1. Pain management in children
Dr David Tran
FVHospital
A&E depatment

2. Pain evaluation
Each child coming in A&E with pain, needs to have an evaluation of his pain.
This evaluation is necessary to chose the adapted painkiller and to follow the efficiency of the treatment.
Auto-evaluation is the best if possible
Different tools help evaluation (pain scale)

3. Face pain scale / Visual Analog Scale / Verbal descriptor scale
1 - 2
3 - 4
5 - 6
7 - 8
9 - 10

4. Pain assessment in infants
1 - 2
3 - 4
5 - 6
7 - 10

6. Pain assessment / age Less than 4 years > Behavioral scale
Between 4-6 years > Face scale
More than 6 years > VAS or numeric scale
Scale type
VAS
Face
Behavior
Mild pain
1 - 3 2
1 - 2
Moderate pain
3 - 5 4
3 - 4
Severe pain
5 - 7 6
5 - 6
Very severe
> 7
8 - 10
7 - 10
Painkiller
3/10
4/10

7. Different types of painkillers
Level
Painkiller 1
Paracetamol 2
Codeine
Non Steroid Anti-inflammatory
Tramadol 3
Morphine

8. How to chose painkiller
Level 1 & 2: can be administrated by the nurse (triage nurse)
Level 3: medical prescription only
Association between different levels is possible (ex: or 1 + 3)
No pain
Mild pain
Moderate pain
Severe pain
Very severe pain
No use
Level 1
Level 1 or 2
Level 2 or 3
Level 3

9. Level 1 = Paracetamol DOLIPRANE / EFFERALGAN
Dose 15mg/Kg by mouth (better than intra-rectal)
< 5 Kg
Doliprane 100mg
½ sachet
5 – 8 Kg
1 sachet
8 – 12 Kg
Doliprane 150mg
12 – 16 Kg
Doliprane 200mg
16 – 27 Kg
Doliprane 300mg
> 27 Kg
Dopirane 500mg

10. Level 2 : Codeine CODENFAN 0.5ml/Kg/6h (soon available in FVH)
EFFERALGAN Codeine (only if > 15Kg)
Weight
Posologie
15-22 Kg
½ tablet / 6h
23 – 30 Kg
½ tablet / 4h
31 – 50 Kg
1cp / 4 to 6h
> 50 Kg
1 to 2 tablets/ 4h

11. Level 2 : Tramadol Authorized for children of 15 years old or more
1 tablet /every 6 hours
Association with paracetamol possible
There is a sirup of tramadol (Topalgic 100mg/ml for children > or = 3 years) but not available in FVH…

12. Level 2 : Non Steroid Anti-inflammatory = Children’s Ibrafen® sirup
If needed, repeat dose every 6 hours
Age
Weight (Kg)
Dose
(teaspoon)
Under 2
<11 Kg
1/2
2 - 3 1
4 – 5
1.5
6 – 8 2
9 – 10
2.5 11 3

13. Level 3 : Morphine IV Indicated if severe or very severe pain
Use only if medical supervision (Pain, consciousness, respiratory rate)
Ventilation device available (balloon, high concentration mask, Oxygen) and Naloxone available.
Contre-indication: hepatic failure, asthma in crisis, cranial trauma, hypersensitivity to morphine

14. Management of morphine
Use bolus of morphine (titration)
First dose : 0.1mg/Kg IVD (always < 5mg)
Reevaluation every 5 minutes (use the same scale)
Reinjection of 0.025mg/Kg every 5 to 7 minutes if EVA > 4 (objective = EVA < 4)
There is no maximum dose but medical assessment is necessary after 5 injections

15. Preparation of morphine
1 ampoule of morphine = 10mg
Dilute the ampoule in 9ml of serum 
You get 10mg / 10ml (1mg/1ml)
First dose 0.1mg/Kg
Example: child 20Kg > needs 2mg = 2ml of the diluted preparation.
Next bolus 0.025mg/Kg > 0.5mg = 0.5ml

16. Safe control during morphine treatment : 3 criteria
Re-assessment of the pain
Conscious evaluation (sedation score)
Respiratory Rate
Score
Sedation
Clinical signs
No sedation
Alert, eyes opened 1
Mild sedation
Eyes open on demand 2
Important sedation
Eyes open on stimulation 3
Very severe
Impossible to wake up

17. Respiratory depression
Respiratory rate is the best criteria with consciousness
Age
Respiratory Rate
< 1 year
> 20/min.
1 to 5 years
> 15/min.
> 5 years
> 10/min.

18. In case of overdose signs
Sedation score < 2 and RR to law (depend of age)
Stimulate the child and ask him to breath
Oxygenation with high concentrated mask if SaO2 < 94% 6 to 8l/min
If no improvement after stimulation, use Naloxone (NARCAN®)

19. Use of Naloxone = NARCAN®
1 ampoule = 0.4mg = 400g = 1ml
Posologie: 1 to 2 g / Kg IVD
Dilute 1 ampoule of 1ml in 9 ml of serum 
Inject 1ml by 1ml until the child recover normal conscious & respiratory rate
Problem: the antalgic effect of morphine is removed

20. Criteria of discharged after use of morphine in children
Only after 2 hours of surveillance in A&E (after the last bolus of morphine)
Child awake (sedation score = 0)
Respiratory rate normal for the age
Parents agree for assessment at home (give and explain special form for assessment after use of morphine)