01Purpose and principlesWhat the treatment does and how it fits into care.
Characterise the pain before choosing treatment. Nociceptive somatic pain is often localised and sharp, visceral pain diffuse or colicky, neuropathic pain burning, electric or associated with allodynia, and inflammatory pain may cause tenderness and stiffness. Acute procedural, traumatic and postoperative pain differs from chronic or recurrent pain, where sleep, mood, school, family responses and function become central. Mechanism guides adjuvants and referral.
Self-report is the preferred intensity measure when developmentally possible. Explain the tool and ask about pain now, not how frightened the child feels. A faces pain scale shows increasing pain rather than mood. Numerical scales require understanding that numbers represent ordered intensity. Avoid changing tools simply because a score is high or low. A score should guide urgency and response, not replace examination or the child's narrative.
Neonates and infants need composite observation. Locally approved tools such as PIPP-R, NIPS or CRIES combine facial expression, cry, body movement, consolability and sometimes physiological variables, with tool choice depending on gestation and setting. Heart rate and saturation are non-specific and can normalise during prolonged pain. Prematurity, neurological impairment and sedation change expression, so compare with baseline and use neonatal expertise.
For children unable to self-report, FLACC scores face, legs, activity, cry and consolability. Revised FLACC permits caregiver-described individual pain behaviours and is useful in cognitive impairment. Establish how the child usually expresses discomfort, hunger, fear and tiredness. Treat likely pain, repeat the same measure and observe functional change. A low behavioural score in a motionless or profoundly impaired child does not by itself exclude pain.
Non-pharmacological care is active treatment, not a consolation after medicines. Use caregiver presence, skin-to-skin care, breastfeeding or locally governed oral sucrose for brief neonatal procedures, swaddling, comfort positioning, distraction, guided breathing, virtual or play-based engagement and environmental control. Explain sensation honestly and offer bounded choices. Immobilisation, elevation, cooling a fresh small burn with appropriate first aid, splinting and treatment of constipation or urinary retention address the cause.
For mild acute nociceptive pain, oral treatment is first line when the child can tolerate it. Paracetamol and ibuprofen have different contraindications and may be used as appropriate components of multimodal care. In fever, NICE advises using either paracetamol or ibuprofen only when the child is distressed, not solely to reduce temperature; do not give both simultaneously and consider alternating only if distress persists or recurs before the next dose is due.
Paracetamol dosing depends on route, age, gestation, weight and product. A commonly used acute oral weight-based regimen for a child at least 3 months old is 15 mg/kg per dose every 4–6 hours, at least 4 hours apart, with no more than four doses and usually no more than 60 mg/kg in 24 hours, without exceeding the BNFC or product absolute maximum. Neonates, low body weight, malnutrition, dehydration and liver disease require lower or specialist limits. Count every paracetamol-containing product and every route.
Ibuprofen is useful for inflammatory pain in eligible children. A common acute oral regimen from 3 months and at least 5 kg is 5–10 mg/kg per dose every 6–8 hours, usually no more than 30 mg/kg in 24 hours and within the product age-band maximum. Avoid or seek specialist advice in dehydration, kidney disease, active gastrointestinal ulcer or bleeding, previous NSAID hypersensitivity, NSAID-triggered asthma and varicella. Do not assume another NSAID can be added safely.
Moderate or severe pain should not wait for oral medicines to take effect if a faster route is needed. Intravenous morphine can be titrated in monitored acute care by experienced clinicians, commonly starting with 50–100 micrograms/kg given slowly and incrementally according to age, prior exposure and local paediatric protocol. Use lower starting exposure in neonates, infants, opioid-naive children and those with respiratory, neurological, hepatic or renal impairment. Never confuse micrograms with milligrams.
Reassessment closes the treatment loop. Record tool and baseline, intervention, time, repeat score, function and adverse effects. Reassess sooner after intravenous opioid than after oral non-opioid medicine and after every dose increment. If pain persists, reconsider dose calculation, delivery, diagnosis, compartment or ischaemic complications and the pain mechanism. If pain improves, continue the least intensive effective plan with clear maximums and stop dates.
Discharge only after documented response and recovery. State medicine, formulation, mg and mL, interval, daily maximum and stop date; demonstrate the oral syringe, use caregiver teach-back and give cause-specific red flags and follow-up.
Key points
- Believe self-report when the child can understand and use a scale; behaviour and physiology support assessment but do not invalidate the child's account.
- Select one validated tool matched to development and communication, record its name and use the same tool for reassessment whenever possible.
- For neonates use a locally approved neonatal composite tool; for non-verbal children use behavioural assessment such as FLACC or revised FLACC with caregiver input.
- A faces scale can support children from about 4 years who can order pain intensity; a 0–10 numerical scale is often useful from about 8 years if understood.
- Pain score is one part of assessment: record site, onset, quality, triggers, function, sleep, previous response, fear and the likely mechanism.
