Pediatric Analgesic

Aka: Pediatric Analgesic, Analgesics in Children, Acute Pain Management in Children, Acute Pediatric Pain Management in the Emergency Department, Intranasal Analgesics in Children, Pediatric Intranasal Analgesia, Pediatric Non-Oral Analgesia, Procedural Sedation and Analgesia in Children

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II. Evaluation: Pain Rating Scales

  1. FLACC Scale (Face, Legs, Activity, Cry, Consolability Scale)
    1. Indicated for preverbal children over age 2 months
  2. Wong-Baker FACES Pain Rating Scale
    1. Reliable pain rating scale for ages 4 to 12 years old
  3. Numeric Rating Scale (adult Pain Scale)
    1. Rate pain from 0 (no pain) to 10 (worst possible pain)
    2. May be appropriate for children over age 8 years old

III. Precautions

  1. Children's pain is frequently under-treated in the emergency department
    1. Conditions are just as painful for children as they are for adults
      1. Pain transmission pathways are fully developed by 22 to 24 weeks gestation
      2. However pain inhibitory pathways are no fully developed in infants
        1. Infants may experience pain more than in older children
    2. Do not lie and do not make promises you cannot keep
    3. Empower children to pause the procedure when something is too painful
      1. Increases the pain threshold when they have the power to say stop
    4. Repeated and persistent untreated pain in children can have short and long lasting effects
      1. Short-term: Greater suffering, decreased function, increased and prolonged encounters
      2. Long-term: Procedure avoidance, heightened sensitivity and fear, lower pain thresholds, hyperalgesia
  2. Avoid Tramadol in children (risk of significant respiratory depression)
    1. Seen with Ultrarapid CYP2D6 metabolizers
    2. Avoid Tramadol use in children
    3. http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm463499.htm
  3. Avoid Codeine in children
    1. Same concern with CYP2D6 ultrarapid metabolizers
  4. Exercise caution with Hydrocodone and Oxycodone
    1. Also metabolized by CYP2D6, but issues with Codeine and Tramadol not reported with these other agents

IV. Medications: Non-Opioid Oral and IV Analgesics

  1. Acetaminophen (Tylenol)
    1. Dose: 15 mg/kg/dose (up to 650 mg) every 6 hours (max: 75 mg/kg/day up to 4000 mg/day)
  2. Ibuprofen (Children's Motrin)
    1. Dose: 10 mg/kg/dose (up to 800 mg) every 6-8 hours (max: 2400 mg/day)
    2. Avoid under age 3 to 6 months
  3. Naproxen (Children's Naprosyn, for age >2 years old)
    1. Dose: 5-7 mg/kg (up to 500 mg) every 8-12 hours (max: 1250 mg/day)
  4. Ketorolac (Toradol)
    1. Dose: 0.5 mg/kg IV or IM (up to 30 mg) every 6 hours (90 mg/day, and limit to <5 days of use)
  5. Ketamine
    1. See Procedural Sedation and Analgesia
    2. Dose: 0.1 to 0.2 mg/kg IV
      1. Pure Analgesic at this dose without the Hallucinations that occur at higher dose (0.5 mg/kg)

V. Medications: Oral Opioid Analgesics

  1. Precautions
    1. Consider Naloxone prescriptions (e.g. nasal) for accidental Overdose
  2. Oxycodone
    1. Dose: 0.05 to 0.15 mg/kg/dose (up to 5 mg) orally every 4-6 hours as needed
  3. Morphine Sulfate immediate release
    1. Start: 0.2 mg/kg (up to 5 mg) per dose orally every 4 hours as needed
    2. Range: 0.1 to 0.5 mg/kg (up to 30 mg) per dose orally every 4-6 hours as needed
  4. Hydromorphone (Dilaudid)
    1. Dosing: 0.05 mg/kg (up to 5 mg) orally every 4 to 6 hours as needed

