Management of Severe Pain in an 11-Year-Old Child
For an 11-year-old with severe pain, immediately administer oral ibuprofen (5-10 mg/kg every 6-8 hours) or acetaminophen (10-15 mg/kg every 4-6 hours) as first-line treatment, and do not delay analgesia while pursuing a diagnosis. 1
Immediate Assessment and Action
First-Line Pharmacologic Management
- Administer oral NSAIDs (ibuprofen) immediately for mild to moderate pain if no contraindications exist such as gastrointestinal bleeding, severe dehydration, or renal disease 1, 2
- For moderate pain, both ibuprofen and acetaminophen can be used together for additive effect 2
- Maximum acetaminophen dosing is 6 caplets (650mg each) in 24 hours for children 12 years and older, with hepatotoxicity risk at >140 mg/kg/day for several days 1, 3
Escalation for Severe Pain
- If oral analgesics are insufficient for severe pain, administer intravenous opioids (morphine) in small, controlled doses using the IV route for rapid relief and titration 1
- Intranasal fentanyl is an alternative that provides faster onset than oral opioids and can be given on arrival pending IV access 2
- Avoid intramuscular route as it is painful and does not allow adequate titration 1
Critical Principle: Never Withhold Analgesia
Do not delay administering analgesics while waiting for a diagnosis—this outdated practice hinders examination without improving diagnostic accuracy. 1 Multiple pediatric and adult studies demonstrate that analgesics, including morphine, do not mask symptoms or affect diagnostic accuracy in abdominal pain 1. This is a common pitfall that leads to unnecessary suffering and can actually impair the physical examination 1.
Non-Pharmacological Adjuncts
- Apply heat (warm compresses or heating pads) to help relax muscles and reduce discomfort 4
- Use distraction techniques as a useful tool for managing pain episodes 4
- Address anxiety, as pain episodes can cause anxiety in both children and parents, which may exacerbate symptoms 4
Contraindications and Safety Considerations
NSAID Precautions
- Avoid NSAIDs if there is suspected active gastrointestinal bleeding, severe dehydration, or renal compromise 1
- Ibuprofen has antiplatelet activity and rare but recognized gastrointestinal and renal toxicity 1
Opioid Precautions
- Reserve opioids for severe pain that does not respond to non-opioids 1
- If prescribing opioids, educate on safe storage and disposal of unused medication 1
When to Refer or Escalate
- Consider referral to a pediatric specialist when pain significantly impacts daily functioning or quality of life 4, 5
- Refer if acute medication provides insufficient pain relief 5
- Warning signs requiring urgent evaluation include: constant pain lasting several weeks, spontaneous night pain, pain that repeatedly interferes with school/play/sports, marked stiffness and limitation of motion, fever, or neurologic abnormalities 6
Special Considerations by Pain Type
If Sickle Cell Disease is Known or Suspected
- Pain must be treated aggressively according to a predetermined personalized analgesic plan when possible 7
- Many uncomplicated episodes can be managed at home with oral fluids, rest, heat, oral analgesics (full doses of both mild opioid and NSAIDs), comfort measures, and distraction 7
- When home management fails, patients require rapid triage and aggressive, appropriately monitored parenteral analgesia 7
- Monitor closely for acute chest syndrome, a life-threatening complication 7
If Abdominal Pain
- Administer oral non-opioid analgesics immediately with ibuprofen or acetaminophen as first-line options 1
- For severe abdominal pain, use IV opioids in small controlled doses 1