INTRODUCTION — Assessment and management of pain are essential components of pediatric care. In children, especially young children, it can be challenging to identify the presence and severity of pain and then to treat the pain. The use of assessment tools based upon cognitive ability is important to ensure that children of all ages receive adequate pain control.
Assessment of pain and an overview of pain management in children will be reviewed here. Pain management for specific pediatric clinical settings and conditions are discussed separately:
●Neonatal pain (see "Assessment of neonatal pain" and "Prevention and treatment of neonatal pain")
●Procedural pain management and sedation (see "Procedural sedation in children outside of the operating room" and "Selection of medications for pediatric procedural sedation outside of the operating room", section on 'Sedation for painful procedures' and "Pharmacologic agents for pediatric procedural sedation outside of the operating room", section on 'Analgesic agents')
●Perioperative pain (see "Approach to the management of acute perioperative pain in infants and children" and "Pharmacologic management of acute perioperative pain in infants and children")
●The use of topical anesthetics in children (see "Clinical use of topical anesthetics in children")
●Pain management in children with sickle cell disease (see "Acute vaso-occlusive pain management in sickle cell disease")
●Chronic abdominal pain (see "Functional abdominal pain in children and adolescents: Management in primary care")
●Pain management following burn injury (see "Paradigm-based treatment approaches for management of burn pain")
●Pain in children at the end of life (see "Pediatric palliative care", section on 'Management of end-of-life symptoms')
EVALUATION — The evaluation of pediatric pain includes determining the underlying type, source and location, and severity of pain.
Types of pain — Pain can be defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage [1].
Pain can be classified as being nociceptive, neuropathic, or nociplastic [1]. Determining the type of pain helps in identifying the cause of pain, which may guide treatment choices. (See "Assessment of cancer pain", section on 'Inferred pathophysiology and treatment implications'.)
●Nociceptive pain is caused by stimulation of intact nociceptors as a result of tissue injury and inflammation (figure 1). It is divided into somatic pain with receptors in skin, soft tissue, skeletal muscle, and bone; and visceral pain with receptors in internal organs, such as the kidney and gastrointestinal tract. Somatic pain is well localized and described as sharp, aching, squeezing, stabbing, or throbbing. Visceral pain is typically poorly localized and is often described as dull, crampy, or achy.
●Neuropathic pain is caused by nerve injury (eg, resulting from compression, transection, infiltration, ischemia, or metabolic injury to the nerves). It is often described as burning, shooting, electric, or tingling.
●Nociplastic pain is a third category that is mechanistically distinct from nociceptive and neuropathic pain and that occurs without evidence of tissue or nerve damage. The mechanisms that underlie this type of pain are not well understood. It is thought that augmented central nervous system pain and sensory processing and altered pain modulation (eg, enhanced central excitability and/or diminished central inhibition) play prominent roles [2].
Source and location — Details of the primary disease may be helpful in determining the source and type of pain, which may guide management decisions.
●Cancer – Children with cancer may have nociceptive somatic pain (as defined in the preceding section) from bone metastases or tumor, nociceptive visceral pain (eg, from hepatic distention and bowel wall edema), and neuropathic pain from tumor infiltration of peripheral nerves.
●Developmental impairment – Children with severe developmental impairment have nociceptive pain that may occur acutely from fractures, urinary tract infection, or pancreatitis or chronically from gastroesophageal reflex, constipation, positioning, or spasticity. Such children are also at risk for neuropathic pain as a result of visceral hyperalgesia, central neuropathic pain, and development of peripheral neuropathic pain following surgery [3,4]. (See 'Neurologic impairment' below.)
●Procedural and postoperative somatic pain.
●Sickle cell disease – Children with sickle cell disease often have acute nociceptive pain (ie, painful crisis) due to vaso-occlusive episodes. (See "Overview of the clinical manifestations of sickle cell disease", section on 'Acute painful episodes'.)
●Chronic pain – Chronic headaches, abdominal pain, and musculoskeletal pain require a comprehensive assessment; however, it often does not stem from an organic disease process [5]. (See "Headache in children: Approach to evaluation and general management strategies" and "Chronic abdominal pain in children and adolescents: Approach to the evaluation".)
