Paediatric Pain Summary

Key Principles

  • Start pain assessment at triage
  • Monitor throughout ED stay
  • Ensure adequate analgesia at discharge
  • Pain is often under-recognized in children

Pain Assessment

  • Use validated pain scales
  • APLS pain ladder recommended
  • Consider behavioral cues (CHEOPS)
  • Staff experience crucial

Non-Pharmacological

  • Parent involvement
  • Distraction techniques
  • Child-friendly environment
  • Immobilization/elevation

Mild Pain

  • Paracetamol 20mg/kg loading
  • Ibuprofen 10mg/kg 6-8hrly

Moderate Pain

  • Add diclofenac 1mg/kg
  • Codeine (≥12 years) 1mg/kg
  • Oral morphine 0.2-0.5mg/kg

Severe Pain

  • Entonox as holding measure
  • Intranasal diamorphine 0.1mg/kg
  • IV morphine 0.1-0.2mg/kg

Procedural Options

  • Topical anaesthetics (Ametop/EMLA)
  • Local anaesthesia
  • Ketamine/Midazolam sedation
  • Regional nerve blocks

Paediatric Pain Management

Comprehensive approach to recognition and alleviation of pain in children

Introduction

Recognition and alleviation of pain should be a priority when treating ill and injured children. This process should start at the triage, be monitored during their time in the ED and finish with ensuring adequate analgesia at, and if appropriate, beyond discharge.

Challenge: Pain is commonly under-recognised, under-treated and treatment may be delayed. This is especially true in children. Reasons include difficulty in assessing severity, the child may not appear distressed or have difficulty describing/admitting to pain. Drug choice and dosage may also cause problems due to unfamiliarity.

Pain Assessment

Pain assessment forms an integral part of the Manchester Triage Scale. Multiple assessment tools are in use. The better known uni-direction scales have some evidence in the context of an ED environment, and even where the atmosphere is tense and the child and parent are using such tools for the first time, are satisfactory for the purpose of pain assessment and management.

Assessment Tools

  • Pain ladder: Objective and subjective descriptions with numerical scale
  • Faces scales: Visual representations of pain intensity
  • APLS pain ladder: Combines objective descriptions with panda faces
  • RCEM recommends: Use of validated assessment tools or locally developed alternatives

Behavioral Assessment

  • Staff experience: Crucial in estimating pain severity
  • Visual clues: Crying, loss of movement, facial expressions
  • CHEOPS score: Behavioral scoring system particularly useful in non-verbal children
  • Context consideration: Fear, parental distress, unfamiliar environment

Treatment Approaches

Psychological Strategies

Environmental

  • Parent and family member involvement
  • Child-friendly environment
  • Explanation with reassurance
  • Play specialist involvement

Distraction Techniques

  • Toys and games
  • Blowing bubbles
  • Reading or storytelling
  • Age-appropriate activities

Non-Pharmacological Adjuncts

  • Limb immobilisation and elevation
  • Cooling and dressings for burns
  • Definitive treatment (e.g., reduction of pulled elbow)
  • Comfort positioning

Pharmacological Options

Analgesia

Paracetamol

  • Most widely used analgesic in paediatric practice
  • Routes: Oral, rectal, intravenous
  • Mechanism: Inhibits cyclooxygenase in CNS
  • Generally well tolerated

NSAIDs

  • Anti-inflammatory and antipyretic with moderate analgesia
  • Less well tolerated than paracetamol
  • Side effects: Gastric irritation, platelet disorders, bronchospasm, renal impairment
  • Useful for post-traumatic pain (anti-inflammatory effect)
  • Ibuprofen (oral), Diclofenac (rectal if needed)

Weak Opioids

  • Codeine phosphate
  • Consider age restrictions and metabolism variations
  • Monitor for respiratory depression

Strong Opioids

  • Morphine (IV - rapid onset, titratable)
  • Intranasal diamorphine/fentanyl (safe, effective)
  • Side effects: Respiratory depression, nausea, vomiting
  • Cardiovascular effects: Vasodilation, venous pooling
  • Reversible with naloxone if necessary

