Page 150 WHO - Guidelines on the pharmacological treatment of persisting pain in children with medical illness

16. A careful distinction between end-of-dose pain episodes, incident pain related to movement or
procedure, and breakthrough pain is needed. (pages 46, 94)
17. It is strongly recommended that children with persisting pain receive regular medication to control
pain and also appropriate medicines for breakthrough pain. (pages 46, 94)
There is insufficient evidence to recommend a particular opioid or route of administration for
breakthrough pain in children. There is a need to make an appropriate choice of treatment modality
based on clinical judgement, availability, pharmacological considerations and patient-related factors.
(pages 46, 94)

18. The use of corticosteroids as adjuvant medicines is not recommended in the treatment of persisting
pain in children with medical illnesses. (pages 50, 95)
19. The use of bisphosphonates as adjuvant medicines is not recommended in the treatment of bone
pain in children. (pages 50, 95)

At present, it is not possible to make recommendations:
- for or against the use of tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors
(SSRIs) as adjuvant medicines in the treatment of neuropathic pain in children. (pages 51, 96)
- for any anticonvulsant as an adjuvant in the management of neuropathic pain in children. (pages
51, 97)
- regarding the benefits and risks of ketamine as an adjuvant to opioids for neuropathic pain in
children. (pages 52, 98)
- regarding the benefits and risks of the systemic use of local anaesthetics for persisting neuropathic
pain in children. (pages 52, 98)
- for the use of benzodiazepines and/or baclofen as an adjuvant in the management of pain in children
with muscle spasm and spasticity. (pages 52, 99)

Health system recommendations
20. Education of health professionals in the standardized management of persisting pain in children
with medical illnesses and in the handling of the necessary medicines, including opioid analgesics,
is encouraged. (pages 59, 101)
21. Health professionals will be allowed to handle opioids within their scope of practice or professional
role based on their general professional licence without any additional licensing requirements.
(pages 59, 101)

22. In addition, countries may consider, subject to their situation, allowing other professions to
diagnose, prescribe, administer and/or dispense opioids for reasons of flexibility, efficiency,
increased coverage of services and/or improved quality of care. (pages 59, 101)
23. The conditions under which such permission is granted should be based on the demonstration of
competence, sufficient training, and personal accountability for professional performance. (pages
59, 101)

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