Pain Management In Children
ANALGESICS | COMMENTS |
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STEP 1: MILD PAIN (NON-OPIOID ± ADJUVANTS) | |
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STEP 2: MODERATE AND SEVERE PAIN (OPIOID ± NON-OPIOID ± ADJUVANT) |
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Adjuvants
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General principles in use of opioids
- Health professionals specially trained in palliative care
should supervise management of chronic pain in advanced
or incurable conditions (e.g., cancer, AIDS) - Morphine is usually the drug of choice for severe pain.
Liquid morphine is available, easy to dose, and is well
absorbed from the oral mucosae and can be dripped in the
mouth of adults and children - In continuous pain, analgesics should be given:
- By the clock (i.e. according to a regular dose schedule)
- By the patient (i.e. self-administered)
- By the mouth (i.e. as oral dose forms)
- Pain is better controlled using regular oral doses which
control pain. If pain is not controlled, increase the 24-hour
dose by 30-50%- Repeated injections are not indicated
- Consider extra doses when painful procedure is planned
and for breakthrough pain. If using breakthrough doses
regularly, then increase the regular dose! - Side effects are minor and well-manageable if careful
dosing and titration are done
Cautions on use of opioids
Opioids need to be effectively managed and administered,
considering the associated cautions and side effects below.
- Do not use opioids in severe respiratory depression and
head injury - Use with care in the following conditions
- Advanced liver disease (but can be used in hepatocellular
carcinoma when titrated as above) - Acute asthma
- Acute abdominal pain (can use while awaiting diagnostic
tests; never leave the patient in pain) - Hypothyroidism
- Renal failure (reduce starting dose and/or reduce dose
frequency) - Elderly or severely wasted patient (reduce starting dose
and/or reduce dose frequency)
- Advanced liver disease (but can be used in hepatocellular
- Use with extreme care (i.e., start with small doses and use
small incremental increases) in:- Recurrent or concurrent intake of alcohol or other CNS
depressants
- Recurrent or concurrent intake of alcohol or other CNS
Management of Side Effects of Opioids
SIDE EFFECT:Respiratory depression
- Rarely occurs if small
oral doses are used
and gradually titrated
to response - Can occur when
morphine used
parenterally - Reverse respiratory
depression using naloxone
0.4-2 mg slow IV every
2-3 minutes according to
response
Child: 0.01 mg/kg slow
IV; repeat 0.1 mg/kg if no
response
Constipation
- Give Bisacodyl 10-15 mg
nocte to prevent constipation
except if diarrhoea is present
Child: 5 mg rectally - Add liquid paraffin 10 ml
once a day if bisacodyl is not
enough
Nausea or Vomiting
- Usually occurs in first 5 days
and is self-limiting - Vomiting later on may be due
to another cause - Give anti-emetic (e.g.
metoclopramide 10 mg
every 8 hours for 3–5 days)
Child 9-18 yrs: 5 mg 8 hourly
Child 5-9 yrs: 2.5 mg 8 hourly
Child 3-9 yrs: 2-2.5 mg 8
hourly
Child 1-3 yrs: 1 mg 8 hourly
Child <1 yr: 100 micrograms
per kg every 12 hours
Confusion or
Drowsiness
- If excessive continuous
drowsiness, titrate the opioid
dose down slowly
Referral criteria
- If pain does not respond to above measures, refer to
palliative care specialist - Refer for radiotherapy at national referral hospital for
severe bone pain not responding to above medications - Refer for surgery if the cause of pain is amenable to surgery
MANAGE AS |
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