REVIEW

URRENT
C
OPINION

Management of acute pediatric pain in the

emergency department
Stephanie Ruest a and Angela Anderson b

Purpose of review
This article provides a summary of recommendations for the multimodal and multidisciplinary approach to
acute pediatric pain management and highlights recent research on this topic.
Recent findings
Recent literature has focused on updating recommendations for the use of various analgesics in the
pediatric population. While codeine is no longer recommended due to increasing evidence of adverse
effects, the more liberal use of intranasal fentanyl is now encouraged because of the ease of administration
and rapid delivery. The evidence base for the use of ultrasound-guided regional nerve blocks by qualified
providers in the acute pediatric pain setting continues to grow.
Summary
The pediatric emergency medicine provider should be able to assess pain and develop individualized pain
plans by utilizing a range of nonpharmacologic and pharmacologic strategies. Knowledge of the most
recent literature and changes in recommendations for various pain medications is essential.
Keywords
acute pain, analgesia, pediatric pain management

INTRODUCTION
The majority of children who seek care in the emergency department (ED) present with complaints of
pain or may experience pain during their evaluation
and treatment [1]. The experience of pain includes
physiological, emotional, cultural, and cognitive
components [2]. Inadequate management of acute
pain can have both immediate and long-term consequences [37].
In 2001, the American Academy of Pediatrics
and the American Pain Society published a statement noting that pediatricians are responsible for
treating and eliminating pain in children whenever
possible, with the use of a multimodal and
multidisciplinary approach [8]. Additionally, the
Joint commission on Accreditation of Healthcare
Organizations began mandating the assessment
and documentation of patients pain [9]. Multiple
studies and clinical practice guidelines support
the use of validated pain assessment tools in
concert with this multimodal and multidisciplinary
approach to pain management [2,1012].
This article will review recommendations for
acute pediatric pain management from infancy
through adolescence, and highlight recent literature
on this topic.
www.co-pediatrics.com

RECOGNITION OF ACUTE PEDIATRIC PAIN

AND THE APPROACH TO PAIN
MANAGEMENT
It is imperative that clinicians employ validated
pain assessment tools that are appropriate for the
childs developmental level. Some examples include
the Face, Legs, Activity, Cry, Consolability (FLACC)
scale for infants; the Wong-Baker FACES pain scale
for young children through adolescents; the Visual
Analog Scale for children above 8 years of age, and
special or revised scales for children with neurocognitive impairments [1,11,13].
Although acute pain management has been a
key focus of pediatric emergency medical care, treatment of pain, particularly among neonates, infants,
and children with neurocognitive disabilities,
has historically been inadequate. Despite the
a

Emergency Medicine, Section of Pediatric Emergency Medicine and

Departments of Pediatrics and Emergency Medicine, Hasbro Childrens
Hospital, Providence, Rhode Island, USA
b

Correspondence to Stephanie Ruest, MD, 593 Eddy Street, Providence,

RI 02903, USA. Tel: +1 401 444 6680;
e-mail: Stephanie.Ruest@lifespan.org
Curr Opin Pediatr 2016, 28:298304
DOI:10.1097/MOP.0000000000000347
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Number 3
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Acute pediatric pain in the emergency department Ruest and Anderson

KEY POINTS

Pediatric pain is still under recognized and
undertreated, particularly in neonates, infants, and
children with neurocognitive disabilities, and the
consequences of inadequate pain management can be
both short-term and long-term.

The approach to acute pediatric pain management
should be multidisciplinary, including child life
specialists, parents/caregivers, nurses, and physicians,
and multimodal, with nonpharmacologic and
pharmacologic components.

employed by the childs caregiver, child life specialists, or other staff [11,1820]. Functional MRI studies provide evidence that distraction has direct pain
modulation and reduction effects by activating the
midbrain periaqueductal gray, as well as higher
cortical regions [21,22]. Children less than 57 years
are generally not yet able to understand verbal
reasoning or reassurance; distraction techniques are
likely to be of greater use [23 ]. A 2015 randomized
control trial demonstrated that children 712 years
old exposed to distraction techniques during venipuncture had a statistically significant reduction in
pain reports compared to controls [24 ].
Parental holding and strategic positioning may
also be helpful. Whereas there is no evidence to
show that the presence of family members decreases
pain, there are data to support that it may decrease
the childs anxiety and distress; thus, parents and
caregivers should be offered, although not required,
to be present for painful procedures, so long as the
parents own anxiety does not impede the childs
care [18,19,23 ]. Coaching parents about what to
expect and providing developmentally appropriate
ways for them to participate in their childs care can
be beneficial both to the child and parents [23 ].
Sucrose and non-nutritive sucking (NNS), swaddling/facilitated tucking, and skin-to-skin contact
are important analgesic methods for preterm and
full-term neonates and infants [25 ,26,27 ,28 ,29].
The use of 2430% sucrose with NNS, skin-to-skin
contact, and breastfeeding during minor procedures
have all been shown to decrease objective measures
of pain such as heart rate and crying [11]. These
methods appear to be effective only in children
under 1 year of age [30 ].
&

