Pain Management for a 12-Year-Old
For a 12-year-old with pain, start with paracetamol (acetaminophen) 15 mg/kg every 4-6 hours as first-line therapy, and add ibuprofen 10 mg/kg every 6-8 hours if pain persists after initial dosing. 1
First-Line: Paracetamol (Acetaminophen)
- Administer 15 mg/kg per dose every 4-6 hours, not exceeding 60 mg/kg/day or 4 grams/day (whichever is lower) 1
- The oral route is strongly preferred when the child can tolerate it 1
- Rectal administration is an option but has erratic absorption and should be used cautiously 1
- For a typical 12-year-old (approximately 40 kg), this translates to 600 mg per dose, up to 2400 mg daily 1
Second-Line: Add Ibuprofen
If paracetamol alone provides insufficient relief after the first dose, add ibuprofen rather than waiting 24-48 hours. 1
- Ibuprofen 10 mg/kg every 6-8 hours (maximum 30-40 mg/kg/day) 1
- The combination of paracetamol and ibuprofen is more effective than either agent alone and reduces overall analgesic requirements 2, 1
- For a 40 kg child, this means 400 mg ibuprofen every 6-8 hours 1
- Contraindications: renal insufficiency, gastrointestinal bleeding history, or dehydration 1
Pain Severity Algorithm
Mild pain (NRS ≤4):
- Paracetamol alone 1
Moderate pain (NRS 5-6):
- Paracetamol plus ibuprofen 1
Severe pain (NRS ≥7):
- Paracetamol plus ibuprofen, with consideration for opioid rescue 1
- Oral tramadol can be used as a weak opioid for moderate-to-severe pain 2, 1
- Intravenous fentanyl or morphine requires hospitalization with appropriate monitoring 2, 1
When to Escalate to Opioids
If pain remains uncontrolled after 24-48 hours of adequate doses of paracetamol plus ibuprofen, escalation to opioids is warranted. 1
- Oral tramadol is the preferred weak opioid for outpatient management 2, 1
- Opioids should only be administered in settings with adequate monitoring capabilities (minimum: pulse oximetry and clinical observation) 2, 1
- Prescribe laxatives routinely if opioids are used to prevent constipation 1
Critical Safety Considerations
- Acetaminophen in children 12 years and older: maximum 2 caplets every 8 hours, not exceeding 6 caplets in 24 hours, for no more than 10 days unless directed by a physician 3
- Ibuprofen and acetaminophen have similar safety profiles with notably fewer adverse events than opioids 4, 5
- Dual therapy with a nonopioid/opioid combination results in lower risk of adverse events than opioids alone 4
- NSAIDs should be avoided in dehydrated patients or those with renal/GI concerns 1
Common Pitfalls to Avoid
- Undertreatment of pain in children is a significant problem; use appropriate analgesic therapy proactively 1, 6
- Do not delay adding ibuprofen if paracetamol alone is insufficient—combination therapy is safe and more effective 2, 1
- Avoid alternating acetaminophen and ibuprofen on a scheduled basis for long-term use due to lack of safety evidence, though short trials may be appropriate 7
- Ensure adequate dosing intervals and doses are maintained—underdosing is a common cause of treatment failure 8