What are the basic guidelines for selecting and administering analgesics to children with pain?
Selection of analgesics for children with pain should be part of a multimodal treatment plan. Consistent with principles of analgesia, consider the six rights of medication administration: (1) right patient, (2) right drug, (3) right route, (4) right dose, (5) right time, and (6) right way.
First, right patient—is an analgesic even recommended to treat the child’s pain? Most minor cuts and abrasions are well tolerated with a parent’s kiss and a bandage. Local anesthetics are also available in over-the-counter topical antibiotics. Does the patient have any comorbid conditions that would prevent the use of certain analgesics, such as the contraindication to use acetaminophen with patients with liver failure, or over-the-counter ibuprofen for patients with bleeding disorders? Analgesic agents should be based on each child’s circumstances. No analgesic will reliably relieve pain for all children who have a similar medical condition or a similar location, quality, or intensity of pain.
Second, right drug—the choice of analgesics should be based on diagnosis, mechanisms of pain, and the mechanisms of action of the analgesic. Thus nonsteroidal antiinflammatory drugs (NSAIDs) are preferred for inflammatory pain. As previously mentioned, most analgesics are not approved by the FDA for administration to children. However, few are contraindicated for children. Thus treatment of children’s pain with analgesics often requires the prescriber to translate knowledge gained from adult use of the drug to determine the drug’s actions, dose, duration of analgesia, and adverse effects when used with children. Prescribers are forced to make patient care decisions based on professional experience with the analgesic and off-label dosing guidelines and recommendations.
Third, right route—consider the location of the pain and the pharmacokinetics and dynamics of the analgesic. For example, a topical anesthetic is far more appropriate for the prevention of pain from a needle procedure than a strong opioid would be for treating the pain after the procedure. Also consider the pattern of the pain. For severe pain of sudden onset, the fast action of the parental route may be preferred. However, the intramuscular (IM) route should be avoided whenever possible. The IM route is painful, dangerous, and results in erratic drug absorption. Analgesics administered by the oral route tend to have a longer duration of analgesia and may be less expensive. The oral route is considered the preferred route for analgesic administration. This route, however, may not be appropriate if the child cannot tolerate enteral medications, if the appropriate dose is not available in an oral formulation, if the child cannot swallow pills, or the child may not prefer this route if the liquid analgesic has a particularly nasty taste!
Fourth, right dose—analgesic doses are based on empiric evidence and extrapolation of adult doses to children’s sizes. Initial analgesic dose is based on the child’s weight up to the normal starting dose for an adult. Health care professionals may use current body weight, adjusted body weight, or ideal body weight to calculate dose—since there is no accepted standard for weight-based dose calculations. The dose for nonopioids, like acetaminophen and NSAIDs, are standardized by age and weight, whereas opioid doses need to be titrated to determine the optimal safe dose to use to relieve each individual child’s pain. Predetermined pain intensity scores for different pain treatments or different analgesic doses are inappropriate. There is no research linking analgesic dose to specific pain intensity scores. This practice puts children at risk for oversedation, respiratory depression, and poorly managed pain. Analgesic dosage may vary by route. Consider the relative strength of analgesics given by different routes.
Fifth, right time—analgesics may be given before the painful event to prevent pain, intermittently to quickly treat pain, or infused on a continuous basis to maintain pain relief. Analgesics should be given on a timed schedule consistent with their duration of action for predictable or continuous pain.
Sixth, right way—pain treatment should always be multimodal. Could pain be prevented by avoiding triggers or using preventative medication strategies, such as topical anesthetics for needle procedures? Are patient controlled analgesia (PCA) and epidural analgesics appropriate for child?