Localization of pain is also helpful in determining the etiology. There are separate topics that review the evaluation of pain in children for the following specific anatomical sites:
●Hip (see "Approach to hip pain in childhood")
●Back (see "Back pain in children and adolescents: Evaluation")
●Chest (see "Nontraumatic chest pain in children and adolescents: Approach and initial management")
●Joints (see "Evaluation of the child with joint pain and/or swelling")
●Abdomen (see "Causes of acute abdominal pain in children and adolescents" and "Chronic abdominal pain in children and adolescents: Approach to the evaluation")
Severity assessment — The goal of pain assessment is to identify pain, assess severity, and track the response to interventions. Postoperative pain management, for example, can be guided by self-reporting or with use of a pain assessment tool. Assessment of chronic pain involves identifying the frequency, duration, and severity of pain episodes. Parents and children can be asked to rate the severity of a typical episode using general categories (mild, moderate, severe) and how pain impacts daily function (attendance at school, play with friends). Pain assessment tools can be used to supplement this information.
In children, assessment of the severity of pain is performed by the following two methods [6]:
●Self-reporting
●Use of behavioral observational scales in patients who are unable to perform self-reporting
Self-reporting — Self-reporting relies upon the cognitive ability of the child to understand that his or her pain severity can be measured along a continuum [6]. In younger children, evaluation of pediatric pain typically uses age-based pain rating scales.
●Younger children (three to eight years of age) – Some children as young as three years of age are capable of quantifying their pain and translating it to a visual representation. In this age group, pain is quantified using visual analog pain scales based upon a series of faces showing an increase in distress or pain (figure 2) [7-10]. The reliability of pain assessment increases with age and the cognitive ability of the child.
●Older children (8 to 11 years of age) – Pain assessment in this age group is generally performed using visual analog tools that rate the intensity of pain on a horizontal or numeric scale (eg, 0 to 10 scale).
●Adolescents – Adolescents can rate their pain using a numerical rating scale without the use of an accessory pain assessment tool (form 1). In this age group, a description of the following components of pain usually can be obtained from the history:
•Description – Is the pain sharp, stabbing, dull, burning, or tingling?
•Location and radiation – Where does the pain start and spread to?
•Intensity – How would you rate your pain on a scale of 1 to 10?
•Duration and constancy – Is the pain steady or does it come and go?
•Frequency – How often does the pain occur?
•Factors that worsen or relieve pain – Is there anything that makes the pain better or worse?
Pain location tools — Several graphic-based pain location tools have been used to determine the location of pain in children and adolescents, including the Adolescent and Pediatric Pain Tool and the Pediatric Pain Questionnaire. These tools typically use a graphic outline of the body, and the patient is asked to "color" in the areas where he or she is experiencing pain. A systematic review of the literature reported that although the quality of the studies included was not high, overall, there was moderate evidence that these tools reliably located pain in older children (average age of patients 10 years) [11].
Observational tools — The following observational tools are used to assess pain in infants and children who are unable to self-report. These pain scales are based upon scoring facial expressions, ability to be consoled, level of interaction, limb and trunk motor responses, and verbal responses [6,12,13].
●Revised Face, Legs, Activity, Cry, Consolability (r-FLACC) tool (table 1) [14,15] – Nonverbal children
●Non-Communicating Children's Pain Checklist-Postoperative Version (NCCPC-PV) [13] – Nonverbal children
●Nursing Assessment of Pain Intensity (NAPI) – Newborn to 16 years of age
●Paediatric Pain Profile (PPP) [16,17] – Nonverbal children
●Individualized Numeric Rating Scale (INRS) [18]
In a study that compared the r-FLACC, NCCPC-PV, and NAPI assessment tools, the r-FLACC received the highest clinical utility score, followed by the NAPI [19]. Based upon the limited data, no tool can be recommended over another. It is important that each center adopt guidelines of routine assessment for the detection of pain and provide staff training in the use of the selected pain assessment tool.
