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URRENT
C
OPINION
Purpose of review
This article provides a summary of recommendations for the multimodal and multidisciplinary approach to
acute pediatric pain management and highlights recent research on this topic.
Recent findings
Recent literature has focused on updating recommendations for the use of various analgesics in the
pediatric population. While codeine is no longer recommended due to increasing evidence of adverse
effects, the more liberal use of intranasal fentanyl is now encouraged because of the ease of administration
and rapid delivery. The evidence base for the use of ultrasound-guided regional nerve blocks by qualified
providers in the acute pediatric pain setting continues to grow.
Summary
The pediatric emergency medicine provider should be able to assess pain and develop individualized pain
plans by utilizing a range of nonpharmacologic and pharmacologic strategies. Knowledge of the most
recent literature and changes in recommendations for various pain medications is essential.
Keywords
acute pain, analgesia, pediatric pain management
INTRODUCTION
The majority of children who seek care in the emergency department (ED) present with complaints of
pain or may experience pain during their evaluation
and treatment [1]. The experience of pain includes
physiological, emotional, cultural, and cognitive
components [2]. Inadequate management of acute
pain can have both immediate and long-term consequences [37].
In 2001, the American Academy of Pediatrics
and the American Pain Society published a statement noting that pediatricians are responsible for
treating and eliminating pain in children whenever
possible, with the use of a multimodal and
multidisciplinary approach [8]. Additionally, the
Joint commission on Accreditation of Healthcare
Organizations began mandating the assessment
and documentation of patients pain [9]. Multiple
studies and clinical practice guidelines support
the use of validated pain assessment tools in
concert with this multimodal and multidisciplinary
approach to pain management [2,1012].
This article will review recommendations for
acute pediatric pain management from infancy
through adolescence, and highlight recent literature
on this topic.
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KEY POINTS
Pediatric pain is still under recognized and
undertreated, particularly in neonates, infants, and
children with neurocognitive disabilities, and the
consequences of inadequate pain management can be
both short-term and long-term.
The approach to acute pediatric pain management
should be multidisciplinary, including child life
specialists, parents/caregivers, nurses, and physicians,
and multimodal, with nonpharmacologic and
pharmacologic components.
employed by the childs caregiver, child life specialists, or other staff [11,1820]. Functional MRI studies provide evidence that distraction has direct pain
modulation and reduction effects by activating the
midbrain periaqueductal gray, as well as higher
cortical regions [21,22]. Children less than 57 years
are generally not yet able to understand verbal
reasoning or reassurance; distraction techniques are
likely to be of greater use [23 ]. A 2015 randomized
control trial demonstrated that children 712 years
old exposed to distraction techniques during venipuncture had a statistically significant reduction in
pain reports compared to controls [24 ].
Parental holding and strategic positioning may
also be helpful. Whereas there is no evidence to
show that the presence of family members decreases
pain, there are data to support that it may decrease
the childs anxiety and distress; thus, parents and
caregivers should be offered, although not required,
to be present for painful procedures, so long as the
parents own anxiety does not impede the childs
care [18,19,23 ]. Coaching parents about what to
expect and providing developmentally appropriate
ways for them to participate in their childs care can
be beneficial both to the child and parents [23 ].
Sucrose and non-nutritive sucking (NNS), swaddling/facilitated tucking, and skin-to-skin contact
are important analgesic methods for preterm and
full-term neonates and infants [25 ,26,27 ,28 ,29].
The use of 2430% sucrose with NNS, skin-to-skin
contact, and breastfeeding during minor procedures
have all been shown to decrease objective measures
of pain such as heart rate and crying [11]. These
methods appear to be effective only in children
under 1 year of age [30 ].
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NONPHARMACOLOGIC PAIN
MANAGEMENT
Creating an age-appropriate, child-friendly environment is an important step in minimizing anxiety
and pain in the ED [18,19]. Distraction techniques
such as bubbles, toys, pinwheels, deep breathing,
guided imagery, and technology devices can be
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NONOPIOID ANALGESICS
For mild pain, the use of nonopioid analgesics
alone may be adequate (Table 1). Commonly
used nonopioid medications include acetaminophen and nonsteroidal anti-inflammatory drugs
(NSAIDs). Due to the risk of Reyes syndrome,
aspirin is no longer routinely recommended for
young children.
