Relieving acute pain in children

14 November 2018

First published September 2014

What tools and treatment are available for acute paediatric pain management?

Intended learning outcomes

This learning module is for health visitors and other community practitioners who may need to advise parents about relieving acute pain in children. After studying this module and completing the self-assessment, you should:

  • be aware of current guidelines concerning acute paediatric pain management
  • recognise that tools are available to help assess children's pain
  • know what treatment options are available
  • gain confidence in advising parents how to relieve their children's symptoms and when to seek further medical advice.

 

About children’s pains

Merskey defines pain as an unpleasant experience which we primarily associate with tissue damage or describe in terms of such damage or both. 1Young children may lack the language needed to report pain but we can assume that the ability to experience pain is present from birth onwards 2. The physiological means to detect pain develops in utero and it has been demonstrated that neonates can display pain responses. 2,3 In fact, due to immature mechanisms that modulate pain perception, children may actually experience more pain and distress following a painful stimulus than adults.2

What is acute pain?

Acute pain is an immediate intense feeling of short duration. It usually has an identifiable cause. It has been defined as pain that subsides as healing takes place, that is to say, is of a limited duration and has a predictable end. 3 Chronic pain, on the other hand, is pain that persists beyond the expected time of healing - sometimes defined as pain lasting longer than 3 months. 4

 

Why do children experience pain?

The ability to perceive pain provides a vital means of protection. Acute pain produces a reflexive retraction from a harmful stimulus (e.g. a hot pan), helps the child detect injury or disease, makes them protect the affected  part of their body while it heals, and warns them to avoid that harmful situation in the future. Pain that persists however can cause children much distress but appears to serve no useful purpose.

 

What causes pain in children?

Pain can occur in many medical conditions, medical procedures and surgery.  

There are two main categories:

  • Nociceptive pain: This occurs when pain receptors (nociceptors) are activated by heat, cold, vibration, stretch or chemicals. It can be subdivided according to the location of the activated pain receptors into visceral (internal organs), deep somatic (ligaments, tendons, bones, blood vessels, connective tissues and muscles) or superficial somatic (skin and mucosa).
  • Neuropathic pain: This type of pain is relatively uncommon in children. It  results  from  damage or compression and dysfunction of part of the nervous system. It can be peripheral (arising from a nerve) or central (arising from the spinal cord or brain) and may cause a burning, tingling, shooting or stabbing feeling. Striking the ulnar nerve (hitting the 'funny bone') is a familiar example of neuropathic pain.

Many acute pains common in childhood are nociceptive pains associated with tissue damage and inflammation, such as those caused by infections (e.g. otitis media, pharyngitis, colds and flu), musculoskeletal injuries (e.g. sprains), dental decay and teething. Tissue damage causes the release of inflammatory mediators and induction of the enzyme cyclo-oxygenase-2 (COX-2). This enzyme is responsible for the production of  prostaglandins that increase blood flow into the damaged tissues to cause redness and swelling, and act on the nociceptors to cause pain.

Two types of nerve fibres send the pain signals from the nociceptors toward the spinal cord.2A-delta fibres have a thin myelin covering and are the most rapidly conducting of the two types. They are thought to be associated with the initial sharp, well-localized pain sensation that occurs. The smaller, unmyelinated C-fibres are thought to be associated with the lingering, poorly localized sensation that follows.

The pain signals ascend the spinal cord to the brain (see Figure 1 below) which discriminates the location, intensity and duration of the pain. The pain perceived can be affected by psychological factors, such as anxiety and fear. Pain signals are thought to be inhibited by neurochemicals through a descending pathway.

 

 

Managing children’s pain

Determining just how much pain a child is experiencing is difficult. There are three main approaches:

  • Listen to what the child says: If self­ report is possible, it is recommended as it is considered the most valid measure of pain intensity. 3,6 From 18 months of age, children begin to use words for pain, and from 3-4 years can indicate its location and describe how it feels. Using simple self-report scales showing pictures of facial expressions, or tokens representing pieces of hurt (Poker Chip Tool) can help children convey the intensity of their pain. Most children over 8 years can use a numerical (0-10) rating scale.
  • Observe the child's behaviour: Pain can produce behaviours such as crying, grimacing, guarding, reduced motion, loss of appetite and restlessness that can be useful surrogate measures of pain for children unable to self-report. Validated observational pain tools are available, including tools for cognitively impaired children.3Tool selection is made according to the child's age and development.
  • Measure physiological changes: Increases in heart rate, respiratory rate, blood pressure and sweating; and decreases in oxygen saturation can be used to infer the presence of pain together with behavioural indicators. However, using physiological measures alone is unreliable as they can be affected by disease (e.g. sepsis can increase heart rate), distress and environmental factor.

