This document discusses methods of assessing and treating pain in children. It begins by outlining three ways to assess pain in children: asking the child directly using a pain scale, asking parents or caregivers, and observing the child's behavior. It then provides more details on the Wong-Baker FACES scale and FLACC scale for assessing pain levels in older and younger children respectively. The document reviews the WHO analgesic ladder for treating pain in children, which is a two-step approach using non-opioids for mild pain and strong opioids like morphine for moderate to severe pain. It provides dosing guidelines for common pain medications in children of different ages. The principles of managing procedural pain and side effects of opioids are also summarized.

1. 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

2. 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
2

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
Children’s Palliative Care in Africa, 2009 3

4. 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) 4

5. FLACC scale
ICPCN (2009): Adapted from Merkel et al 5
• 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

6. Practice using FLACC scale
• Samuel is 18 months old. You observe that he is withdrawn,
kicking his legs, and squirming. His is constantly crying or
screaming, but is calmed down by breastfeeding.
6
Category Score
Face
Legs
Activity
Cry
Consolability
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

7. Practice using FLACC scale
• Samuel is 18 months old. You observe that he is withdrawn,
kicking his legs, and squirming. His is constantly crying or
screaming, but is calmed down by breastfeeding.
7
Category Score
Face
Legs
Activity
Cry
Consolability
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

8. 8
Mild pain
Moderate or
Severe pain
Step 1
Non-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
8

9. 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) 9

10. 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
WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses, WHO (2012) 10

11. Dosing of Step 1 analgesics
WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses, WHO (2012) 11
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

12. 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
WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses, WHO (2012) 12

13. 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
WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses, WHO (2012) 13

14. Starting dose for opioid-naïve neonates
WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses, WHO (2012) 14
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/hour
100mcg/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

15. Starting dose for opioid-naïve infants (1 mo-1 yr)
WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses, WHO (2012) 15
Medicine Route Starting dose
Morphine Oral (immediate release) 80-200mcg/kg every 4 hours
IV/Sc injection 1-6 months: 100mcg/kg every 6 hours
6-12 months: 100mcg/kg every 4 hours
(max 2.5mg/dose)
IV infusion 1-6 months: Initial IV dose: 50mcg/kg, then:
10-30mcg/kg/hour
6-12 months: Initial IV dose: 100-200mcg/kg
then: 20-30mcg/kg/hour
Sc infusion 1-3 months: 10mcg/kg/hour
3-12 months: 20mcg/kg/hour
* Administer IV morphine slowly over at least 5 minutes

16. Starting dose for opioid-naïve infants (1 mo-1 yr)
WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses, WHO (2012) 16
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

17. Starting doses for opioid-naïve children (1-12 yrs)
WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses, WHO (2012) 17
Medicine Route Starting dose
Morphine Oral (immediate release) 1-2 years: 200-400mcg/kg every 4
hours
2-12 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 hours
2-12 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

18. Starting doses for opioid-naïve children (1-12 yrs)
WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses, WHO (2012) 18
Medicine Route Starting dose
Fentanyl 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

19. 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
WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses, WHO (2012) 19

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

21. 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) 21

22. 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) 22

23. 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) 23

24. 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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25. 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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