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Pain management should start when a child is first diagnosed and should continue throughout the illness. Childhood pain is often complex (particularly cancer pain) and ideally a multidisciplinary approach should be used.
While providing analgesia, the underlying cause of the pain should be determined and treated if possible, remembering that the pain of both diagnostic and therapeutic procedures (eg, bone marrow biopsy) may often be worse than that of the disease. Such pain due to procedures should be treated appropriately.
Assessment of children
The initial pain assessment of a child reporting or presenting behavioural signs of pain includes:
- A detailed pain history including location, duration and characteristics of the pain.
- Details regarding the impact of the pain on the child's sleep, emotional state, relationships, development and physical function.
- A physical examination.
- The diagnosis of the causes.
- The measurement of pain severity using an age-appropriate pain measurement tool.
- Information regarding treatments already tried.
- Sucrose, glucose or other sweet solutions have been all shown to reduce pain responses during commonly performed painful procedures in diverse populations of infants up to 12 months of age.
- Sucrose has been shown to be safe and effective for reducing procedural pain from single events.
- Although sucrose has been widely recommended for routine use during painful procedures in newborn and young infants, the use of sucrose is still not very common.
- If available, breast-feeding or breast milk should be used, rather than placebo, positioning or no intervention, to alleviate procedural pain in neonates undergoing a single painful procedure. Administration of glucose or sucrose has been shown to have similar effectiveness to breast-feeding for reducing pain.
The World Health Organization (WHO) has produced new guidelines on the pharmacological treatment of persisting pain in children with medical illnesses. They include several clinical recommendations, including a new two-step approach of pharmacological treatment. These guidelines exclude acute traumas, and perioperative and procedural pain.
The guidelines have replaced the previous three-step guidelines which recommended the use of codeine as a weak opioid for the treatment of moderate pain. The two-step approach advises the use of low doses of strong opioid, which is considered safer then using codeine or tramadol which are weak opioids.
The correct use of analgesic medicines will relieve pain in most children with persisting pain due to medical illness, and relies on the following key concepts:
- Using a two-step strategy.
- Dosing at regular intervals.
- Using the appropriate route of administration.
- Adapting treatment to the individual child.
The first step: mild pain
For children aged under 3 months, paracetamol should be offered.
Children aged over 3 months can be offered both paracetamol and ibuprofen.
The second step: moderate-to-severe pain
When the pain is more severe, an opioid drug is necessary to control the pain. Morphine is the medicine of choice for the second step. The WHO guidelines clearly state that fear and lack of knowledge regarding the use of opioids in children should not be a barrier for effective analgesia.
It is recommended that medication should be given regularly for persisting pain, rather than on an 'as required basis', unless pain episodes are truly intermittent and unpredictable. Children should, therefore, receive analgesics at regular intervals, with the addition of 'rescue doses' for intermittent and breakthrough pain.
- Sugar-free preparation is appropriate for many children with mild-to-moderate pain.
- It does not cause respiratory depression but overdose is dangerous, as it may cause hepatic damage and not be apparent for 4-6 days.
- The dosing for liquid paracetamol products for children was revised in 2011 to one that is based on narrower age bands with a single dosing option per band.
- The current recommended paracetamol doses are:
- Child 1-3 months: 30-60 mg every 8 hours as necessary; maximum 60 mg/kg daily in divided doses.
- Child 3-6 months: 60 mg every 4-6 hours (maximum 4 doses in 24 hours).
- Child 6 months-2 years: 120 mg every 4-6 hours (maximum 4 doses in 24 hours).
- Child 2-4 years: 180 mg every 4-6 hours (maximum 4 doses in 24 hours).
- Child 4-6 years: 240 mg every 4-6 hours (maximum 4 doses in 24 hours).
- Child 6-8 years: 240-250 mg every 4-6 hours (maximum 4 doses in 24 hours).
- Child 8-10 years: 360-375 mg every 4-6 hours (maximum 4 doses in 24 hours).
- Child 10-12 years: 480-500 mg every 4-6 hours (maximum 4 doses in 24 hours).
- Child 12-16 years: 480-750 mg every 4-6 hours (maximum 4 doses in 24 hours).
- Child 16-18 years: 500 mg-1 g every 4-6 hours (maximum 4 doses in 24 hours).
Non-steroidal anti-inflammatory drugs (NSAIDs)
- These are particularly useful where pain is associated with fever (especially in children over the age of 5), dental pain and for control of pain in long-term inflammatory conditions.
- They do, however, cause more gastric irritation than paracetamol and for mild-to-moderate pain, paracetamol is often preferred.
- Warn asthmatic patients/parents taking NSAIDs for the first time to watch for worsening of bronchospasm.
- Avoid aspirin in children aged under 16 due to risk of Reye's syndrome.
- The current recommended ibuprofen doses are:
- Child 1-3 months: 5 mg/kg 3-4 times daily.