&

A stepwise and individually tailored pain regimen

should be utilized for all pediatric patients.

development of prehospital and ED-based practice

guidelines, pain assessment, analgesic administration, and postanalgesic pain assessment are not
consistently performed, and practice variability
remains high [11,14,15]. A 2014 publication on
the prehospital management of injured children
highlighted that although pain is often initially
identified, rates of subsequent pain medication
administration are reported to be as low as 0.3
37% [16 ].
Inadequate pediatric pain management is likely
a consequence of misconceptions regarding how
infants and children perceive pain, lack of provider
education and comfort with use of pain medications, and unfamiliarity with the assessment of
pain in infants and children [8,10,13,17,18].
Additionally, a common misconception is that
treatment of acute pain may mask symptoms, affect
diagnostic accuracy, or interfere with neurologic
assessments. To date, there is no evidence to support
these misconceptions in either the adult or pediatric
literature; in fact, adequate pain management may
facilitate the diagnostic work-up [18].
Upon recognition of acute pain, the development of an acute pain control regimen should be
individually tailored with a goal of optimizing pain
control while limiting adverse effects. A stepwise
approach utilizing nonpharmacologic tools along
with pharmacologic analgesics should be taken.
&

NONPHARMACOLOGIC PAIN
MANAGEMENT
Creating an age-appropriate, child-friendly environment is an important step in minimizing anxiety
and pain in the ED [18,19]. Distraction techniques
such as bubbles, toys, pinwheels, deep breathing,
guided imagery, and technology devices can be

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TOPICAL, TRANSDERMAL, AND LOCAL

ANALGESICS
Early application of topical anesthetics, particularly
by nurse-driven triage protocols, should be considered for children who are likely to require any
nonemergent procedure, such as venipuncture,
small abscess drainage, lumbar puncture, or wound
closure. Eutectic mixture of local anaesthetics
(EMLA) cream (lidocaine 2.5% and prilocaine
2.5%) is effective at numbing the tissue below intact
skin to a depth of 67 mm if left on for 3060 min
[2]. LMX4, a topical liposomal 4% lidocaine cream
similar to EMLA, has full effectiveness by 30 min.
LET or LAT (lidocaine, epinephrine/adrenaline,
tetracaine) works within 2030 min when applied
to open wounds. Recent data suggest that LET may
be most useful for short lacerations (<4 cm) and
lacerations on the head and fingers, although its
use is not limited to these specifications [31].

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Emergency and critical care medicine

Local or regional anesthesia should be utilized

for procedural pain relief whenever possible [32].
Nerve blocks can provide excellent pain control,
minimize the use of systemic analgesics, and obviate
the need for moderate sedation. In regards to the use
of local anesthetics such as lidocaine with epinephrine for digital blocks, a 2015 literature review concluded that using epinephrine 1 : 100 000200 000 is
well tolerated in healthy individuals [33 ]. Ultrasound-guided regional anesthesia for traumatic
injuries is well tolerated and effective in children
when performed by providers proficient in ultrasound use [34,35,36 ].
&&

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NONOPIOID ANALGESICS
For mild pain, the use of nonopioid analgesics
alone may be adequate (Table 1). Commonly
used nonopioid medications include acetaminophen and nonsteroidal anti-inflammatory drugs
(NSAIDs). Due to the risk of Reyes syndrome,
aspirin is no longer routinely recommended for
young children.

