Choice of analgesics in children
Pain has often been undertreated in infants and children because of fears of respiratory depression, cardiovascular collapse, depressed levels of consciousness, and addiction with potent opioid analgesics.
Assessment of pain is also a problem in children of all ages1-3 and it is not that long since it was widely believed that neonates were incapable of feeling pain.
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Non-opioid analgesics are used ininfants and children, either alone for minor pain or as an adjunct to opioid analgesics in severe pain,4,5 (they can reduce opioid re-quirements,1,6 perhaps by up to 40%5).
Paracetamol is frequently used but it lacks any anti-inflammatory effect.
#جهاد: كيف نجمع بين قولك هذا وقولك سابقا ان باراسيتامول له تأثير ضعيف كمضاد للالتهاب؟#
NSAIDs such as ibuprofen are useful for minor pain,4,5,7 especially when associated with inflammation or trauma.
The use of aspirin is greatly restricted by its association with Reye’s syndrome.
#جهاد: وعليه يحظر استخدام الاسبرين في الاطفال والرضع#
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The opioids are still the mainstay of analgesia for moderate to severe pain in paediatric patients, and morphine is the standard against which the others are compared.
It is given intravenously for rapid relief of severe pain
(for example after burns, fractures or other injuries), and is titrated to achieve a suitable analgesic dose.4,5,7,8
Where intravenous access is not readily achievable, oral morphine may be given but its onset is slower and less predictable; some favour intranasal diamorphine as an alternative to intravenous morphine.4
Continuous intravenous morphine infusion with or without initial loading doses has become popular for postoperative pain relief,6,8 but titration of the infusion rate is necessary to achieve a balance between analgesia and respiratory depression (particular care is needed in neonates, see below).
Subcutaneous infusions of morphine have also been used,5 mostly for the relief of terminal cancer pain in children.
Intramuscular injections are painful7-10 and therefore probably only suitable for short-term use.
Fentanyl has also been widely used for short-term analgesia in surgical procedures,6-8,10,11 and other opioids such as buprenorphine, hydromorphone, oxycodone, and tramadol have been given.5
Patient-controlled analgesia using morphine has been tried in children (see below).
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Morphine has also been given to children by the epidural route;8 experience with the intrathecal route is more limited.
Other methods of opioid drug delivery of possible value in paediatric analgesia include transmucosal,6,11 nasal,4,7 and transdermal6,9 dosage.
#جهاد: بدا لي مصطلح ترانس ميوكوزال غريبا، فبحثت عنه فوجدت هذا التعريف على ويكبيديا
Transmucosal refers to the route
of administration in which the drug is diffused through the mucous
membrane.
This can refer to inhalation, nasal, sublingual, vaginal,
rectal, or ocular routes. #
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Cancer pain in children may be treated using the analgesic ladder scheme described under Cancer Pain (see below).
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Inhaled nitrous oxide and oxygen mixtures may be useful for preliminary pain relief and short, painful procedures.4,7,8,10
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Local anaesthetics are especially suitable for the management of acute pain in day-care situations.
Single injections given by the epidural route are often used to provide analgesia during and after surgery.
Continuous epidural infusions of local anaesthetics have also been used. However, simpler techniques such as wound infiltration or peripheral nerve blocks can also provide effective analgesia for some procedures and are free of the problems of lower limb weakness or urinary retention associated with caudal blocks.5,7,8,10
Application of eutectic creams (see Surface Anaesthesia, p.1866) containing lidocaine with prilocaine to intact skin, to produce surface anaesthesia, may be sufficient for some minor painful procedures in children.6-9,11
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Ketamine is used in outpatients for brief, painful procedures such as fracture reduction and to provide immobility for repair of facial lacerations in young children.11,12
The emergence reactions that limit its use in adults are less common in children,11 and can be ameliorated by benzodiazepines.7,10
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Most neonates requiring analgesia and receiving respiratory support can be managed with an infusion of morphine but in neonates who are breathing spontaneously there is a substantial risk of respiratory depression.
Morphine has been used in such neonates8 but should be limited to those under intensive care, as for example after major surgery
(see also Intensive Care, p.957).
Fentanyl citrate1 and codeine phosphate have also been used in neonates.
