Treating pain in children

Dr Donna Cosgrove MPSI looks at the special considerations that are required when treating pain in children and infants

Chronic pain, which refers to pain lasting longer than three months, can be primary (where pain itself is the disease and cannot be better explained by another underlying condition, although biological, psychological and social factors all contribute) or secondary to a clear, underlying aetiology.

Pain in children differs from that in adults for a number of physiological, developmental and social reasons, which means that research and clinical experiences with adults may not be directly applicable to children. This includes evidence that suggests early exposure to persistent pain may increase the risk of future chronic pain and altered pain processing; and neuroimaging studies suggest chronic pain may be linked with long-term, maladaptive neurological changes.1

Childhood chronic pain has a significant negative impact on a child over their life course, therefore appropriate diagnosis and management is vital. There is a lack of high-quality research evidence on pain treatment interventions and management for children, although we know that a personalised, multimodal approach is required for best outcomes.

Pain assessment and communication

WHO guidance on pain management emphasises five principles for the appropriate use of analgesics:2

• Use oral forms where possible.
• Give at regular intervals.
• Administer based on pain severity, where severity is assessed by a pain intensity scale.
• Tailor the dose to the individual patient
• Maintain attention to detail throughout the prescription of pain medications.

For optimal pain management, frequent and appropriate assessment of pain should be performed. Assessing and managing pain in young children (from newborn up to age six) can be particularly challenging. This age group may be unable to communicate the quality and location of their pain clearly to enable diagnosis and treatment.3 Nonetheless, effective pain management — which avoids both under- and over- treatment — during this critical stage of development is essential.

If self-report is not possible, particularly in preverbal or non-verbal children, pain should be assessed using behavioural indicators (such as facial expression, crying, irritability, feeding, sleep disturbance and activity level), physiological parameters (heart rate, respiratory rate, blood pressure, skin colour and oxygen saturation), together with caregiver reports.2,4

Notably, the absence of change in physiological parameters does not mean absence of pain. Although physiological parameters can be measured in a hospital setting, the caregivers’ interpretation and description of the child’s pain is often the only information offered in community pharmacy. In some cases this can lead to misunderstanding of the condition, either by the caregiver or the healthcare worker, and inappropriate management decisions.3

More than 60 paediatric pain assessment tools are available, with no evidence to recommend one over any other, although it is vital that a developmentally appropriate assessment tool should be used. One of the most commonly used tools for young children, due to its ease of use, is the Face, Legs, Activity, Cry and Consolability Scale (FLACC). This is an observational tool to assess pain, validated for children from the age of two months to seven years, in many different pain conditions.5

Common early childhood pain-related complaints encountered by pharmacists include:3

• Teething pain.
• Colic.
• Constipation.
• Diarrhoea.
• Gastro-oesophageal reflux.
• Soft tissues trauma/injuries, such as bruising or cuts.
• Otitis media.
• Pharyngitis.
• Pain associated with fever (colds and flu). ? Headache.

Treatment of paediatric pain

The two first-line analgesics for children are paracetamol and ibuprofen. These can be used as monotherapy, or may be used together where monotherapy has not provided adequate pain relief, with or without additional physical and psychological approaches.4 Ibuprofen is more effective than paracetamol for treatment of acute pain like musculoskeletal trauma, headache, and dental pain; and has a similar safety profile. Ibuprofen has comparable efficacy to oral morphine for certain types of pain (sprains, fractures, and post orthopaedic procedures, tonsillectomy), and a superior safety profile.

For dental pain and pain post- tonsillectomy, the combination of paracetamol and ibuprofen is more effective than paracetamol only.6 In infants, swaddling, tucking, and breast milk (including breastfeeding where appropriate) have been shown to reduce procedural pain. There is also strong evidence for the use of sucrose solution (24%) to manage moderate procedural pain in infants up to 12 months and beyond, although this is not commonly used outside the hospital setting.3 The analgesic mechanism is not fully understood, but is thought to involve activation of endogenous opioid pathways — it does not work if sucrose is administered via nasogastric tube.7

Other non-pharmacological methods, including distraction and relaxation techniques, play a significant role in alleviating pain and anxiety in babies and older children.8 Among some parents and caregivers, hesitancy to use analgesics in children can result in delayed pain management. In some cases the opposite is true — a child may be given unintentionally high or frequent doses due to caregiver anxiety about relieving the child’s pain.3

An Irish study9 investigated the prevalence of parent/guardian administration of analgesic medication to their children for the treatment of acutely painful conditions (ie, trauma and non-trauma causes) prior to emergency department arrival. Results of this parental survey indicated that 47 per cent (189) of the children received an analgesic prior to the arrival at ED. The majority surveyed had analgesics available at home — paracetamol (75 per cent) and ibuprofen (68 per cent). Reasons given for not administering pain relief included thinking that the child did not need it (29.3 per cent), the accident not happening at home (18.4 per cent), not wanting to mask the presence of pain (16.1 per cent), believing the hospital should give the medications (9 per cent),

and being afraid it would be wrong/ harmful (8.5 per cent).

Of the parents who did not think their child needed pain relief, 75 per cent of these children reported having a moderate-severe pain score (?4/10). The proportion of parents that gave their child analgesia in this study (47 per cent) has increased when compared to a similar Irish study from 1999,10 which found that just 26 per cent of children in the same situation were given analgesia.

WHO has issued guidelines1 for managing chronic pain in paediatric patients (defined as persons aged 0-to- 19 years of age). Several best practice statements are included in these, such as: ?Children with chronic pain as well as their families and caregivers require care from both a biomedical and biopsychosocial perspective, rather than symptomatic management only. ?Children with chronic pain must have a thorough evaluation of underlying conditions in addition to appropriate management for pain.