Observational assessment may underestimate pain severity compared with self-reporting. This was illustrated in a study of young children (three to seven years of age) following surgery, in whom pain severity obtained by observational assessment was lower than that obtained by self-reporting [20].
Behavioral measurement of pain must also be assessed in the context of other sources of distress, such as hunger or anxiety [21]. In addition, parental response to the child's pain can impact the child's behavior.
Nonverbal children with neurologic impairment — Nonverbal children with neurologic impairment present unique challenges in evaluating the presence and severity of pain as they cannot self-report their pain. For many such children, pain can remain a frequent, recurrent problem that often remains undertreated without appropriate evaluation.
In this group of children, similar core pain behaviors are consistently identified and can be used to assess and identify pain. However, each child will display a unique set of responses and behaviors. This unique and variable expression necessitates input from a consistent care provider, often a parent, with knowledge of a child's typical behavior patterns at baseline and in response to painful and nonpainful (such as hunger) events.
Specific behaviors that are associated with pain in nonverbal children with neurologic impairment include:
●Vocalizations (crying, moaning)
●Facial expression (grimacing)
●Inability to be consoled
●Increased movement, tone and posture (arching, stiffening), and physiologic responses
●In addition, some children display atypical behaviors such as laughing, becoming withdrawn, increased aggression, or lack of facial expression
Although pain assessment tools cannot replace the input of a parent or caregiver involved with the child on a daily basis, these tools can supplement the information from the parent/caregiver and assist with monitoring by assessing severity prior to an intervention to treat pain. The pain assessment tools for nonverbal children with neurologic impairment include the r-FLACC scale and the INRS [14,18]. These scales can be individualized by indicating behaviors specific to each child, with examples provided. This ability to add specific behaviors is an important feature for children with atypical pain behaviors that are not present in the other tools.
Impact on daily life — Pain can impact participation in school, activities, sports, and relationships. Identifying this impact can then guide goals of management of chronic pain conditions. In chronic pain conditions, improvement in such areas is more meaningful than routine measurement of pain intensity.
OVERVIEW OF MANAGEMENT — The main goals of pediatric pain management are to reduce, control, and prevent pain. Management varies depending upon the type, source, severity, and duration of pain. In some cases, treating the underlying source of pain or other related symptoms, such as distress or anxiety, can relieve the symptom. Even if specific therapy is available to treat the underlying source of pain, it is important to also provide adequate therapy to relieve any pain and suffering.
General principles — General principles of pain management in children include the following [22-29]:
●Regular pain assessments should be made throughout the course of treatment; self-reports should be obtained whenever possible. If the child is not able to self-report, an appropriate validated observational tool should be used (eg, r-FLACC (table 1)). It is important to base management decisions on an accurate assessment of the child's pain. For children with chronic pain, the clinician should assess the degree to which it interferes with daily functioning (eg, participation in school and other activities). (See 'Severity assessment' above.)
●Pain management includes both nonpharmacologic and pharmacologic measures. Nonpharmacologic measures (eg, cognitive, behavioral, physical, and supportive therapies) should be provided for children undergoing painful procedures and/or those who require pharmacologic therapy.
●Oral analgesics should be used when possible to avoid painful routes of administration.
●Side effects of analgesic agents should be anticipated and treated appropriately (eg, pruritus and/or constipation with opioids).
●Adjuvant therapy can be helpful in certain clinical settings (eg, anticonvulsants for neuropathic pain, antidepressants or anxiolytics for coexisting mood disturbances). (See 'Adjuvant agents' below.)
Clinicians who care for children at risk for pain should develop a consistent approach to the management of pediatric pain that is modifiable based upon the clinical setting. Important considerations include [30]:
●Type and duration of pain
●Patient's current pain medication regimen
●Prior experience with pain medications, including adverse effects
●Parental experience and fears regarding the use of pain medications
●Previous use of nonpharmacologic interventions
●Child's coping skills
●Social, cultural, and spiritual factors
Referral — Referral to a pain specialist or palliative care team can be helpful in managing patients with pain that is chronic and/or difficult to control. For hospitalized patients, many institutions have policies in place to guide referral to inpatient pain teams. For example, pain service consultation is often automatically triggered when epidural or patient-controlled analgesia is used or for postoperative pain management.
