Neobook — clinical reference

This clinical guideline aims to:

Key points to remember:

Children are only able to verbalise ‘pain’ at 5 years, and their self-report is still unreliable.
Know the pharmacokinetics and pharmacodynamics of the drugs that you are prescribing.
Even if patients are being starved for theatre they can get oral analgesia.

Non-pharmacological pain management strategies: physical & psychological

PHYSICAL:

PSYCHOLOGICAL:

Explanation – explain what is happening, what is about to happen, and reassure child & parent
Distraction – play, music, TV, reading

PAIN ASSESSMENT TOOLS:

Use a pain assessment tool (see below) to diagnose no pain, mild, moderate or severe pain:
- 0 = NO PAIN
- 1 - 3 = MILD pain
- 4 - 7 = MODERATE pain
- 8 - 10 = SEVERE pain
Once the assessment has been made, document the pain ‘score’ and initiate the appropriate level of treatment.

PAIN ASSESSMENT TOOL – BEHAVIOURAL: NIPS SCORE - NEONATES

PAIN ASSESSMENT TOOL - BEHAVIOURAL: FLACC SCORE - 2 MONTHS OLD – 16 YEARS

	0	1	2
Face	No particular expression or smile	Occasional grimace/frown; withdrawn or disinterest [Appears sad or worried]	Consistent grimace or frown; frequent/constant quivering chin, clenched jaw [Distressed-looking face; expression of fright or panic]
Legs	Normal position or relaxed	Uneasy, restless, tense [Occasional tremors]	Kicking, or legs drawn up [Marked increase in spasticity, constant tremors or jerking]
Activity	Lying quietly, normal position, moves easily	Squirming, shifting back and forth, tense [Mildly agitated (e.g., head back and forth, aggression); shallow, splinting respirations, intermittent sighs]	Arched, rigid, or jerking [Severe agitation head banging; shivering (not rigors); breath holding, gasping or sharp intake of breath; severe splinting]
Cry	No cry (awake or asleep)	Moans or whimpers, occasional complain [Occasional verbal outburst or grunt]	Crying steadily, screams, or sobs; frequent complaints [Repeated outbursts, constant grunting]
Consolability	Content, relaxed	Reassured by occasional touching, hugging, or "talking to"; distractible	Difficult to console or comfort [Pushing away caregiver, resisting care or comfort measures]

*Revised descriptors for children with disabilities shown in brackets.

PAIN ASSESSMENT TOOLS – SELF REPORT: > 7 YEARS OLD

PAIN MANAGEMENT ACCORDING TO SEVERITY:

See below for dosing.

MANAGEMENT OF MILD PAIN:

MANAGEMENT OF MODERATE PAIN:

Non-pharmacological pain management strategies
Simple analgesia: Paracetamol
- + NSAID: Ibuprofen
- Or Diclofenac
+ Opioid: S/L: Tilidine
- OR PO: Morphine syrup
- OR Intranasal: Fentanyl
- OR Tramadol IV

MANAGEMENT OF SEVERE PAIN:

AND ASK…?

Is the pain ongoing or expected to last > 12 hours?
Consider PCA or opioid infusion – call on-call pain anaesthetist.
Consider calling on – call pain anaesthetist to provide regional anaesthesia where appropriate.

FORMULARY:

Sucrose 25%:

Paracetamol:

NSAIDs:

Opioids:

Tilidine:
- 1mg/kg/dose 4-6 hourly. 1 drop = 2.5mg
- Weight / 2.5 = number of drops.
- Decant dose into a syringe. Don’t ‘pour’ into the child’s mouth.
Morphine:
- Per Os: Morphine syrup 0.2-0.4mg/kg/dose 4-6 hourly.
- IV: < 6 months old: Morphine 0.02mg/kg/dose
- > 6 months old: 0.04mg/kg/dose
- > 50kg: 2mg
- Can be dosed at 0.1mg/kg BUT the safety of titration is lost
- Titrate at 15 minute intervals until comfortable then dose 4-6 hourly.
Intranasal Fentanyl:
- 1^st Dose: 1.5mcg/kg
- 2^nd Dose: 0.5mcg/kg after 10 minutes
- Technique: Use 1ml syringe + MAD (Mucosal Atomiser Device)
- The patient should be reclining at 45 degrees and the syringe should be held horizontally and the contents expelled into the nares in one rapid dose.
- Do not ask patient to sniff.
- Doses of 1 mL (50 micrograms) or more should be divided between nares.
- Observe in Casualty for 20 minutes after dose.
- Suitable for discharge one hour after dose if responding appropriately
Tramadol:
- IV: 1mg/kg 4-6 hourly

MONITORING:

All patients receiving opiates MUST have the following monitored AND documented:
- Heart rate
- Oxygen saturation via CONTINUOUS saturation monitoring for 1^st 15 minutes.
- Respiratory Rate
- Level of consciousness
- Pain score
Frequency of monitoring: Observe closely for 15 minutes after administering opioid dose. Then do observations every 30 mins for the 1^st hour. Thereafter, observations can be documented 2 hourly.
There must be a nurse available to respond to the monitor, initiate management and escalate care appropriately.
Resuscitation equipment should be readily available, checked and in working order.

Paediatric Pain Management