Paediatric Palliative Care Guidelines
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Edition/Revision: 4.0
Validated 22 Oct 2016

Pain management

  • Assessment should include a careful history and examination to elucidate the exact nature and likely cause(s) of pain so that the most effective management can be initiated
  • Assessment should include discussion with parents/carers and staff as well as the child if possible
  • There are a number of pain assessment tools available to aid diagnosis, monitoring, and analgesic effect. These tools should be used as scores can be invaluable means of measuring progress in situations that are often complex
  • Assessment of pain in children particularly young infants and non-verbal children may be difficult. Observational pain tools are used to aide assessment.
  • Pain may be under-diagnosed and therefore inadequately treated in children, particularly those unable to communicate readily.
  • Pain is closely associated with fear and anxiety

Recognising pain in children with communication difficulties:

  • Discuss with family/carers who know the child well.
  • Look for signs including: crying, becoming withdrawn, increased flexion or extension, hypersensitivity, frowning/grimacing on passive movement, increasing numbers of fits
Management

General measures

  • Management should include a holistic approach considering both pharmacological and non-pharmacological strategies.
  • Explanations and discussion often help to reduce anxiety.

Principles of medication in the management of pain:

  • Use the ladder (see below)
  • Administer regularly, by the clock
  • Preferred route: oral
  • Filtrate to effect: aim to relieve symptoms with minimal side effects
  • Once requirement is stable, minimise the number of doses per day: convert to a sustained release preparation
  • Remember non-opioids and adjuncts all have a role to play
  • Seek further advice, if pain is not controlled swiftly

Recent WHO guidance (Pharmacological treatment of persisting pain in children with medical illness) has changed the WHO analgesic ladder from a three step to a two step approach. This removes the role of weak opiates which coincides with the MHRA warning around use of Codeine in children especially under 12years.

Recommendations now suggest that when moving from step 1 to step 2 i.e. moving to an opiate, commencement of low dose strong opiates are recommended at initial exposure to opiates.

World Health Organisation Three step analgestic ladder
  • Step1 Non Opioid
    (eg Paracetamol)
  • Step 2 Weak Opioid
    ± Non Opioid
    ± Adjuvant drugs
  • Step 3 Strong Opioid
    ± Non Opioid
    ± Adjuvant drugs
Edition/Revision: 4.0
Created 21 Oct 2016
Validated 22 Oct 2016 by Ian Back
Last modified 3 Apr 2020
Sat 04 Apr 2020 06:23:22 GMT +0100 (DST)
Last modified 3 Apr 2020