Other reasons for referral to pain teams include assessment and management of chronic pain conditions that interfere with attendance in school and participation in activities. Pain has both a physical and psychological effect on children and parents. Social workers, child life specialists, and psychologists should be consulted to support the child and the family. Referral to palliative care teams can be particularly beneficial when pain occurs in the setting of a life-limiting condition. Such teams can assist with pain management, decision-making, and psychosocial support. (See "Pediatric palliative care".)
Nonpharmacologic interventions — Nonpharmacologic interventions for pain management include:
●Physical measures, such as massage, heat and cold stimulation, and acupuncture
●Behavioral measures, such as exercise, operant conditioning, relaxation, biofeedback, desensitization, and art and play therapy
●Cognitive measures, such as distraction, imagery, hypnosis, and psychotherapy
Nonpharmacologic measures are particularly useful in reducing stress and anxiety in children undergoing invasive procedures. In a meta-analysis of 39 randomized clinical trials evaluating various psychological interventions for needle-related procedural pain in children, distraction and hypnosis significantly reduced pain and stress [31]. (See "Procedural sedation in children outside of the operating room", section on 'Nonpharmacologic interventions'.)
PHARMACOLOGIC THERAPY
Analgesic strategy based on pain severity — The choice of analgesic medication depends upon the pain intensity and the child's response to previously administered agents:
●Mild pain – Mild pain can generally be adequately treated with acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDs) (see 'Nonopioid analgesics' below)
●Moderate to severe pain – Moderate to severe pain is generally treated with opioid agents, often in combination with nonopioid analgesics (see 'Opioids' below)
Nonopioid analgesics — Nonopioid analgesics include acetaminophen and NSAIDs. Aspirin use has declined since the 1970s because of its association with Reye syndrome.
Nonopioid analgesics are effective for treatment of mild pain; they can also be used in combination with opioids to treat moderate and severe pain.
Acetaminophen — Acetaminophen can be administered orally, rectally, or intravenously (IV). The oral dose of acetaminophen is 10 to 15 mg/kg every four to six hours (not to exceed five doses in 24 hours; maximum daily dose 75 mg/kg/day [not to exceed 4000 mg/day]). Rectal acetaminophen can be given at doses of10 to 20 mg/kg every four to six hours (not to exceed five doses in 24 hours; maximum daily dose 75 mg/kg/day [not to exceed 4000 mg/day]).
IV acetaminophen dosing is based on age and weight of the patient, as follows:
●Infants and children <2 years – 7.5 to 15 mg/kg/dose every six hours (maximum daily dose 60 mg/kg/day)
●Children ≥2 years and adolescents:
•<50 kg – 15 mg/kg/dose every six hours or 12.5 mg/kg/dose every four hours (maximum single dose 750 mg; maximum daily dose 75 mg/kg/day [not to exceed 3750 mg/day])
•≥50 kg – 1000 mg every six hours or 650 mg every four hours (maximum daily dose 4000 mg/day)
Dosing errors have been reported with use of IV acetaminophen in children [32]. This issue is discussed in a separate topic review. (See "Clinical manifestations and diagnosis of acetaminophen (paracetamol) poisoning in children and adolescents", section on 'Iatrogenic IV overdose'.)
Nonsteroidal antiinflammatory drugs — Ibuprofen is the most commonly used NSAID in children. The dose of oral ibuprofen for pain reduction is 4 to 10 mg/kg every six to eight hours (maximum daily dose 40 mg/kg/day). Other commonly used nonselective NSAIDS include ketoprofen, naproxen, indomethacin, and ketorolac (the latter is given IV and is particularly useful in the emergency department and inpatient settings). Selective cyclooxygenase-2 (COX-2) inhibitors are used less commonly in children.