Sucrose and other sweet tasting solutions have been shown to reduce physiologic and behavioural indicators of stress and pain in neonates undergoing painful procedures9
although there had been some doubt expressed over whether this indicates effective analgesia.13
The American Academy of Pediatrics has suggested that oral sucrose together with other non-pharmacological methods such as swaddling should be used for minor routine procedures; topical local anaesthetics may be used for more painful procedures such as venepuncture
if time permits.
Opioids should be the basis of postoperative analgesia after major surgery in the absence of regional anaesthesia;
a rapidly acting opioid such as fentanyl is advocated, together with infiltration of the site with a local anaesthetic where time permits, for insertion of a chest drain.14
Similar recommendations for painful procedures in neonates have been made by an international consensus group.15 =======================================
The use of analgesic adjuncts (see Choice of Analgesic, above) has also been advocated in some children.16 =================================
1. American Academy of Pediatrics and Canadian Paediatric Society. Prevention and management of pain and stress in the neonate. Pediatrics 2000;105:454–61. Also available at:http://aappolicy.aappublications.org/cgi/reprint/pediatrics;105/2/454.pdf (accessed 23/06/08)
2. American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health, American Pain Society Task Force on Pain in Infants, Children, and Adolescents. The assessment and manageme nt of acute pain in infants, children, and adolescents. Pediatrics 2001; 108: 793–7. Also available at: http://pediatrics.aappublications.org/cgi/reprint/108/3/793.pdf (accessed 23/06/08)
3. Maurice SC, et al. Emergency analgesia in the paediatric population (part I): current practice and perspectives. Emerg Med J 2002; 19: 4–7.
4. British Association for Emergency Medicine. Clinical Effectiveness Committee guideline for the management of pain in children (2004). Available at: http://www.emergencymed.org.uk/BAEM/CEC/assets/cec_pain_in_children.pdf (accessed 23/06/08)
5. Morton NS. Management of postoperative pain in children. Arch Dis Child Educ Pract Ed 2007; 92: ep14–ep19.
6. Berde CB, Sethna NF. Analgesics for the treatment of pain in children. N Engl J Med 2002; 347: 1094–1103.
7. Maurice SC, et al. Emergency analgesia in the paediatric population (part II): pharmacological methods of pain relief. Emerg Med J 2002; 19: 101–5.
8. Alder Hey Royal Liverpool Children’s NHS Trust. Guidelines on the management of pain in children. 1st edn, 1998. Available at: http://painsourcebook.ca/pdfs/pps55.pdf (accessed 23/06/08)
9. Zempsky WT, et al. Relief of pain and anxiety in pediatric patients in emergency medical systems. Pediatrics 2004; 114: 1348–56.
10. Harvey AJ, Morton NS. Management of procedural pain in children. Arch Dis Child Educ Pract Ed 2007; 92: ep20–ep26.
11. Krauss B, Green SM. Sedation and analgesia for procedures in children. N Engl J Med 2000; 342: 938–45.
12. Howes MC. Ketamine for paediatric sedation/analgesia in the emergency department. Emerg Med J 2004; 21: 275–80.
13. Stevens B, et al. Sucrose for analgesia in newborn infants undergoing painful procedures. Available in The Cochrane Data-base of Systematic Reviews; Issue 3. Chichester: John Wiley; 2004 (accessed 23/06/08).
14. American Academy of Pediatrics Committee on Fetus and New-born and Section on Surgery, Canadian Paediatric Society Fetus and Newborn Committee. Prevention and management of pain in the neonate: an update. Pediatrics 2006; 118: 2231–41. Correction. ibid. 2007; 119: 425. Also available at: http://pediatrics.aappublications.org/cgi/reprint/118/5/2231.pdf (accessed 23/06/08)
15. Anand KJ; International Evidence-Based Group for Neonatal Pain. Consensus statement for the prevention and management of pain in the newborn. Arch Pediatr Adolesc Med 2001; 155: 173–80. Also available at: http://archpedi.ama-assn.org/cgi/reprint/155/2/173.pdf (accessed 23/06/08)
16. Chambliss CR, et al. The assessment and management of chronic pain in children. Paediatr Drugs 2002; 4: 737–46.
if time permits. 
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