Page 92 WHO - Guidelines on the pharmacological treatment of persisting pain in children with medical illness

Domains and considerations

Quality of evidence A1
The panel noted that morphine has been available for a considerable amount of time and that
high quality of evidence is unlikely to be available. The second recommendation was based on
comparisons between different opioids and routes of administration in acute pain and post-operative
pain in children. (Annex 4. Evidence retrieval and appraisal, GRADE tables 2–4, 6, 7). The assessed
level of quality of evidence was downgraded because of the differences in conditions treated and
duration of treatment.
Uncertainty: yes.
A2 A2

Risks/benefits
Benefits
Morphine is well established as first-line strong opioid.
Risks
Risks are well described and considered to be manageable.
Uncertainty: no, for the use of morphine as a first-line opioid analgesic; yes, in relation to the A3
comparative safety and efficacy of different opioids.

Values and acceptability
In favour
The panel valued access to effective treatment.
Against
None A4
Uncertainty: none.

Cost
Morphine is relatively inexpensive, although prolonged-release oral solid forms are more costly.
Uncertainty: none.
A5

Feasibility
A wide range of morphine formulations have been already included in the 2010 EMLc:
• granules, modified release (to mix with water) – 20 mg, 30 mg, 60 mg, 100 mg, 200 mg
• injection – 10 mg (morphine hydrochloride or morphine sulfate) in 1 ml ampoule
• oral liquid – 10 mg (morphine hydrochloride or morphine sulfate)/5 ml
• tablet – 10 mg (morphine sulfate)
• tablet (prolonged release) – 10 mg, 30 mg, 60 mg, 100 mg, 200 mg (morphine sulfate). A6
Uncertainty: none.

Research agenda
Comparative trials of strong opioids, including fentanyl, hydromorphone, oxycodone and methadone,
in the treatment of persisting moderate to severe pain in children of all ages with medical illnesses
are needed. They should investigate effectiveness, side-effects and feasibility of use in this
population. A7
Child appropriate oral solid dosage forms are needed.

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