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procedural interventions, increase dose flexibility, and improve parent and nurse satisfaction –
see Howard et al (Howard et al, 2008) for dose recommendations. The incidence of adverse
events was similar (24 or 22%) in children self‐administering conventional PCA and those
receiving NCA (administered by nurses or physicians). Rescue events (requiring naloxone,
airway management or admission to high dependency unit or ICU) were more common in the
NCA group, but this group was also younger and had a higher prevalence of comorbidities.
Cognitive impairment and high opioid dose requirements on day 1 were associated with
increased adverse events (Voepel‐Lewis et al, 2008 Level III‐2).
NCA has also been used in older children in intensive care who are unable to activate a
conventional PCA device. Adequate analgesia comparable to PCA was reported, but efficacy
was dependent on accurate nurse assessment of pain (Weldon et al, 1993 Level III‐2).
Administration by a nurse trained in pain assessment, rather than parents, is recommended in
most centres (Howard, 2003). ‘PCA by proxy’ has also been used to describe administration by
nurses and/or parents. In a prospective series of PCA by proxy (parents or health care
providers), effective analgesia was achieved in 81% to 95% of children under 6 years of age,
25% required supplemental oxygen, and 4% required naloxone for respiratory depression
(Monitto et al, 2000 Level IV). In a retrospective series, PCA by proxy resulted in low pain scores
in children with developmental delay, and somnolence or respiratory depression requiring
naloxone occurred in 2.8% of patients (Czarnecki et al, 2008 Level IV). PCA by proxy in children
with cancer pain was associated with comparable complication rates as conventional PCA in
this specific patient group (Anghelescu et al, 2005 Level III‐3).
Key messages
1. Routine morphine infusion does not improve neurological outcome in ventilated preterm
neonates (N) (Level I [Cochrane Review]).
2. Postoperative intravenous opioid requirements vary with age in neonates, infants and
children (N) (Level II).
3. Effective PCA prescription in children incorporates a bolus that is adequate for control of
movement‐related pain, and may include a low dose background infusion (U) (Level II).
4. Intermittent intramuscular injections are distressing for children and are less effective for
pain control than intravenous infusions (U) (Level III‐1).
The following tick boxes represent conclusions based on clinical experience and expert
opinion.
Intravenous opioids can be used safely and effectively in children of all ages (U). CHAPTER 10
Initial doses of opioid should be based on the age, weight and clinical status of the child
and then titrated against the individual’s response (U).
10.7 REGIONAL ANALGESIA
10.7.1 Peripheral nerve blocks
Peripheral local anaesthetic techniques are an effective and safe adjunct for the management
of procedural, perioperative, and injury‐related acute pain (Giaufre et al, 1996 Level IV). As
placebos are rarely used in children, many current studies compare two active treatments.
Differences between groups can be difficult to detect if the sample size is small or the
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