Residency · Residency · Medicine Pediatrics

Pain Management Across the Lifespan

Overview

Pain assessment and management require a developmental approach. Neonates and preverbal children cannot self-report, necessitating behavioral and physiologic pain scales. Adolescents and adults face the competing pressures of adequate pain control and opioid stewardship. Med-Peds physicians must navigate multimodal analgesia strategies while recognizing the neurobiology of pain perception across ages.

Developmental Neurobiology of Pain

Neonatal Pain Processing

Nociceptive pathways are functional by 24 weeks gestational age. Neonates have lower pain thresholds than older children and adults due to incomplete descending inhibitory pathways. Repetitive painful stimuli in neonates (e.g., NICU procedures) cause central sensitization and altered pain processing into childhood. Long-term consequences: increased pain sensitivity, stress reactivity, and neurodevelopmental impacts.

Pediatric Pain Development

Myelination of pain pathways continues through infancy and early childhood. Children develop cognitive pain modulation gradually (catastrophizing, anxiety amplification) By adolescence, pain processing is physiologically mature but psychosocial influences are amplified.

Adult and Geriatric Pain

Chronic pain syndromes (fibromyalgia, chronic low back pain) involve central sensitization. Elderly patients may have altered pain perception (neuropathy, cognitive impairment) leading to underreporting. Geriatric patients are at higher risk for adverse drug effects from analgesics.

Pain Assessment Tools by Age

Neonates and Preverbal Children

NIPS (Neonatal Infant Pain Scale): facial expression, cry, breathing pattern, arm/leg movement, arousal (0-7 scale) CRIES: crying, requires O2, increased vital signs, expression, sleeplessness (postoperative neonatal scale) FLACC (Face, Legs, Activity, Cry, Consolability): validated for ages 2 months to 7 years; also used in cognitively impaired patients of any age (0-10 scale)

Verbal Children (Ages 3-7)

Wong-Baker FACES Pain Rating Scale: self-report using cartoon faces from smiling to crying (0-10) Oucher Scale: photographic faces showing increasing distress; culturally adapted versions available.

Older Children and Adolescents

Numeric Rating Scale (NRS): self-report 0-10 scale; reliable from approximately age 8. Visual Analog Scale (VAS): 100 mm line; requires abstract thinking; reliable from age 8-10.

Adults

NRS (0-10): most widely used. VAS: research standard. McGill Pain Questionnaire: multidimensional (sensory, affective, evaluative) Brief Pain Inventory: assesses pain interference with function.

Cognitively Impaired / Nonverbal Patients (Any Age)

FLACC-R (Revised): modified for children with cognitive impairment. PAINAD: Pain Assessment in Advanced Dementia (0-10 scale based on breathing, vocalization, facial expression, body language, consolability)

Multimodal Analgesia Strategies

Non-Pharmacologic Approaches (All Ages)

Neonates: skin-to-skin (kangaroo care), non-nutritive sucking, sucrose/glucose on pacifier, swaddling, facilitated tucking. Children: distraction (child life specialists, virtual reality, tablet devices), guided imagery, hypnosis, cognitive behavioral therapy. Adolescents/Adults: CBT, mindfulness-based stress reduction, physical therapy, TENS, acupuncture, heat/cold therapy. All ages: positioning, environmental modification, music therapy.

Acetaminophen

Dosing: 15 mg/kg/dose PO/PR q4-6h (max 75 mg/kg/day in children, 4 g/day in adults; 2 g/day with liver disease) IV acetaminophen: available for all ages; improved bioavailability but costly. Neonatal dosing: reduced (10-12.5 mg/kg/dose) due to immature glucuronidation. No anti-inflammatory effect; excellent safety profile when dosed appropriately. Hepatotoxicity risk with chronic supratherapeutic dosing or acute overdose.

