Paeds · pain-palliative-and-end-of-life-care
Acute nociceptive pain management
Also known as Acute pain management in children · WHO two-step analgesic ladder for children · Paediatric multimodal analgesia · Morphine titration and PCA in children · Postoperative and sickle-cell pain management
A fellowship approach to acute nociceptive pain in a child: score the pain with an age-appropriate tool, build a multimodal foundation of regular paracetamol (15 mg per kg per dose, max 60 mg per kg per day, adult max 1 g per dose and 4 g per day) and an NSAID (ibuprofen 5 to 10 mg per kg per dose, max 30 mg per kg per day, from three months and over 5 kg), and escalate up the WHO two-step ladder to morphine 0.1 mg per kg intravenously for moderate-to-severe pain. The 2025 JAMA Pediatrics network meta-analysis places NSAIDs first-line for acute paediatric pain. Severe or postoperative pain is run with a titrated opioid by patient- or nurse-controlled analgesia, a regional block and opioid-sparing adjuvants, with the sedation score and respiratory rate monitored and naloxone available. Codeine and tramadol are contraindicated under 12 and after tonsillectomy.
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Red flags
- Opioid-induced respiratory depression is the central safety fear: a child on a morphine infusion or PCA who becomes sedated with a falling respiratory rate needs the opioid held, stimulation, airway support and naloxone titrated to the respiratory rate. The sedation score, not the pain score, is the early warning.
- Never escalate an opioid in a sedated or agitated child without re-checking the sedation score. Agitation may be hypoxia, delirium, a full bladder or opioid-induced hyperalgesia rather than pain; more opioid in that state causes harm.
- Codeine and tramadol are contraindicated in children under 12 and in any child after tonsillectomy or adenoidectomy: a CYP2D6 ultrarapid metaboliser converts the prodrug to a fatal morphine dose. The modern step-two opioid is morphine.
- Do not give an NSAID to a dehydrated or renally impaired child: restore circulating volume first. An NSAID in the under-perfused kidney precipitates acute kidney injury.
- Acute pain that is escalating despite a correct regimen may signal a new surgical or medical emergency: a compartment syndrome under a cast, a testicular torsion, a sickle chest syndrome or an intra-abdominal emergency. Re-diagnose before escalating the opioid.
- Sucre for neonatal procedures is a small absolute volume (about 0.1 to 2 mL of 24 per cent sucrose two minutes beforehand), never millilitres per kilogram.
Life stages
Care settings
Clinical exam formats
Board mappings
- Clinical Sciences — Pharmacology and pain
- General Paediatrics — Acute and critical care: assessment and management of pain in the acutely ill child
- Current 2026 PREP curriculum — Learning Objective 2.2.1: Recognise, prioritise and manage an acutely ill infant, child or young person, including the child in acute pain
- Current 2026 PREP curriculum — Learning Objective 1.5.2: Demonstrate safe and quality use of medicines, including acute analgesia in children
- Renewed curriculum for first-year trainees from 2027 — Learning goal 4: Safe and effective prescribing
- Clinical Applications
- Medical Sciences
- Long Cases
- Short Cases
- 7. Patient safety, including safe prescribing
- 4. Professional skills and knowledge: Patient management
- 8. Pharmacology: Lead on the safe and effective use of medicines
- Applied Knowledge in Practice (AKP)
- Theory and Science (TAS)
- Clinical
- History
- Communication
- General Pediatrics Content Outline — Universal Task 4: Management and Treatment
- General Pediatrics Content Outline — Universal Task 7: Patient Safety and Quality Improvement
- General Pediatrics EPA 4: Writing Prescriptions
- Patient Care 5: Patient Management
- Systems-Based Practice 1: Patient Safety
- Practice-Based Learning 2: Reflects on unsafe practice and medication safety
- Medical Expert
- Pediatrics: Foundations EPA #5 — Prescribing medications safely
