Page 149 WHO - Guidelines on the pharmacological treatment of persisting pain in children with medical illness

sUMMARY oF PRIncIPLes AnD RecoMMenDAtIons

Principles
Optimal pain management may require a comprehensive approach comprising a combination of non-
opioid, opioid analgesics, adjuvants and non-pharmacological strategies. A comprehensive approach is
possible even in resource-limited settings.

Correct use of analgesic medicines will relieve pain in most children with persisting pain due to medical
illness and relies on the following key concepts (pages 38–40):
• using a two-step strategy
• dosing at regular intervals (“by the clock”)
• using the appropriate route of administration (“by the mouth”)
• tailoring treatment to the individual child (“by the individual”).

Clinical recommendations
1. It is recommended to use the analgesic treatment in two steps according to the child’s level of pain
severity. (pages 38, 84)
2. Paracetamol and ibuprofen are the medicines of choice in the first step (mild pain). (pages 38,
86)

3. Both paracetamol and ibuprofen need to be made available for treatment in the first step. (pages
38, 86)
4. The use of strong opioid analgesics is recommended for the relief of moderate to severe persisting
pain in children with medical illnesses. (pages 42, 87)
5. Morphine is recommended as the first-line strong opioid for the treatment of persisting moderate to
severe pain in children with medical illnesses. (pages 42, 88)
6. There is insufficient evidence to recommend any alternative opioid in preference to morphine as the
opioid of first choice. (pages 42, 88)
7. Selection of alternative opioid analgesics to morphine should be guided by considerations of safety,
availability, cost and suitability, including patient-related factors. (pages 42, 88)
8. It is strongly recommended that immediate-release oral morphine formulations be available for the
treatment of persistent pain in children with medical illnesses. (pages 43, 90)
9. It is also recommended that child-appropriate prolonged-release oral dosage forms be available, if
affordable. (pages 43, 90)
10. Switching opioids and/or route of administration in children is strongly recommended in the
presence of inadequate analgesic effect with intolerable side-effects. (pages 44, 91)
11. Alternative opioids and/or dosage forms as an alternative to oral morphine should be available to
practitioners, in addition to morphine, if possible. (pages 44, 91)
12. Routine rotation of opioids is not recommended. (pages 44, 91)
13. Oral administration of opioids is the recommended route of administration. (pages 45, 92)
14. The choice of alternative routes of administration when the oral route is not available should be
based on clinical judgement, availability, feasibility and patient preference. (pages 45, 92)
15. The intramuscular route of administration is to be avoided in children. (pages 45, 92)

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