Pediatric Analgesic

FLACC Scale (Face, Legs, Activity, Cry, Consolability Scale)
1. Indicated for preverbal children over age 2 months
Wong-Baker FACES Pain Rating Scale
1. Reliable pain rating scale for ages 4 to 12 years old
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

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
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
Avoid Codeine in children
1. Same concern with CYP2D6 ultrarapid metabolizers
Exercise caution with Hydrocodone and Oxycodone
1. Also metabolized by CYP2D6, but issues with Codeine and Tramadol not reported with these other agents

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)
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
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)
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)
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)

Acetaminophen with Hydrocodone (Lortab Elixir)
1. Better alternative to 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)
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
Oxycodone
1. Dose: 0.05 to 0.15 mg/kg/dose (up to 5 mg) orally every 4-6 hours as needed
Morphine Sulfate immediate release
1. Dosing: 0.1 to 0.5 mg/kg (up to 30 mg) per dose orally every 4-6 hours as needed
Hydromorphone (Dilaudid)
1. Dosing: 0.05 mg/kg (up to 5 mg) orally every 4 to 6 hours as needed

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

Intranasal Fentanyl
1. Dose: 2 mcg/kg intranasal up to 100 mcg/dose (1/2 in each nostril) via MAD Atomizer
Intranasal Versed (for sedation)
1. Opioids are generally used instead
2. Dose: 0.2 to 0.5 mg/kg up to 10 mg/dose intranasal (1/2 in each nostril) using 5 mg/ml solution
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
  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
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

Sucrose (infants)
1. 50% solution, 2 ml on the Tongue, 2 minutes prior to procedure
2. Offers good analgesia prior to Heel Stick
3. Haouari (1995) BMJ 310:1498-500 [PubMed]
Sweet-ease Pacifiers
Nonnutritive sucking via Pacifier
Swaddling in warm blanket
Facilitated Tucking
1. Hold infant's arms and legs flexed close to torso