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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Pain assessment and analgesia by age

Paediatrics and child health · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull
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Severe pain with physiological compromise

Severe pain requires analgesia during ABCDE care, but shock, compartment syndrome, testicular torsion, ischaemia, major trauma, burns or raised intracranial pressure must not be hidden by a pain score.

Action: Call senior help, assess ABCDE, expose and immobilise the suspected injury, and treat time-critical causes in parallel. Give prompt route-appropriate multimodal analgesia using a measured weight where feasible, without delaying because diagnosis or imaging is incomplete. For intravenous opioid, use small weight-based increments by an experienced team with continuous oxygen-saturation and respiratory monitoring, direct observation, resuscitation equipment and naloxone immediately available. Reassess pain, sedation, ventilation and perfusion after each dose.

Synopsis

Recognise pain across developmental stages, use a validated and repeatable assessment, provide prompt multimodal analgesia with safe age- and weight-specific prescribing, and prove benefit through reassessment.

  • 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.

Key red flags

Pain out of proportion, pain on passive stretch, tense swelling, neurological change or impaired distal perfusion suggests compartment syndrome or ischaemia and needs immediate surgical assessment.

Sudden severe scrotal or abdominal pain, bilious vomiting, peritonism or haemodynamic compromise requires urgent cause-specific surgical review rather than repeated analgesia alone.

Severe headache with reduced consciousness, focal neurology, neck stiffness, papilloedema or persistent vomiting requires urgent neurological and infection assessment.

Increasing sleepiness, slow or shallow breathing, apnoea, small pupils or falling oxygen saturation after opioid indicates toxicity until proved otherwise.

Persistent or recurrent pain with weight loss, night waking, neurological deficit, fever, bruising, functional regression or safeguarding concern requires investigation beyond symptom treatment.

A non-speaking child's new withdrawal, guarding, agitation or physiological change can be severe pain even when no verbal score is possible.

Investigation priorities

01
First-line: age- and development-matched pain toolFirst stepFirst line

Establish a repeatable baseline and quantify response to treatment.

02
First-line: pain and functional historyFirst line

Identify site, mechanism, urgency, prior treatment and the activities pain prevents.

Management branches

AssessmentChoose and document the right measure

A child has possible pain at presentation, procedure, ward review or deterioration.

  1. Ask for self-report if developmentally possible; otherwise choose a validated neonatal or behavioural tool with caregiver input.
  2. Characterise site, mechanism, time course, functional impact, prior analgesia and red flags, then examine gently.
  3. Record tool, baseline and target, and plan the exact time and safety observations for reassessment.
Mild painFirst-line oral multimodal care

Pain is mild, the child is stable and the enteral route is available.

  1. Use comfort, explanation and cause-specific physical measures immediately.
  2. Give oral paracetamol or ibuprofen at the verified age- and weight-specific dose when not contraindicated.
  3. Reassess pain and function after expected onset and escalate route, diagnosis or treatment if the response is inadequate.

Key medicines

Paracetamol by mouthFor 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 mouthFor 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.
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Sources and review status5 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.

  • Royal College of Emergency Medicine management of pain in childrenUK pain assessment, age-appropriate tools, timely analgesia and reassessment standards.
  • BNFC analgesics treatment summaryUK paediatric analgesic selection and prescribing cautions; individual monographs must be checked for age-specific dosing.
  • BNFC morphine monographCurrent UK age- and route-specific morphine doses, contraindications and monitoring information.
  • NICE NG143 fever in under 5s recommendationsUse of paracetamol or ibuprofen for distress and cautions about simultaneous or alternating administration.
  • RCPCH medication safety clinical practice guidelinePaediatric prescribing, administration, monitoring and discharge medication safety principles.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom