The purpose of the titration phase is to match the dose of analgesia prescribed to the degree of pain experienced, aiming to keep the child comfortable without unnecessary toxicity.  The opioid of choice in the titration phase is immediate release morphine.  Formulations with long half-lives or slow release delivery systems are not appropriate.

• Once appropriate initial and breakthrough opioid doses have been prescribed leave for 48hrs before first review.
• At 48hrs review the regular opioid dose + total breakthrough required.
• If the child has needed only 1-2 breakthrough doses in each 24hr period: Do not alter dose.
• If the child has needed >2 breakthrough doses in each 24hr period:
  • Calculate the new total daily dose (TDD) by adding up all regular and breakthrough doses of morphine given.
  • Divide the new TDD by 6 to calculate the new 4 hourly dose and the new breakthrough dose of morphine.
• Review again after 48hrs and repeat as necessary.