Paediatric Analgesia

Children feel pain at every age, including neonates, and untreated pain increases later pain sensitivity and anxiety. Analgesia is chosen by pain severity, age, route availability and procedure, and is given regularly rather than as needed for continuous pain.

Assessment. Use an age-suitable tool: a neonatal behavioural score in neonates, a behavioural score such as FLACC in infants and children up to 7 years, a faces scale from 4 years and a numerical scale from 8 years. Reassess within 30 to 60 minutes of treatment.

Approach. Mild pain: paracetamol. Moderate pain: paracetamol plus ibuprofen. Severe pain: add an opioid. Combine with non-drug measures such as distraction, feeding, skin-to-skin contact and splinting.

• Paracetamol oral: 15 mg/kg every 4 to 6 hours, maximum 60 mg/kg/day and 4 g/day. Intravenous: under 10 kg 7.5 mg/kg every 6 hours (maximum 30 mg/kg/day); 10 to 50 kg 15 mg/kg every 6 hours (maximum 60 mg/kg/day); over 50 kg 1 g every 6 hours (maximum 4 g/day). Rectal dosing is erratic and rarely used.
• Ibuprofen oral: 5 to 10 mg/kg every 6 to 8 hours with food, maximum 30 mg/kg/day and 1.2 g/day. Not for infants under 3 months or under 5 kg.
• Topical anaesthetic before cannulation: lidocaine 4% cream applied 30 minutes before, or lidocaine 2.5% with prilocaine 2.5% applied 60 minutes before (avoid prilocaine under 3 months because of methaemoglobinaemia).
• Neonatal procedural pain: sucrose 24% 0.5 to 2 mL orally 2 minutes before the procedure, with skin-to-skin contact or breastfeeding.
• Local anaesthetic infiltration: plain lidocaine maximum 3 mg/kg (7 mg/kg with adrenaline); bupivacaine maximum 2 mg/kg (lower in neonates).
• Intranasal fentanyl for acute severe pain: 1.5 mcg/kg once, maximum 100 mcg.
• Severe pain: morphine 0.05 to 0.1 mg/kg intravenously, titrated slowly, or 0.2 to 0.3 mg/kg orally every 4 hours from 1 year of age. Codeine is avoided under 12 years and after tonsillectomy or adenoidectomy under 18 years.
• Neuropathic or chronic pain: specialist-directed gabapentin or amitriptyline.

Neonates and preterm infants. Reduce paracetamol and opioid doses and lengthen intervals by gestation. Avoid ibuprofen under 3 months.

Kidney impairment. Avoid ibuprofen in acute kidney injury, dehydration and nephrotic syndrome.

Liver impairment. Reduce paracetamol to the lower end and the maximum, and avoid in acute liver failure.

Other cautions. Avoid ibuprofen with asthma exacerbation, active bleeding, thrombocytopenia, varicella with skin infection, and in volume depletion.

Special groups. Sickle cell crises need early opioid dosing without delay. In East Africa, availability of oral morphine varies, and paracetamol plus ibuprofen are the base of most prescriptions.

Monitoring. Re-score pain at 30 to 60 minutes after each dose. For opioid use, check sedation, respiratory rate and oxygen saturation. Count total paracetamol from all products.

Referral and escalation. Escalate for uncontrolled severe pain after two doses of an opioid, signs of compartment syndrome, or suspected non-accidental injury.

Stopping. Move from regular to as-needed dosing as pain falls and stop when pain scores are 0 to 1. Do not continue opioids beyond need.