- Stress and anxiety can exacerbate the perception of pain. Strategies that may be helpful to minimise stress and anxiety include:
- Parental presence and comforting touch when possible
- Use distraction therapy eg video, music, toys, blowing bubbles, storytelling by the child, counting
- Engage child life therapist (play therapy) if available
- Swaddling, feeding, skin to skin care and dummy use for infants
- Breathing techniques
- Tactile stimulation: touching the skin near the site using rhythmic rubbing, manual pressure, ‘Buzzy bee’
- In the case of injuries, useful strategies include:
- Immediate immobilisation of potential fractures with a splint or backslab
- Applying ice (if age appropriate) and elevating injured limbs
- Prompt dressing of burns (see Burns)
- For limb or finger injuries consider regional local anaesthesia/nerve block
Systemic Analgesia
| Mild | Moderate | Severe |
|---|---|---|
| Paracetamol ± ibuprofen | Oxycodone orally Intranasal fentanyl via atomiser (>12 months) Tramadol (>12 years) | Notify senior Morphine IV or Fentanyl IV |
| In neonates consider sucrose | Consider obtaining IV access for further analgesia | Consider regional anaesthesia, PCA or infusion Consider discussion with pain service Consider other causes e.g. compartment, infection |
| R/v every 30-60 minutes | R/v every 15-30 minutes | R/v every 10 minutes |
Dosages
| Analgesic | Route | Dose | Maximum daily | Notes |
|---|---|---|---|---|
| Sucrose (any % e.g. 24, 33) | PO | Preterm: 0.2-0.5 mL/procedure <1 month: 0.5-1 mL/procedure 1-18 months: 1-2 mL/procedure | Preterm: 2.5 mL <3 months: 5 mL ≥3 months: 10 mL | Most effective <6 months Provider 1/4 to anterior tongue 2 mins prior to procedure with dummy if available Lasts 5-8 minutes from administration |
| Paracetamol | PO | 15 mg/kg (max 1 g) 4-6 hourly | <1 month: 60mg/kg >1 month: 90 mg/kg up to 4g for max 48 hours then 60 mg/kg | Onset = 30 minutes Oral preferred Administer commercial syrup carefully as several concentrations available |
| PR | 15-20 mg/kg (max 1g) 6 hourly | As above | If not tolerated orally as rectal absorption delayed and erratic PR medication should be avoided in immunocompromised children | |
| IV | ||||
Local Analgesia
- Prior to venepuncture, cannulation, suprapubic aspirate: Anaesthetic cream e.g. EMLA, AnGel, LMX4
- Nasal/pharyngeal foreign body removal, NGT insertion: Lignocaine: Phenylephrine (CoPhenylcaine Forte) nasal spray