What is the pediatric pain ladder?

The Pediatric Pain Ladder

The pediatric pain ladder is a stepwise approach to pain management in children that progresses from non-opioid analgesics to weak opioids and then to strong opioids, complemented by adjuvant medications, regional anesthesia techniques, and non-pharmacological interventions based on pain intensity. 1

Core Components of the Pediatric Pain Ladder

Basic Level (Mild Pain)

• Non-opioid analgesics:

  • Paracetamol (acetaminophen) - first-line for mild pain
  • NSAIDs (ibuprofen, naproxen) - when no contraindications exist
  • Metamizole (in countries where available)

• Non-pharmacological techniques:

  • Age-appropriate distraction (stories, videogames, virtual reality)
  • Cutaneous stimulation and cooling techniques
  • Comfort positioning and parental presence
  • For infants: swaddling, sucrose solutions, breastfeeding 2, 3

Intermediate Level (Moderate Pain)

• Weak opioids (added to non-opioids):

  • Tramadol - most commonly used WHO step 2 medication in pediatrics 4
  • Codeine (though increasingly avoided due to genetic metabolism variability)

• Regional anesthesia techniques:

  • Simple nerve blocks using landmark techniques
  • Topical anesthetics (EMLA, lidocaine 4% cream) applied 30-60 minutes before procedures 5, 3

Advanced Level (Severe Pain)

• Strong opioids:

  • Morphine - primary strong opioid for severe pain
  • Alternatives: hydromorphone, fentanyl, oxycodone

• Advanced regional anesthesia:

  • Ultrasound-guided nerve blocks
  • Continuous catheter techniques
  • Long-acting local anesthetics (bupivacaine, levobupivacaine, ropivacaine) 5

• Adjuvant medications:

  • Dexamethasone - shown to reduce pain scores and opioid requirements 1
  • Ketamine (low-dose) for procedural pain
  • Gabapentinoids for neuropathic pain components

Implementation Principles

Pain Assessment

• Use age-appropriate validated pain scales:
  • Infants: behavioral scales (crying, facial expression, body posture)
  • Toddlers/preschoolers: observational scales combined with simple self-report
  • School-age and older: self-report is the gold standard 6

Multimodal Approach

The European Society for Paediatric Anaesthesiology (ESPA) emphasizes that:

• Combine medications from different classes for synergistic effect
• Integrate regional anesthesia whenever possible
• Always incorporate non-pharmacological techniques
• Timely and sufficient use of non-opioid analgesics has an opioid-sparing effect 1

Common Pitfalls to Avoid

• Undertreatment: Up to 85% of pediatric patients still suffer moderate to severe postoperative pain despite advances in pain management 1
• Inappropriate scaling: Avoid using adult dosing formulas - children require weight-based dosing
• Neglecting procedural pain: Always provide preventive analgesia before painful procedures
• Failure to reassess: Pain management regimes must be evaluated using age-adapted monitoring tools and adjusted as needed 1

Special Considerations

• The ESPA Pain Ladder initiative recommends patient-tailored and procedure-specific analgesic strategies rather than a one-size-fits-all approach 1
• Inadequate pain management can lead to immediate distress, delayed recovery, and possibly development of chronic pain 1
• Early painful experiences may cause long-lasting behavioral changes and increased sensitivity to pain later in life 1, 6

The pediatric pain ladder represents a structured approach to managing pain in children that emphasizes multimodal analgesia, appropriate assessment, and prevention of pain whenever possible. Proper implementation requires consideration of the child's developmental stage, the specific procedure or condition causing pain, and available institutional resources.