- Child 3-6 months: 50 mg 3 times daily; maximum 30 mg/kg daily in 3-4 divided doses.
- Child 6 months-1 year: 50 mg 3-4 times daily; maximum 30 mg/kg daily in 3-4 divided doses.
- Child 1-4 years: 100 mg 3 times daily; maximum 30 mg/kg daily in 3-4 divided doses.
- Child 4-7 years: 150 mg 3 times daily; maximum 30 mg/kg daily in 3-4 divided doses.
- Child 7-10 years: 200 mg 3 times daily; maximum 30 mg/kg (maximum 2.4 g) daily in 3-4 divided doses.
- Child 10-12 years: 300 mg 3 times daily; maximum 30 mg/kg (maximum 2.4 g) daily in 3-4 divided doses.
- Child 12-18 years: initially 300-400 mg 3-4 times daily; increased if necessary to maximum 600 mg 4 times daily; maintenance dose of 200-400 mg 3 times daily may be adequate.
- Morphine is recommended as the first-line strong opioid for the treatment of persisting moderate-to-severe pain in children with medical illnesses.
- As when prescribing for adults, immediate-release tablets are recommended for titrating morphine dosage and also for defining the adequate dose for pain control. They should also be given for episodic or breakthrough pain.
- The oral route is usually preferable in children. Palatability, availability of oral solutions, size of tablets and frequency of dosing are important factors to consider.
- In some children alternative opioids may be given. However, switching opioids should only be considered when the administered medicine has been adequately titrated but the analgesic response is inadequate and side-effects experienced by the child are intolerable.
- There is insufficient evidence to recommend any alternative opioid in preference to morphine as the opioid of first choice.
- Fentanyl, hydromorphone, methadone and oxycodone formulations have been considered alternatives to morphine for switching in children with persisting pain.
- Intranasal fentanyl is being used in some countries, as it has been shown to be safe and also equally effective as intravenous morphine in paediatric patients with moderate-to-severe acute pain.[8, 9]
- However, in the UK fentanyl is currently licensed for usage for paediatric pain via the intravenous route but not via the intranasal route.
- The main side-effects of opioids as a class are nausea, vomiting, constipation, and drowsiness. Respiratory depression and hypotension occur in larger doses. Neonates, particularly if preterm, may be more susceptible.
- As long-term opioid use is usually associated with constipation, patients should also receive a combination of a stimulant laxative and a stool softener prophylactically.
- Doses may need to be adjusted individually according to the degree of analgesia and side-effects.
- Opioid doses should be calculated and checked with care.
- Pain associated with acute problems of the oral mucosa (eg, acute herpetic gingivostomatitis, erythema multiforme) are sometimes given benzydamine or topical anaesthetics until resolution, in addition to paracetamol or ibuprofen.
- However, there is actually little evidence for topical lidocaine's efficacy as an analgesic and in aiding oral intake in children with painful infectious mouth conditions.
- A recent study has shown that topical lidocaine is actually no more effective than a flavored gel placebo in improving oral intake in children with painful infectious mouth ulcers.
- Inhaled nitrous oxide provides useful short-term analgesia for patients undergoing painful procedures and for those who have needle phobia.
- EMLA® cream may be used to reduce the pain of venepuncture and has also been successfully used to reduce pain post-circumcision.
Controlling pain in palliative care
Whilst the same principles apply to the palliative control of pain in children as for any other condition, additional considerations apply. Care should be comprehensive and address psychological, cultural and spiritual needs. If so desired, this care should be provided at home. Remember factors such as the physical environment, attitudes and behaviours can profoundly increase or decrease children's pain. Pain management therefore relies not only on the use of pain-relieving drugs but also on practical cognitive, behavioural, physical and supportive therapies (many of these therapies can be provided by family members).
- Paracetamol or an NSAID given regularly will often make the use of opioids unnecessary.
- NSAIDs are also useful in controlling bone secondaries.
- Treatment of bone cancer pain usually requires a multidisciplinary approach, such as an orthopaedic intervention, palliative radiotherapy alongside disease-modifying treatment (chemotherapy) and supportive care (analgesic and integrative therapies).
- When reducing or stopping opioids, doses should be tapered gradually to avoid causing severe pain flare or withdrawal symptoms.
- Morphine is given by mouth as an oral solution or as standard (immediate-release') tablets regularly every four hours, the initial dose depending largely on the patient's previous treatment. Increase the next dose by 50% if the previous dose was no more effective than the preceding analgesic. Choose the lowest dose which prevents pain and consider adjuvant analgesics (eg, NSAIDs). Titrate stepwise depending on response. Omit an overnight dose if double the usual dose is given at bedtime.
- Consider rescue doses for breakthrough pain and prophylactic doses 30 minutes before a potentially painful procedure (eg, dressing changes). Use oral morphine solution or standard tablets, about one sixth of the total daily dose every four hours.