Acetaminophen (paracetamol) is an antipyretic

and weak analgesic. It is available in a number of
enteral and parenteral formulations, and has been
studied in neonates as young as 28 weeks gestational age [37,38]. Intravenous (i.v.) acetaminophen
has been commercially available and US Food and
Drug Administration (FDA)-approved since 2011 for
use in children aged 2 years and older for mild-tomoderate pain, as an adjunct to opioids for moderate to severe pain, and for the treatment of fever
[38]. Compared to the oral formulation, i.v. acetaminophen achieves a higher and more rapid mean
peak plasma concentration and crosses the blood
brain barrier more quickly, leading to higher cerebrospinal fluid levels [38]. If available, the i.v. route
should be considered when oral administration is
not possible or contraindicated. The cost of i.v.
acetaminophen is significantly higher than other
formulations, thus limiting its availability in some
settings [38].
Ibuprofen and naproxen are the most commonly used oral NSAIDs; ketorolac is the only i.v.
NSAID available in the United States. Of note,

Table 1. Frequently used nonopioid analgesics

Recommended
dosing for <40 kga

Recommended
dosing for 40 kg

Considerations and
contraindications

Dosing comments

i.v.

7.515 mg/kg every

46 h

325650 mg every
46 h; may give
up to 1000 mg in
one loading dose

Use with caution in patients

with hepatic impairment
or severe renal
impairment

Max dose: 75 mg/kg/day

for infants; 100 mg/kg/
day for children <40 kg;
34 g/day for >40 kg

p.o.

1015 mg/kg
every 46 h

p.r.

Loading dose of 30 mg/kg,

then 1520 mg/kg
every 6 h

p.o.

510 mg/kg
every 68 h

Route
Acetaminophen
(paracetamol)

Ibuprofenb

p.o. form comes as

tablet or liquid

200800 mg
every 68 h

Use with caution in patients

with asthma, bleeding
disorders or on
anticoagulation, volume
depletion, renal disease,
or if on multiple
nephrotoxic medications

Max dose: 40 mg/kg/day

for infants and children
<40 kg; 2400 mg/day
for >40 kg

p.o. form comes as

tablet or liquid
Liquid may be given
rectally
Naproxenb

p.o.

57 mg/kg
every 12 h

200400 mg
every 12 h

Same as ibuprofen

Max dose: 600 mg/day

for age 12 years

Ketorolacb

i.m./i.v.

0.251 mg/kg
every 68 h

1530 mg
every 68 h

Same as ibuprofen

Max dose: 100120 mg/

day for >40 kg

Diclofenac

p.o.

1 mg/kg
every 8 h

2550 mg
every 8 h

Limited data for

children <18 years

Max dose: 150 mg/day

for >40 kg

i.m., intramuscular; i.v., intravenous; p.o., oral; p.r., per rectum.

a
Do not exceed recommended adult doses.
b
Limited data in infants less than 6 months to 1 year of age.

300

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Acute pediatric pain in the emergency department Ruest and Anderson

although there are no rectal formulations of

ibuprofen, liquid ibuprofen could be given rectally
if needed.
Because of genetic polymorphisms, some
NSAIDs may be more effective in some individuals
than others [39]. Consequently, if pain relief has not
been effective with one NSAID, it is reasonable to try
another NSAID. Diclofenac is only available as an
oral tablet in the United States. It is generally used in
pediatrics for treatment of juvenile idiopathic
arthritis or postsurgical pain [40,41]. NSAIDs less
commonly used but available in some EDs and
approved for limited indications include etodolac
(approved for children as young as 6 years) [42],
meloxicam (approved for children as young as
2 years) [43], and celecoxib (approved for children
as young as 2 years) [44].
Although NSAIDs are typically well tolerated,
they pose the risks of gastric irritation, increased
bleeding, and acute kidney injury. Balestracci et al.
[45 ] found that among children with acute gastroenteritis and dehydration, 54% of those who were
given ibuprofen developed some degree of renal
impairment, albeit mostly mild and self-limited.
They concluded that exposure to ibuprofen
increased the risk of developing acute renal injury
by more than two-fold, independent of the degree of
the patients level of dehydration. Although not a
strict contraindication for patients presenting with
coexisting pain and volume depletion, caution
should be exercised when considering NSAID use
in this population.
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OPIOID ANALGESICS
Children with moderate-to-severe pain may require
opioid analgesics in addition to the nonopioids
(Table 2). Historically, children are less likely than
adults to receive opioids [46]. This discrepancy is
likely multifactorial and may include concerns
about the development of future opioid addiction.
Although pediatric patients may present with drugseeking behaviors, Tobias [37] noted that the incidence of addiction in patients receiving opioids for
acute pain management is exceedingly rare and
should not limit the delivery of effective analgesia
(p. 103).
All opioids can cause respiratory depression,
and, at high-enough doses, apnea. Those at higher
risk of adverse events include young infants and
children, those with altered mental status or underlying medical abnormalities, and patients using other sedating medications such as benzodiazepines
[37]. A 2012 review of all published case reports of
severe opioid-induced respiratory depression in children included the following: use of morphine in

