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Key messages
1. Sucrose reduces the behavioural response to heel‐stick blood sampling in neonates (U)
(Level I [Cochrane Review]).
2. Breastfeeding or breast milk reduces measures of distress in neonates undergoing a single
painful procedure compared to positioning or no intervention (U) (Level I [Cochrane
Review]).
3. Distraction, hypnosis, and combined cognitive‐behavioural interventions reduce pain and
distress associated with needle‐related procedures in children and adolescents (S) (Level I
[Cochrane Review]).
4. EMLA® is an effective topical anaesthetic for children, but amethocaine is superior for
reducing needle insertion pain (N) (Level I [Cochrane Review]).
5. Topical local anaesthetic application, inhalation of nitrous oxide (50%) or the combination
of both provides effective and safe analgesia for minor procedures (U) (Level I).
6. Combinations of hypnotic and analgesic agents are effective for procedures of moderate
severity (U) (Level II).
The following tick box represents conclusions based on clinical experience and expert
opinion.
Inadequate monitoring of the child, lack of adequate resuscitation skills and equipment,
and the use of multiple drug combinations has been associated with major adverse
outcomes during procedural analgesia and sedation (U).
10.5 ANALGESIC AGENTS
10.5.1 Paracetamol
Paracetamol (acetaminophen) is effective for mild pain in children (Anderson, 2008), but the
dose required for analgesia is greater than for an antipyretic effect (Anderson, 2004). It has
similar efficacy to non‐selective non‐steroidal anti‐inflammatory drugs (nsNSAIDs), and may be
a useful adjunct to other treatments for more severe pain. Supplemental opioid requirements
were reduced after day case surgery by 40 mg/kg but not 20 mg/kg rectal paracetamol (Korpela
et al, 1999 Level II) and after tonsillectomy by 40 mg/kg oral paracetamol (Anderson et al, 1996
Level II). Rectal paracetamol did not reduce morphine requirements in infants following major
surgery (van der Marel et al, 2007 Level II). CHAPTER 10
Pharmacokinetics and pharmacodynamics
Paracetamol’s bioavailability is dependent on the route of administration. Oral doses are
subject to first pass hepatic metabolism of 10% to 40% and peak plasma concentrations are
reached in 30 minutes (Arana et al, 2001). Rectal administration is associated with slower and
more erratic absorption and loading doses of 30 to 40 mg/kg paracetamol may be required to
achieve therapeutic plasma concentrations (Anderson et al, 1996 Level II; Howell & Patel, 2003
Level II). An IV formulation of paracetamol increased dosing accuracy with less
pharmacokinetic variability attributable to absorption, but also had more rapid offset than
a rectal preparation (Capici et al, 2008 Level II).
Dose regimens that target a steady state plasma concentration of 10 to 20 mg/L have been
determined. There is some evidence for analgesic efficacy at this concentration in children
(Anderson et al, 2001 Level III‐3) but a relationship between plasma concentration and analgesia
Acute pain management: scientific evidence 347
