Acute pain management in paediatrics

Overview

This clinical practice guideline from the Royal Children's Hospital Melbourne, last updated in October 2024, covers acute pain management in children. Its key messages are that regular assessment of pain and of the response to treatment matters most, that combining non-pharmacological and pharmacological methods works best, and that a graded pharmacological approach should be used. Pain can be hard to tell apart from anxiety and distress, especially in pre-verbal or non-verbal children, and untreated pain affects later experiences of care, healing and development.

Assessment

Pain is assessed and reassessed throughout the encounter, using age-appropriate language, observation of behaviour (a child in pain may be very quiet) and physiology, parent reports and cultural factors. Tools are chosen by age: faces scales (FPS-R and Wong-Baker) for ages 3 to 18, numeric and visual analogue scales above 7 years, the Neonatal/Infant Pain Scale under 3 months, FLACC from 2 months to 7 years and revised FLACC for children with developmental disability or cognitive impairment.

Non-pharmacological and local measures

Parental presence and comforting touch, distraction (video, music, bubbles, storytelling), child life or play therapy, swaddling, feeding, skin-to-skin care and dummy use for infants, and breathing techniques reduce stress. For injuries, fractures are splinted early, ice and elevation are used, burns are dressed promptly and nerve blocks are considered. Topical and local agents are matched to the situation, such as anaesthetic creams before venepuncture, lignocaine infiltration or nerve blocks for limb and finger injuries, and ALA gel for open wounds.

Systemic analgesia

Analgesics are given regularly when pain is constant. Paracetamol and ibuprofen are used together as appropriate (ibuprofen from 3 months), sucrose helps infants up to 18 months, and moderate to severe pain is treated early with opioids (oxycodone, morphine or intranasal fentanyl from 12 months). Tramadol is for children over 12 years and is avoided in epilepsy or with SSRIs. Doses are weight-based and are set out in the guideline. Opioids should never be the only agent, and close observation is needed. Naloxone treats opioid toxicity, fentanyl is preferred to morphine in renal impairment, and regional anaesthesia, PCA or a pain team can be used for significant ongoing pain.

Prescribing and discharge

Pain management courses are kept short, aperients are prescribed with opioids, prescription databases are checked for regulated medicines and the GP is involved if treatment lasts more than a week. A child can go home when pain is well controlled and anticipated pain has been considered.