PAIN MANAGEMENT IN CHILDREN

Pain Management In Children

ANALGESICS COMMENTS
STEP 1: MILD PAIN (NON-OPIOID ± ADJUVANTS)
  • Paracetamol 10-15
    mg/kg every 6 hours
    And/or
  • Ibuprofen 5-10 mg/
    kg every 6-8 hours (use
    only in children >3
    months)
  • Continue with step 1
    analgesics when moving to
    step 2
  • Prolonged use of high doses
    of paracetamol may cause
    liver toxicity
STEP 2: MODERATE AND SEVERE PAIN
(OPIOID ± NON-OPIOID ± ADJUVANT)
  • Morphine every 4
    hours
    1-6 months: 0.01 mg/kg
    6-12 months: 0.2 mg/kg
    1-2 years: 0.2-0.4 mg/kg
    2-12 years: 0.2-0.5 mg/
    kg (max 10 mg)

    • Increase the dose
      slowly, until pain is
      controlled
    • Increase dose by max
      50% every 24 hours
  • Codeine and tramadol are
    not used in children
  • Give Bisacodyl
    (suppository only) 5
    mg nocte to prevent
    constipation except if
    diarrhoea is present

Adjuvants

  • Amitriptyline nocte for neuropathic pain
    Child 2-12 years: 0.2-0.5 mg/kg (max 1 mg/kg or 25 mg)
  • Or Carbamazepine 5-20 mg/kg in 2-3 divided doses,
    increase gradually to avoid side effects (second line)
  • Prednisolone 1-2 mg/kg per day
  • Hyoscine
    1 month-2 years: 0.5 mg/kg every 8 hours
    2-5 years: 5 mg every 8 hours
    6-12 years: 10 mg every 8 hours
  • Diazepam for associated anxiety
    Child 1-6 years: 1 mg/day in 2-3 divided doses
    Child 6-14 years: 2-10 mg/day in 2-3 divided doses

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)
  • 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

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