To ensure adequate pain relief, pain may need re-evaluating at regular intervals. It is therefore useful if community practitioners are familiar with some of the commonly used tools. (See below)


 

Useful tools

 


 

The only drugs that are available over the counter for relieving pain in children include the non-steroidal anti­ inflammatory drug (NSAID) ibuprofen and paracetamol. Both have well­ established safety profiles and similar tolerability in children. (7) Ibuprofen works by binding with COX-2 to inhibit synthesis of prostaglandins - the chemicals that mediate inflammation and pain. Paracetamol's mode of action is unclear but it is a weak inhibitor of prostaglandin synthesis.

Aspirin should not be given to children younger than 16 year of age (except when specifically advised by a doctor) due to a possible association with Reye's syndrome.

Opioids are controlled drugs and their use must be monitored by a specialist. Although community practitioners cannot prescribe opioids, they may encounter children in the community who are taking prescribed opioids following discharge from hospital. Opioids have an established role in managing pain associated with terminal illness and acute pain following trauma and surgery. They work by binding to opioid receptors in the nerves, brain and spinal cord.

Codeine (an opioid analgesic) is no longer considered suitable for children under 12 years of age or anyone under 18 years of age undergoing removal of tonsils or adenoids for obstructive sleep apnoea. Its use has been restricted following a review of adverse events and fatalities in children.8

Global guidelines

The World Health Organization (WHO) provides some evidence-based guidance on managing pain. You may be familiar with the WHO three-step analgesic ladder introduced in 1986 for cancer pain relief in adults, which guides the choice of analgesia according to whether the patient's pain is mild, moderate or severe.4,9 In 2012, the WHO published guidance on the pharmacological treatment of persisting pain in children with medical illnesses. This guidance is not intended to apply to children with acute pain, but it does offer a new two-step approach to pain management that is more appropriate for children than the three-step ladder.4 This advises either ibuprofen or paracetamol at regular intervals as a first step for mild pain. 4The WHO does not currently provide guidance concerning acute pain management. However, it is planning to produce some. 10

UK guidance

Guidance on analgesia provided by the National Institute for Health and Care Excellence (NlCE) differs from the advice issued by the WHO for children with medical illnesses. Whereas the WHO guidance suggests ibuprofen or paracetamol as suitable first-line choices only for mild pain, NICE considers ibuprofen or paracetamol suitable first-line choices for children with mild-to-moderate pain (see Figure 2, below). Furthermore, NICE advises that if the first agent does not relieve the child's pain, compliance should be checked and it should be confirmed that an appropriate dose has been given. If so, NICE advises switching to the other agent. If after switching to the second agent the child's pain persists or recurs before the next dose is due, NICE advises that alternating doses of ibuprofen and paracetamol may be considered.However, since it is usual to give paracetamol 4-6 hourly and ibuprofen 6-8 hourly (or with a minimum of 4 hours between each ibuprofen dose, if required), a simple alternating regime may not be readily apparent and great care will be required not to exceed the maximum dose of either drug in any 24-hour period. Parents may need a treatment diary to help them.

For children in primary care, NICE warns not to administer paracetamol and ibuprofen at the same time, nor to give children other analgesics. If a child is still in pain or if more than short courses of analgesics are required, NICE advises that referral to a paediatrician may be necessary, as specialist advice is required before other analgesics can be prescribed.