- Give analgesia promptly; it does not prevent reliable diagnosis and should proceed alongside examination, imaging and surgical review.
- First-line mild acute pain usually combines comfort and cause-specific measures with oral paracetamol or ibuprofen when safe.
- Moderate to severe pain often requires multimodal treatment and a titrated opioid; route and urgency should match severity and access.
- Use non-pharmacological methods at every age: caregiver contact, feeding or sucrose in appropriate neonates, comfort positioning, play, distraction, relaxation and preparation.
- For procedures, plan analgesia before restraint: topical or local anaesthesia, an appropriate systemic agent and anxiety support are different components.
- Prescribe every medicine in mg and mL where liquid is used, with weight, concentration, interval, maximum dose and total exposure from all products checked.
- Reassess within a clinically appropriate interval and after each opioid increment; an analgesic order without documented response is incomplete care.
02Indications, selection and cautionsWho may benefit, who needs urgent treatment and important alternatives.
A developmentally capable child describes intensity and impact using words, faces or numbers; their report is the primary measure.
Facial action, cry, movement, consolability and physiological change are combined in a gestation- and setting-appropriate validated tool.
Guarding, altered movement, vocalisation, sleep, interaction or personalised behaviours are assessed with FLACC or revised FLACC and caregiver knowledge.
Burning, shooting, electric pain, paraesthesia or allodynia suggests a mechanism that may need specialist adjuvant treatment.
Reduced walking, play, sleep, breathing, drinking or school participation adds clinically meaningful severity beyond a numeric score.
Increasing sedation, bradypnoea, shallow breathing, apnoea, airway obstruction or hypoxia after opioid requires immediate ABC support and reversal assessment.
03Assessment before treatmentTests and checks that guide safe selection.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
First-line: age- and development-matched pain toolFirst stepFirst line - Why
- Establish a repeatable baseline and quantify response to treatment.
- Interpretation and limitations
- Prefer self-report when understood; otherwise use a validated neonatal or behavioural tool and record which one was used.
- 02
First-line: pain and functional historyFirst line - Why
- Identify site, mechanism, urgency, prior treatment and the activities pain prevents.
- Interpretation and limitations
- Sudden, disproportionate, nocturnal, progressive or function-limiting pain directs examination and escalation even if the score is modest.
- 03
Focused examination - Why
- Find the cause and urgent complications while minimising additional distress.
- Interpretation and limitations
- Observe first, examine least painful areas before the focus and assess neurovascular status where limb pain is present.
- 04
Medication and risk review - Why
- Prevent duplicate dosing and identify renal, hepatic, respiratory, bleeding or allergy modifiers.
- Interpretation and limitations
- Reconcile every product, route, concentration and administration time before prescribing further analgesia.
- 05
Targeted diagnostic tests - Why
- Investigate the suspected cause when results will alter urgent or definitive treatment.
- Interpretation and limitations
- Analgesia proceeds in parallel; imaging or blood tests are not routine solely because pain is severe.
- 06
Post-treatment reassessment - Why
- Demonstrate efficacy and detect sedation, respiratory depression, hypotension or diagnostic progression.
- Interpretation and limitations
- Persistent pain or toxicity triggers immediate dose, route, diagnosis and level-of-care review rather than automatic repetition.
04Treatment approachPreparation, options, escalation and aftercare.
01AssessmentChoose and document the right measureFirst stepA child has possible pain at presentation, procedure, ward review or deterioration.+
- 1Ask for self-report if developmentally possible; otherwise choose a validated neonatal or behavioural tool with caregiver input.
- 2Characterise site, mechanism, time course, functional impact, prior analgesia and red flags, then examine gently.
- 3Record tool, baseline and target, and plan the exact time and safety observations for reassessment.
02Mild painFirst-line oral multimodal careFirst linePain is mild, the child is stable and the enteral route is available.+
- 1Use comfort, explanation and cause-specific physical measures immediately.
- 2Give oral paracetamol or ibuprofen at the verified age- and weight-specific dose when not contraindicated.
- 3EscalationReassess pain and function after expected onset and escalate route, diagnosis or treatment if the response is inadequate.
03Moderate or severe painPrompt titrated analgesiaPain impairs function, is severe, or cannot wait for oral therapy alone.+
- 1Continue ABCDE and urgent cause-specific assessment while giving non-pharmacological and non-opioid components.
- 2Give route-appropriate opioid using measured weight and the local paediatric protocol, with direct respiratory and sedation monitoring.
- 3Titrate to response, seek senior or pain-team support early and reassess the diagnosis if analgesia repeatedly fails.
04ProcedurePlan pain, fear and movement separatelyCannulation, wound care, reduction, lumbar puncture or another painful procedure is planned.+
- 1Explain honestly, use preparation and comfort positioning, and choose local or topical anaesthesia with enough onset time.
- 2Add systemic analgesia and distraction; use sedation only within a governed paediatric pathway with trained staff and monitoring.
