What are the recommended medications and dosages for pain control in children?

Recommended Medications and Dosages for Pain Control in Children

For pediatric pain management, a multimodal approach using acetaminophen and ibuprofen as first-line agents is recommended, with specific weight-based dosing and appropriate monitoring for optimal pain control and safety. 1

First-Line Medications

Acetaminophen

• Dosage: 15 mg/kg per dose every 4-6 hours 1
• Maximum daily dose: 60 mg/kg/day 1
• Administration: Oral liquid formulation preferred for children
• Age considerations:
  • Under 12 years: Weight-based dosing as above
  • 12 years and older: 650 mg every 8 hours 2

Ibuprofen (NSAIDs)

• Dosage: 10 mg/kg per dose every 6-8 hours 1
• Maximum daily dose: 40 mg/kg/day 1
• Administration: Oral liquid formulation preferred for younger children
• Note: Superior to acetaminophen alone for musculoskeletal pain 3

Second-Line Medications (for moderate to severe pain)

Tramadol

• Dosage: 1-1.5 mg/kg every 4-6 hours 4, 1
• Use: When pain control is inadequate with acetaminophen and ibuprofen

Morphine (for severe pain requiring opioids)

• Dosage by age:
  • <3 months: 25-50 μg/kg every 4-6 hours 4
  • 3-12 months: 50-100 μg/kg every 4-6 hours 4
  • 1-5 years: 100-150 μg/kg every 4-6 hours 4
  • 5-18 years: 200-300 μg/kg (single dose adjusted according to response) 4

Codeine

• Dosage by age:
  • 6 to <12 years: 5 mL (1 tsp) every 4 hours 5
  • ≥12 years: 10 mL (2 tsp) every 4 hours 5
  • Maximum: 6 doses in 24 hours 5
  • Caution: Not recommended for children under 6 years 5

Patient-Controlled Analgesia (PCA) Options (with adequate monitoring)

• Morphine PCA according to institutional standards 4
• Fentanyl PCA according to institutional standards 4
• Piritramide PCA according to institutional standards 4

Regional Anesthesia Options

For wound infiltration/peripheral nerve block:

• Bupivacaine 0.25%: maximum 1 mL/kg (2.5 mg/kg) 4
• Ropivacaine 0.2%: maximum 1.5 mL/kg (3 mg/kg) 4

Adjunctive Medications

Anti-emetics (for opioid-induced nausea)

• Dexamethasone: 0.15 mg/kg every 12 hours 4
• Ondansetron: 0.15 mg/kg every 8 hours 4
• Note: Metoclopramide (0.1 mg/kg) should not be combined with tramadol or used in children <1 year 4

Pain Assessment and Monitoring

• Use age-appropriate pain scales to regularly assess pain 1
• Monitor for potential side effects:
  • Acetaminophen: Hepatotoxicity with overdose
  • NSAIDs: GI upset, potential renal effects with prolonged use
  • Opioids: Respiratory depression, constipation, nausea

Important Considerations

• Combination therapy: Acetaminophen plus ibuprofen provides superior analgesia through different mechanisms of action 1, 6
• Ibuprofen superiority: For musculoskeletal injuries, ibuprofen (10 mg/kg) provides better analgesia than acetaminophen (15 mg/kg) or codeine (1 mg/kg) 3
• Dosing accuracy: Carefully record all medication administration times to avoid exceeding maximum recommended doses 6
• Caution with codeine: Due to variable metabolism in children, codeine should be used with caution and is not recommended for children under 6 years 5

Common Pitfalls to Avoid

• Underdosing: Many dosing schedules recommend inadequate amounts of acetaminophen 7
• Overdosing: 8% of children exceed maximum recommended doses of acetaminophen and 11% exceed maximum doses of ibuprofen in 24 hours 6
• Inadequate monitoring: Failure to reassess pain after medication administration
• Monotherapy: Using only one agent when combination therapy may be more effective 1, 6