Pain Treatment

The majority of healthcare visits are related to pain.¹ Untreated pain has short-term (pain and distress for the child, caregivers, and healthcare providers; prolonged procedure time; slower healing) and long-term consequences (increased sensitivity to pain; avoidance of healthcare settings; needle phobia; higher levels of anxiety before a procedure). Timely and effective multi-modal pain care improves procedure success rates, prevents the need for repeated attempts, improves patient flow, and improves patient and caregiver satisfaction.² Repeated pain measures and consideration of each family’s situation, level of distress, and life experience can help guide appropriate therapy.

Children should be asked to rate their pain. If unable (e.g., cognitive issues, non-verbal), then FLACC-R should be used.¹

1. FLACC-R Score – For children 0-3 years of age or non-verbal.
2. Faces Pain Scale-Revised – For children 4-12 years of age.
3. Verbal Numerical Rating Score – For children over 6 years of age (e.g., “On a scale of 0-10, where 0 is no pain and 10 is the worst pain 0 2 4 6 8 10 you can imagine, tell me what number your pain is”).

Physical

• Ask the caregiver(s) to remain present if possible and provide them with guidance to calmly support their child with distraction, gentle touch (if desired by the child), conversation, music, and/or suggestions for deep breathing.
• Caregivers may hold the child in a number of comfort positions that do not interfere with examinations or procedures (e.g., upright and in direct physical contact with caregiver), and rock the child after the intervention.
• Infants <2 months can benefit from facilitated tucking (e.g., legs and arms tucked close to body) or swaddling with blankets to calm them while awaiting assessment/results.
• Caregivers may provide infants with skin-to-skin contact while awaiting assessment/results.
• Breastfeeding can be very soothing in the infant/child if the patient is not NPO, otherwise non-nutritive sucking (e.g., pacifier) can be used.
• Use of warm/cold packs for pain can be soothing (e.g., warm packs in sickle cell pain crisis or back pain, cold packs for acute musculoskeletal injuries).

Distraction Techniques

• Simple techniques such as bubbles, books, I-spy books/cards, singing, portable distraction kits (e.g., poppers, fidget spinners) and conversation.
• Technology-based distraction such as smart phone videos/games, tablet device, tv/video, music, and virtual reality.

• To be used in conjunction with physical and distraction interventions.
• Reassess response to pharmacotherapy regularly. Re-dosing, as required, is recommended.
• Diagnostic accuracy is NOT affected by the provision of early analgesia.
• Intramuscular and subcutaneous injections should be avoided in children, as intranasal and intravenous options provide less painful modes of delivery and more predictable absorption.
• For infants <12 months old, consultation with Pediatric Referral Centre is advised for recommendations when opioids or IV analgesics are being considered for pain management.

Opioids

• Titrate all opioids to clinical effect and to minimize adverse effects.
• Always use opioids as co-therapy and never on their own.
• Side effects such as nausea, sedation, or confusion can be mislabeled as an allergy. An accurate drug allergy history is essential as true allergy to morphine and other opioids is extremely rare; cross reactivity is also rare.
• Health Canada and the US FDA advise avoidance of codeine in children <18³ and hydrocodone in children <6.⁴
• Opioid administration prior to procedural sedation increases the risk of oxygen desaturation, vomiting, and need for positive pressure ventilation. This risk is greatest if procedure is performed within 30 min of opioid administration.
• All families should have a substance use risk assessment performed before prescribing outpatient opioids.
• If discharging patient home with PO opioids, prescribe for no more than 3 days (or 10 doses total) for most conditions.
• Recommend stool softener for those discharged with PO opioids. Refer to TREKK Recommendations for Constipation.
• Opioids should be stored safely out of reach and only given as needed. Unused quantities of any medication should be returned to the pharmacy or disposal site for safe disposal.

