Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Acute pain and procedural distress
Paediatrics and child health · UK scope · Sources checked 27 Aug 2026 · Clinical review pending
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Severe pain with physiological instability or sedation complication
Pain with shock, compartment syndrome, meningism, acute abdomen, testicular torsion, ischaemia or reduced consciousness is a signal to treat pain while diagnosing a time-critical cause. Airway obstruction, apnoea, hypoxaemia or hypotension during sedation is a resuscitation emergency.
Action: Use ABCDE, call senior and specialty help, give prompt titrated analgesia and treat the cause. If sedation causes respiratory compromise, stop the procedure, stimulate, open the airway, give oxygen and bag-mask ventilation, call for resuscitation support and use a specific reversal agent only when indicated and supported by ongoing observation.
Overview
Assess pain developmentally, provide prompt multimodal analgesia, distinguish analgesia from sedation, prepare children psychologically and deliver procedures with consent, monitoring, rescue capability and equitable reassessment.
Begin with belief, observation and physiology. Ask the child directly using language, pictures or numerical scales appropriate to development; use FLACC or another validated behavioural tool when self-report is impossible. Record baseline pain at rest and movement, distress, functional effect and the scale used. Parents help interpret usual behaviour, but their score does not replace the child's report.
Treat in parallel with diagnosis. Splint and elevate injury, use comfortable positioning, warmth or cooling as appropriate, reduce noise, explain what will happen and offer controlled choices. A play specialist, distraction, breathing, virtual or sensory aids and caregiver presence reduce distress and medicine requirements. Forced restraint should be exceptional, proportionate and reviewed.
Choose medicines by severity and mechanism. Paracetamol
Practice
Two practice questions
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Paediatrics and child healthOriginal SBA
Severe pain without IV access
A monitored emergency department is treating a 7-year-old with a displaced forearm fracture and severe pain. IV access is not yet available. Which option offers the most appropriate rapid analgesia under a local paediatric protocol?
Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
Sources
Sources and review status
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.
NICE CG112 sedation in under 19sCurrent UK assessment, consent, fasting, medicine-selection, monitoring, staffing and recovery recommendations.
are first-line for mild to moderate nociceptive pain and can be combined rather than alternated unpredictably. Severe pain needs a titratable opioid route or
intranasal fentanyl
when IV access is absent. Confirm weight, allergies, doses already given and combination-product contents to avoid duplication.
Intranasal fentanyl provides rapid analgesia without a needle for eligible children in monitored emergency care. A commonly used current UK emergency regimen is 1.5 micrograms/kg, with one repeat after about 30 minutes according to local protocol. Record baseline observations and continue oxygen-saturation, respiratory and sedation monitoring for at least an hour. Intravenous opioids are titrated in small increments by trained clinicians with naloxone and ventilation equipment available.
Plan a procedure before opening equipment. Decide whether cooperation can be achieved with preparation, topical or infiltrated local anaesthetic and non-pharmacological support. If sedation is needed, perform a pre-sedation airway, medical, medicine, allergy and fasting-risk assessment; agree target depth; obtain consent; allocate a trained sedationist and separate proceduralist or assistant; check suction, oxygen, bag-mask equipment, monitoring and reversal or emergency medicines.
For a painless procedure, NICE supports nitrous oxide and/or oral or intranasal midazolam for minimal or moderate sedation when suitable. Every painful procedure also receives local anaesthetic. If these are unsuitable, ketamine or IV midazolam with or without fentanyl may be used within a competent service. Fasting is not automatically required for minimal sedation, nitrous oxide alone or moderate sedation with maintained verbal contact, but urgency and individual aspiration risk are considered.
Monitor to the medicine and depth: continuous clinical airway and ventilation observation, pulse oximetry, respiratory rate and heart rate, with blood pressure and capnography according to depth, medicine and local standard. Verbal responsiveness is followed when intended. If sedation deepens, stop, call for help and provide airway opening, oxygen and bag-mask ventilation before relying on antagonists.
Reassessment closes the loop. Repeat the same pain scale, sedation score, observations and functional assessment at the expected onset and after movement or procedure. Escalate persistent pain to senior review for missed diagnosis, regional anaesthesia, acute pain service or specialist input. At discharge provide exact dosing intervals and maxima, safe storage, constipation or nausea advice where relevant and clear red flags.
Key points
Pain is what the child experiences; use self-report whenever development allows and behavioural tools when it does not.
First-line assessment combines site, quality, severity, timing, function and red flags with an age-appropriate validated scale.
Give analgesia during assessment; it does not prevent diagnosis and severe pain should receive an appropriate medicine within about 20 minutes.
Use multimodal care: comfort and positioning, explanation, distraction, topical or local anaesthesia and weight-based systemic analgesia.
Paracetamol is useful for mild pain; add ibuprofen when inflammation is relevant and there is no dehydration, renal, bleeding, asthma or other contraindication.
For severe pain without IV access, intranasal fentanyl is a rapid first-line option in an appropriately monitored emergency setting for eligible children.
Reassess pain, sedation, physiology and function after every intervention and before repeating or escalating medication.
Procedural analgesia and sedation are different: local anaesthetic treats pain, while sedation reduces distress or movement but may not provide analgesia.
Aetiology
01
Tissue injury and inflammation
Trauma, surgery, infection and inflammatory disease activate peripheral nociceptors and sensitise ascending and central pain pathways.
02
Visceral or neuropathic pain
Distension, ischaemia, nerve injury and central sensitisation produce patterns that may respond poorly to simple analgesics alone.