children with renal impairment, medication dosing

or administration errors, and codeine use in children who are ultrarapid metabolizers (discussed
below) [47]. Opioid choice and dosing may require
modification in patients with renal or hepatic
impairment, special care must be taken to prevent
medication dosing and administration errors, and
codeine use should be abandoned.
Codeine (an inactive compound) must be
metabolized by the cytochrome P450 enzyme 2D6
to morphine (the active compound) to relieve pain.
Poor metabolizers of codeine may make 015% of
the normal concentrations of morphine causing
them to receive little or no analgesia from codeine.
Ultrarapid metabolizers may make up to 50% more
morphine than normal metabolizers a potentially
life-threatening situation. Severe respiratory depression and death have occurred, particularly in children who have obstructive sleep apnea and those
post-tonsillectomy or adenoidectomy. The US FDA
placed a black box warning on codeine; current
recommendations note that codeine should not
be used in children less than age 12 years who have
acute moderate pain, or in children less than age 18
years, who have obstructive sleep apnea or are posttonsillectomy or adenoidectomy [32,48 ,49].
Morphine, oxycodone, and hydromorphone are
active compounds that do not require enzyme conversion to provide analgesia [37]. They typically
have an analgesic effect within 20 min and peak
at around 60 min when given orally [12]. Morphine
and hydromorphone are available in both enteral
and i.v. preparations. Oxycodone is only available
enterally in the United States. All three are available
in liquid form. Hydromorphone is less commonly
used in the acute pediatric pain setting; however,
children with chronic pain, such as those with sickle
cell disease, may be tolerant to other opioids and
require this more potent opioid. As it is 58 times as
potent as morphine, careful dose selection should be
undertaken [37]. Although each of these medications is available in extended-release formulations, their use in the acute setting is not
recommended. Combination formulations of oxycodone-acetaminophen and hydrocodone-acetaminophen have fixed opioid-to-acetaminophen dose
ratios. Consequently, the acetaminophen dose
will be limited by the opioid component of the
formulation. Clinicians should consider prescribing
the opioid and acetaminophen components separately to optimize pain control while limiting opioid
use.
Fentanyl, a synthetic opioid, has few, if any,
cardiovascular effects; this is in contrast to morphine, which may exacerbate hypotension via its
peripheral vasodilatory effects [37]. Fentanyl may be

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Emergency and critical care medicine

Table 2. Frequently used opioid analgesicsa
Route

Recommended
dosing for <40 kgb

Recommended
dosing for 40 kg

Considerations and
contraindications

Dosing commentsc

Oxycodone

p.o.d

0.10.2 mg/kg
every 46 h

510 mg
every 46 h

Consider dose adjustment

with hepatic or renal
impairment
p.o. form comes as tablet
or liquid

Max dose: 510 mg/dose;

May give up to 15
20 mg/dose in opioidtolerant patients

Morphine

i.v.

0.050.2 mg/kg
every 14 h

210 mg
every 14 h

Consider dose adjustment

with hepatic or renal
impairment
May cause hypotension
i.m. dosing no longer
recommended

Max i.v. dose: 2 mg/dose

for infants; 4 mg/dose
for children aged 16
years; 8 mg/dose for
children aged 712
years; 10 mg/dose for
adolescents

p.o.d

0.20.5 mg/kg
every 34 h

1520 mg
every 34 h

Hydrocodone

p.o.d

0.10.2 mg/kg
every 46 h

510 mg
every 46 h

Same as oxycodone

Same as oxycodone

Fentanyl

i.v.

0.52 mcg/kg
every 24 h

25100 mcg
every 24 h

May case chest wall

rigidity with
rapid i.v. push
Little to no effect on
blood pressure

Max i.v. dose: 50 mcg for

children aged <2 years;
may repeat 1/2 original
dose every 35 min;
may repeat 1/2 full dose
every 5 min for
adolescents and adults

i.n.

12 mcg/kg

50100 mcg

Max i.n. dose: 100 mcg/

dose; larger doses are
limited by the intranasal
volume

i.v.

