Acute pain management

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  • See also

    Comfort kids
    Communicating procedures to children
    Intranasal fentanyl
    Minimising distress in healthcare settings
    Pain assessment and measurement
    Procedural sedation

     Key points

    1. The key to effective acute pain management is regular assessment of pain and response to interventions
    2. Strategies combining non-pharmacological and pharmacological methods are most effective
    3. A graded pharmacological approach should be used

     Background

    • Pain is difficult to differentiate from anxiety and distress, especially in the pre-verbal or non-verbal child. It is therefore important to consider a child’s age, cognitive ability, environment and cause of pain
    • Undertreated pain has a lasting impact on a child’s experience of pain and subsequent medical encounters and can negatively impact healing and developmental outcomes

    Assessment

    • Proactive, regular assessment and reassessment throughout the encounter and after interventions
    • Enquire about pain level using age and developmentally appropriate language, eg in younger children words like ‘ouchy’, ‘yucky’ or ‘hurting’ can be useful instead of ‘pain’ or ‘sore’
    • Evaluation of behaviour and level of activity, note that a child in pain may be very quiet
    • Assess physiology:
      • heart rate
      • blood pressure
      • level of activity
      • ease of movement
    • Parental report of pain/distress
    • Parental report of previously successful pain management strategies
    • Cultural differences in pain expression should be considered
    • Behaviour, physiology and pain should be reassessed after intervention, ie review after predicted onset of action for pharmacological management

    Pain assessment tools

    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)
    Pain assessment tools 1

    Wong-Baker FACES® scale

    3-18 years

    Child self-rates their pain (not clinician or parent assessment)
    Pain assessment tools
    *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)
    Pain assessment tools 3

    Linear scale (visual analogue scale)

    >7 years

    Child self-rates their pain (not clinician or parent assessment)
    Pain assessment tools 4

    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

    Management

    • Strategies combining non-pharmacological and pharmacological methods are most effective
    • When pain is constant, prescribe analgesics at regular intervals as opposed to PRN
    • Utilise the synergistic effects of paracetamol and ibuprofen and give together as appropriate
    • If there is an expectation of ongoing pain, consider longer acting analgesic agents to help provide consistent pain relief and reduce the burden related to frequent dosing
    • Treat moderate to severe pain with opioids early

     Non-pharmacological methods

    • Age-appropriate techniques should be used in all children with pain
    • Stress and anxiety can exacerbate the perception of pain. Strategies that may be helpful to minimise stress and anxiety include:
      • Parental presence and comforting touch when possible
      • Use distraction therapy eg video, music, toys, blowing bubbles, storytelling by the child, counting
      • Engage child life therapist (play therapy) if available
      • Swaddling, feeding, skin to skin care and dummy use for infants
      • Breathing techniques
      • Tactile stimulation: touching the skin near the site using rhythmic rubbing, manual pressure, ‘Buzzy bee’
    • In the case of injuries, useful strategies include:
      • Immediate immobilisation of potential fractures with a splint or backslab
      • Applying ice (if age appropriate) and elevating injured limbs          
      • Prompt dressing of burns (see Burns)
      • For limb or finger injuries consider regional local anaesthesia/nerve block

    Pharmacological management

    Local analgesia

    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

    See also Procedural sedation

    Systemic analgesia

    All pain management should begin with an assessment and pre-emptive escalation through the flowchart based on the severity of pain

    Ongoing reassessment is essential, particularly to assess intervention and whether further analgesia is required

    Systemic analgesia

    Medications


    Analgesic

    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)

    Other considerations

    For any child in pain, consider referring to Child Life therapy, play therapy or Comfort Kids. If pain is difficult to control, refer to acute pain services for advice

    Significant ongoing pain

    • Opiates should not be given as the sole analgesic agent, ensure in combination with regular simple analgesia
    • Consider causes for ongoing severe pain eg compartment syndrome
    • Utilise regional anaesthesia, PCA, discussion with local pain team or retrieval service

    Renal impairment

    • See renal dosing guidelines for impaired renal function
    • Prefer fentanyl over morphine
    • Reduce dose and frequency of oxycodone
    • Closely monitor for signs of opiate accumulation

    Opiate toxicity/overdose

    • Airway support and oxygen (see Resuscitation)
    • Assist ventilation
    • Consider naloxone bolus 0.1 mg/kg (max 2 mg) IM or IV
    • Repeat naloxone doses may be required in long-acting opiate overdose

    Prescribing information

    • For safe prescribing, involve GP in prolonged pain management courses (>1 week)
    • Keep pain management courses short to maintain the proactive regular reassessment approach
    • Prescribe aperients along with ongoing opioids
    • When prescribing regulated medications (eg opioids) check safe prescribing databases for the child’s prescription history

    Consider consultation with local paediatric team when

    Inadequate analgesia achieved despite regular oral/IV regimen

    Consider transfer when

    Analgesic requirements and care are above the level of comfort of the local centre

    For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services.

    Consider discharge when

    Pain or distress is appropriately managed
    Anticipated pain is appropriately considered

    Parent information

    Pain relief for children – paracetamol and ibuprofen
    Reduce children’s discomfort during test and procedures

    Last updated October 2024

  • Reference List

    1. Ali S, Chambers AL, Johnson DW, et al. Paediatric pain management practice and policies across Alberta emergency departments. Paediatr Child Health. 2014;19(4):190-194
    2. Harvard Health Publishing, Harvard Medical School. The pain of measuring of pain. https://www.health.harvard.edu/pain/the-pain-of-measuring-pain (viewed May 2024)
    3. Johns, C. Infants and Children: Management of Acute and Procedural Pain in Emergency Departments, NSW Health https://slideplayer.com/slide/10305911/ (viewed May 2024)
    4. Schug SA, Palmer GM, Scott DA, Halliwell R, Trinca J; APM:SE Working Group of the Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine (2015), Acute Pain Management: Scientific Evidence (4th edition), ANZCA & FPM, Melbourne
    5. Starship Child Health. Assessing Children’s Pain (viewed May 2024) https://media.starship.org.nz/rflacc/rflacc.pdf
    6. Therapeutic Goods Administration 2017. Safety review: Codeine use in children and ultra-rapid metabolisers  https://www.tga.gov.au/alert/safety-review-codeine-use-children-and-ultra-rapid-metabolisers (viewed May 2024)
    7. Wong-Baker FACES Foundation. Wong-Baker FACES Pain Rating Scale  https://wongbakerfaces.org/ (viewed April 2024)