Acute pain management in children

Many paediatric presentations will present with pain.  It is important that any child in pain is assessed and given appropriate analgesia.  This is our responsibility as healthcare professionals and it will aid further assessment.

Assessment

Initial assessment of pain should take place at triage.  The RCEM Clinical Effectiveness Committee standard states that the assessment and provision of analgesia should take place within 20 minutes of arrival in the Emergency Department.  Recognition of pain in children is notoriously difficult – the child may not appear distressed, the child may not be able to communicate, the child may not be able to describe the pain or even want to admit being in pain.    The assessment should include history of the presenting complaint (which may point towards a diagnosis), clinical observations and general observation of the child’s behaviour.  There is also the Wong Baker faces pain scale (figure 1) in our Paediatric ED card which can help and should be utilised.

Figure 1 – Wong Baker FACES pain scale (freely available here)

Be aware that there may be other factors causing distress to the child such as fear of unfamiliar environment, parental distress, fear of strangers, needle phobia.  Think of ways to alleviate these.

Analgesia

The analgesia prescribed should be appropriate for the level of pain the child is experiencing.

  NO PAIN MILD PAIN MODERATE PAIN SEVERE PAIN
Ladder Score 0 1-3 4-6 7-10
 

Behaviour

 

Normal Activity

No reduced movement

Happy

 

Rubbing affected area

Decrease movement

Neutral expression

Able to play/talk normally

 

 

Protective of affected area

Reduced movement

Quiet

Complaining of pain

Consolable crying

Grimaces when affected part moved/touched

 

Defensive of affected part

No movement

Looking frightened

Complaining of a lot of pain

Inconsolable crying

Restless/Unsettled

 

Injury Example

 

Bump on the head

 

Abrasion

Small laceration

Strain / Sprain

Fracture fingers / clavicle

Sore throat

 

Small burn / scald

Fingertip injury

Fracture – elbow / forearm / ankle

Appendicitis

Testicular Torsion

Sickle cell crisis

 

Large Burn

Fracture long bone – humerus / femur / tibia

Dislocation of large joint

Appendicitis

Testicular Torsion

Sickle cell crisis

 

Analgesia

Paracetamol PO/PR      Dose age dependant – see BNFc

 

 

Ibuprofen PO           Dose age dependant – see BNFc

As for Mild Pain

PLUS

Diclofenac PO/PR        Dose age dependant – see BNFc and if Ibuprofen not already given

Codeine PO                30-60mg every 6 hours when necessary; max 240mg daily; max 3days (Only in children over 12 years without Contraindications – see BNFc)

OR

Oral Morphine     Dose age dependant – see BNFc /  Intranet clinical guideline

As for Mild Pain

PLUS

Intranasal Diamorphine     Dose weight dependant – see Intranet clinical guideline

 

Followed by / OR

 

IV Morphine       Dose weight dependant – see BNFc / Intranet clinical guideline

 

Do not forget to double check the doses of medication in children, in the BNFc or on your intranet guidelines, and with another member of staff.

Ensure there are no contraindications before prescribing and administering the medication.

Think of non-pharmacological techniques to alleviate pain in combination with the medication, techniques such as play and distraction, dressings, immobilisation of a limb.

Reassessment

Moderate and severe pain should be reassessed one hour after analgesia administration.  Following re-assessment if analgesia is found to be inadequate, stronger analgesia should be used.

Procedural Pain Management

In children that require painful procedures to be undertaken, consider the different possible techniques that can be utilised and discuss with a senior doctor – Middle-grade or consultant about the best approach.

Mildly painful procedures – Blood sampling, cannulation

  • Under 1 years old – milk feed, sucrose, Over 1 years old – Ametop

Moderately painful procedures – change of dressings, suturing minor wound, reduction of small joint dislocation, stabilisation of stable fracture

  • Oral analgesia
  • Intranasal diamorphine
  • Entonox
  • Local anaesthesia* – local infiltration, regional block

Significantly painful procedures – fracture manipulation, reduction of large joint dislocation, stabilisation of unstable fracture

  • Oral analgesia
  • Intranasal diamorphine
  • Intravenous morphine
  • Entonox
  • Local anaesthesia* – local infiltration, regional block
  • Conscious sedation*

Again, do not forget to double check the doses of medication in children, in the BNFc or on your intranet guidelines, and with another member of staff.

Ensure there are no contraindications before prescribing and administering the medication.

Some of these techniques (*) require specialist training and should only be undertaken by a clinician with the appropriate competency.    

                                                                        Catrin Dyer             

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