Page 90 WHO - Guidelines on the pharmacological treatment of persisting pain in children with medical illness

Feasibility
No problem with feasibility is anticipated.
Uncertainty: none. A1

Policy and research agenda
Child-appropriate dosage forms exist for both paracetamol and ibuprofen, but the development of
divisible dispersible oral solid dosage forms should be prioritized.
Long-term safety data for NSAIDs and paracetamol in the paediatric population are needed.
A2 A2
A2.2.3 Strong opioids essential in pain treatment

Clinical question
In children with persisting pain due to medical illnesses, what are the benefits as compared to the risks
(hastening death, developing dependence, respiratory depression, influencing the child’s development)
of taking regular or intermittent morphine for pain control as compared with a similar group of patients
with persisting pain not taking any opioid analgesics? A3

Recommendation
4. The use of strong opioid analgesics is recommended for the relief of moderate to severe persisting
pain in children with medical illnesses.
Strong recommendation, low quality of evidence

Domains and considerations A4

Quality of evidence
Although, no systematic reviews or randomized control trials were retrieved to guide determination
of the balance between the benefits and disadvantages of the use of strong opioids in children, the
panel considered indirect evidence from adult chronic non-cancer pain (71).
The panel noted the following statement, which supported the inclusion of morphine in the 2010
EMLc: “Morphine is the strong opioid of choice in moderate to severe pain in children and this is A5
confirmed by a number of consensus guidelines. There is extensive clinical experience of its use in
children and its use should be promoted to ensure adequate analgesia as necessary” (72).
Uncertainty: none.

Risks/benefits
Benefits
The efficacy of strong opioids in the relief of pain is well accepted. The panel noted, however, that A6
studies comparing opioids are possible in this age group provided that acceptable and appropriate
trial methodology is used.
Risks
Risks associated with severe side-effects and mortality arising from medication errors were considered
manageable, although more data on long-term use in children are necessary.
Uncertainty: none.
A7

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