Pharmacology Book

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Pediatric Analgesic

Aka: Pediatric Analgesic, Analgesics in Children, Acute Pain Management in Children, Acute Pediatric Pain Management in the Emergency Department
  1. See Also
    1. Procedural Sedation and Analgesia
    2. Childlife Specialist Measures to Calm Children
  2. Evaluation: Pain rating scales
    1. FLACC Scale (Face, Legs, Activity, Cry, Consolability Scale)
    2. Wong-Baker FACES Pain Rating Scale
      1. Reliable pain rating scale for ages 4 to 12 years old
  3. Precautions
    1. Children's pain is frequently under-treated in the emergency department
      1. Conditions are just as painful for children as they are for adults
      2. Do not lie and do not make promises you cannot keep
      3. Empower children to pause the procedure when something is too painful
        1. Increases the pain threshold when they have the power to say stop
      4. Repeated and persistent untreated pain in children can have short and long lasting effects
        1. Short-term: Greater suffering, decreased function, increased and prolonged encounters
        2. Long-term: Procedure avoidance, heightened sensitivity and fear, lower pain thresholds, hyperalgesia
    2. Avoid Tramadol in children (risk of significant respiratory depression)
      1. Seen with Ultrarapid CYP2D6 metabolizers
      2. Avoid Tramadol use in children
      3. http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm463499.htm
    3. Avoid Codeine in children
      1. Same concern with CYP2D6 ultrarapid metabolizers
    4. Exercise caution with Hydrocodone and Oxycodone
      1. Also metabolized by CYP2D6, but issues with Codeine and Tramadol not reported with these other agents
  4. Preparations: Non-Opioid oral and IV Analgesics
    1. Acetaminophen (Tylenol)
      1. Dose: 15 mg/kg/dose (up to 650 mg) every 6 hours (max: 4 g/day)
    2. Ibuprofen (Children's Motrin)
      1. Dose: 10 mg/kg/dose (up to 800 mg) every 6-8 hours (max: 2400 mg/day)
    3. Naproxen (Children's Naprosyn, for age >2 years old)
      1. Dose: 5-7 mg/kg (up to 500 mg) every 8-12 hours (max: 1250 mg/day)
    4. Ketorolac (Toradol)
      1. Dose: 0.5 mg/kg IV or IM (up to 30 mg) every 6 hours (90 mg/day, and limit to <5 days of use)
    5. Ketamine
      1. See Procedural Sedation and Analgesia
      2. Dose: 0.1 to 0.2 mg/kg IV
        1. Pure Analgesic at this dose without the Hallucinations that occur at higher dose (0.5 mg/kg)
  5. Preparations: Oral Opioid Analgesics
    1. Acetaminophen with Hydrocodone (Lortab Elixir)
      1. Better alternative to Acetaminophen with Codeine (which should be avoided in general)
      2. Components per 15 ml
        1. Hydrocodone 7.5 mg
        2. Acetaminophen 500 mg
      3. Dosing
        1. Age 2-3 years (12-15 kg or 27-34 lbs)
          1. Dose: 3.75 ml (0.75 tsp)
        2. Age 4-6 years (16-22 kg or 35-50 lbs)
          1. Dose: 5 ml (1 tsp)
        3. Age 7-9 years (23-31 kg or 51-69 lbs)
          1. Dose: 7.5 ml (1.5 tsp)
        4. Age 10-13 years (35-45 kg or 70-100 lbs)
          1. Dose: 10 ml (2.0 tsp)
    2. Acetaminophen with Oxycodone (Roxicet)
      1. Components
        1. Oxycodone 5 mg/5ml
        2. Acetaminophen 325 mg/5 ml
      2. Dosing
        1. Base on Oxycodone dose of 0.05 to 0.15 mg/kg/dose every 4-6 hours up to 5 mg/dose
    3. Oxycodone
      1. Dose: 0.05 to 0.15 mg/kg/dose (up to 5 mg) orally every 4-6 hours as needed
    4. Morphine Sulfate immediate release
      1. Dosing: 0.2 to 0.5 mg/kg (up to 30 mg) per dose orally every 4-6 hours as needed
    5. Hydromorphone (Dilaudid)
      1. Dosing: 0.05 mg/kg (up to 5 mg) orally every 4 to 6 hours as needed
  6. Preparations: Topical anesthetics
    1. Used prior to Laceration Repair, or pre-phlebotomy
    2. LET Anesthesia (Lidocaine-Epinephrine-Tetracaine)
      1. Cover with Tegaderm for 20 minutes
    3. Jet Injection (J-Tip)
      1. Needle-free, high pressure, subcutaneous delivery of Buffered Lidocaine at future IV or phlebotomy site
    4. EMLA cream
      1. Delayed onset of action (60 min) makes it less helpful in ED (better for scheduled phlebotomy)
    5. LMX-4
      1. Liposomal Lidocaine within onset of action in 30 min (effect wanes by 60 min)
    6. Vapocoolant Sprays (e.g. Fluori-Methane spray)
      1. Replaced ethyl chloride sprays (newer agents are less volatile, flammable)
    7. Buzzy Bee
      1. Vibrating plastic device with frozen liquid rings
  7. Preparations: Intranasal Analgesics and sedatives
    1. Intranasal Fentanyl
      1. Dose: 2 mcg/kg intranasal (1/2 in each nostril) via MAD Atomizer
    2. Intranasal Versed (for Sedation)
      1. Opioids are generally used instead
      2. Dose: 0.2 to 0.5 mg/kg intranasal (1/2 in each nostril) using 5 mg/ml up to 10 mg
    3. Intranasal Ketamine (not in mainstream use yet as of 2016)
      1. Ketamine 1 mg.kg (1/2 in each nostril)
      2. Graudins (2015) Ann Emerg Med 65(3): 248-54 [PubMed]
  8. Preparations: Intravenous Opioid Analgesics
    1. Fentanyl
      1. Dose: 1 mcg/kg IV or IM (up to 100 mcg) every 30-60 min
    2. Hydromorphone (Dilaudid)
      1. Dose: 0.015 mg/kg (up to 1 mg) every 4-6 hours
    3. Morphine Sulfate
      1. Dose: 0.1 mg/kg IV or IM (up to 15 mg) every 1-2 hours
  9. Preparations: Opioid and Benzodiazepine antagonists
    1. Naloxone (Narcan) 0.1 mg mg/kg (up to 2 mg) IV, IM, SQ, ET
    2. Nalmefene
    3. Flumazenil (Romazicon)
  10. Management: Infants - General measures
    1. Sucrose (infants)
      1. 50% solution, 2 ml on the Tongue, 2 minutes prior to procedure
      2. Offers good analgesia prior to Heel Stick
      3. Haouari (1995) BMJ 310:1498-500 [PubMed]
    2. Sweet-ease Pacifiers
    3. Nonnutritive sucking via Pacifier
    4. Swaddling in warm blanket
    5. Facilitated Tucking
      1. Hold infant's arms and legs flexed close to torso
  11. Management: Children - General measures
    1. See Childlife Specialist Measures to Calm Children
  12. References
    1. Dannenberg in Herbert (2017) EM:Rap 17(10): 5
    2. Hipskind and Kamboj (2016) Crit Dec Emerg Med 30(10): 15-23
    3. Khetarpal and Scott (2016) Crit Dec Emerg Med 30(5): 17-23

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