A 10-Year-Old Boy With Acute Postoperative Pain: A Rational Approach to Opioid Prescribing

Johanne Lynch, MD; Fiona Campbell, MD; Jason Hayes, MD


August 17, 2010

General Approach to Management of Pediatric Pain

Pain Assessment

Assessment is the first step in a rational approach to pediatric pain management. The goals are to describe the pain and the factors influencing it, to predict the need for intervention, and to evaluate the effectiveness of treatment. The main component of pain assessment is the use of validated age-appropriate pain intensity scales (Table 1). These scales use 3 methods of assessment: self-report, behavioral reactions, and physiologic parameters. Self-report is considered the most reliable method; even children as young as age 4 years can self-report. Behavioral observational scales are the primary method used in children younger than 4 years or in noncommunicative children. Behavioral scales evaluate facial expressions, limb and trunk motor responses, verbal responses, or combinations of behavioral and autonomic responses.

Table 1. Examples of Validated Pain Assessment Tools

Assessment Tool Age/Cognition Stage
PIPP Preterm and full-term neonates
FLACC 2 months to 7 years; nonverbal older and/or cognitively impaired
Pain word scale 3-7 years; older children unable to use 0-10 number rating scale
Faces Pain Scale 5-12 years
NRS ≥ 7 years

FLACC = Face, Legs, Activity, Cry, Consolability; NRS = Numeric Rating Scale; PIPP = Premature Infant Pain Profile

Pain Management

For management of pediatric pain, a "multimodal" approach with use of pharmacologic, physical, and psychological strategies is recommended. An analgesic plan, formulated with parents and children in advance of a procedure or surgery, may help to ascertain how children respond to various situations (eg, pain or hunger) and the best mode of analgesia for them.

Physical therapies may include (1) cold packs, (2) heating packs, (3) positioning, (4) transcutaneous electrical nerve stimulation, and (5) exercise.

Commonly used psychological techniques include: (1) relaxation, (2) age-appropriate distraction (music, movies, television, computer games, and conversation), and (3) behavioral rehearsal.

When analgesic agents are used, a combination that acts synergistically at different points of the pain pathway is more effective than a single agent and allows for lower doses to be used, with a reduction in adverse effects.[5] The World Health Organization recommends a stepwise approach for the administration of analgesics, beginning with nonopioid agents, such as acetaminophen and nonsteroidal anti-inflammatory drugs for mild pain, then progressing to opioids of increasing potency with increasing pain.[6]


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