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Children experience pain in the same way as adults, but may not have the verbal or communication skills to adequately express the location, type and intensity of pain. These factors, along with a cautious approach to giving analgesia to children, can sometimes result in pain being undertreated.

Assessing and managing mild pain associated with general childhood illnesses

  • The overall aim is to identify the location, quality, duration and intensity of the child’s pain
  • If the child is verbal, ask them about their pain – input from parents is important, but the child’s own report is a key aspect of assessment
  • Look for behavioural cues which may gives clues about the pain
  • Ask parents about any analgesics already used to manage the pain, including their efficacy and tolerability
  • Paracetamol and ibuprofen are the most appropriate analgesics for short-term mild pain relief, while the underlying cause of pain is managed
  • Paracetamol is usually first-line, and should be dosed based on the weight of the child
  • Ibuprofen is the preferred NSAID, but is associated with increased risk of kidney injury even at recommended doses; no other NSAID should be routinely used in children
  • Combining or alternating paracetamol and ibuprofen is acceptable, but not routinely recommended

Assessment and management of children requiring referral for moderate to severe pain

  • If referral to secondary care is required in an acute situation, pain relief should ideally be started prior to transfer; this allows the child to be moved more easily and can reduce the total amount of analgesic administered overall
  • Morphine is the first-line analgesic for children with moderate to severe pain; the appropriate dose is the lowest dose which provides effective analgesia with manageable adverse effects
  • Intranasal fentanyl can be considered if available. This is especially useful if gaining IV access is likely to be difficult, or is not likely to be required in secondary care, or if the child has had previous intolerable effects with morphine.
  • Weak opioids, such as codeine and tramadol are best avoided in children, as sufficient safety data is unavailable and their efficacy is unpredictable

Managing persistent pain in children

  • Pain management in children with chronic conditions will usually be in conjunction with a relevant specialist. Choice of analgesic is based on the severity and type of pain, e.g. cancer pain, neuropathic pain.
  • Pain should be frequently assessed and the analgesic regimen tailored as required
  • Psychosocial aspects of persistent pain should be considered, with regular assessment of development, social function and mental health

Peer group discussion points

  • How do you usually assess pain in a young child? Are there any particular challenges?
  • What analgesic regimen do you usually prescribe for mild pain, e.g. otitis media? What advice do you give to parents/caregivers about managing pain?
  • Have you prescribed paracetamol and ibuprofen in combination or in alternate doses for a child? What is your view on this practice?
  • Do you use codeine or tramadol in children, and if so, why and for what indications?
  • How comfortable are you using morphine in a young child? When would you consider it?
  • What are your views on using intranasal fentanyl?
  • What has been your experience in assessing and managing chronic, unexplained pain in a child?