FRCA Notes

Analgesia in Paediatrics

The curriculum asks us to 'explain the management of post-operative pain in children', and provide 'correct postoperative pain management, including the use of regional and local anaesthetic techniques, simple analgesics, NSAIDs and opioids' in paediatric patients.

Furthermore, one should be able to calculate 'the analgesic requirements of neonates and infants'.

Resources

  • Aims of analgesic management should be to:
    • Prevent pain where it is predictable i.e. using multi-modal perioperative analgesia
    • Recognise pain using appropriate assessment tools
    • Minimise moderate-severe pain by using analgesia in a safe, effective manner
    • Continue pain control after discharge from hospital
  • Preparation for anticipated painful events
    • Adequate preparation for both children and parent as to how the procedure will be conducted
    • Provision of age- and developmentally-appropriate information about what to expect
    • Facilitate question-asking
    • Allow younger children to act out the procedure with a toy medical kit
    • Use of staff trained in psychological techniques e.g. play therapists
  • Distraction techniques e.g. interactive books, toys, bubbles, (video) games

  • Paracetamol is effective and safe, and should be considered at all stages
  • It's suitable for mild-moderate pain in combination with an NSAID, and has opioid-sparing effects for moderate-severe pain
  • A number of routes are available; PO (syrup, dispersible tablet), IV, PR

Oral paracetamol (in general)


Age Dose Frequency Max. daily dose
Neonate 28-32 weeks corrected age 10-15mg/kg 8-12hrly 30mg/kg
Neonate >32 weeks corrected age 10-15mg/kg 6-8hrly 60mg/kg
1-2 months 30-60mg 8hrly 60mg/kg
>2 months 10-15mg/kg 4-6hrly QDS

Oral paracetamol (for post-operative pain)

  • Perhaps confusingly, things are slightly different in the realms of post-operative pain:
Age 1-off dose Dose thereafter Frequency Max. daily dose
1month - 5yrs 20-30mg/kg 15-20mg/kg 4-6hrly 75mg/kg
6-11yrs 20-30mg/kg 15-20mg/kg 4-6hrly 75mg/kg or 4g
>12yrs - 1g 4-6hrly 4g

Intravenous paracetamol

  • There is a risk of paracetamol overdose when IV preparations are used, especially in small children, infants and neonates
  • There is therefore different dosing once again:
Age or wt. (kg) Dose Frequency Max. daily dose
Neonate <32 weeks 7.5mg/kg 8hrly 22.5mg/kg
Neonate >32 weeks 10mg/kg 4-6hrly 30mg/kg
≤10kg 10mg/kg 4-6hrly 30mg/kg
10-50kg 15mg/kg 4-6hrly 60mg/kg
>50kg 1g 4-6hrly 4g


  • Synergistic effect with paracetamol, providing an opioid-sparing effect of up to 30-40%
  • There is generally little difference in analgesic effectiveness between them
  • Routes include oral, rectal, IV, IM and eye drops

  • Special circumstances:
    • Generally not given until >3-6months of age
    • Tonsillectomy: must balance risk of increased post-tonsillectomy bleeding vs. benefit of better analgesia and reduced PONV
    • Asthma: presence of NSAID-induced bronchospasm in approximately 5% (i.e. less common than in adults, where the incidence is 20%)
    • Bone healing: short-term analgesic benefit may outweigh low risk, but limit use for those undergoing fusions, limb-lengthening or where there's a prior history of complicated bone healing

  • Options include:
    • Ibuprofen (PO or IV) - generally for those >3 months although BFNC does describe doses for those 1-2months
    • Diclofenac (PO, PR, IV, or eye drops) - for those >6 months
    • Ketorolac (IM or IV) - for those >6 months
    • Naproxen (PO)

'Weak' opioids

  • These drugs are generally avoided owing to issues regarding their metabolism
  • Such drugs include:
    • Codeine - not advised owing to its idiosyncratic metabolic pathways with up to 40% lacking the necessary enzyme
    • Tramadol - not licensed for those <12yrs owing to varying degree of metabolism to the O-desmethyl-tramadol metabolite, which has 200x MOP affinity vs. tramadol
    • Pethidine - not licensed for those <12yrs owing to the effects of its active metabolite norpethidine

Oral opioids

  • Morphine 0.2mg/kg PO every 2-4hrs, with a reduced dose for infants or patients with OSA
  • May be given as a TTO for rescue medication to treat 'pain at home' after painful procedures e.g. tonsillectomy, orchidopexy

  • Other opioid options include:
    • Oxycodone - for those >12yrs
    • Hydromorphone - for those >12yrs (and generally reserved for cancer pain)
    • Buprenorphine - sublingual

IV opioids

  • Fentanyl (total dose 0.5 - 1μg/kg) in divided boluses titrated to effect for acute, severe pain in fully monitored situations

  • Morphine
    • 0.1-0.2mg/kg in divided boluses titrated to effect for acute, severe pain in fully monitored situations
    • As an infusion e.g. sedation on PICU at a rate of 20-60mcg/kg/hr

  • Remifentanil
    • A bolus of 0.1-1μg/kg over 30s if required
    • A continuous infusion, usually 3-80μg/kg/hr although for older children may be up to 120μg/kg/hr

  • Other options include oxycodone, buprenorphine, alfentanil and sufentanil

PCA & NCA

  • NCAs may be used for young children not capable of using a PCA, but who need titrated analgesia
  • PCAs may be appropriate for patients >5yrs old with no motor disability and normal development

  • Morphine is the go-to drug, with a set up which might look like:
    • 10 - 20μg/kg bolus
    • Lockout of 5mins (PCA) to 20mins (NCA), although may be longer (e.g. 10 - 30mins) for younger age group
    • A low dose background infusion may be used for patients >5kg but of a younger age group, and is associated with improved sleep

  • Indications include:
    • Major surgery e.g. scoliosis correction
    • Acute sickle cell pain
    • Mucositis from cancer therapies
    • Chronic pain

  • 1 in 10,000 risk of serious harm

Sucrose

  • 20% sucrose is effective for babies having short, painful procedures

Ketamine

  • May be used for sedation inc. procedural sedation, or analgesia
  • Analgesic dose is:
    • 1 - 2mg/kg IV
    • 4 - 13mg/kg IM

ɑ2-agonists

  • Clonidine
    • 1μg/kg IV bolus in recovery
    • 1 - 2μg/kg PO

  • Dexmedetomidine
    • As an infusion of 0.2-0.5μg/kg/hr

Entonox

  • Self-administration using Entonox for those >5yrs may be suitable for short-duration painful procedures e.g. dressing changes, wound debridement