- Side-effects of opioids (eg, constipation) should be anticipated, aggressively treated and regularly reassessed.
- Once the daily requirement is established, give the total dose od or bd. If required, increase the strength of the dose, not the frequency of administration.
- Situations when the enteral route is not suitable and an alternative route (eg, subcutaneous, rectal or transdermal) should be sought include:
- Pain crisis requiring rapid titration of intravenous opioids.
- Poor absorption: vomiting, disordered gastrointestinal motility.
- Inability to comply: unconscious; severe nausea, poor swallow; risk of aspiration, medication refusal.
- Gastrointestinal pain - bowel colic pain may be reduced by loperamide or hyoscine hydrobromide sublingually. Subcutaneous hyoscine can be given via a syringe driver.
- Muscle spasm - antispasmodic agents, such as baclofen and dantrolene, can be useful although they can cause sedation and hypersalivation. Targeted treatments such as botulinum toxin, surgical intervention and intrathecal drug delivery are becoming more common.
- Neuropathic pain - a combination of integrative, rehabilitative and supportive treatments with medications such as NSAIDs, opioids, low-dose tricyclics and gabapentinoids are often given.However, there are very few trials regarding the management of neuropathic pain in children with cancer.
- Nerve compression may be reduced by a corticosteroid such as dexamethasone, which reduces oedema around the tumour, thus reducing compression.
Although children's understanding of death may vary at different times in their development, they often know when they are dying; their major concerns are frequently fear of abandonment and fear of suffering. It is important to emphasise to such children that they will be kept comfortable and that the people they love will always be with them.
Further reading and references
Harrison D, Beggs S, Stevens B; Sucrose for procedural pain management in infants. Pediatrics. 2012 Nov130(5):918-25. doi: 10.1542/peds.2011-3848. Epub 2012 Oct 8.
Stevens B, Yamada J, Lee GY, et al; Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database Syst Rev. 2013 Jan 311:CD001069. doi: 10.1002/14651858.CD001069.pub4.
Pasek TA, Huber JM; Hospitalized infants who hurt: a sweet solution with oral sucrose. Crit Care Nurse. 2012 Feb32(1):61-9. doi: 10.4037/ccn2012912.
Shah PS, Herbozo C, Aliwalas LL, et al; Breastfeeding or breast milk for procedural pain in neonates. Cochrane Database Syst Rev. 2012 Dec 1212:CD004950. doi: 10.1002/14651858.CD004950.pub3.
WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses; World Health Organization, 2012
Paracetamol: updated dosing for children to be introduced; Medicines and Healthcare products Regulatory Agency (MHRA), July 2011
Bendall JC, Simpson PM, Middleton PM; Effectiveness of prehospital morphine, fentanyl, and methoxyflurane in pediatric patients. Prehosp Emerg Care. 2011 Apr-Jun15(2):158-65. doi: 10.3109/10903127.2010.541980. Epub 2011 Feb 4.
Karlsen AP, Pedersen DM, Trautner S, et al; Safety of Intranasal Fentanyl in the Out-of-Hospital Setting: A Prospective Observational Study. Ann Emerg Med. 2013 Nov 13. pii: S0196-0644(13)01544-8. doi: 10.1016/j.annemergmed.2013.10.025.
Hopper SM, Babl FE, McCarthy M, et al; A double blind, randomised placebo controlled trial of topical 2% viscous lidocaine in improving oral intake in children with painful infectious mouth conditions. BMC Pediatr. 2011 Nov 2111:106. doi: 10.1186/1471-2431-11-106.
Hopper SM, McCarthy M, Tancharoen C, et al; Topical Lidocaine to Improve Oral Intake in Children With Painful Infectious Mouth Ulcers: A Blinded, Randomized, Placebo-Controlled Trial. Ann Emerg Med. 2014 Mar63(3):292-9. doi: 10.1016/j.annemergmed.2013.08.022. Epub 2013 Nov 7.
Tobias JD; Applications of nitrous oxide for procedural sedation in the pediatric population. Pediatr Emerg Care. 2013 Feb29(2):245-65. doi: 10.1097/PEC.0b013e318280d824.
Mujeeb S, Akhtar J, Ahmed S; Comparison of eutectic mixture of local anesthetics cream with dorsal penile nerve block using lignocaine for circumcision in infants. Pak J Med Sci. 2013 Jan29(1):27-30. doi: 10.12669/pjms.291.2944.
Basic Symptom Control in Paediatric Palliative Care; Together for Short Lives, 2013
Friedrichsdorf SJ, Nugent AP; Management of neuropathic pain in children with cancer. Curr Opin Support Palliat Care. 2013 Jun7(2):131-8. doi: 10.1097/SPC.0b013e3283615ebe.
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