Treatment in children Disclaimer: This presentation contains information on the general principles...

Treatment in children

Disclaimer: This presentation contains information on the general principles of pain management. This presentation cannot account for individual variation among patients and cannot be considered inclusive of all proper methods of care or exclusive of other treatments. It is the responsibility of the treating physician, or health care provider, to determine the best course of treatment for the patient. Treat the Pain and its partners assume no responsibility for any injury or damage to persons or property arising out of or related to any use of these materials, or for any errors or omissions. Last updated on January 12, 2015

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Objectives

• Review methods of assessing pain in children• Discuss treatment options and dosing for children based on

the age of the child and their level of pain

Children’s Palliative Care in Africa, 2009 3

Three ways to assess pain in children

• Ask the child: FACES scale• Ask the parent or caregiver– Ask about previous exposure to pain, verbal pain

indicators, usual behavior or temperament • Observe the child: FLACC scale • The child is the best person to report their pain

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Wong-Baker FACES scale

• Use in children who can talk (usually 3 years and older)• Explain to the child that each face is for a person who feels

happy because he has no pain, or a little sad because he has a little pain, or very sad because he has a lot of pain

• Ask the child to pick one face that best describes his or her current pain intensity

• Record the number of the pain level that the child reports to make treatment decisions, follow-up, and compare between examinations

Palliative Care for HIV/AIDS and Cancer Patients in Vietnam, Basic Training Curriculum: Harvard Medical School, Centre for Palliative Care (2007)

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FLACC scale

ICPCN (2009): Adapted from Merkel et al

• Use in children less than 3 years of age or older children who can’t talk • Use it like an APGAR (Appearance, Pulse, Grimace, Activity, Respiration) score,

arriving at a score out of 10

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Practice using FLACC scale

• Samuel is 18 months old. You observe that he is withdrawn, kicking his legs, and squirming. He is constantly crying or screaming, but is calmed down by breastfeeding.

Category Score

Face

Legs

Activity

CryConsolability

Total

Score

1

Score

1

2

Score

1

2

1

Score

1

2

1

2

Score

1

2

1

2

1

Score

1

2

1

2

1

7

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Practice using FLACC scale

• Samuel is 18 months old. You observe that he is withdrawn, kicking his legs, and squirming. He is constantly crying or screaming, but is calmed down by breastfeeding.

Category Score

Face

Legs

Activity

CryConsolability

Total

Score

1

Score

1

2

Score

1

2

1

Score

1

2

1

2

Score

1

2

1

2

1

Score

1

2

1

2

1

7

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Mild pain

Moderate or Severe pain

Step 1Non-opioid

Step 2 Strong opioid

+/- adjuvant

+/- non-opioid+/- adjuvant

Consider prophylactic laxatives to avoid constipation

Step up if pain persists or increases

Non-opioids Age>3 mos: ibuprofen or paracetamol (acetaminophen); Age<3 mos: paracetamol

Strong opioids morphine (medicine of choice) or fentanyl, oxycodone, hydromorphone, buprenorphine

Adjuvants antidepressant, anticonvulsant, antispasmodic, muscle relaxant, bisphosphonate, or corticosteroid

Combining an opioid and non-opioid is effective, but do not combine drugs of the same class.

Time doses based on drug half-life (“dose by the clock”); do not wait for pain to recur

Ref: Adapted by Treat the Pain from World Health Organization http://www.who.int/cancer/palliative/painladder/en/ (accessed 7 November 2013)

WHO Analgesic Ladder: Pediatric

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WHO ladder: pediatric

• Recently updated guidelines from the World Health Organization (WHO) recommend using a 2-step ladder which does not include the rung for weak opioids

• Weak opioids are not recommended for use in children– Codeine• Safety and efficacy problems related to genetic

variability that affects metabolism• Low analgesic effect in infants and young children

– Tramadol• Data are lacking on safety and efficacy in children

WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses, WHO (2012)

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Step 1: mild pain

• Paracetamol and ibuprofen are the only medicines in this step– No other NSAIDs are recommended