- Pharmacotherapeutic stewardship and safe medication use
Overview & Definition
Acute nociceptive pain is the normal, time-limited protective response to a defined tissue injury — a fracture, a surgical wound, a burn, a sickle-cell vaso-occlusive crisis, a needle — with an expected trajectory of healing. The pain is the symptom, the injury is the cause, and the analgesia is one half of the plan; the other half is finding and fixing the source. A child who is given good analgesia but is still sent home from the emergency department with a missed torsion has been failed twice over, so analgesia never substitutes for diagnosis. [8]
The work begins with one question: how much does it hurt, and how do you know? Pre-verbal and cognitively impaired children cannot tell you in words, so a validated, age-appropriate pain score stands in for the words. The FLACC scale (Face, Legs, Activity, Cry, Consolability, each scored 0 to 2 for a total of 0 to 10) is the standard for the infant and pre-verbal child; the revised FLACC extends the same framework to children with cognitive impairment by adding individualised behaviours; the school-age child uses a 0-to-10 numeric or faces scale. The score is taken before the drug, and again at the expected onset of action, because a documented reassessment is the safeguard against both under-treatment and over-treatment. [10]
The unifying principle is the right drug, at the right weight-based dose, capped at the adult maximum, combined across classes, and judged on the child by a repeat pain score. The modern standard is multimodal and opioid-sparing: regular paracetamol and an NSAID carry most of the load, a regional or local anaesthetic technique targets the surgical site, and an opioid is titrated only for breakthrough or severe pain. The goal is a comfortable, breathing, recovering child — not a silenced one — and the sedation score is watched as closely as the pain score. [11] [12]
References12ShowHide
- [1]Olejnik L, Lima JP, Sadeghirad B, et al. Pharmacologic Management of Acute Pain in Children: A Systematic Review and Network Meta-Analysis JAMA Pediatr, 2025.PMID 39899301
- [2]Brandow AM, Carroll CP, Creary S, et al. American Society of Hematology 2020 guidelines for sickle cell disease: management of acute and chronic pain Blood Adv, 2020.PMID 32559294
- [3]Darbari DS The vaso-occlusive pain crisis in sickle cell disease: Definition, pathophysiology, and management Eur J Haematol, 2020.PMID 32301178
- [4]Ciornei B, David VL, Popescu D, et al. Pain Management in Pediatric Burns: A Review of the Science behind It Glob Health Epidemiol Genom, 2023.PMID 37745034
- [5]Pillai Riddell RR, Bucsea O, Shiff I, et al. Non-pharmacological management of infant and young child procedural pain Cochrane Database Syst Rev, 2023.PMID 37314064
- [6]Shah PS, Torgalkar R, Shah VS Breastfeeding or breast milk for procedural pain in neonates Cochrane Database Syst Rev, 2023.PMID 37643989
- [7]Stevens B, Yamada J, Ohlsson A, et al. Sucrose for analgesia in newborn infants undergoing painful procedures Cochrane Database Syst Rev, 2016.PMID 27420164
- [8]Krauss BS, Calligaris L, Green SM, Barbi E Current concepts in management of pain in children in the emergency department Lancet, 2016.PMID 26095580
- [9]Smith HAB, Besunder JB, Betters KA, et al. 2022 Society of Critical Care Medicine Clinical Practice Guidelines for Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients Pediatr Crit Care Med, 2022.PMID 35119438
- [10]Malviya S, Voepel-Lewis T, Burke C, Merkel S, Tait AR The revised FLACC observational pain tool: improved reliability and validity for pain assessment in children with cognitive impairment Paediatr Anaesth, 2006.PMID 16490089
- [11]Chou R, Gordon DB, de Leon-Casasola OA, et al. Management of Postoperative Pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists J Pain, 2016.PMID 26827847
- [12]Dumbarton TC Regional anesthesia in complex pediatric patients: advances in opioid-sparing analgesia Can J Anaesth, 2024.PMID 37884770