Because of their antiinflammatory properties, NSAIDs may be more effective than acetaminophen for pain reduction in inflammatory conditions (eg, systemic juvenile idiopathic arthritis). (See "Systemic juvenile idiopathic arthritis: Treatment", section on 'Nonsteroidal antiinflammatory drugs'.)
Adverse events associated with NSAID use, particularly chronic use, include gastrointestinal bleeding and renal toxicity. (See "Nonselective NSAIDs: Overview of adverse effects".)
Opioids — Opioids are generally used in children with moderate or severe pain or pain that is refractory to nonopioid analgesics. They are most commonly used for pain relief following surgery or associated with specific conditions, such as sickle cell disease or cancer. (See "Management of acute perioperative pain in adults" and "Cancer pain management: General principles and risk management for patients receiving opioids" and "Acute vaso-occlusive pain management in sickle cell disease", section on 'Overview of acute pain management'.)
Opioids reduce pain by interacting with one or more of the opiate receptors in the central nervous system (table 2).
Opioid prescribing precautions — Opioid prescription requires individual expertise and systems that adequately monitor safe use so as to minimize the risks of addiction and withdrawal. When managing acute pain, opioids should be prescribed in no greater quantity than what required for the expected duration of pain. For most painful conditions unrelated to major surgery or trauma, a three-day supply is sufficient. When opioids are prescribed postoperatively, the amount prescribed should be tailored to the expected intensity and duration of pain for the specific procedure. This is discussed separately. (See "Pharmacologic management of acute perioperative pain in infants and children", section on 'Postdischarge analgesia with opioids'.)
Other considerations include informing the family/caregivers to store opioids in a safe location (ideally, in a locked cabinet) to reduce the risk of accidental overdose by other children and discourage diversion of opioids for illicit use. Unsafe practices regarding use, storage, and disposal of opioids prescribed to children are common [33,34].
Chronic pain is ideally managed by a team with expertise in all modalities of management, including nonpharmacologic and nonopioid medications, so as to minimize chronic use of opioids. When opioids are used, contracts can be drafted and signed by parents stating that they will request the medication from a single provider. The need for such steps should not be a barrier to opioid use in individuals receiving palliative care for life-limiting conditions. (See "Use of opioids in the management of chronic non-cancer pain", section on 'Opioid agreement/consent form'.)
Choice of opioid — The choice of opioid is based upon the intensity and duration of pain, preferred mode of administration, associated adverse effects, prior experience (if available), and preference of the patient and family. For children with acute pain who are opioid-naïve, short-acting agents are generally preferred over long-acting or extended-release preparations. Oral agents are used for pain of moderate severity if the patient is able to tolerate oral medication. IV opioids may be warranted for severe acute pain. For chronic severe pain, a sustained-release preparation (eg, OxyContin or transdermal fentanyl) or agents with a long half-life (eg, oral methadone) may be used.
Specific agents — A comprehensive discussion of all opioids used in the management of pain in children is beyond the scope of this topic. Commonly used agents are listed below; the initial doses and route of administrations are presented in the table (table 3) [6,30,35]. Additional information is available in Lexicomp.
●Morphine is the most commonly used opioid in children with moderate to severe pain because of its demonstrated efficacy and relative safety [30]. Morphine is available in oral, sublingual, subcutaneous, IV, rectal, and intrathecal preparations.
●Hydromorphone has similar properties to morphine but is more lipid-soluble, which may increase its potency. It also has slightly more rapid onset. Anecdotally, hydromorphone is often perceived as causing fewer side effects (eg, pruritus, gastrointestinal upset) compared with morphine; however, data supporting these advantages are generally lacking.
●Oxycodone has similar properties to morphine but is more potent and has a slightly longer half-life.
●Hydrocodone has similar potency as morphine. It is often prescribed in combination with acetaminophen (hydrocodone-acetaminophen). If this preparation is used, caregivers should be instructed not to give the child other acetaminophen-containing medications, as this can lead to acetaminophen overdose and hepatotoxicity. (See "Clinical manifestations and diagnosis of acetaminophen (paracetamol) poisoning in children and adolescents", section on 'Inappropriate dosing by a caregiver'.)
