What is the recommended analgesia approach for pediatric patients with appendicitis?

Analgesia in Children with Appendicitis

Pediatric patients with appendicitis should receive an around-the-clock multimodal analgesic regimen including NSAIDs or acetaminophen, with intravenous opioids (morphine) for moderate-to-severe pain, administered proactively without delay for diagnostic workup. 1

Core Analgesic Approach

Multimodal analgesia is mandatory for children with appendicitis, combining scheduled non-opioid and opioid medications based on pain severity, age, and weight. 1

First-Line Analgesics

• NSAIDs or acetaminophen should be administered around-the-clock unless contraindicated, forming the foundation of pain management. 1
• Intravenous morphine is the primary opioid for moderate-to-severe pain, with initial dosing of 0.05-0.1 mg/kg (typical doses range 0.04-0.09 mg/kg based on real-world data). 2, 3
• Oral ibuprofen (5-10 mg/kg every 6-8 hours) or oral acetaminophen (15 mg/kg every 4-6 hours) can be used for mild pain or as adjuncts. 2

Regional Analgesia Considerations

• Regional blockade with local anesthetics should be considered as part of the multimodal approach, particularly for surgical cases. 1
• Ultrasound-guided bilateral rectus sheath block (RSB) before single-incision laparoscopic appendectomy significantly reduces opioid consumption (0.112 mg/kg vs 0.290 mg/kg morphine), lowers pain scores, and delays time to rescue analgesia compared to local anesthetic infiltration. 4
• RSB adds only approximately 7 minutes to anesthesia time and provides superior postoperative pain control. 4

Critical Timing Issues

Analgesia must be administered immediately upon diagnosis consideration, not delayed for imaging or surgical consultation. This addresses the widespread problem of delayed and inadequate pain management in pediatric appendicitis. 2, 3, 5, 6

Current Practice Gaps to Avoid

• Only 61% of children with suspected appendicitis receive any analgesia in Canadian emergency departments, with median time from triage to first dose being 196 minutes (over 3 hours). 2
• 43% of children receive their first analgesic only after surgical consultation, and 44% only after ultrasound completion—both represent unacceptable delays. 2
• Underdosing occurs in 14-24% of cases, particularly with morphine administration. 3
• Children are significantly less likely than adults to have pain scores documented (33% vs 75%) or receive IV morphine (28% vs 75%). 5

Developmentally Appropriate Pain Assessment

Pain assessment tools must be age-appropriate and developmentally matched to the child's cognitive abilities, with aggressive and proactive evaluation to overcome historic undertreatment. 1

• Use validated pediatric pain scales (FLACC for younger children, numerical rating scale for older children/adolescents). 1
• Document pain scores systematically—documentation increases likelihood of receiving appropriate analgesia. 5
• Children with triage pain scores >6/10 are more likely to receive analgesia (71% vs 51%), but all children with appendicitis warrant treatment regardless of initial score. 6

Dosing Principles

All analgesic dosing must be weight-based and age-appropriate, with careful titration to optimize efficacy while minimizing adverse events. 1

• Avoid the common pitfall of underdosing opioids—ensure adequate initial doses rather than multiple small increments. 3
• Monitor for opioid-induced respiratory depression, though fear of this complication should not prevent appropriate analgesia. 1
• Consider that pediatric patients may be taking other medications, requiring vigilant assessment for drug interactions. 1

Behavioral and Environmental Considerations

The emotional component of pain is particularly strong in children, requiring attention beyond pharmacologic interventions. 1

• Minimize invasive routes when possible—children fear injections, making IV or IM routes aversive. 1
• Apply behavioral techniques to address emotional suffering from absence of parents, unfamiliar surroundings, and procedural anxiety. 1
• Recognize that absence of obvious pain behavior does not mean pain is absent—proactive treatment is essential. 1

Perioperative Analgesia

For children undergoing appendectomy, continue multimodal analgesia perioperatively with regional techniques when feasible. 1

• Laparoscopic appendectomy is associated with lower postoperative pain compared to open surgery, but still requires adequate analgesia. 1, 7, 8
• Consider caudal analgesia or other regional blocks more commonly used in pediatric populations. 1
• Sedative and analgesic medications are synergistic—ensure appropriate monitoring during procedures and recovery. 1

Common Pitfalls

• Never delay analgesia pending imaging, surgical consultation, or definitive diagnosis—suspected appendicitis warrants immediate pain management. 2, 3
• Never assume that lack of pain behavior means lack of pain—children may not express pain in expected ways. 1
• Never underdose opioids due to unfounded fears—respiratory depression risk is manageable with appropriate monitoring. 1, 3
• Never use single-agent therapy when multimodal approaches are superior and recommended. 1