• Management should be tailored to the individual child’s health, underlying conditions, developmental age, abilities and needs; and should be child- and family-centered.

The types of treatments recommended for chronic pain management include physical therapy, psychological therapy (with evidence supporting mainly Cognitive Behavioural Therapy), and pharmacological management tailored to specific indications and conditions.

Role of the pharmacist

In children, the pharmacokinetics and pharmacodynamics of drugs are different to those in adults, leaving children more exposed to the risk of developing adverse effects, such as Reye’s syndrome with aspirin, or acute kidney injury with ibuprofen in dehydration.11 Children are also more vulnerable to drug interactions, misuse, delayed diagnosis, or worsening of an underlying condition, eg, the use of ibuprofen may increase the risk of mucocutaneous complications of varicella. Pharmacists can play an important role in pain management in early childhood3 by:

Ensuring appropriate use of prescription and non-prescription analgesics; conducting medication reviews as required to help optimise treatment outcomes.

In cases where pharmacists are supporting paediatric pain management, time constraints can sometimes limit opportunities for effective counselling. Where possible, pharmacists should use empathetic listening. Where possible, adequate time as well as empathetic and attentive listening can be used to foster trust and provide the opportunity to respond with care. Where there are time constraints, directing caregivers to appropriate resources for further information may be useful.

Individualising pain management plans

Age-related variations in pharmacokinetics and pharmacodynamics exist for infants and young children, compared to each other and compared to adults. Accurate formulation and dosing should be emphasised, using weight- based dosing where appropriate, rather than age-banded doses. Often, there is a mismatch between the child’s age and the standardised weight for this age, which can result in under- or overdosing.3 Where appropriate, pharmacists can help with this by, eg, helping parents convert between weight measurements of stone/pounds and kilograms, and using reliable paracetamol and ibuprofen weight-based dosing charts, such as those available on the HSE website.

Educating parents and caregivers about medication options and use, including about potential drug interactions or contraindications, monitoring treatment response, and when referral is necessary. A French study12 looking at paediatric pharmaceutical interventions (in community pharmacies) found that the maximum daily dose of paracetamol and ibuprofen was known by 58 per cent and 18 per cent of users, respectively. Pharmacists can promote awareness of dose quantity and frequency, along with the use of accurate measuring devices to ensure safe and appropriate dosing in young children. Clear and appropriate information, using easy-to-understand language, can significantly enhance caregivers’ health literacy and increase their confidence in pain management.3

To offer this advice in early-life pain management, pharmacists need sufficient skills in a number of areas, including communication, pain assessment techniques, and clinical knowledge to recommend safe and age- appropriate treatments. Increasingly, pharmacists also need to educate on how to use artificial intelligence tools responsibly, offering evidence-based options. As patients increasingly use artificial intelligence and online health resources to seek information about medicines, pharmacists are also well placed to help families interpret this information and direct them towards reliable, evidence-based sources.

References

1. World Health Organisation (2020). Guidelines on the Management of chronic pain in children. Available https://iris.who.int/server/api/core/ bitstreams/fca81e62-b0c1-4eca-b8f8- 0bd5ad94a2d5/content.

2. Gai N, Naser B, Hanley J, Peliowski A, Hayes J, & Aoyama K (2020). A practical guide to acute pain management in children. Journal of Anesthesia, 34(3), 421-433. Available https://pmc.ncbi.nlm. nih.gov/articles/PMC7256029/.

3. International Pharmaceutical Federation (2025). Pain management in children, from newborn to 6 years: Exploring pharmacists’ roles and challenges. Available https://www.fip.org/ file/6335.

4. Trottier ED, Ali S, Doré-Bergeron MJ, & Chauvin-Kimoff L (2022). Best practices in pain assessment and management for children. Paediatrics & Child Health, 27(7), 429-437.

5. Children’s Health Ireland (2017). FLACC Behavioural Pain Assessment Scale. Available https://media.childrenshealthireland.ie/ documents/Pain-FLACC-Revised-June-2017.pdf. 6. International Association for the Study of

Pain (2021). Fact Sheets. Pain in Children: Management. Available https://www.iasp-pain. org/resources/fact-sheets/pain-in-children- management/.

7. National Health Service Scotland (2026). Right Decision Service: Supporting decisions for Scotland’s health and care. Oral sucrose for procedural pain, neonates (CG 1210). Available https://www.rightdecisions.scot.nhs.uk/shared- content/ggc-clinical-guidelines/neonatology/oral- sucrose-for-procedural-pain-neonates-1210/.

8. Atefeh S (2025). Barriers and facilitators of pain management in children: a scoping review. BMC Anesthesiology, 25(1), 148.

9. Daly T, O’Brien R, Murphy A (2020). Parental administration of analgesia to children attending the emergency department with acutely painful conditions. https://www.medrxiv.org/ content/10.1101/2020.12.15.20248274v1.full.pdf.

10. Spedding RL, Harley D, Dunn FJ, & McKinney LA (1999). Who gives pain relief to children? Emergency Medicine Journal, 16(4), 261-264.

11. Bedhomme S, Vaillant-Roussel H, Vorilhon P, Lafarge E, Pereton B, Prunet-Spano C, … & Savanovitch C (2023). Pediatric pharmaceutical interventions in self-medication: a descriptive study in community pharmacies. BMC Primary Care, 24(1), 232. https://link.springer.com/ article/10.1186/s12875-023-02180-9.

12. Grézy-Chabardès C, Fournier JP, Dupouy J, Poutrain JC, & Oustric S (2015). Patients’ knowledge about analgesic-antipyretic medications purchased in community pharmacies: a descriptive study. Journal of Pain & Palliative Care Pharmacotherapy, 29(4), 334-340.