First-line choices

Either ibuprofen or paracetamol can be considered as first-line choices for children with mild-to-moderate pain. Oral ibuprofen suspensions (100 mg/5 ml) for short-term relief of mild-to-moderate pain are available over the counter for children aged over 3 months (and weighing more than 5 kg). Sugar- and colour-free formats are available which children can take with food or on an empty stomach. Ibuprofen can be given to relieve many of the common childhood pains, such as sore throats, headaches, muscular pain, toothache, teething pain, minor aches and sprains.Ibuprofen also provides fast and long-lasting relief from fever - a symptom which often accompanies pains that arise due to infections, such as colds and flu. Ibuprofen has the advantage of providing longer-lasting fever relief than paracetamol. 12 However, ibuprofen is not suitable for children under 3 months of age or for children with certain conditions. So for some children with mild-to-moderate pain, paracetamol may be the only available option. Community practitioners should refer to the medicine's Summary of Product Characteristics to inform any advice they give concerning individual children.

FIGURE 2 – Analgesia for mild-to-moderate pain in children11

What are the new doses?


Doses for children’s liquid paracetamol were previously defined based on three age groups:

3 months to under 1 year

2.5ml of infant paracetamol suspension, given up to four times a day 

1 year to under 6 year

5 to 10ml of infant paracetamol suspension, given up to four times a day 

6 years to 12 years

5 to 10ml of paracetamol six-plus suspension, given up to four times a day 

 

However, these old dosage recommendations are now being replaced by new ones that classify children into seven more precisely defined age groups:

 

3 months to 6 months

2.5ml of infant paracetamol suspension, given up to four times per day 

6 months to 24 months

5ml of infant paracetamol suspension, given up to four times a day 

2 years to 4 years

7.5ml of infant paracetamol suspension, given up to four times a day 

4 years to 6 years

10ml of infant paracetamol suspension, given up to four times a day 

6 years to 8 years

5ml of paracetamol six-plus suspension, given up to four times a day 

8 years to 10 years

7.5ml of paracetamol six-plus suspension, given up to four times a day 

10 years to 12 years

10ml of paracetamol six-plus suspension, given up to four times a day 

 

The existing three-dose levels can still be used by parents, although the upcoming dosing is simply more exact and easier for parents or carers to follow.

 

Ibuprofen syrup dosages for children (5ml equals 100mg)

Age

How much

3 to 5 months 
(weighing more than 5kg)

2.5ml 3 times in 24 hours

6 to 11 months

2.5ml 3 to 4 times in 24 hours

1 to 3 years

5ml 3 times in 24 hours

4 to 6 years

7.5ml 3 times in 24 hours

7 to 9 years

10ml 3 times in 24 hours

10 to 11 years

15ml 3 times in 24 hours

12 to 17 years

15 to 20ml 3 to 4 times in 24 hours

Ibuprofen tablet dosages for children

Age

How much

7 to 9 years

200mg 3 times in 24 hours

10 to 11 years

300mg 3 times in 24 hours

12 to 17 years

300 to 400mg 3 to 4 times in 24 Hours 

 

 

Successful management

Young children experience a variety of acute pain conditions associated with common childhood illnesses and injuries. As a community practitioner, you have a unique opportunity to promote the safe use of analgesic medicines within the community. These case studies offer ideas to help you advise your clients.

Situation one:

Mikey, a 3-year old, has earache. His father Sam wants to know whether to give paracetamol or ibuprofen to relieve the pain. How would you respond?

POINTS TO CONSIDER

Either paracetamol or ibuprofen can be considered for mild-to-moderate pain in children.

SUGGESTED ACTION

Using age-appropriate language, reassure Mikey that his earache should settle soon, but that in the meantime Sam can give him some medicine to take the hurt away. Provided there are no contraindications, tell Sam that he can consider giving Mikey either children's ibuprofen or paracetamol. Tell Sam to follow the medicine's instructions carefully and to consult a doctor if Mikey's symptoms do not improve within 2-3 days, or if there is a significant worsening of symptoms at any time. You could provide Sam with a simple self-report scale to help him monitor how Mikey is feeling.

Situation two:

Jessica, aged 4 months, is teething. Her carer Helen wants to know what she can do to alleviate Jessica's pain. What advice would you give?

POINTS TO CONSIDER

NICE advises parents to consider using either ibuprofen or paracetamol to relieve teething pain.13 Simple non­ pharmacological methods may be tried. Massaging the gums and biting down on objects may bring relief by producing counter-pressure against the gums.

Biting cold objects may ease the pain by numbing the gums. Teething gels are available, some of which are suitable for babies as young as 2 months.

SUGGESTED ACTION

Reassure Helen that teething symptoms are generally mild and self-limiting.