Specialised Pain Management

Entonox (Nitrous Oxide)

  • Analgesia in sub-anaesthetic concentrations
  • Patient requirements: Awake and cooperative
  • Age: Free-flow circuit from 2 years, demand valve from 4-5 years
  • Onset: Rapid (2-3 minutes to peak effect)
  • Duration: Short-lived (wears off over minutes)
  • Indications: Dressing changes, suturing, needle procedures, splinting
  • Side effects: Nausea, vomiting, euphoria, disinhibition
  • Contraindications: Intracranial or intrathoracic air

Topical Anaesthesia

Ametop Gel

  • Tetracaine (amethocaine) base 4%
  • Applied under occlusive dressing
  • Onset: 30-45 minutes
  • Duration: 4-6 hours after removal
  • Side effects: Erythema, itching, edema
  • Not recommended for children < 1 month

EMLA Cream

  • Lidocaine 2.5% + Prilocaine 2.5%
  • Alternative to Ametop
  • Onset: ~60 minutes
  • Similar application technique

Ethyl Chloride Spray

  • Immediate onset
  • Very short duration
  • Use for quick procedures

Local and Regional Anaesthesia

Lidocaine 1%

  • Rapid, intense sensory nerve block
  • Onset: Significant within 2 minutes
  • Duration: Up to 2 hours
  • With adrenaline: Prolongs duration, reduces toxicity
  • Maximum dose: 3 mg/kg (plain), 7 mg/kg (with adrenaline)
  • Avoid in end-artery areas (digits)

Bupivacaine

  • Longer lasting local anaesthetic
  • Concentrations: 0.25% or 0.5%
  • Indications: Femoral nerve block, prolonged procedures
  • L-Bupivacaine: Less toxicity
  • Onset: Up to 15 minutes
  • Duration: Up to 8 hours
  • Maximum dose: 2 mg/kg

Procedural Sedation

Ketamine

  • Dissociative anaesthetic with amnesic and analgesic properties
  • Minimal effect on breathing and airway reflexes
  • Side effects: Hypersalivation, tachycardia, hypertension
  • Rare complication: Laryngospasm
  • Emergency phenomenon treatable with midazolam

Midazolam

  • Amnesic and sedative drug
  • Routes: IV, IM, oral, intranasal
  • Onset: 15 minutes (oral), recovery after ~1 hour
  • Side effects: Respiratory depression, hyperexcitability
  • Reversible with flumazenil (rarely necessary)

Treatment Algorithm

Initial Assessment

  • Assess pain severity using appropriate scale
  • Use splints/slings/dressings as appropriate
  • Consider other causes of distress:
    • Fear of unfamiliar environment
    • Parental distress
    • Fear of strangers
    • Needle phobia
    • Fear of injury severity
  • Consider regional blocks or conscious sedation for procedures

Pain-Specific Management

Pain Severity Management
Mild Pain
  • Oral/rectal paracetamol 20 mg/kg loading dose, then 15 mg/kg 4-6 hourly OR
  • Oral ibuprofen 10 mg/kg 6-8 hourly
Moderate Pain
  • As for mild pain PLUS
  • Oral/rectal diclofenac 1 mg/kg 8 hourly (unless already had ibuprofen) AND/OR
  • Oral codeine phosphate 1 mg/kg 4-6 hourly (over 12 years only) OR
  • Oral morphine 0.2-0.5 mg/kg stat
Severe Pain
  • Consider entonox as holding measure THEN
  • Intranasal diamorphine 0.2 ml (= 0.1 mg/kg) FOLLOWED BY/OR
  • IV morphine 0.1-0.2 mg/kg infused over 2-3 minutes
  • Supplemented by oral analgesics

Important Considerations: Always consider the child's age, weight, comorbidities, and specific contraindications when selecting analgesic agents. Monitor for side effects and effectiveness of treatment throughout the ED stay.