“The most reliable indicator of the existence and intensity of acute pain” is the patient’s self-report (Emerg Med Clin North Am 2005;23:393).
- For nonverbal or cognitively impaired children, use behavioral and physiologic indicators or scales.
- Pain intensity and response to treatment must be continually monitored and reassessed regularly.
- Pain assessment should be individualized, taking into account age, race, gender, culture, emotions, development, expectations, and prior experiences.
- Pain prevention is better than treatment; anticipate procedure-related pain and prepare patient and parents.
- Poorly controlled pain can have short- and long-term physical and psychological consequences.
- Adequate pain prevention and control can have short- and long-term benefits.
- Unexpected intense pain, especially if associated with altered vital signs, should be evaluated for other possible diagnoses.
- World Health Organization Analgesic Ladder: Physical measures, nonopioid analgesics, oral opiates, and IV opiates may be used in a stepwise manner.
- Other adjuncts, including local anesthetics, anxiolytics, antidepressants, muscle relaxants, anticonvulsants, and cognitive/behavioral therapies should be used with analgesics for an integrated approach to pain management.
- The goal is to reduce pain to acceptable levels while considering the possible adverse reactions and side effects of each medication.
Scale | Type | Description | Age Group |
|---|---|---|---|
Numeric | Self-report | 0–10 scale; 0 = no pain, 10 = worst pain you could ever imagine | Children who understand the concepts of numbers, rank, and order; generally older than 8 years of age |
Beiri and Wong-Baker scales | Self-report | Six faces that range from no pain to the worst pain you can imagine | Younger children who have difficulty with numeric scale; cognitive age, 3–7 years |
FLACC* | Behavioral observer | Five categories: face, legs, activity, cry, and consolability; range of total scores is 0–10; score ≥7 is severe pain | Nonverbal children older than 1 year of age |
CRIES†, NIPS, PIPP | Behavioral observer | Rates a set of standard criteria and gives a score | Nonverbal infants younger than 1 year of age |
Categories | Score 0 | Score 1 | Score 2 |
|---|---|---|---|
Face | No particular expression or smile | Occasional grimace or frown, withdrawn, disinterested | Frequent to constant frown, clenched jaw, quivering chin |
Legs | Normal position or relaxed | Uneasy, restless, tense | Kicking or legs drawn up |
Activity | Lying quietly, normal position, moves easily | Squirming, shifting back and forth, tense | Arched, rigid, or jerking |
Cry | No cry (awake or asleep) | Moans or whimpers, occasional complaint | Crying steadily, screams or sobs, frequent complaints |
Consolability | Content, relaxed | Reassured by occasional touching, hugging, or being talked to; distractible | Difficult to console or comfort |
- Cognitive: Music, guided imagery, distraction, positive reinforcement, decentralization, hypnosis
- Behavioral: Relaxation techniques, biofeedback exercises, breathing control, distraction, education
- Physical: Hot and cold compresses, massage or touch, position and comfort, temperature regulation, transcutaneous electrical nerve stimulation, acupuncture, chiropractic therapy, immobilization
- Gate control hypothesis: Close the “pain gates” via nonpainful receptors or excitatory messages from the brain
- Formulations containing epinephrine should NOT be used in terminal capillary circulations (eg, pinna, digits, nose, penis, and other areas of end-capillary circulation).
Category | Drug | Dosage | Warnings |
|---|---|---|---|
Topical local anesthetic | LET (lidocaine, epinephrine, tetracaine) suturing solution | ⩽3 mL on gauze or cotton pad in direct contact with wound |
|
ELA-Max, L.M.X. 4% (lidocaine) or EMLA (eutectic mixture of lidocaine and prilocaine) | Maximum dosing to intact skin (30 min for ELA-Max; 60 min for EMLA): Birth–3 mo or <5 kg: 1 g 3–12 mo and >5 kg: 2 g 1–6 yr and >10 kg: 10 g >7 yr and >20 kg: 20 g |
| |
Ethyl chloride topical spray | Spray at target area 3–9 in away for 3–7 s until skin turns just white; immediate onset |
| |
Injectable local anesthetic | Lidocaine (with or without epinephrine) | Maximum dose: 4.5 mg/kg Buffer 1:10 with sodium bicarbonate (8.4%) to reduce burning sensation at injection site |
|
Bupivacaine | Maximum dose: 2.5 mg/kg Buffer 1:30 with sodium bicarbonate (8.4%) to reduce burning sensation at injection site |
- Avoid salicylates because of their association with Reye syndrome.
- Oral sucrose: Neonates and infants younger than age 6 months during procedures such as heel sticks, venipunctures, and LPs up to 1 mL for three doses.
- Nonopioid analgesics: For mild to moderate pain if the FACES pain scale below 5 or objective pain scale or numeric pain scale below 6.
- Nonopioid analgesics are used very infrequently in the NICU and should be used only after discussion with the attending physician.
Drug | Dosage | Comments |
|---|---|---|
Acetaminophen (nonsalicylate) | PO or PR 10–15 mg/kg q 4–6 h Maximum dosage: 1000 mg q 6 h |
|
Ibuprofen (NSAID) | PO 4–10 mg/kg q 6-8 h (not for use in patients younger than 6 mo of age) Maximum dosage: 800 mg q 6 h |
|
Ketorolac (NSAID) | IV or IM 0.5–1.0 mg/kg q 6 h followed by 0.5 mg/kg q 6 h Maximum dosage, 30 mg q 6 h; no more than 5 days/mo |
|
Naproxen (NSAID) | PO 5–7 mg/kg q 8–12 h (not for use in patients younger than 2 yr of age) Maximum dosage: 500 mg q 8 h |
|
Indomethacin (NSAID) | PO 1 mg/kg q 6–8 h Maximum dosage: 50 mg q 6 h |
|
- Opioid analgesics: For moderate to severe pain if pain scales above 6; bind m-receptors in the CNS.
- Opiates may cause severe respiratory depression, hypotension, CNS depression, bladder retention, ileus, pruritus, nausea and vomiting.
- Opiate antagonist Naloxone: For intoxication, use 0.1 mg/kg up to 2 mg IV/IM; for respiratory depression, use 0.01 mg/kg, which may be repeated every 2 to 3 minutes up to 0.05 mg/kg if needed.
Drug | Dosage | Comments |
|---|---|---|
Codeine | PO 0.5–1 mg/kg q 4–6 h Maximum dose: 60 mg | Commonly combined with acetaminophen |
Fentanyl | IV 1–2 mcg/kg/dose < 12 yr IV 0.5–1 mcg/kg/dose ≥ 12 yr | Muscle rigidity and chest wall spasm (may require a nondepolarizing muscle relaxant) IV onset: 4–5 min Duration: 20–60 min |
Hydrocodone | PO 2.5–5.0 mg q 6-8 h Maximum dose: 10 mg | Commonly combined with acetaminophen |
Hydromorphone | IV 0.015 mg/kg q 3–4 h PO 0.03–0.08 mg/kg q 3–4 h Maximum dose: 2 mg | High potential for abuse |
Methadone | PO 0.1 mg/kg q 4–12 h Maximum dose: 20 mg | Used in narcotic detoxification May cause QT prolongation |
Morphine | IV 0.05–0.2 mg/kg q 2–4 h PO 0.1–0.5 mg/kg q 4–6 h MS Contin: Can give q 8–12 h Maximum dosage: IV 15 mg, PO 30 mg | Do not crush or chew controlled-release tablets IV onset: 5–10 min Duration: 2–4 h |
Oxycodone | PO IR 0.2 mg/kg q 3–4 h PO SR 10–20 mg q 12 h Maximum dose: 30 mg | Do not use sustained-release tablets as a PRN analgesic |
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