Give advice on the simple measures Helen can try to comfort her baby such as rubbing Jessica's gums with a clean finger or allowing her to bite on a clean cool object, such as a chilled teething ring. (13) If Helen wants to apply a teething gel to Jessica's gums, check it is one suitable for Jessica's age. Provided there are no contraindications, you can suggest Helen considers giving Jessica an appropriate dose of children's ibuprofen or paracetamol suspension. Remind Helen to follow the instructions for using the medicine carefully and to seek medical advice if Jessica becomes systemically unwell, as this is likely to indicate an illness unrelated to teething.

Situation three:

Leo, aged 2 years, has a painful sore throat and a raised temperature due to a cold. Cathy, his mother, wants to know if she can give Leo paracetamol and ibuprofen at the same time.

What advice would you give?

POINTS TO CONSIDER

For children in primary care, NICE warns not to administer paracetamol and ibuprofen at the same time. (11) For children with mild-to-moderate pain and/or fever, either ibuprofen or paracetamol are suitable first-line choices. However, ibuprofen has the advantage of providing longer-lasting fever relief than paracetamol. (12) If the first agent does not relieve the symptoms, provided there are no contraindications, parents can consider switching to the other agent.

SUGGESTED ACTION

Tell Cathy not to give both medicines at the same time (unless a doctor has specifically told her to do so). Explain that either of these medicines alone should relieve Leo's pain and fever. However, if she has tried giving the appropriate dosage of one of these medicines without success then (provided there are no contraindications) she can try switching to the other medicine. Remind Cathy to follow the medicine usage instructions carefully. Use of an age-appropriate pain measurement tool may help reassure Cathy of Leo's response to treatment.

 

 

Learn more about NMC revalidation here.

References

  1. MERSKEYH (1970) On the development of pain. Headache: The Journal of Head and Face Pain 10:116--123.
  2. MACINTYRE PE et al (Eds) APM: SE Working Group of the Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine (2010) Acute Pain Management: Scientific Evidence (3rd edition) ANZCA & FPM, Melbourne.
  3. ROYAL COLLEGE OF NURSING (2009) The recognition and assessment of acute pain in children: Clinical practice guidelines. London, RCN.
  4. WORLD HEALTH ORGANIZATION (2012) WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses. Geneva, WHO.
  5. WALCO GA et al (2010) Neuropathic pain in children: Special considerations. Mayo Clin Proc 85(3):S33-S41.
  6. ASSOCIATION OF PAEDIATRIC ANAESTHETISTS (2008) Good practice in postoperative and procedural pain. Available at: h ttp://www.apagbi.org.uk/sites/default/files/ APA%20Guideline%20part%201.pdf [Accessed 2 June 2014].
  7. SOUTHEY ER et al (2009) Systematic review and meta­ analysis of the clinical safety and tolerability of ibuprofen compared with paracetamol in paediatric pain and fever. Curr Med Res Opin 25(9):2207-2222.
  8. MEDICINES AND HEALTHCARE PRODUCTS REGULATORY AGENCY (2013) Codeine: Restricted use as analgesic in children and adolescents after European safety review. Drug Safety Update 6(11):S1.
  9. WORLD HEALTH ORGANIZATION (undated) WHO's cancer pain ladder for adults.Available at: http://www.who. int/cancer/ palliative/painladder/en/ [Accessed 2 June 2014].
  10. WORLD   HEALTH   ORGANIZATION   (undated) Treatment guidelines on pain.Available at: http://www.who. int/m edicines/areas/ qµalitv safetv/gµide on pain /en / [Accessed 2 June 2014].
  11. NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE (2010) Analgesia-Mild-to-moderate pain. NICE Clinical Knowledge Summaries. Available at: h ttp://cks.nice.org.uk/analgesia-mild-to-m oderate­ pain#!topicsumm arv [Accessed 2 June 2014].
  12. KELLEY MT et al (1992) Pharmacokinetics and pharmacodynarnics of ibuprofen isomers and acetaminophen in febrile children. Clin Pharmacol Ther 52(2):181-189.
  13. NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE (2009) Teething. NICE Clinical Knowledge Summaries. Available at: h ttp:// cks.nice.or g.uk/ te thing#!sc enariorecommendation [Accessed 2 June 2014].

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