VI. Medications: Oral Opioid Analgesic Combinations

  1. Precautions
    1. Opioids are best dosed as non-combination products (see above)
      1. Allows for maximizing use of non-Opioids with prn coverage of breakthrough pain
    2. Combination products are higher risk for overdosing Acetaminophen component
    3. Combination products limit dosing options
  2. Acetaminophen with Hydrocodone (Lortab Elixir)
    1. Replaces Acetaminophen with Codeine (which should be avoided in general)
    2. Components per 15 ml
      1. Hydrocodone 7.5 mg
      2. Acetaminophen 500 mg
    3. Dosing
      1. Age 2-3 years (12-15 kg or 27-34 lbs)
        1. Dose: 3.75 ml (0.75 tsp)
      2. Age 4-6 years (16-22 kg or 35-50 lbs)
        1. Dose: 5 ml (1 tsp)
      3. Age 7-9 years (23-31 kg or 51-69 lbs)
        1. Dose: 7.5 ml (1.5 tsp)
      4. Age 10-13 years (35-45 kg or 70-100 lbs)
        1. Dose: 10 ml (2.0 tsp)
  3. Acetaminophen with Oxycodone (Roxicet)
    1. Components
      1. Oxycodone 5 mg/5ml
      2. Acetaminophen 325 mg/5 ml
    2. Dosing
      1. Base on Oxycodone dose of 0.05 to 0.15 mg/kg/dose every 4-6 hours up to 5 mg/dose

VII. Medications: Topical Anesthetics

  1. Used prior to Laceration Repair, or pre-Phlebotomy
  2. LET Anesthesia (Lidocaine-Epinephrine-Tetracaine)
    1. Cover with Tegaderm for 20 minutes
  3. Jet Injection (J-Tip)
    1. Needle-free, high pressure, subcutaneous delivery of Buffered Lidocaine at future IV or Phlebotomy site
  4. EMLA cream
    1. Delayed onset of action (60 min) makes it less helpful in ED (better for scheduled Phlebotomy)
  5. LMX-4
    1. Liposomal Lidocaine within onset of action in 30 min (effect wanes by 60 min)
  6. Vapocoolant Sprays (e.g. Fluori-Methane spray)
    1. Replaced ethyl chloride sprays (newer agents are less volatile, less flammable)
  7. Buzzy Bee
    1. Vibrating plastic device with frozen liquid rings

VIII. Medications: Local Anesthetics

  1. See Local Skin Anesthesia (includes maximum doses)
  2. See Regional Anesthesia
  3. See Hematoma Block
  4. See Digital Block
  5. See Lidocaine Local Skin Anesthesia
  6. See Field Block
  7. See Local Anesthetic Systemic Toxicity