03
Procedure-related distress
Needles, dressings, positioning and unfamiliar equipment combine nociception with fear, loss of control and memory of previous care.
04
Communication and contextual factors
Age, neurodevelopment, culture, prior trauma, caregiver response, fatigue and sensory needs shape expression without determining whether pain is genuine.
Pathophysiology
1
Nociceptive transmission
Peripheral A-delta and C-fibre signals ascend through spinal pathways and are modulated by descending inhibitory and facilitatory circuits.
2
Peripheral and central sensitisation
Inflammatory mediators lower nociceptor thresholds and repeated untreated input amplifies spinal responses, increasing pain from subsequent stimuli.
3
Stress response
Pain and fear increase catecholamines, oxygen demand, muscle tension and avoidance and can impair examination, sleep and recovery.
4
Sedation continuum
Drug response can deepen unpredictably from anxiolysis to loss of airway reflexes; the team must be able to rescue one level deeper than intended.
Clinical features and red flags
Self-reported pain
Faces or numerical scales can quantify severity when the child understands the task; trend on the same instrument is more useful than cross-scale comparison.
Behavioural pain
Facial expression, legs, activity, cry and consolability support assessment in preverbal or non-speaking children but require their baseline context.
Procedural fear
Avoidance, freezing, crying and loss of cooperation may reflect anticipatory threat and need preparation as well as analgesia.
Opioid toxicity
Increasing sedation, slow or shallow breathing, desaturation and miosis require stopping opioid, airway support and titrated reversal when needed.
Sedation deeper than intended
Loss of verbal contact, airway tone or spontaneous ventilation means the team must stop and rescue immediately.
Red flags requiring action
Pain out of proportion, pain on passive stretch, tense swelling, pallor, coolness or neurological change suggests compartment syndrome or ischaemia.
NICE first-line options for painless procedures include distraction plus nitrous oxide or oral or intranasal midazolam when suitable; painful procedures also require local anaesthesia.
Ketamine or IV midazolam with or without fentanyl requires trained sedation staff, an independent assistant, monitoring and airway rescue capability.
Seek consent from the person with parental responsibility and the capable young person; seek the child's assent and respect communication and sensory needs.
Discharge only after return to baseline consciousness, stable observations, adequate pain control, safe mobility and clear medicine and return advice.
No response to apparently adequate analgesia demands reassessment of diagnosis, dose, route, delivery and evolving complications rather than repeated unstructured dosing.
Apnoea, stridor, loss of verbal contact, oxygen desaturation, hypotension or paradoxical agitation during sedation requires immediate rescue.
05
Sedation physiological monitoring
Why
Detect airway obstruction, hypoventilation, hypoxaemia and cardiovascular effect early.
Interpretation and limitations
Clinical observation is continuous; capnography can reveal hypoventilation before desaturation and is used according to depth and service standard.
06Reference-standard repeated clinical assessment
Why
Determine whether analgesia improved pain and function without toxicity and whether the diagnosis remains safe.
Interpretation and limitations
No laboratory test validates pain; serial child report, behaviour, function and physiology guide escalation.
3
Monitor airway, breathing, sedation and circulation with rescue equipment ready.
4Reassess diagnosis, dose delivery and need for regional or acute-pain input.
03Procedure planningAnalgesia before sedationA potentially painful or distressing procedure is proposed.+
1Prepare the child, obtain consent and assent and use distraction and topical or local anaesthesia.
2Choose the least deep effective sedation option after risk assessment.
3Allocate trained staff, an assistant, monitoring and airway rescue resources.
4Confirm recovery to baseline and give written discharge instructions.
04Sedation complicationStop and rescueAirway tone, ventilation, oxygenation, circulation or intended responsiveness is lost.+
1Stop the procedure and summon resuscitation support.
2Open the airway, give oxygen and provide bag-mask ventilation.
3Use reversal medicine only for a suitable agent while continuing support.
4Observe longer, document the event and review future sedation risk.
Key medicines and prescribing safety3 treatments · regimens, roles and cautions+
First-line non-opioid analgesic for mild pain and part of multimodal treatment for more severe pain.
Paracetamol
A commonly used acute paediatric oral dose is 15 mg/kg per dose, subject to age-specific product limits, dosing interval and local maximum daily dose; check previous and combination-product exposure.
Use local or BNF for Children dosing for age, weight and route; reduce or seek advice in low body weight, malnutrition, hepatic impairment or repeated dosing and treat overdose through NPIS guidance.
First-line anti-inflammatory analgesia when inflammation contributes and oral therapy is suitable.
Ibuprofen
Use the age- and weight-specific oral dose in the current BNF for Children or local formulary, usually divided up to three or four times daily for the shortest necessary course.
Avoid or seek advice with significant dehydration, kidney injury, active bleeding or ulceration, relevant NSAID hypersensitivity, severe asthma sensitivity and varicella; do not combine multiple NSAIDs.
Rapid first-line severe-pain analgesia when IV access is not yet available, commonly for children at least 1 year and 10 kg in services using this pathway.
Intranasal fentanyl
In an eligible monitored emergency patient, a commonly used first dose is 1.5 micrograms/kg intranasally; one repeat may be given after about 30 minutes under the local protocol.
Confirm concentration and weight; monitor respiratory rate, SpO2, sedation and pain continuously or frequently, have oxygen, bag-mask ventilation and naloxone available, and observe for at least one hour after dosing under the cited local guideline.