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Acute pain management

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  • See also

    Intranasal fentanyl
    Pain assessment and measurement

    Key Points

    1. The key to effective acute pain management is regular assessment of pain and response to interventions
    2. Multi-modal strategies following a step-wise approach should be used to provide pain relief to children 

    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 cognitive ability, environment and cause of pain
    • Under-treated pain has a lasting impact on a child’s experience of pain and subsequent medical encounters

    Assessment

    • Use self-reporting to measure pain where possible (see Pain assessment and measurement which describes alternative means to assess pain in children unable to provide self-report)
    • Take into account parental report of pain and previously successful pain management strategies

    Management

    • Multi-modal strategies combining non-pharmacological and pharmacological methods are most effective
    • When pain is constant, prescribe analgesia at regular intervals as opposed to “as needed”

    Non-pharmacological methods

    • Age appropriate techniques should be used in all children with pain
    • These include:
      • parental presence and comforting touch when possible
      • engaging child life specialist if available or using distraction therapy (eg video, music, toys, blowing bubbles, storytelling by the child, counting)
      • swaddling, feeding, skin to skin care and dummy use for infants
      • breathing techniques
    • In the case of injuries, useful strategies include:
      • immediate immobilisation for potential fractures
      • applying ice and elevating injured limbs      
      • prompt dressing of burns (see Burns)

    Pharmacological agents

    Use a stepwise approach to guide pain management with plan to escalate agents according to pain severity

    Analgesic

    Route

    Dose

    Maximum dosing

    Notes

    Mild to moderate pain

    Sucrose

    oral 

    0.1–0.5 mL increments

    <3 months:
    5 mL/day

    ≥3 months:
    10 mL/day

    Children 0–18 months (most effective in younger children)
    Provide dose 2 minutes prior to painful procedure (with dummy if available)

    and / or

    Paracetamol

    oral

    15 mg/kg (max 1 g)
    4–6 hourly

    Birth - 1 month:
    60 mg/kg/day

    >1 month:
    90 mg/kg (up to 4 g/day)

    Dose on ideal body weight
    Dose commercial syrup carefully as available in several strengths

    PR

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

    Birth - 1 month:

    60 mg/kg/day

    > 1 month:
    90 mg/kg (up to 4 g/day)

    If oral not tolerated
    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 6 hourly (max 1 g)

    < 1 month:

    40 mg/kg/day

    > 1 month:

    60 mg/kg (up to 4 g/day)

    If oral/PR not tolerated
    Dose on ideal body weight
    Dose (mg) and volume (mL) errors have caused significant overdoses in young children

    and / or

    Ibuprofen

    oral 

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

    30 mg/kg (up to 2.4 g/day)

    Precautions include renal impairment, dehydration, bleeding and anticoagulant use
    Asthma is not a contraindication
    Dose commercial syrup carefully as available in several strengths

    Moderate to severe pain

    Use medications above, and consider adding the following

    Oxycodone  

    oral

    1–12 months: 0.05–0.1 mg/kg, 
    >12 months:
    0.1–0.2 mg/kg
    4 hourly 

    5–10 mg
    4 hourly

    For short term use
    Do not prescribe for outpatient use if no clear diagnosis
    Higher / more frequent dosing can be used in inpatient settings

    or

    Morphine

    IV / subcutaneous

    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
    1–12 months:

    0.1 mg/kg 2–4 hourly
    >12 months:

    0.2 mg/kg 2–4 hourly

    Higher / more frequent dosing can be used in inpatient settings

    or

    Fentanyl

    Intranasal

    >12 months:
    0.75–1.5 microg/kg
    (max 75 microg)
    10 minutely

    Total dose of 3 microg/kg

    Rapid onset (5 minutes)
    Divide dose between nostrils
    Consider alternative ongoing analgesia after second dose
    Not recommended <12 months of age

    or

    Tramadol

    oral / IV

    1–18 years
    0.5–1 mg/kg (max 100 mg)
    6–8 hourly

    8 mg/kg (up to 400 mg/day)

    Can give up to 2 mg/kg if no risk sleep apnoea/risk factors for respiratory depression
    Avoid in epilepsy (lowers seizure threshold) and patients on SSRIs (risk of serotonin syndrome)

     Topical agents

    Context

    Suggested topical agent

    Open wounds in preparation for closure

    Amethocaine, lignocaine and adrenaline (ALA/Laceraine®)

    Prior to intravenous access and venepuncture

    Anaesthetic creams, ice, Coolsense® or BUZZY®

    Prior to suprapubic aspirate and lumbar puncture

    Anaesthetic creams

    Nasal / pharyngeal foreign body removal, NGT insertion

    Lignocaine - Phenylephrine (CoPhenylcaine Forte®) nasal spray

    Teething

    Salicylate teething gels (NB risk of Reye syndrome)

    Gingivostomatitis

    Lignocaine viscous gel

    Mouth ulcers

    Triamcinolone acetonide (Kenalog® in Orabase®)

    Eye pain / corneal abrasions

    Topical amethocaine eye drops

    Severe, acute ear pain

    Short-term use of topical 2% lignocaine, 1–2 drops applied to an intact tympanic membrane

    Consider consultation with local paediatric team when

    Inadequate analgesia achieved

    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 has been appropriately managed  

    Parent information

    Pain relief – Paracetamol and Ibuprofen
    Reduce children’s discomfort during test and procedures 

    Last Updated March 2020

  • 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. 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
    3. Therapeutic Goods Administration 2017, Safety review: Codeine use in children and ultra-rapid metabolisers, accessed 19 July 2019, <https://www.tga.gov.au/alert/safety-review-codeine-use-children-and-ultra-rapid-metabolisers>