Synopsis
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.
- 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.
- 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.
Key red flags
Pain out of proportion, pain on passive stretch, tense swelling, pallor, coolness or neurological change suggests compartment syndrome or ischaemia.
Bilious vomiting, guarding, rigid abdomen, sudden scrotal pain, meningism, focal neurology or a non-blanching rash requires urgent diagnostic escalation despite analgesia.
Unexpected bruising, repeated injuries, inconsistent history, pain behaviour around a caregiver or genital injury requires safeguarding assessment.
Reduced consciousness, obstructive sleep apnoea, difficult airway, cardiorespiratory disease, fasting aspiration risk or previous sedation reaction increases procedural-sedation risk.
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.
Investigation priorities
Establish severity and provide a reproducible response measure.
Management branches
A child presents with acute pain.
- Use ABCDE and identify any time-critical underlying causes.
- Record an age-appropriate pain and functional score.
- Give non-drug support and weight-based multimodal analgesia promptly.
- Repeat the same score and physiology at expected onset and escalate if inadequate.