●Fentanyl has some unique properties that make it a useful opioid in pediatric pain control. IV fentanyl has a shorter onset and duration of action than morphine, which makes it particularly useful in children undergoing invasive procedures who require conscious sedation and analgesia. (See "Pharmacologic agents for pediatric procedural sedation outside of the operating room", section on 'Analgesic agents'.)
In addition, fentanyl is the only opioid that is available in a transdermal form. The fentanyl patch has a long duration of action, which provides consistent and prolonged analgesia for children with chronic severe pain who are unable to take oral medications. Fentanyl patches cannot be used as the initial opioid for pain, because of its long onset of action, and cannot be used for acute or escalating pain, because its long half-life makes it difficult to titrate drug dose.
●Methadone requires less frequent administration compared with other opioids. Methadone is also available as an elixir that can be used as an extended analgesic agent in children who are unable to swallow pills. However, titration of methadone is complicated because of its rapid distribution (half-life two to three hours), followed by its slow variable elimination (half-life 4.2 to 130 hours) that may result in drug accumulation and toxicity two to five days after initiation or an increase in dose [36].
Agents not recommended — We suggest avoiding codeine and tramadol in children <12 years because of variability in metabolism that can alter the level of active drug the child is exposed to, resulting in fatal overdoses in extreme cases [37-40]. In children ≥12 years, caution should be used in prescribing these drugs, particularly in obese patients and those with obstructive sleep apnea or severe lung disease, which may increase the risk of serious breathing problems. These drugs should not be used for management of postoperative pain following tonsillectomy and/or adenoidectomy in children of any age [41-43]. (See "Tonsillectomy (with or without adenoidectomy) in children: Postoperative care and complications", section on 'Pain'.)
In 2017, the US Food and Drug Administration issued warnings and contraindications for the use of codeine and tramadol for pain management in all children <12 years old [40]. Similar warnings regarding codeine have been issued by other agencies, including Health Canada [44] and the European Medicines Agency [45].
Metabolism of codeine and tramadol is genetically determined by the highly polymorphic enzyme P450 2D6 (CYP2D6) pathway. These drugs are ineffective in some children due to genetic polymorphisms in CYP2D6 that cause poor metabolism of the drug [46]. Of even greater concern, a small portion of children may have increased conversion to active metabolites (ultrarapid-metabolizer phenotypes), which can lead to overdose [37,38,46-49].
There have been more pediatric fatalities reported in association with codeine than with tramadol. The 2017 US Food and Drug Administration statement cited data from the adverse event reporting system from 1969 to 2015, during which time there were 64 cases reported worldwide of respiratory depression associated with codeine use in children, including 24 deaths [40]. During the same period, there were nine reported cases of respiratory depression associated with tramadol use in children, including three deaths. All three fatalities occurred outside the United States and involved tramadol oral drops, a formulation not available in the United States.
Determining which children are ultrarapid-metabolizers is difficult, making routine testing impractical. With any opioid, there is an increased chance of an overdose in overweight/obese children if dosing is based upon total body weight rather than lean mass since there is a lower distribution of morphine to fatty tissue.
Initial dosing — Dosing guidance for commonly used agents is summarized in the table (table 3). The suggested doses are appropriate for opiate-naïve patients. As a general rule, short-acting agents should be used for treatment of acute pain. The opioid dose and interval are adjusted to obtain pain relief and avoid unacceptable side effects. The required dose varies with the severity of the pain, type of pain, and preexisting opioid tolerance.
Patient-controlled analgesia — Patient-controlled analgesia is an option for adolescent and mature preadolescent children who are able to reliably assess their pain. For children who are not developmentally appropriate for patient-controlled analgesia (eg, because of young age or developmental disability), nursing-controlled analgesia with close monitoring is an option [50-52]. This is discussed separately. (See "Pharmacologic management of acute perioperative pain in infants and children", section on 'Patient-controlled analgesia in children' and "Cancer pain management with opioids: Optimizing analgesia", section on 'Patient-controlled analgesia'.)
