What is the recommended approach to managing pain in pediatric patients, considering their age, weight, and medical history?

Pediatric Pain Management: Evidence-Based Approach

Implement a multimodal analgesic strategy combining non-opioid analgesics (NSAIDs, acetaminophen), regional anesthesia when appropriate, and age-appropriate non-pharmacological interventions, with opioids reserved for severe pain only. 1

Core Pharmacological Strategy

First-Line Non-Opioid Analgesics

• Administer scheduled (around-the-clock) non-opioid analgesics rather than PRN dosing to maintain therapeutic levels and prevent pain escalation 1
• Use combination therapy with acetaminophen plus NSAIDs for enhanced analgesic effect through different mechanisms of action 1, 2
• Naproxen is the preferred first-line NSAID over other selective COX-1 or COX-2 inhibitors due to established efficacy and safety profile in children 2, 3
• Ibuprofen is an acceptable alternative NSAID with dosing based on age, weight, and comorbidities 2, 3
• Never use aspirin (acetylsalicylic acid) in children due to controversial efficacy, safety concerns, and toxicity risks 2, 3

Critical Dosing Principle

• Most children receive less than one full daily dose of non-opioid analgesics, leading to inadequate pain control—ensure full therapeutic dosing throughout the pain period 1

Opioid Use Guidelines

• Reserve opioids for severe pain only, using them as adjuncts to non-opioid multimodal therapy rather than monotherapy 1
• Small titrated doses of opioids can be used safely without affecting clinical examination or neurologic assessments 2
• Minimize opioid use through aggressive non-opioid and regional anesthesia strategies to reduce adverse effects including nausea, vomiting, pruritus, and respiratory depression 1

Regional Anesthesia Integration

When to Use Regional Techniques

• Incorporate local and regional anesthesia as a cornerstone of multimodal pain management for surgical and procedural pain 1
• Ultrasound guidance should be used whenever available for peripheral nerve blocks and abdominal wall blocks (TAP, quadratus lumborum) 1
• Caudal blocks and landmark-based femoral/fascia iliaca blocks can be performed safely by experienced pediatric anesthetists when ultrasound is unavailable 1
• Single-dose dexamethasone combined with regional anesthesia reduces postoperative pain scores and adverse effects 1

Safety Considerations

• Only perform abdominal wall blocks with ultrasound guidance due to safety concerns with landmark techniques 1
• Regional blocks should only be performed by experienced pediatric anesthetists familiar with age-appropriate techniques and dosing 1

Non-Pharmacological Interventions (Essential Components)

Cognitive-Behavioral Strategies

• Implement distraction, guided imagery, and breathing interventions as these are highly effective in reducing pain and improving patient compliance 1, 2
• Engage parents as "coaches" for cognitive behavioral strategies, providing encouragement for coping mechanisms 1
• Use age-appropriate distraction techniques including audio-visual entertainment, which is highly effective in reducing anxiety and minimizing motion 1

Physical Comfort Measures

• Apply massage, heat compresses, ice packs, and repositioning as adjuncts to pharmacological therapy 1
• For infants, use comfort positioning such as skin-to-skin contact rather than restraining 4, 5
• Provide sucrose or breastfeeding for infants during painful procedures 4, 5

Procedural Pain Management (Needle Procedures)

Mandatory Four-Modality Bundle

For every elective needle procedure (blood draws, IV access, injections, vaccination), offer all four modalities every time: 4, 5

1. Topical anesthesia (e.g., lidocaine 4% cream applied 30-60 minutes before procedure)
2. Comfort positioning (skin-to-skin for infants, no restraints for older children)
3. Sucrose or breastfeeding for infants
4. Age-appropriate distraction techniques

Backup Strategies

• Nitrous oxide inhalation provides effective analgesia and anxiolysis with minimal side effects, though 20-30% failure rate exists and it's less effective under age 3 1
• Combination of topical lidocaine cream plus instant topical anesthetic refrigerant or oral sucrose is more effective than single-method approaches 1

Age-Appropriate Pain Assessment

Assessment Tools by Age

• Use validated pain scales adapted to developmental stage: 1
  • Numerical Rating Scale (NRS) for older children
  • Revised Face Legs Activity Cry Consolability (r-FLACC) scale for younger children
  • Revised Premature Infant Pain Profile (PIPP-R) for neonates
  • Faces Pain Scale-Revised (FPS-R) for children who can self-report

Assessment Frequency

• Reassess pain regularly using age-appropriate tools to adjust therapy and ensure adequate control 1
• Children's pain is frequently underestimated and inadequately treated—proactive assessment prevents this pitfall 1

Special Populations and Considerations

Postoperative Pain Management

• Up to 85% of pediatric surgical patients still experience moderate to severe postoperative pain, indicating widespread undertreatment 1
• 63% of children suffer clinically significant pain when discharged home, requiring robust discharge pain plans 1
• Inadequate pain management leads to immediate distress, delayed recovery, prolonged pain, and possibly chronic pain development 1

Institutional Requirements

• Elective major procedures should only be performed if adequate postoperative pain management can be provided, including IV administration of opioids and non-opioids in the ward 1
• Establish a basic standard of care as minimal requirement before performing complex operations in any institution 1

Common Pitfalls to Avoid

Critical Errors in Pediatric Pain Management

• Undertreatment of pain is the most significant problem—proactive use of appropriate analgesic therapy is essential, not optional 1, 6, 2
• Never assume pain management will mask symptoms or cloud mental status—pain medications make children more comfortable and facilitate examination 2
• Don't wait for pain behaviors to appear before treating—absence of obvious pain behavior doesn't mean pain is absent, especially in infants and young children 1
• Avoid fear-based underdosing of non-opioids—most children receive inadequate doses of basic analgesics 1
• Don't rely on intramuscular injections—children's fear of injections makes this route aversive and should be avoided 1

Caregiver Misconceptions

• Address parental misperceptions about analgesia risks and benefits through education, as these influence treatment decisions 1
• Recognize that emotional components of pain are particularly strong in children—absence of parents, security objects, and familiar surroundings causes significant suffering 1

When to Refer to Specialist

Refer to pediatric pain specialist when: 6, 2

• Pain significantly impacts daily functioning or quality of life
• Standard multimodal therapy provides insufficient relief
• Chronic pain develops requiring interdisciplinary rehabilitative approach
• Complex regional pain syndrome or neuropathic pain features emerge

Quality of Life and Long-Term Outcomes

• Insufficient pain management causes immediate and long-lasting behavioral changes, including increased fear and sensitivity to pain during future medical treatment 1
• Failure to implement evidence-based pain prevention and treatment is now considered inadmissible and poor standard of care 4, 5
• Adequate pain control is a fundamental right under the Convention on the Rights of the Child 1