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Key messages
1. Topical local anaesthetic does not adequately control pain associated with circumcision in
awake neonates (U) (Level I [Cochrane Review]).
2. Caudal local anaesthetic and dorsal penile nerve block provide perioperative analgesia for
circumcision (U) (Level I [Cochrane Review]).
3. Clonidine prolongs analgesia when added to caudal local anaesthetic blocks (U) (Level I)
and improves analgesia when added to epidural local anaesthetic infusions (U) (Level II).
4. Wound infiltration, peripheral nerve blocks, and caudal local anaesthetic provide effective
analgesia after day‐case inguinal surgery (U) (Level II).
5. Epidural infusions of local anaesthetic and systemic opioids provide similar levels of
analgesia (U) (Level II).
6. Epidural opioids alone are less effective than local anaesthetic or combinations of local
anaesthetic and opioid (U) (Level II).
7. Intrathecal opioids provide prolonged analgesia after surgery (N) (Level II) and reduce
blood loss during spinal fusion (N) (Level II).
The following tick boxes represent conclusions based on clinical experience and expert
opinion.
Caudal local anaesthetic blocks provide effective analgesia for lower abdominal, perineal
and lower limb surgery and have a low incidence of serious complications (U).
Continuous epidural infusions provide effective postoperative analgesia in children of all
ages and are safe if appropriate doses and equipment are used by experienced
practitioners, with adequate monitoring and management of complications (U).
10.8 ACUTE PAIN IN CHILDREN WITH CANCER
Pain is a common symptom in children with cancer and is associated with significant fear and
distress (Ljungman et al, 1999 Level IV). Compared with adults, the pattern and sources of acute
pain differ significantly in children with cancer.
10.8.1 Cancer-related pain
Pain due to tumour is present at diagnosis in the majority of children (Miser et al, 1987 CHAPTER 10
Level IV) and usually resolves with initial chemotherapy treatment. Breakthrough cancer pain
in children is usually of sudden onset, severe, and of short duration (Friedrichsdorf et al, 2007
Level IV). Pain and opioid requirements may escalate in terminal stages of cancer, and benefit
has been reported with use of PCA opioids to allow rapid dose titration (Schiessl et al, 2008
Level IV) and with addition of ketamine (Finkel et al, 2007 Level IV).
10.8.2 Procedure-related pain
Children, their parents, and physicians and nurses all rate pain due to procedural interventions
and treatment as a significant source of pain (Ljungman et al, 1996; Ljungman et al, 1999).
Multiple diagnostic and therapeutic interventions (eg lumbar punctures, bone marrow
aspirations, blood samples) are required during the course of treatment and require analgesia
matched to the type of procedure and needs of the child (see Section 10.4). EMLA® was
evaluated as superior to placebo for pain relief during central venous port access in children
Acute pain management: scientific evidence 361