Opioid equivalence dosing — When changing opioid agents, it is important to be familiar with equivalent analgesic dosing of the different opioids so that the desired analgesic effect can be maintained (table 3). Opioid doses generally are expressed in parenteral morphine equivalents. The unit opioid dose generally used is 10 mg of parenteral morphine, and doses of other drugs for oral or parenteral administration are listed in equianalgesic amounts.
When opioids are changed, the dose of the calculated equivalent analgesic dose of the new drug should be lowered by 25 to 50 percent and increased as needed. This avoids overmedication, which occurs due to differences in the structure of the different opioids and their affinity for the opiate receptors (ie, cross-tolerance).
Adverse effects — When treating pain with opioids, it is important to anticipate and manage their adverse effects to assure continued use. The following adverse effects of opioids and their management are discussed in greater detail separately. (See "Prevention and management of side effects in patients receiving opioids for chronic pain".)
●Nausea and vomiting
●Constipation
●Sedation and cognitive dysfunction
●Respiratory depression
●Myoclonus and hyperalgesia
●Pruritus
Use in patients with kidney or liver disease — In patients with kidney or hepatic impairment, side effects can occur more readily due to accumulation of metabolites, especially with meperidine, morphine, and tramadol. As previously discussed, tramadol is not recommended in pediatric patients regardless of kidney and liver function. (See 'Agents not recommended' above.)
In patients with impaired kidney function, fentanyl, hydromorphone, and methadone are considered the safest opioids; oxycodone and morphine should be avoided or used with caution [53,54]. (See "Cancer pain management with opioids: Optimizing analgesia", section on 'Patients with kidney impairment'.)
Adjuvant agents — Adjuvant therapy can be used in any child with pain, regardless of the intensity. It can enhance analgesic efficacy, treat concurrent symptoms, and/or provide independent analgesic activity for specific types of pain. Adjuvant therapy is particularly helpful for neuropathic pain and chronic pain, including in children with cancer or with severe neurologic impairment. Consultation with a pain specialist or palliative care team can assist with use of these medications.
Adjuvant therapy in children includes the following classes of drugs, which are discussed in greater detail separately (see "Cancer pain management: Role of adjuvant analgesics (coanalgesics)"):
●Antidepressants for neuropathic pain (eg, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants)
●Anticonvulsants for neuropathic pain (gabapentin, carbamazepine)
●Glucocorticoids for hepatic distention and cerebral edema
●Bisphosphonates for bone pain due to tumor
●Radiation therapy for bone pain due to tumor
PAIN MANAGEMENT IN SPECIFIC CIRCUMSTANCES
Procedural pain — For children undergoing invasive procedures, adequate pain management is a key component to procedural success. Pain management in this setting may include nonpharmacologic measures (eg, distraction), topical or local anesthetic therapy (table 4), and/or systemic analgesic agents. Preparing the child prior to the intervention by describing the various steps can help decrease the stress and anxiety associated with the procedure. Pediatric procedural pain management is discussed in greater detail separately. (See "Procedural sedation in children outside of the operating room" and "Pharmacologic agents for pediatric procedural sedation outside of the operating room", section on 'Analgesic agents'.)
Perioperative pain — Pediatric perioperative pain management is discussed in detail separately. (See "Approach to the management of acute perioperative pain in infants and children" and "Pharmacologic management of acute perioperative pain in infants and children".)
Sickle cell disease — Management of pain in children with sickle cell disease is discussed in detail separately. (See "Acute vaso-occlusive pain management in sickle cell disease".)
Cancer — Management of chronic pain in patients with cancer is discussed in detail separately. (See "Cancer pain management: General principles and risk management for patients receiving opioids" and "Cancer pain management with opioids: Optimizing analgesia" and "Cancer pain management: Role of adjuvant analgesics (coanalgesics)".)
Functional abdominal pain — Management of functional abdominal pain in children and adolescents is discussed separately. (See "Functional abdominal pain in children and adolescents: Management in primary care", section on 'Management of symptoms'.)
