pain, you can consider using opioids. If they are irritable and restless with no obvious nociceptive pain source, you can consider using benzodiazepine. You can also integrate non-pharmacological strategies, which include: skin-to-skin contact, facilitated tucking/swaddling, temperature regulation, non-nutritive sucking, or sucrose (see site specific guidelines). 


Dyspnea is a subjective feeling of breathing discomfort/shortness of breath and may not be correlated with changes in breathing patterns. In a neonate we would assess to determine if the work of breathing, noisy breathing, or irregular breathing (gasping, apnea) is accompanied by distress/discomfort (grimacing, crying, restlessness). Opioids can relieve dyspnea by decreasing hyper-responsiveness to hypercapnia and hypoxia, decreasing oxygen consumption and pulmonary vasodilation. Benzodiazepines can relieve dyspnea by decreasing anxiety and restlessness. Trial each of these separately and assess the effect. You can also integrate non-pharmacological strategies, which include: repositioning (head up or side lying/prone), use of a fan (or open window/fresh air), or oxygen (may or may not help) 


New onset seizures, although not common, are distressing to witness for family and staff so should be treated promptly.

Medication Recommendations

Choice of medication and route

When symptoms are severe and time is likely short, use medication and route of administration with fast onset. Fentanyl and midazolam are useful as they have fast onset of action when given sublingual or buccal or intra-nasal without requiring IV/subcutaneous access. If these short acting agents are given repeatedly and symptoms managed, or if symptoms are not as severe and there is time, consider a longer acting agent (morphine/lorazepam). 

Pain or dyspnea

Fentanyl 1-2 mcg/kg sublingual/buccal/intra-nasal/IV/subcutaneous q15 mins. PRN for pain or dyspnea 


Morphine 0.03-0.05 mg/kg IV/subcutaneous q15 mins. PRN for pain or dyspnea. 

If longer acting agent required: Morphine 0.05-0.1 mg/kg PO/buccal/sublingual/rectal q1-4 hrs. PRN 

Morphine 0.03-0.05 mg/kg IV/subcutaneous q1-4 hr. PRN

Dyspnea or irritability

Midazolam 0.1 mg-0.2 mg sublingual/buccal/intra-nasal q15 mins. PRN for dyspnea or irritability Midazolam 0.05 mg-0.1 mg IV/subcutaneous q15 mins. PRN for dyspnea or irritability 

If longer acting agent required: 

Lorazepam 0.05 – 0.1 mg sublingual/buccal/PO/IV/subcutaneous q6h pr 


Midazolam 0.2mg-0.3mg buccal/sublingual /intranasal q15 mins. Prn for seizure

Perinatal PPC Symptom Guide.2021 pdf 626.67 kb