- 3Reassess pain and recovery, debrief the child and document any restraint or adverse event.
05Persistent or complex painRestore function with specialist supportPain recurs, lasts beyond expected healing, has neuropathic features or needs repeated opioid.+
- 1Re-evaluate red flags, diagnosis, medication exposure, sleep, mood, school, family context and functional goals.
- 2EscalationRefer to paediatric pain, relevant specialty, psychology or palliative care rather than escalating unsupervised medicines.
- 3Create a written multimodal plan with review, taper or stop criteria and crisis safety-netting.
05Regimens, contraindications and interactionsTreatment details and the circumstances that modify them.
Paracetamol by mouth
For many children aged at least 3 months in acute weight-based practice, give 15 mg/kg by mouth every 4–6 hours with at least 4 hours between doses; give no more than 4 doses and usually no more than 60 mg/kg in 24 hours, without exceeding the current BNFC or product age-band absolute maximum.Verify gestation, age, weight, formulation and all recent oral, rectal, intravenous and combination exposure. Neonates and children with low body weight, malnutrition, dehydration or liver disease need lower or specialist limits. Prescribe liquid in both mg and mL and never assume every product has the same concentration.
Ibuprofen by mouth
For a child aged at least 3 months and weighing at least 5 kg, a common acute regimen is 5–10 mg/kg by mouth every 6–8 hours, usually to a maximum of 30 mg/kg in 24 hours and within the current BNFC and product age-band maximum.Avoid or seek specialist advice with dehydration, kidney impairment, active gastrointestinal ulcer or bleeding, NSAID hypersensitivity, previous NSAID-triggered asthma or varicella. Check for another NSAID and use the shortest necessary course. Children younger than 3 months require specialist prescribing.
Morphine by slow intravenous injection
In monitored acute care, an experienced paediatric clinician may give 50–100 micrograms/kg intravenously slowly and incrementally, then reassess and titrate using the current BNFC and local age-specific protocol; specify micrograms and apply the protocol maximum rather than extrapolating an adult dose.Use lower initial exposure and specialist advice in neonates, young infants, opioid-naive or obese children and in sleep-disordered breathing, neuromuscular disease, head injury, respiratory compromise, renal or hepatic impairment. Continuously observe breathing and sedation, have bag-mask ventilation and naloxone available, and never confuse micrograms with milligrams or analgesia with procedural sedation.
06Complications, monitoring and follow-upAdverse effects, response and longer-term review.
- Record pain-tool name, baseline score, site and functional limitation before treatment whenever urgency permits.
- After oral analgesia, reassess at the expected onset and before discharge; after intravenous opioid, reassess pain, sedation and breathing after every increment.
- Monitor respiratory rate and effort, oxygen saturation, sedation, heart rate and blood pressure during parenteral opioid treatment; add carbon-dioxide monitoring when risk or sedation warrants it.
- Audit total daily paracetamol and NSAID exposure across all routes and products, particularly during transfers and perioperative care.
- Track drinking, urine output and renal risk when NSAIDs are used during acute illness.
- For persistent pain, follow sleep, school attendance, mobility, participation and agreed functional goals as well as intensity.
- At discharge, use caregiver teach-back for mg, mL, interval, maximum and stop date and document the result.
07Special situationsVariants, exceptions and circumstances that change the usual approach.
Self-report leads
A calm appearance does not invalidate a child who can reliably describe pain; behaviour is most useful when self-report is unavailable.
Use the same ruler twice
Repeating the same appropriate tool makes change interpretable; switching from faces to numbers can create a false trend.
Function makes severity tangible
Whether the child can breathe deeply, walk, sleep or drink often guides urgency and discharge better than a score alone.
Analgesia and diagnosis can coexist
Prompt pain relief improves humane examination and should run alongside, not behind, investigation of the cause.
Every dose needs a response
Reassessment detects undertreatment, toxicity and evolving pathology and is part of prescribing rather than optional documentation.
08Common pitfallsFrequent interpretation and management errors.
- 01
Do not dismiss pain because the child is playing, quiet or has normal vital signs.
- 02
Do not use an adult numerical scale in a child who cannot understand ordered magnitude.
- 03
Do not interpret facial-expression tools as measures of sadness or fear.
- 04
Do not withhold analgesia until imaging or surgical review is complete.
- 05
Do not prescribe liquid medicine in mL without the dose in mg and verified concentration.
- 06
Do not exceed the total paracetamol maximum by overlooking combination products or another route.
- 07
Do not give an NSAID to a dehydrated child without reviewing renal risk.
- 08
Do not give intravenous opioid without respiratory and sedation monitoring and reversal readiness.
- 09
Do not repeat escalating analgesia for disproportionate pain without reconsidering ischaemia, compartment syndrome or another emergency.
- 10
Do not discharge severe pain without demonstrated response, a usable dosing plan and cause-specific safety-netting.