Pain assessment tool

Appropriate age group

Example

Faces pain scale revised (FPS-R)

3-18 years

Child self-rates their pain (not clinician or parent assessment)

Wong-Baker FACES® scale

3-18 years

Child self-rates their pain (not clinician or parent assessment)

*Note that there can be inaccuracy as many children will not select the smiling face regardless of level of pain

Numeric rating scale

>7 years

Child self-rates their pain (not clinician or parent assessment)

Linear scale (visual analogue scale)

>7 years

Child self-rates their pain (not clinician or parent assessment)

Neonatal/infant pain scale (NIPS)

<3 months

Clinician assessment
Add scores of six behaviour assessments (facial expression, cry, breathing pattern, arms, legs, state of arousal) for a score 0-7

Faces legs activity cry consolability (FLACC)

2 months to 7 years

Clinician assessment
Add scores of five assessments (faces, legs, activity, cry, consolability) for a score 0-10

Revised FLACC (R-FLACC)

All non-verbal children

Clinician assessment
Pain rating scale for children with development disability, or cognitive impairment

Context

Suggested topical agent

Limb or finger injuries: local anaestheasia/nerve block

Immobilisation with splint/backslab
Lignocaine 1% for skin infiltration
Ropivacaine, bupivacaine or lignocaine for nerve block
See Femoral nerve block, Bier block

Open wounds in preparation for closure

Amethocaine, lignocaine and adrenaline (ALA/Laceraine®)
See Lacerations

Gingivostomatitis

Lignocaine viscous gel

Mouth ulcers

Triamcinolone acetonide or (Kenalog in Orabase®)

Eye pain/corneal abrasions

Topical anaesthetic eye drops (only for examination, interferes with healing)
Consider dilating drops for larger abrasions

Severe, acute ear pain

Short-term use of topical 2% lignocaine or Auralgan®, apply 1-2 drops to intact tympanic membrane

Prior to intravenous access, venepuncture, suprapubic aspirate, lumbar puncture

Anaesthetic creams eg Emla®, AnGel ®, LMX4®
Other topical agents such as ice, Coolsense® or BUZZY®

Nasal/pharyngeal foreign body removal, NGT insertion

Lignocaine: Phenylephrine (CoPhenylcaine Forte®) nasal spray

Route

Dose

Maximum daily dosing

Notes/onset of action

Sucrose
(any concentration eg 24%, 33%)

PO

Preterm (corrected age 32-40/40 weeks): 02-0.5 mL per procedure

<1 month: 0.5-1 mL per procedure

1-18 months: 1-2 mL per procedure

Preterm: max 2.5 mL/day

<3 months: max 5 mL/day

≥3 months: max 10 mL/day

Children 0-18 months (most effective in children <6 months)

Provide one-quarter of dose to anterior tongue 2 minutes prior to painful procedure, with dummy if available. Continue in small increments as required

Analgesic effect may last 5-8 minutes from administration

Paracetamol

PO

15 mg/kg (max 1 g)
4-6 hourly

Birth-1 month:
60 mg/kg/day

>1 month:
90 mg/kg/day (max 4 g) for severe pain for max 48 hours, then 60 mg/kg/day subsequently

Onset of action 30 minutes

Oral route is preferred

Dose on ideal body weight

Administer commercial syrup carefully as available in several concentrations

PR

15-20 mg/kg (max 1 g)
6 hourly

<1 month: 60 mg/kg/day

>1 month:
90 mg/kg/day (max 4 g) for max 48 hours, then 60 mg/kg/day subsequently

If not tolerated orally

Rectal absorption can be delayed and erratic

Dose on ideal body weight
125 mg, 250 mg, 500 mg suppositories available

PR medication should be avoided in immunocompromised children

IV

<1 month:
10 mg/kg 6 hourly

>1 month:
15 mg/kg (max 1 g) 6 hourly

<1 month: 40 mg/kg/day

>1 month: 60 mg/kg/day (max 4 g)

Onset of action 5-10 minutes

If PO/PR not tolerated

More expensive

Dose on ideal body weight

Dose (mg) and volume (mL) errors have caused significant overdoses in young children

Ibuprofen

PO

>3 months:
10 mg/kg
(max 400 mg)
6-8 hourly with food

30 mg/kg/day (max 2.4 g)

Onset of action 30 minutes

Precautions include renal impairment, dehydration, bleeding, anticoagulant use

Asthma is not a contraindication

Administer commercial syrup carefully as available in several concentrations

Oxycodone  

PO

1–12 months: 0.05-0.1 mg/kg 4 hourly
 
>12 months:
0.1-0.2 mg/kg (adult dose 5-10 mg) 4 hourly 

1-12 months: max 0.6 mg/kg/day

 >12 months:
max 1.2 mg/kg/day

Onset of action 10-30 minutes

Higher/more frequent dosing can be used in hospital settings

For short term use

Do not prescribe for outpatient use if no clear diagnosis

Morphine

IV/SC

<1 month: 0.025 mg/kg, repeat as needed

1-12 months: 0.05 mg/kg

>12 months: up to 0.2 mg/kg (max 5-10 mg)

Cumulative maximum:

<1 month:  0.1 mg/kg 4-6 hourly (max 0.6 mg/kg/day)

1-12 months: 0.1 mg/kg 2-4 hourly (max 1.2 mg/kg/day)

>12 months: 0.2 mg/kg 2-4 hourly (max 2.4 mg/kg/day)

Rapid onset, peak effect 5-10 minutes

Higher/more frequent dosing can be used in hospital settings

Fentanyl

Intra-nasal

>12 months:
1.5 microg/kg
(max 100 microg) for first dose

0.75 microg/kg for subsequent doses after
10 minutes

Total dose of 3 microg/kg/day

Rapid onset (5 minutes)

Divide dose between nostrils using atomiser

Consider alternative ongoing analgesics after second dose

Not recommended <12 months of age

Tramadol

PO/IV

>12 years
0.5-1 mg/kg (max 100 mg) 6 hourly

4 mg/kg/day (max 400 mg)

Onset of action 30-60 minutes

Can give up to 2 mg/kg if no risk of sleep apnoea/risk factors for respiratory depression

Avoid in epilepsy (lowers seizure threshold)

Avoid in young people on SSRIs (risk of serotonin syndrome)