• Infants <3 months old– Only paracetamol is recommended

• Children >3 months old– Paracetamol or ibuprofen can be used



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Dosing of Step 1 analgesics

Medicine <1 month 1-3 months 3 months-12 years

Maximum daily dose

Paracetamol 5-10mg/kg every 6-8 hours

10mg/kg every 4-6 hours

10-15mg/kg every 4-6 hours (max 1g at a time)

4 doses per day

Ibuprofen Not recommended 5-10mg/kg every 6-8 hours

40mg/kg/day

* Children with poor nutritional state may be more susceptible to toxicity at standard doses

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Step 2: moderate or severe pain

“There is no other class of medicines than strong opioids that is effective in the treatment of moderate and severe pain. Therefore, strong opioids are an essential element in pain management.”

World Health Organization


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Step 2: moderate or severe pain

• Morphine is the “medicine of choice”– Alternatives can be used if a child experiences intolerable

side-effects• As with adults, there is no maximum dose for opioids– Titrate upward to find the dose that relieves pain with

tolerable side-effects• Constipation is a common side effect, and all children taking

opioids should also take a stimulant laxative and a stool softener



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Starting dose for opioid-naïve neonates

Medicine Route Starting dose

Morphine IV/Sc injection 25-50mcg/kg every 6 hours

IV infusion Initial IV dose 25-50mcg/kg, then 5-10mcg/kg/hour100mcg/kg every 4 or 6 hours

Fentanyl IV injection 1-2mcg/kg every 2 to 4 hours

IV infusion Initial IV dose 1-2mcg/kg, then 0.5-1mcg/kg/hour

* Administer IV morphine slowly over at least 5 minutes* IV doses are based on acute pain management and sedation. Lower doses are required for non-ventilated

neonates* Administer IV fentanyl slowly over 3-5 minutes


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Starting dose for opioid-naïve infants (1 mo-1 yr)Medicine Route Starting dose

Morphine Oral (immediate release) 80-200mcg/kg every 4 hours

IV/Sc injection 1-6 months: 100mcg/kg every 6 hours6-12 months: 100mcg/kg every 4 hours(max 2.5mg/dose)

IV infusion 1-6 months: Initial IV dose: 50mcg/kg, then: 10-30mcg/kg/hour6-12 months: Initial IV dose: 100-200mcg/kg then: 20-30mcg/kg/hour

Sc infusion 1-3 months: 10mcg/kg/hour3-12 months: 20mcg/kg/hour

* Administer IV morphine slowly over at least 5 minutes


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Starting dose for opioid-naïve infants (1 mo-1 yr)Medicine Route Starting dose

Fentanyl IV injection 1-2mcg/kg every 2 to 4 hours

IV infusion Initial IV dose 1-2mcg/kg, then 0.5-1mcg/kg/hour

Oxycodone Oral (immediate release) 50-125mcg/kg every 4 hours

* IV doses of fentanyl are based on acute pain management and sedation dosing information

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Starting doses for opioid-naïve children (1-12 yrs)


Medicine Route Starting dose

Morphine Oral (immediate release) 1-2 years: 200-400mcg/kg every 4 hours2-12 years: 200-500mcg/kg every 4 hours (max 5mg)

Oral (prolonged release) 200-800 mcg/kg every 12 hours

IV/Sc injection 1-2 years: 100mcg/kg every 4 hours2-12 years: 100-200mcg/kg every 4 hours (max 2.5mg)

IV infusion Initial IV dose: 100-200mcg/kg, then 20-30 mcg/kg/hour

Sc infusion 20mcg/kg/hour* Administer IV morphine slowly over at least 5 minutes

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Starting doses for opioid-naïve children (1-12 yrs)


Medicine Route Starting doseFentanyl IV injection 1-2mcg/kg, repeated every 30-60 minutes

IV infusion Initial IV dose 1-2mcg/kg, then 1mcg/kg/hour

Hydromorphone Oral (immediate release) 30-80mcg/kg/hour every 3 to 4 hours (max 2mg/dose)

IV/Sc injection 15mcg/kg every 3 to 6 hours

Methadone Oral (immediate release) 100-200mcg/kg every 4 hours for the first 2-3 doses, then every 6 to 12 hours (max 5mg/dose initially)