Chronic headaches — Management of chronic headaches in children is discussed separately (See "Headache in children: Approach to evaluation and general management strategies", section on 'Management'.)
Burn pain — Management of pain in patients with severe burns is discussed separately. (See "Paradigm-based treatment approaches for management of burn pain".)
Neurologic impairment — Pain is a frequent and significant problem for children with neurologic impairment (eg, cerebral palsy), and it is often underrecognized and undertreated in this patient population [55]. Sources of nociceptive pain may include gastroesophageal reflux, urinary tract infection, bone fracture, hip dislocation/subluxation, dystonia, constipation, acute pancreatitis, and gallstones. In nonverbal children with neurologic impairment who present with apparent pain, an assessment for these causes is appropriate. (See "Cerebral palsy: Classification and clinical features", section on 'Chronic pain'.)
If no treatable cause is identified, an empirical trial of gabapentin therapy can be initiated. Gabapentin can be beneficial in these children because it targets visceral hyperalgesia and central neuropathic pain [3,4]. Other medications that have been used to treat chronic pain in this setting include tricyclic antidepressants, clonidine, and opioids [4,56]. Given the complexities of assessing pain in children with neurologic impairment and the need for ongoing adjustments in the care plan, often over many years, referral to a pediatric palliative care team is generally warranted.
SUMMARY AND RECOMMENDATIONS
●Evaluation – The evaluation of pediatric pain includes (see 'Evaluation' above):
•Characterizing the type of pain (nociceptive versus neuropathic) (see 'Types of pain' above)
•Identifying its source and location (see 'Source and location' above and 'Pain location tools' above)
•Assessing the severity and its psychological impact (see 'Severity assessment' above and 'Impact on daily life' above)
●Severity assessment – The approach to assessing the severity of pediatric pain depends upon the child's cognitive ability (see 'Severity assessment' above):
•Self-reporting is used in children who are able to understand and report their pain severity along a continuum (eg, visual analog scales, FACES scale (figure 2)). (See 'Self-reporting' above.)
•In infants and children who are unable to perform self-reporting, behavioral observational scales are used (eg, revised Face, Legs, Activity, Cry, Consolability [r-FLACC] tool (table 1)). It is important to recognize that parental response to the child's pain can impact the child's behavior. (See 'Observational tools' above.)
•Pain assessment in nonverbal children with neurologic impairment is challenging because they are unable to self-report. However, observational tools based on behavioral response including input from daily caregivers (eg, parents) are helpful in the assessment of pain in this group of children. (See 'Nonverbal children with neurologic impairment' above.)
●Management – The goal of pediatric pain management is to reduce, control, or prevent pain in children. Pain management varies depending upon the type, source, severity, and duration of pain. General principles of pain management in children include the following (see 'Overview of management' above):
•Regular pain assessments should be made throughout the course of treatment. (See 'Severity assessment' above.)
•Pain management includes both nonpharmacologic and pharmacologic measures. Nonpharmacologic therapy (eg, cognitive, behavioral, physical, and supportive therapies) should be provided for children undergoing painful procedures and/or those who require pharmacologic therapy. (See 'Nonpharmacologic interventions' above.)
•Mild pain can generally be adequately treated with acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDs). (See 'Nonopioid analgesics' above.)
•Moderate to severe pain is generally treated with opioid agents (eg, morphine, hydromorphone, oxycodone, hydrocodone, fentanyl, methadone) (table 3). The choice of opioid is dependent upon the intensity and duration of pain, preferred mode of administration, associated adverse effects, previous experience (if available), and preference of the patient and family. (See 'Opioids' above.)
•Oral analgesics should be used when possible to avoid painful routes of administration.
•Side effects of analgesic agents should be anticipated and treated appropriately (eg, pruritus and/or constipation with opioids). (See 'Adverse effects' above.)
•Adjuvant therapy can be helpful in certain clinical settings (eg, anticonvulsants for neuropathic pain, antidepressants or anxiolytics for coexisting mood disturbances). (See 'Adjuvant agents' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Joanne Wolfe, MD, who contributed to an earlier version of this topic review.
