Pain is often under-recognised and under treated in children. It is a fundamental part of the clinical care of children in hospital, and is a duty of the ward teams. This is a summary of the most useful information in managing pain.
The palliative care team is available to help any child with a pain management problem – do not hesitate to consult the team for advice.
Examples of common painful conditions
Diagnosing the cause of pain may identify a reversible cause, and always helps in managing the pain.
Acute causes of pain
- Acute surgical abdomen
- Fracture/ acute trauma/ burns
- Acute infections – otitis media, pleuritic chest pain
- Procedures – LP, chest drain
Chronic causes of pain
- Chronic inflammatory processes – arthritis, oesophageal candida,osteomyelitis
- Cryptococcal meningitis
Take history from child and carer– position, quality, severity, timing, provoking and relieving factors, response to analgesics. Ask about behaviour changes which suggest chronic pain: decreased appetite, sleep disturbance, and lack of interest in play. Observe for evidence of pain.
Assume that a condition that would be painful for you is painful for the child.
- Facial expression- grimacing, anxiety, withdrawn, crying
- Abnormal posture - guarding a limb, sitting with head in hands, increased tone
- Abnormal movement – unusually still, restlessness, clutching at carer
- Physiological signs of pain like pallor, tachypnoea, tachycardia are not necessarily present in chronic pain
Reverse cause if possible.
Give analgesia regularly (not PRN), and by mouth rather than injection.
For painful procedures give morphine 0.2mg/kg 1 hour prior.
Non drug measures like explanation, distraction and play are useful.
In chronic pain, use the analgesic ladder which has 2 steps for children
Step 1 – for mild/moderate pain
- Paracetamol 10-15-20mg/kg 8 hourly
- Ibuprofen 5-10mg/kg 8 hourly
Step 2 – for severe pain, and pain not controlled with step 1 analgesics
Morphine liquid 1mg/ml - prescribe on the drug chart in the usual way.
Morphine is kept in the drug cupboard on Paed Special Care Ward, Oncology, Surgical ward, and in the drug store off the corridor near the annexe. If morphine requirement persists, let the palliative care team know about the child so that the carer can be taught how to give morphine 4 hourly.
- Over 1 year, dose start at 0.2mg/kg
- Under 1 year, dose start at 0.1mg/kg
- Maximum starting dose of morphine is 3mg, even for children larger than 15kg.
- In renal failure, jaundice and severe malnutrition start on 0.1mg/kg and review effect
- Reassess pain for children on morphine at least daily and increase dose by 30-50% if pain not controlled.
- Ask about constipation and prescribe bisacodyl 5mg nocte at the first sign of decreased bowel activity.
- If cause of pain resolves, decrease morphine dose by 25% every 2 days to avoid opiate withdrawal symptoms
- Using this cautious dosing schedule, adverse effects are very rare. Sedation is almost never seen unless there is renal failure. If you think a child has an adverse effect of morphine, please consult the palliative care team before stopping the drug.