Analgesia

Disclaimer These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.  Read the full CAHS Clinical disclaimer.

Aim

To guide PCH Emergency Department (ED) staff in the appropriate use of analgesia in the ED.

Background 

• Painful medical conditions and injuries in children are a common presentation to the ED.
• Pain is more challenging to diagnose and assess in children in comparison to adults and as a result, is often untreated or under treated in children.
• Sub-optimal analgesia can result in delaying a child’s recovery and increasing their risk of developing chronic pain.

Assessment

• Older children can use numerical or visual analogue scales to self-report pain.
• Physiological and behavioural parameters can be used in patients of all ages to assess pain.
• It is important to obtain an accurate history from the parent/carer on the child’s pain.
• Reassessment of pain is important after providing analgesia.
• Refer to Assessment of Acute Pain in infants, Children, and Adolescents – Clinical Practice Manual (internal WA Health only) or Pain Assessment and Management - Neonatology Guidelines (internal WA Health only)

Management

• Non-pharmacological strategies, including psychological and physical techniques, are an important adjunct to medications.
• Consider KKIND principles (Keeping Kids in No Distress) e.g. distraction techniques such as blowing bubbles, singing and storytelling are a useful adjunct to analgesic medications, especially during painful procedures.
• Analgesics should be prescribed according to pain intensity.
• Opioids should rarely be given without a simple analgesic such as paracetamol which provides adjunctive pain relief.
• Local anaesthetic and nerve blocking agents provide effective analgesia in suitable patients. Femoral nerve block should be used early and before transport of any child with a fractured femur. Refer to Femoral Nerve Block – ED Guideline
• Painful lacerations may be managed with topical local anaesthetic preparations such as adrenaline (epinephrine) + tetracaine (amethocaine) + lidocaine (lignocaine) Laceraine® gel or local anaesthetic infiltration.
• Painful oral stomatitis can be managed with lidocaine (lignocaine) viscous.

Options for commonly used analgesics for children in the ED 

Mild to moderate pain

Sucrose¹

• For minor procedures like immunisation, removal of adhesive tapes and blood tests.

Dosage:

• Preterm infant (postmenstrual age 32–40 weeks), oral 0.2–0.5 mL per procedure; maximum 2.5 mL in 24 hours.
• Birth (at term) – 1 month, oral 0.5–1 mL per procedure; maximum 5 mL in 24 hours.
• 1–18 months, oral 1–2 mL per procedure; maximum 5 mL in 24 hours if aged <3 months, or 10 mL in 24 hours if >3 months.

Administration:

Only effective when placed on the tongue. Drop one-quarter (or less) of the total dose onto the anterior of the tongue 2 minutes before starting the procedure, give the remainder of the dose incrementally throughout the procedure as required.

Onset:

Give 2 minutes prior to commencing the procedure.

Peak effect:

Time to maximal effect is approximately 2 minutes, duration of effect is approximately 5-10 minutes.²

Efficacy data in preterm infants <32 weeks postmenstrual age or infants >12 months are limited.

Monitoring:

Pre-administration and ongoing pain assessment.

Paracetamol

Precautions:

• Use adjusted body weight when calculating paracetamol dose. Refer to PCH Guidelines forDrug Dosing in Overweight and Obese Children 2 to 18 Years of Age – Medication Management Manual (internal WA Health only).
• Generally, well tolerated, however, higher than recommended doses can cause liver damage.
• Use with caution in patients with kidney or liver impairment, dehydration or chronic malnutrition

Dosage and Administration:

• Neonates refer to the Paracetamol - Neonatal Medication Monograph (internal WA Health only).
• For patients 1 month - 18 years refer to the Paracetamol Monograph – Medication Management Manual (internal WA Health only)
  
  • IV (1 month - 18 years): 15mg/kg (up to 1000mg) every 6 hours; maximum of 60mg/kg (up to 4000mg) per day
  • Oral/Rectal immediate-release (1 month - 18 years): 15mg/kg (up to 1000mg) every 4-6 hours; maximum of 60mg/kg (up to 4000mg) in 24 hours.
    • A loading dose of up to 30mg/kg orally and 40mg/kg rectally (maximum 1000mg) may be used; this must be included in the maximum daily dose.
    • For more severe pain dose may be increased to 90mg/kg/day (not to exceed 4g daily) for a maximum of 48 hours.

Onset:

Paracetamol’s onset of action is 30 minutes following oral administration.^3,4

Peak effect:

60 minutes⁵

Monitoring:

Pre-administration and ongoing pain assessment. 

Ibuprofen

Precautions:

• For dosing in overweight and obese children, refer to PCH Guidelines for Drug Dosing in Overweight and Obese Children 2 to 18 Years of Age – Medication Management Manual (internal WA Health only).
• May cause gastrointestinal upset - give with or soon after food if possible.⁷
• Use with caution in patients who suffer from dehydration, uncontrolled blood pressure or potential renal impairment and in any child with suspected bleeding diathesis or oncological condition.⁷

Dosage (oral):

3 months-18 years: 10mg/kg/dose (maximum 400 mg/dose) 8 hourly. Up to 2.4g daily may be used short term.⁶

Onset and Peak Effect:

Onset of action is within 30-60 minutes following oral administration and it reaches its peak effect at 60-120 minutes⁸ (based on adult data).