IV/Sc injection

Oxycodone Oral (immediate release) 125-200 mcg/kg every 4 hours (max 5mg/dose)

Oral (slow release) 5mg every 12 hours

* Administer IV fentanyl slowly over 3-5 minutes* Hydromorphone is a potent opioid and significant differences exist between oral and intravenous dosing. Use extreme

caution when converting from one route to another. In converting from parenteral to oral hydromorphone, doses may need to be titrated up to 5 times the IV dose. Administer IV hydromorphone slowly over 2-3 minutes

* Due to the complex nature and wide inter-individual variation in pharmacokinetics, methadone should only be commenced by experienced practitioners

These opioids are more complex and should be started by an experienced provider

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General principles

• Dose at regular intervals– Medicines should always be given on a regular schedule and

not “as needed”, except for rescue doses• Use the appropriate route of administration

– Medicines should be given by the simplest, most effective, and least painful route• Oral is preferred• IV or subcutaneous, rectal, or transdermal are alternatives

when oral is not feasible• IM is discouraged because it is painful

• Adapt treatment to the individual child– Titrate to get to the correct dose


Children’s Palliative Care in Africa, Amery (2009) 20

Side effects of opioids

Opioids are generally well-tolerated• Mild sedation for first 48 hours is normal while child catches

up on sleep • Constipation: treat with laxatives• Pruritis: treat with topical treatments (calamine or

hydrocortizone) or oral antihistamines• Urinary retention: treat with carbachol or bethanechol;

catheterization may be required

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Co-analgesia in children

• The WHO does not recommend corticosteroids or biphosphonates to treat pain in children

• Neuropathic pain in children– Consult an expert– WHO guidance in this area is limited due to lack of

evidence

WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses. WHO (2012)

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Procedural pain management principles

• Avoid non-necessary procedures• Prepare for the procedure• Involve the child and family• Encourage the parents to be helpful and supportive• Carry out procedures in child-friendly area away from the bed• Use non-pharmacological and pharmacological interventions

to manage pain and anxiety• After completing the procedure, congratulate the child and

instill a sense of achievement

Children’s Palliative Care in Africa, Amery (2009)

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Procedural pain management

Drugs to use• Topical anaesthetic agents (EMLA cream)• Local anaesthetic: S/c lidocaine (make sure it is at body

temperature and buffer with sodium bicarbonate to reduce pain of administration)

• If anxiety, rather than pain, is the issue: sedate with benzodiazepine, pedichloryal (50-100mg/kg by mouth) or promethizine (5mg/kg by mouth)

• If pain is the issue: use opioids in treatment doses

Children’s Palliative Care in Africa, Amery (2009)

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Take home messages

• Pain in children can be assessed using observation and easy tools

• Children as young as 3 years old can indicate their severity of the pain

• For children, the WHO analgesic ladder is 2 steps

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References

• African Palliative Care Association. Beating Pain: a pocketguide for pain management in Africa, 2nd Ed. [Internet]. 2012. Available from: http://www.africanpalliativecare.org/images/stories/pdf/beating_pain.pdf

• African Palliative Care Association. Using opioids to manage pain: a pocket guide for health professionals in Africa [Internet]. 2010. Available from: http://www.africanpalliativecare.org/images/stories/pdf/using_opiods.pdf

• Amery J, editor. Children’s Palliative Care in Africa [Internet]. 2009. Available from: http://www.icpcn.org/wp-content/uploads/2013/08/Childrens-Palliative-Care-in-Africa-Full-Text.pdf

• Kopf A, Patel N, editors. Guide to Pain Management in Low-Resource Settings [Internet]. 2010. Available from: http://www.iasp-pain.org/files/Content/ContentFolders/Publications2/FreeBooks/Guide_to_Pain_Management_in_Low-Resource_Settings.pdf

• The Palliative Care Association of Uganda and the Uganda Ministry of Health. Introductory Palliative Care Course for Healthcare Professionals. 2013.

• World Health Organization. WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses [Internet]. 2012. Available from: http://www.who.int/medicines/areas/quality_safety/guide_perspainchild/en/

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