Page 275 Guide to Pain Management in Low-Resource Settings

Pain Management in Children 263

• Prayer (the family’s practice must be respected). for opioids. NSAIDs can aff ect bleeding time and should
• Traditional practices that are helpful and not be used with caution in adenotonsillectomy.
harmful. (Health professionals should get to Tramadol hydrochloride, a mild opioid (with only
know what can help in the local setting.) partial opioid receptor agonist activity), is available for
Another important point is to give children and oral and rectal administration in children. It is absorbed
family members proper information about the mecha- rapidly (within less than 30 minutes), and the concen-
nisms and appropriate treatment of pain, to help them tration profi le supports an eff ective clinical duration in
better cope with the situation and encourage better the region of 7 hours. Transmucosal, intraoral, or intra-
compliance with recommended care. For neonates and nasal opioids might become an interesting alternative
infants up to 3 months old, oral glucose/sucrose (e.g., for breakthrough pain in children, since they generally
0.5–1 mL glucose 30%) given orally 1–2 minutes be- accept this form of application well.
fore the painful procedure, in combination with paci-
Parenteral route
fi ers off ered to the baby during the painful procedure,
Th e traditional route of parenteral administration used
are eff ective for reducing procedure-related pain from
to be intramuscular, which should be avoided nowadays
injections or blood sampling. All these methods are “ad-
because of the fear, anxiety, and distress it produces in
ditionals” and should not be used in place of analgesic
children. A subcutaneous route might be an alternative
medications when they are necessary.
in those cases where venous access is diffi cult.
What routes of administration are used What is the role of opioids?
for pharmacotherapy?
Opioids are the fi rst line of systemic therapy in moder-
Non-parenteral route
ate to severe pain, with morphine being the most fre-
Th e most commonly used nonopioid analgesic in chil- quently used. Morphine has been intensively studied in
dren is paracetamol (acetaminophen). Th e traditionally children. Serum levels of 10–25 μg/kg have been found
recommended dose is the antipyretic dose, which is too to be analgesic after major surgery in children. A steady
conservative for pain relief. Th e current recommenda- static serum level of 10 μg/mL can be achieved in chil-
tion is an oral dose of 20 mg/kg followed by 15–20 mg/ dren for moderate perioperative pain with a morphine
kg every 6–8 hours, or a rectal dose of 30–40 mg/kg hydrochloride infusion of 5 μg/kg/h in term neonates
followed by 15–20 mg/kg every 6 hours. Th e total dai- (8.5 μg/kg/hr at 1 month, 13.5 μg/kg/hr at 3 months,
ly dose for either route should not exceed 90–100 mg/ 18.0 μg/kg/hr at 1 year, and 16.0 μg/kg/hr at 1–3 years
kg/day in children and 60 mg/kg/day in neonates. Th is of age). For the use of morphine and fentanyl in the pe-
maximum daily dose should not be given longer than 48 diatric patient, and especially in neonates and infants,
hours in infants under 3 months, and not longer than no strong correlation between dose/serum plasma levels
72 hours in children over 3 months old. If a suppository and analgesic eff ects has been shown, due to the high
is used, it should not be cut, because drug distribution variability in individual opioid metabolism. For that
might be uneven. Multiple suppositories can be used reason it is advisable not to rely on specifi c dose recom-
to obtain the desired dose. Th e use of paracetamol sup- mendations, but use the “WYNIWYG” concept: “what
positories given for analgesia has to be seen very criti- you need is what you get.” Titration of the medication is
cally, because in studies rectal absorption was shown recommended to identify the patient’s individual opioid
to be slow and erratic with substantial variability, es- dose for proper pain relief.
pecially in neonates and infants. Often, rectally applied Total body morphine clearance is 80% of adult val-
paracetamol does not provide therapeutic drug serum ue at 6 months of age. Morphine clearance is higher in
levels. If paracetamol is used, the oral route should be infants than adults, primarily because of higher hepatic
the fi rst choice. blood fl ow and the active alternative sulfation pathway.
Nonsteroidal anti-infl ammatory drugs (NSAIDs) Fentanyl can be used as a substitute for morphine
such as ibuprofen and ketorolac can be used. Ibuprofen in children who have hemodynamic instability and who
(10–20 mg/kg orally) provides eff ective relief for mild cannot tolerate histamine release. In neonates, fentanyl
pain. Ketorolac rectal suppositories have been found to has a prolonged elimination half-life compared to mor-
be useful in children with a narrow therapeutic margin phine. In children older than 1 year, clearance is similar