NSAIDs

Ibuprofen: 10 mg/kg/dose PO q6-8h in children (max 40 mg/kg/day); 400-800 mg q6-8h in adults. Ketorolac: 0.5 mg/kg IV q6h in children (max 30 mg/dose); 15-30 mg IV q6h in adults; limit to 5 days. Naproxen: 5-7 mg/kg/dose PO q12h in children; 250-500 mg PO q12h in adults. Avoid in neonates <6 months, renal insufficiency, active GI bleeding, coagulopathy, dehydration. Caution in asthma (NSAID-exacerbated respiratory disease) Excellent for musculoskeletal pain, headache, renal colic, dysmenorrhea.

Opioids

Pediatric dosing (opioid-naive): Morphine: 0.1 mg/kg IV q2-4h or 0.2-0.5 mg/kg PO q4-6h. Hydromorphone: 0.015 mg/kg IV q2-4h. Oxycodone: 0.1-0.2 mg/kg PO q4-6h. Fentanyl: 0.5-1 mcg/kg IV q1-2h (useful for procedural sedation) Codeine: AVOID in children -- FDA black box warning due to CYP2D6 ultra-rapid metabolizer risk causing fatal respiratory depression. Adult dosing: standard adult doses with adjustment for age, renal/hepatic function, and opioid tolerance. Elderly: start at 25-50% of standard adult dose; avoid meperidine (normeperidine neurotoxicity) PCA (Patient-Controlled Analgesia): appropriate for children age 6+ who can understand the concept; parent/nurse-controlled analgesia for younger children. Constipation prophylaxis: start a bowel regimen with opioid initiation in all age groups.

Adjuvant Analgesics

Gabapentin/Pregabalin: neuropathic pain; increasingly used perioperatively in adults and older children. Tricyclic antidepressants (amitriptyline, nortriptyline): neuropathic pain, functional abdominal pain; QTc monitoring required. SNRIs (duloxetine): FDA-approved for fibromyalgia, diabetic neuropathy, chronic musculoskeletal pain in adults; limited pediatric data. Ketamine: sub-anesthetic doses (0.1-0.3 mg/kg IV) for pain crisis (sickle cell, complex regional pain syndrome); growing evidence in both pediatric and adult ED settings. Lidocaine: topical (LET gel, EMLA cream for procedural pain in children), IV lidocaine infusion for refractory pain. Regional anesthesia: nerve blocks, epidural analgesia; increasingly used in pediatric perioperative care.

Opioid Stewardship Across Ages

The Opioid Crisis and Clinical Practice

Over 100,000 opioid-related overdose deaths annually in the US (as of recent data) Adolescents are particularly vulnerable: developing prefrontal cortex, risk-taking behavior, peer influence. Post-surgical opioid prescribing is a major entry point for opioid exposure.

Best Practices

Prescribe the lowest effective dose for the shortest duration. Multimodal analgesia to reduce opioid requirements (opioid-sparing strategies) State prescription drug monitoring programs (PDMPs): check before prescribing opioids. Safe storage and disposal counseling for families (especially with toddlers in the home) Naloxone co-prescribing for patients on chronic opioids or at risk for overdose. Screening for opioid use disorder: TAPS tool (adults), CRAFFT (adolescents)

Chronic Pain in Adolescents and Young Adults

Functional pain syndromes are common in adolescence (headache, abdominal pain, musculoskeletal pain) Biopsychosocial model is essential: pain is real even when no organic cause is identified. Interdisciplinary pain rehabilitation programs show the best evidence. Avoid chronic opioid therapy for non-cancer pain in adolescents. School re-integration and functional restoration as primary goals.

Procedural Pain and Sedation

Pediatric Procedural Sedation

Topical anesthetics: EMLA (eutectic mixture of lidocaine and prilocaine) applied 45-60 minutes before; LMX (4% lidocaine cream); J-Tip needleless lidocaine. Intranasal fentanyl (1.5-2 mcg/kg) or intranasal midazolam (0.2-0.3 mg/kg): rapid onset, avoids IV access. Nitrous oxide (50:50 or 70:30 N2O:O2): excellent anxiolysis and mild analgesia for minor procedures. Ketamine (1-2 mg/kg IV or 4-5 mg/kg IM): dissociative sedation for fracture reduction, laceration repair; maintains airway reflexes.

