Paediatric analgesic ladder

Paediatric Guidelines for the Management of Acute and Post-operative Pain.
Severe Pain
7-10
Moderate Pain
4-6
Mild Pain
1-3
Simple analgesic
1. PARACETAMOL
Paracetamol + NSAID +/- Weak
Opioid
2. NSAID ie Ibuprofen or Diclofenac
CONSIDER
PLUS
2. NSAID: Ibuprofen or Diclofenac
PLUS CONSIDER
3. Weak Opioid e.g. MORPHINE ORAL
Non- Pharmacological
PLUS
1. PARACETAMOL
PARACETAMOL
Oral, rectal or IV
Paracetamol + NSAID + Strong
Opioid
3. Patient Controlled Analgesia (PCA)
-via dedicated cannula or anti-reflux valve.
Add 1mg/kg of morphine and make up to a final volume
of 50mls with NACL.
20mcg/kg bolus, (1ml bolus) lockout 5mins.
PCA to be prescribed by anaesthetist.
OR
Distraction techniques, play,
sucrose.
Possible alternatives to Oramorph include:
DIHYDROCODEINE (from 1y, avoid in
adenotonsillectomy or airway surgery)
Heat, ice therapy.
OR
3. IV Morphine bolus
Add 1ml of 10mg/ml morphine ampoule to 9mls NaCl
0.9%.
>12years CODEINE
(Contraindicated in children <18years old with
obstructive sleep apnoea undergoing ENT surgery)
0-1month 25microgram/kg
1-3months 50microgram/kg
>3months 100microgram/kg
OR
Monitor Respiratory rate and SPO2 for all children
receiving IV morphine bolus or PCA.
Family involvement.
Patient positioning.
Splinting of fractures.
>12y TRAMADOL
Regular assessment of pain should be carried out using appropriate tools i.e. VAS, FACES, F.L.A.C.C.
C. Haining, S. Russell 2014
Paediatric Dosage Guidelines for the Management of Acute and Post-operative Pain
The doses below apply to short-term use in otherwise healthy children. See BNF for cautions.
Simple analgesic
PARACETAMOL
Oral or Rectal
>3months: 15mg/kg 4hrly, routinely up to max four doses per
day. Max 75mg/kg/day (max 4g)
Consider loading dose 20mg/kg oral or 30-40mg/kg pr
>12y provided >50kg: 1g four times a day (no loading dose)
IV CONSULTANT PRESCRIPTION ONLY
10-50kg: 15mg/kg 4-6hrly
Max daily dose 60mg/kg i.e. four doses per day.
>50kg 1gramme 4-6hrly
Max daily dose 4grammes. No loading dose IV.
+/- NSAID: ibuprofen or diclofenac
IBUPROFEN Oral
1-6months 5mg/kg 6hrly.
>6months 5-10mg/kg 6-8hrly maximum daily dose 30mg/kg/day
Preferred dose for acute pain 10mg/kg tds
DICLOFENAC oral or rectal,
>6months 1mg/kg 8hrly maximum 150mg/day
Weak Opioid
MORPHINE ORAL
0-1month 80 microgram/kg 4hrly.
1-3 months 100 microgram./kg 4hly
3-6months 150 microgram/kg 4hly
6-12 months 200 microgram/kg 4hly
>1year 200-300 microgram/kg 2-4hrly, max per dose 10mg.
100-200 microgram/kg 2-4hly as substitute for oral codeine
OR
DIHYDROCODEINE Oral
1-4y 0.5 mg/kg (max 30mg) 4hrly
>4y 0.5 – 1 mg/kg (max 30mg) 4hly
OR
>12years CODEINE Oral 1mg/kg (max 60mg) 4hly
maximum daily dose 240mg in 24 hrs for maximum 3days
(Contraindicated in children <18years old with obstructive sleep apnoea
undergoing ENT surgery and in children where breathing may be compromised)
OR
>12y TRAMADOL Oral or IV
50-100mg 4-6hrly Max daily dose 400mg
Strong Opioid
Morphine PCA or Morphine IV Bolus (see over)
Note: morphine bolus usually single dose, re-prescribe if repeat.
C. Haining, S. Russell 2014