Monitoring:

Pre-administration and ongoing pain assessment.

Moderate to severe pain 

Oxycodone

Precautions:

• For dosing in overweight and obese children, refer to Guidelines for Drug Dosing in Overweight and Obese Children 2 to 18 Years of Age – Medication Management Manual (internal WA Health only).
• Oxycodone is a high-risk schedule 8 medication. Refer to Schedule 8 and Restricted Schedule 4 Medication – Medication Management Manual (internal WA Health only), for prescription, handling, administration and reporting.

Dosage and Administration (oral-immediate release):

Refer to Oxycodone Monograph – Medication Management Manual (internal WA Health only).

Moderate to severe pain

• 6 -12 months: 0.05-0.1mg/kg 4hrly
• 1 - 18 years: 0.1-0.2mg/kg 4hrly
• Initial maximum dose range is 5 to 10mg per dose.
• Note: More frequent dosing than 4 hourly is written under direction of the Acute Pain Service (APS)/Palliative Care or Oncology Consultant only and requires a clear escalation plan documented on medication chart.

Severe pain post tonsillectomy and/or adenoidectomy for obstructive sleep apnoea

• 0.05- 0.1mg/kg/dose (Max 5mg) every 6 hours when required.
• Appropriate dosage must be determined by consultant anaesthetist based on individual patient’s clinical assessment.

Onset:

15 minutes (based on adult data).¹⁰
Peak effect:

1-2 hours (based on adult data).¹⁰

Monitoring:

• Record baseline vital signs pre-administration and hourly for two hours post first dose: Respiratory rate and effort, oxygen saturation (SpO2), heart rate (HR), sedation score (UMSS) and pain intensity scores
• Monitor for respiratory depression, over-sedation and analgesic effects.

Discharge Information:

• All patients receiving oxycodone for discharge should receive a test dose 1-2 hours before discharge from ED unless approved by an ED Consultant.
• Discharge prescription quantity is restricted to around 15 to 20 doses. Repacks of 10mL, 20mL and 50mL oxycodone liquid are available at PCH.

Intranasal Fentanyl

Precautions:

• For dosing in overweight and obese children, refer to PCH Guidelines for Drug Dosing in Overweight and Obese Children 2 to 18 Years of Age – Medication Management Manual (internal WA Health only)
• Fentanyl is a high-risk schedule 8 medication. Refer to Schedule 8 and Restricted Schedule 4 Medication – Medication Management Manual (internal WA Health only), for prescription, handling, administration and reporting.
• Use with caution in patients with respiratory depression, CNS depression, epilepsy, bradyarrhythmia.

Dosage:

Refer to Fentanyl Monograph – Medication Management Manual (internal Health WA only) and the Fentanyl – Intranasal - ED Guideline.

• Children >1 year: 1.5 micrograms/kg intranasal via 1mL syringe with an atomiser attached.
• Dose may be repeated once after 5 to 10 minutes if required. Usual maximum dose is 100 micrograms due to volume limitations.

Administration:

• Fentanyl vial (100 microgram/2mL) ampoules can be used with an atomiser for intranasal route in ED under the directions of an ED physician. Refer to Fentanyl Monograph – Medication Management Manual (internal Health WA only) for administration.
• Preferred potent analgesic in patients without IV access.

Onset:

Children 3-12 years (Intranasal): 5-10 minutes.¹²

Peak effect:

Intranasal: Median: 15 to 21 minutes (based on adult data)¹²

Monitoring:

• Pre-administration and ongoing pain assessment.
• Record baseline and post dose heart rate, respiratory rate, blood pressure, temperature, oxygen saturation and level of sedation.

Morphine

Precautions:

• For dosing in overweight and obese children, refer to Guidelines for Drug Dosing in Overweight and Obese Children 2 to 18 Years of Age – Medication Management Manual (internal WA Health only).
• Morphine is a high-risk schedule 8 medication. Refer to Schedule 8 and Restricted Schedule 4 Medication – Medication Management Manual (internal WA Health only), for prescription, handling, administration and reporting.
• Use with caution in epilepsy, raised intracranial pressure, hypotension, CNS depression, hypothyroidism, adrenocortical insufficiency, acute alcoholism, hepatic impairment and myasthenia gravis.
• Consider dose reduction or avoid use in renal impairment.

Dosage:

• Neonates, refer to Morphine Sulphate – Neonatal Medication Guideline (internal WA Health only)
• Children 1 month- 18 years, refer to Morphine Monograph – Medication Management Manual (internal WA Health only)
• Intermittent IV Bolus:
  • 6-12 months: 25microg/kg/dose
  • >12 months and <40kg: 25–50microg/kg/dose
  • >40kg: 1-2mg per dose
  • Doses may be given every 15 minutes as required up to a maximum of 5 doses in 60 minutes.