IX. Medications: Intranasal Analgesics and Sedatives

  1. See Intranasal Drug Delivery Route
  2. Approach
    1. Monitor for apnea and Hypoxia
      1. See Procedural Sedation and Analgesia
    2. Maximal amount that may be absorbed intranasally is 0.3 ml
    3. Typical drug delivery is via a Mucosal Atomization Device (MAD Atomizer)
      1. Device has 0.1 ml dead space (draw up extra 0.1 ml medication)
      2. Alternatives when atomizer is unavailable
        1. Slow drip into the nose via syringe
        2. Syringe with angiocatheter plastic tip with slow drips into the nose
    4. Technique
      1. Blow nose before administration (Rhinorrhea and mucous may interfere with absorption)
      2. Direct the MAD Atomizer toward the occiput or ipsilateral eye (not up)
  3. Intranasal Fentanyl
    1. Dose: 1.5 to 2 mcg/kg intranasal up to 100 mcg/dose (1/2 in each nostril) via MAD Atomizer
    2. Duration of action <20 minutes
    3. Consider in children age >2 months
  4. Intranasal Midazolam or Versed (for sedation for anxiolysis)
    1. Opioids are generally used instead (often with better effect)
    2. Dose: 0.3 to 0.5 mg/kg up to 10 mg/dose intranasal (1/2 in each nostril) using 5 mg/ml solution
    3. Onset in 3 to 5 minutes, peak effect in 10 minutes and duration 20 minutes
    4. Consider in children age >6 months
  5. Intranasal Ketamine (not in mainstream use yet as of 2022)
    1. Analgesia
      1. Ketamine 1 to 1.5 mg.kg (1/2 in each nostril)
    2. Procedural Sedation
      1. Use Ketamine 100 mg/ml if available (maximal nasal dose volume 0.5 ml)
      2. Dose: 2 to 4 mg/kg intranasally
      3. Onset of action: 10 min
      4. Duration: 15-20 min (up to 60 min)
      5. Observe for 60 min after procedure
    3. Efficacy
      1. Anecdotally not as affective as other routes of Ketamine, and Intranasal Fentanyl
      2. However prior dosing (1 mg/kg) was likely too low for Procedural Sedation
      3. Consider in children >3 months
    4. References
      1. Graudins (2015) Ann Emerg Med 65(3): 248-54 [PubMed]
      2. Nordt, Poonai and Ramiakhan in Swadron (2022) EM:Rap 22(3): 5-6

X. Medications: Intravenous Opioid Analgesics

  1. Fentanyl
    1. Dose: 1 mcg/kg IV or IM (up to 100 mcg) every 30-60 min
  2. Hydromorphone (Dilaudid)
    1. Dose: 0.015 mg/kg (up to 1 mg) every 4-6 hours
  3. Morphine Sulfate
    1. Dose: 0.1 mg/kg IV or IM (up to 15 mg) every 1-2 hours

XI. Medications: Opioid and Benzodiazepine antagonists

  1. Naloxone (Narcan) 0.1 mg mg/kg (up to 2 mg) IV, IM, SQ, ET
  2. Nalmefene
  3. Flumazenil (Romazicon)

XII. Management: Infants - General Measures

  1. Sucrose or Sweetease Pacifiers (infants)
    1. 50% solution, 2 ml on the Tongue, 2 minutes prior to procedure
    2. Offers good analgesia prior to Heel Stick
    3. Most effective in first 6 weeks of life (may be effective up to age 6 months)
    4. Haouari (1995) BMJ 310:1498-500 [PubMed]
  2. Nonnutritive sucking via Pacifier
  3. Swaddling in warm blanket
  4. Facilitated Tucking
    1. Hold infant's arms and legs flexed close to torso

XIII. Management: Children - General Measures

  1. See Childlife Specialist Measures to Calm Children
  2. See Autism (includes interaction techniques)
  3. See Procedural Sedation and Analgesia
  4. Sedation for Imaging
    1. CT Imaging
      1. Intranasal Midazolam 0.4 mg/kg (75% effective)
      2. Intranasal Ketamine 5 mg/kg AND Intranasal Midazolam 0.5 mg/kg (83% effective)
    2. MRI Imaging
      1. Midazolam 0.5 mg/kg (up to 15 mg) orally AND Diphenhydramine 1.25 mg/kg orally (40% effective, higher if age <5 years)
    3. Noninvasive procedures (e.g. Echocardiogram, VCUG)
      1. Midazolam 0.5 mg/kg orally (up to maximum 15 mg)
    4. References
      1. (2025) Procedural Sedation, Hospital Procedures Consultants
      2. Thomas (2015) J Pediatr Pharmacol Ther 20(6):418-30 +PMID: 26766932 [PubMed]

XIV. References

  1. Dannenberg in Herbert (2017) EM:Rap 17(10): 5
  2. Hipskind and Kamboj (2016) Crit Dec Emerg Med 30(10): 15-23
  3. Khetarpal and Scott (2016) Crit Dec Emerg Med 30(5): 17-23
  4. Kosoko and Tobar (2021) Crit Dec Emerg Med 35(11): 3-9

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