What are the recommended analgesic and muscle relaxant for a child with an injury?

Recommended Analgesics and Muscle Relaxants for Child Injury

For pediatric injuries, the recommended first-line analgesic is acetaminophen (10-15 mg/kg every 4-6 hours) and muscle relaxants are generally not recommended as first-line therapy for most childhood injuries. 1

Analgesic Options for Children with Injuries

Non-Opioid Analgesics

• Acetaminophen (Paracetamol)

  • Dosage: 10-15 mg/kg every 4-6 hours (maximum 60 mg/kg/day) 1, 2, 3
  • Administration: Oral, rectal, or intravenous routes
  • Advantages: Excellent safety profile, no effect on platelet function
  • Best for: Mild to moderate pain, fever associated with injury

• NSAIDs (if no contraindications)

  • Ibuprofen: 10 mg/kg every 6-8 hours
  • Best for: Inflammatory pain, musculoskeletal injuries
  • Caution: Avoid with bleeding risk, renal impairment, or dehydration

Opioid Analgesics (for moderate to severe pain)

For breakthrough or severe pain that doesn't respond to non-opioid analgesics:

• Tramadol

  • Dosage: 1-1.5 mg/kg every 4-6 hours 1
  • Less respiratory depression than other opioids

• Morphine (for severe pain)

  • Dosage based on age: 1
    • <3 months: 25-50 μg/kg every 4-6 hours
    • 3-12 months: 50-100 μg/kg every 4-6 hours
    • 1-5 years: 100-150 μg/kg every 4-6 hours
  • Monitor respiratory status closely

• Fentanyl (for severe pain)

  • Dosage: 0.5-1.0 μg/kg titrated to effect 1
  • Faster onset, shorter duration than morphine
  • Useful for procedural pain

Muscle Relaxants in Pediatric Injuries

Muscle relaxants are not routinely recommended for most childhood injuries. Their use is primarily limited to specific clinical scenarios:

Specific Indications for Muscle Relaxants

1. Severe muscle spasm associated with injury

   • Consider only after failure of appropriate analgesics and non-pharmacological approaches

2. Procedural sedation for fracture reduction

   • Midazolam: 0.05-0.1 mg/kg IV (maximum 5 mg) 1
   • Has muscle relaxant properties in addition to anxiolytic effects

3. Rapid sequence intubation (if needed for severe trauma)

   • Rocuronium: 0.9-1.2 mg/kg IV 1
   • Suxamethonium (age-dependent dosing): 1
     • <1 month: 1.8 mg/kg

     • 1 month and <1 year: 2.0 mg/kg

     • 1 year and <10 years: 1.2 mg/kg

     • 10 years: 1.0 mg/kg

Pain Management Algorithm for Pediatric Injuries

1. Assess pain severity using age-appropriate pain scales

   • Mild pain (1-3/10): Acetaminophen alone
   • Moderate pain (4-6/10): Acetaminophen + NSAID (if no contraindications)
   • Severe pain (7-10/10): Add opioid analgesic

2. Consider regional anesthesia techniques for specific injuries

   • Long-acting local anesthetics for wound infiltration: 1
     • Bupivacaine 0.25%: maximum dose 1 ml/kg (2.5 mg/kg)
     • Ropivacaine 0.2%: maximum dose 1.5 ml/kg (3 mg/kg)

3. Non-pharmacological approaches (should be used alongside medications)

   • Age-appropriate distraction techniques
   • Ice application for acute injuries
   • Immobilization of injured area
   • Positioning for comfort

Important Considerations and Pitfalls

• Avoid under-treatment of pain in children, which is common due to misconceptions about pain perception in pediatric patients
• Monitor for respiratory depression when using opioids, especially in younger children
• Avoid muscle relaxants without appropriate analgesia, as this may mask pain while the child remains uncomfortable
• Be cautious with NSAIDs in dehydrated children or those with renal impairment
• Regularly reassess pain and adjust treatment accordingly
• Avoid benzodiazepines as primary analgesics - they have anxiolytic and sedative effects but minimal analgesic properties

By following this structured approach to analgesic selection and avoiding unnecessary muscle relaxants, most pediatric injuries can be managed effectively while minimizing adverse effects.