Recommended
dosing for 40 kg
Considerations and
contraindications
Dosing comments
i.v.
325650 mg every
46 h; may give
up to 1000 mg in
one loading dose
p.o.
1015 mg/kg
every 46 h
p.r.
p.o.
510 mg/kg
every 68 h
Route
Acetaminophen
(paracetamol)
Ibuprofenb
200800 mg
every 68 h
p.o.
57 mg/kg
every 12 h
200400 mg
every 12 h
Same as ibuprofen
Ketorolacb
i.m./i.v.
0.251 mg/kg
every 68 h
1530 mg
every 68 h
Same as ibuprofen
Diclofenac
p.o.
1 mg/kg
every 8 h
2550 mg
every 8 h
300
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OPIOID ANALGESICS
Children with moderate-to-severe pain may require
opioid analgesics in addition to the nonopioids
(Table 2). Historically, children are less likely than
adults to receive opioids [46]. This discrepancy is
likely multifactorial and may include concerns
about the development of future opioid addiction.
Although pediatric patients may present with drugseeking behaviors, Tobias [37] noted that the incidence of addiction in patients receiving opioids for
acute pain management is exceedingly rare and
should not limit the delivery of effective analgesia
(p. 103).
All opioids can cause respiratory depression,
and, at high-enough doses, apnea. Those at higher
risk of adverse events include young infants and
children, those with altered mental status or underlying medical abnormalities, and patients using other sedating medications such as benzodiazepines
[37]. A 2012 review of all published case reports of
severe opioid-induced respiratory depression in children included the following: use of morphine in
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Recommended
dosing for <40 kgb
Recommended
dosing for 40 kg
Considerations and
contraindications
Dosing commentsc
Oxycodone
p.o.d
0.10.2 mg/kg
every 46 h
510 mg
every 46 h
Morphine
i.v.
0.050.2 mg/kg
every 14 h
210 mg
every 14 h
p.o.d
0.20.5 mg/kg
every 34 h
1520 mg
every 34 h
Hydrocodone
p.o.d
0.10.2 mg/kg
every 46 h
510 mg
every 46 h
Same as oxycodone
Same as oxycodone
Fentanyl
i.v.
0.52 mcg/kg
every 24 h
25100 mcg
every 24 h
i.n.
12 mcg/kg
50100 mcg
i.v.
0.010.015 mg/kg
every 36 h
0.21 mg
every 24 h
p.o.d
0.030.08 mg/kg
every 24 h
14 mg/dose
every 24 h
Hydromorphone
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SPECIAL CONSIDERATIONS
Patients with chronic pain or conditions causing
frequent recurrence of pain may report pain differently and may not demonstrate the same facial or
body language cues as children who do not routinely experience pain [18,23 ]. Furthermore, children with developmental disabilities may have
altered or heightened perceptions of pain and
may not be able to communicate their pain or
anxiety in a way that is readily apparent to providers
[18,23 ]. It is important to rely on parents and caregivers to identify pain and utilize modified pain
assessment tools for noncommunicating children.
Special care must be taken for children who are
on multiple medications (particularly benzodiazepines) or are at risk of respiratory insufficiency
(e.g. sleep apnea). Those with hepatic or renal disease may have impaired metabolism or clearance of
opioids and their metabolites. Patients with renal
disease may be more sensitive to adverse effects
from NSAIDs. Consultation with dosing guidelines
or a pain specialist should be considered for such
children.
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CONCLUSION
Adequate assessment and treatment of pediatric
pain requires knowledge and skill to care for patients
across a broad range of ages, developmental levels,
and communication abilities; these are essential
tasks of medical providers. A systematic approach
to pain assessment utilizing validated patientappropriate pain scales in concert with a multimodal, multidisciplinary approach to pain will allow
individualization and optimization of pain management in this population.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
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