Administration:

Dilute to a maximum of 5mg/mL with water for injections, OR use morphine 0.5mg/mL syringes pre-made by pharmacy and inject slowly over 4-5 minutes.

Onset:

5-10 minutes for IV administration (based on adult data).¹³

Peak effect:

20 minutes for IV administration (based on adult data).¹³

Monitoring:

Monitor for heart rate, sedation, respiratory rate, oxygen saturation and blood pressure (hypotension) 5 minutely for 15 minutes post administration post each bolus.

Nursing

• Pre-administration and ongoing pain assessment recorded on the Observation and Response Tool with additional information recorded on the Clinical Comments chart.
• Analgesia administered to a patient for moderate to severe pain will require baseline observations and post dose observations of heart rate, respiratory rate, oxygen saturations and blood pressure recorded on the Observation and Response Tool with additional information recorded on the Clinical Comments chart.
• Refer to specific ED drug administration guidelines for further nursing considerations:
  • Fentanyl – Intranasal - ED Guideline and Morphine IV – Nurse Administered - ED Guideline (internal WA Health only).
  • Morphine IV – Nurse Administered - ED Guideline (internal WA Health only).

References

1. AMH Children’s Dosing Companion (2021) Australian Medicines Handbook Pty Ltd Sucrose Updated July 2021 [Cited 28 October 2021] Available from: Sucrose - AMH Children's Dosing Companion (health.wa.gov.au)
2. IBM Micromedex 2022. Neonatal. Sucrose [Cited 3 May 2022] Available from: NeoFax® / Pediatrics Drug Monographs results - Neonatal - Mechanism Of Action/ Pharmacokinetics - Pharmacology (health.wa.gov.au)
3. AMH (2022) Australian Medicines Handbook Pty Ltd Paracetamol. Updated January 2022 [Cited 3rd May 2022] Available from: Paracetamol - Australian Medicines Handbook (health.wa.gov.au)
4. Acetaminophen Pediatric Monograph. Clinical Pharmacology [database online]. updated 2022 [cited March 2022]. In: Tampa. FL: Gold Standard, Inc. Available from: Acetaminophen Pharmacokinetics - Clinical Pharmacology (health.wa.gov.au)
5. Brown RD, Wilson JT, Kearns GL, Eichler VF, Johnson VA, Bertrand KM. Single-dose pharmacokinetics of ibuprofen and acetaminophen in febrile children. J Clin Pharmacol. 1992 Mar;32(3):231-41. doi: 10.1002/j.1552-4604.1992.tb03831.x. PMID: 1564127.
6. AMH Children’s Dosing Companion (2021) Australian Medicines Handbook Pty Ltd Ibuprofen. Updated January 2022 [Cited 3 May 2022] Available from: Ibuprofen - AMH Children's Dosing Companion (health.wa.gov.au)
7. AMH (2022) Australian Medicines Handbook Pty Ltd. Ibuprofen [Modified January 2022. Cited: 3 May 2022] Available from: Ibuprofen - Australian Medicines Handbook (health.wa.gov.au)
8. Lexicomp® Inc. Ibuprofen: Drug Information UpToDate. (2022) [Cited 5 may 2022] Available from: Ibuprofen: Drug information - UpToDate (health.wa.gov.a
9. Kokki H, Rasanen I, Reinikainen M, et al: Pharmacokinetics of oxycodone after intravenous, buccal, intramuscular and gastric administration in children. Clin Pharmacokinet 2004; 43(9):613-622. [Cited March 2022]. Available from: Pharmacokinetics of oxycodone after intravenous, buccal, intramuscular and gastric administration in children - PubMed (health.wa.gov.au)
10. Oxycodone Monograph. Clinical Pharmacology [database online]. Updated 2022 [cited March 2022]. In: Tampa. FL: Gold Standard, Inc. Available from: Oxycodone Pharmacokinetics - Clinical Pharmacology (health.wa.gov.au)
11. Finn M & Harris D: Intranasal fentanyl for analgesia in the paediatric emergency department. Emerg Med J 2010; 27(4):300-301. [Cited March 2022]. Available from: Intranasal fentanyl for analgesia in the paediatric emergency department - PubMed (health.wa.gov.au)
12. Lexicomp® Inc. Fentanyl: Drug Information UpToDate. (2022) [Cited 5 may 2022] Available from: Fentanyl: Drug information - UpToDate (health.wa.gov.au)
13. Lexicomp® Inc. Morphine: Drug Information UpToDate. (2022) [Cited 5 may 2022] Available from: Morphine: Drug information - UpToDate (health.wa.gov.au)

Reviewer/Team:	ED HOD, ED Consultants, ED CNM, ED CNS, Pharmacist	Last reviewed:	Apr 2022
		Review date:	Apr 2025
Endorsed by:	Drugs and Therapeutics Committee	Date:	May 2022

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