Adult Procedural Sedation

Propofol: most common in ED and endoscopy settings; requires careful monitoring for apnea. Ketamine: increasingly used in adults for procedural sedation; lower emergence reaction risk with midazolam co-administration (controversial) Moderate (conscious) sedation: midazolam + fentanyl combination.

<image>A developmental pain assessment tool selection guide organized by age from left to right: premature neonates (NIPS, CRIES), term neonates to 3 years (FLACC), 3-7 years (Wong-Baker FACES), 8+ years and adults (Numeric Rating Scale 0-10). Each section shows the tool with a sample scoring illustration. A separate bottom row shows tools for cognitively impaired patients of any age (FLACC-R, PAINAD). Color-coded arrows indicate the transition points between tools.</image>

<image>A multimodal analgesia pyramid diagram showing the stepwise approach to pain management across ages. The base (non-pharmacologic interventions: CBT, physical therapy, distraction, skin-to-skin) supports the second tier (acetaminophen and NSAIDs), the third tier (adjuvants: gabapentin, regional anesthesia, ketamine), and the apex (opioids, used for the shortest duration at the lowest effective dose). Side annotations show age-specific considerations at each tier, such as sucrose for neonatal procedural pain at the base and codeine avoidance in children at the opioid tier.</image>

<image>An infographic comparing opioid prescribing considerations in pediatric versus adult populations. Two columns show key differences: pediatric side shows weight-based dosing, codeine contraindication in children, parent-controlled analgesia option, and safe medication storage counseling; adult side shows fixed dosing, PDMP checking, chronic pain management paradigm, and naloxone co-prescribing. A central overlap zone shows shared principles: multimodal analgesia, lowest effective dose, shortest duration, and constipation prophylaxis.</image>

Clinical Pearls

Neonates DO feel pain -- procedural pain in the NICU should be minimized with sucrose, skin-to-skin contact, and appropriate pharmacologic management. NEVER prescribe codeine to children -- FDA black box warning due to CYP2D6 ultra-rapid metabolizer deaths. The FLACC scale is versatile: use it for preverbal children AND cognitively impaired patients of any age. Intranasal fentanyl (1.5-2 mcg/kg) is a game-changer for pediatric pain management when IV access is not established. Always start a bowel regimen when initiating opioids -- constipation is the one opioid side effect to which patients do not develop tolerance. Multimodal analgesia is not just good medicine, it is the standard of care -- every patient should receive non-opioid analgesics unless contraindicated. In adolescents with chronic non-cancer pain, the goal is functional restoration, not pain elimination. Ketamine at sub-anesthetic doses is an increasingly important tool for acute pain crises (sickle cell, complex regional pain syndrome) in both children and adults.

References

• Cravero JP, Agarwal R, Berde C, et al. The Society for Pediatric Anesthesia recommendations for the use of opioids in children during the perioperative period. Paediatr Anaesth. 2019;29(6):547-571.
• Dowell D, Ragan KR, Jones CM, et al. CDC Clinical Practice Guideline for Prescribing Opioids for Pain -- United States, 2022. MMWR Recomm Rep. 2022;71(3):1-95.
• Tobias JD. Acute pain management in infants and children. Part 1 and 2. Pediatr Ann. 2014;43(7-8):e163-e168, e198-e203.
• Krauss BS, Calligaris L, Green SM, et al. Current concepts in management of pain in children in the emergency department. Lancet. 2016;387(10013):83-92.
• Friedrichsdorf SJ, Goubert L. Pediatric pain treatment and prevention for hospitalized children. Pain Rep. 2020;5(1):e804.

Read this lecture as Markdown