1. Our goal today is to keep your child comfortable while we figure out what is going on; they do not need to remain in pain while we diagnose and treat them.
2. Treating pain does not make a child weak. Untreated pain, however, can have long-term consequences for the way your child experiences future pain or medical encounters.
3. We will first use maximum doses of non-opioid medications, NSAIDs are equivalent to morphine with fewer side effects.
4. Provide education that the worst pain after a musculoskeletal injury occurs in the first 3 days, use adjuncts (e.g., immobilization and ice).
5. There is no clinical evidence that using NSAIDs affects bone healing in children.

Thank you to the following content experts who led the development of this resource.

Samina Ali, MDCM, FRCPC (PEM)
Professor, Pediatrics & Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta

Corrie Chumpitazi, MD, MS
Associate Professor of Pediatrics, Baylor College of Medicine, Division of Emergency Medicine, Texas Children’s Hospital

Amy L. Drendel, DO, MS
Professor of Pediatrics and Medical Director, Children’s Wisconsin Emergency Department Trauma Center, Medical College of  Wisconsin

Naveen Poonai, MSC, MD, FRCPC
Associate Professor, Pediatrics, Internal Medicine, Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry Scientist, Child Health Research Institute Research Director, Division of Pediatric Emergency Medicine

Thank you to the TREKK Editorial Committee and those in the EIIC KEAP Program who provided editorial support, expertise in the development of this resource. Thank you as well to the following people who coordinated and oversaw the development process:

Mateja Carevic, BA, MA 
TREKK Knowledge Broker, University of Manitoba

Corrie Chumpitazi, MD, MS
Associate Professor of Pediatrics, Baylor College of Medicine, Division of Emergency Medicine, Texas Children’s Hospital

Danica Irwin, BSc.Phm 
Pharmacist, CHEO

Mona Jabbour, MD, MEd, FRCPC
TREKK Co-Director; Interim Chair/Chief, Department of Pediatrics Associate Professor, Pediatrics and Emergency Medicine, University of Ottawa Children’s Hospital of Eastern Ontario

Sarah Reid, MD
TREKK Editorial Lead, Clinical Investigator, CHEO Research; Institute Physician, Division of Emergency Medicine, CHEO; Assistant Professor and Director, Emergency Department Outreach, University of Ottawa

Marc Vazquez, MHA/MBA, PMP
EIIC Knowledge Broker, Baylor College of Medicine

1. Birnie KA, Hundert AS, Lalloo C, Nguyen C, Stinson JN. Recommendations for selection of self-report pain intensity measures in children and adolescents: a systematic review and quality assessment of measurement properties. Pain. 2019;160(1):5-18. doi: 10.1097/j.pain.0000000000001377.
2. Drendel AL, Ali S. Ten practical ways to make your ED practice less painful and more child-friendly. Clinical Pediatric Emergency Medicine. Volume 18, Issue 4, December 2017, 242-255.
3. Health Canada. Non-prescription pain relief products containing codeine are not recommended for use in people under 18 years of age. July 2020. Accessed May, 2020.
4. Health Canada. New safety measures for prescription codeine and hydrocodone to further restrict use in children and adolescents. July 2016. Accessed May, 2020.
5. Drendel AL, Kelly BT, & Ali S. Pain assessment for children: overcoming challenges and optimizing care. Pediatr Emerg Care. 2011;27(8):773-81. doi:
6. Fein JA, Zempsky WT, Cravero JP; Committee on Pediatric Emergency Medicine and Section on Anesthesiology and Pain Medicine; American Academy of Pediatrics. Relief of pain and anxiety in pediatric patients in emergency medical systems. Pediatrics. 2012;130(5):e1391-405. doi: 10.1542/ peds.2012-2536. PMID: 23109683

For a complete list of the evidence that informed the creation of the Pain Treatment Bottom Line Recommendations see the Evidence Repository here.

The purpose of this document is to provide healthcare professionals with key facts and recommendations for the diagnosis and treatment of community acquired pneumonia in children in the emergency department. The TREKK Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. THIS DOCUMENT IS SUBJECT TO FULL DISCLAIMER HERE: trekk.ca/terms-of-use