0.010.015 mg/kg
every 36 h

0.21 mg
every 24 h

Max i.v. dose: 1 mg

for >40 kg

p.o.d

0.030.08 mg/kg
every 24 h

14 mg/dose
every 24 h

Max p.o. dose: 24 mg

for >40 kg

Hydromorphone

Max p.o. dose: 15

20 mg/dose for <40 kg

i.m., intramuscular; i.n., intranasal; i.v., intravenous; p.o., oral.

a
All opioids can cause respiratory depression.
b
Do not exceed recommended adult doses.
c
Maximum recommended doses for opioid-nave patients. Consider starting with lower max dosing in opioid-nave patients and repeat doses to titrate to pain
control. Individuals with prior opioid exposure may require higher doses.
d
Dosing for immediate release formulations only.

a preferred choice for acute pain management in

critically ill children who may be hemodynamically
unstable.
An additional benefit of fentanyl is the option
of intranasal administration. A 2014 Cochrane
Review on the use of intranasal fentanyl (INF)
via syringe and nasal atomizer concluded
that INF can be an effective analgesic for children
aged 3 years and above with acute moderate-tosevere pain [50]. Studies in children as young as
6 months have demonstrated INF to result in
effective analgesia and decreased time to medication administration [51,52], and equivalent pain
control when compared to i.v. morphine, oral
morphine, or i.v. fentanyl [53]. Intranasal fentanyl
(1.5 mcg/kg) provided the same pain severity
reduction as 1 mg/kg of intranasal ketamine
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(INK), with a low side-effect profile [54]. For

patients presenting with moderate-to-severe
pain without i.v. access, INF should strongly
be considered, particularly for acute traumatic
injuries.
Ketamine, a dissociative anesthetic and analgesic most commonly used in the ED intravenously for
moderate sedation, has also been studied at subdissociative intranasal doses for acute pain management without sedation. Yeaman et al. [55] found
that an average subdissociative dose of 1 mg/kg of
INK may provide adequate analgesia with minimal
side effects by about 30 min postadministration for
children with acute traumatic pain.
Intravenous patient-controlled analgesia is
occasionally used in the ED; however, it is beyond
the scope of this review.
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Acute pediatric pain in the emergency department Ruest and Anderson

ADJUNCTIVE MEDICATIONS AND

MODERATE SEDATION
Anxiety and fear may impact how a child perceives
and experiences painful procedures [11,56].
Adequately addressing anxiety and fear either by
nonpharmacologic methods (e.g. developmentally
appropriate explanations, and distraction), or via
pharmacologic methods (e.g. anxiolytics such as
midazolam) can be emotionally beneficial and
may reduce the need for opioid analgesics. Midazolam can be administered orally, intravenously, or
intranasally [18,19]. The use of moderate sedation is
an important adjunct to procedural pain management in the pediatric ED, but is beyond the scope of
this article. When safely possible, moderate sedation
should be considered for any significantly painful or
prolonged procedure with the use of institutionbased sedation guidelines.

SPECIAL CONSIDERATIONS
Patients with chronic pain or conditions causing
frequent recurrence of pain may report pain differently and may not demonstrate the same facial or
body language cues as children who do not routinely experience pain [18,23 ]. Furthermore, children with developmental disabilities may have
altered or heightened perceptions of pain and
may not be able to communicate their pain or
anxiety in a way that is readily apparent to providers
[18,23 ]. It is important to rely on parents and caregivers to identify pain and utilize modified pain
assessment tools for noncommunicating children.
Special care must be taken for children who are
on multiple medications (particularly benzodiazepines) or are at risk of respiratory insufficiency
(e.g. sleep apnea). Those with hepatic or renal disease may have impaired metabolism or clearance of
opioids and their metabolites. Patients with renal
disease may be more sensitive to adverse effects
from NSAIDs. Consultation with dosing guidelines
or a pain specialist should be considered for such
children.
&

&

CONCLUSION
Adequate assessment and treatment of pediatric
pain requires knowledge and skill to care for patients
across a broad range of ages, developmental levels,
and communication abilities; these are essential
tasks of medical providers. A systematic approach
to pain assessment utilizing validated patientappropriate pain scales in concert with a multimodal, multidisciplinary approach to pain will allow
individualization and optimization of pain management in this population.

Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.

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Volume 28
Number 3
June 2016

Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved.