Residency · Residency · Pediatrics
Pediatric Pain Management and Procedural Sedation
Overview
Pain is the most common symptom in pediatric emergency and inpatient settings, yet it remains systematically undertreated in children compared to adults, a phenomenon termed oligoanalgesia. Barriers to adequate pediatric pain management include difficulty with age-appropriate assessment, parental anxiety about analgesics, provider knowledge gaps, and concerns about opioid prescribing. Multimodal analgesia and procedural comfort are core competencies for pediatric residents, with the overarching goal of minimizing pain and distress while maintaining safety.
Age-Appropriate Pain Assessment
Self-Report Tools (Gold Standard When Possible)
The Wong-Baker FACES Scale is appropriate for ages 3-7, with the child pointing to a face representing their pain intensity on a 0-10 scale. The Numeric Rating Scale (NRS) is a verbal 0-10 rating suitable for children 8 and older. The Visual Analog Scale (VAS), where the child marks on a 10-cm line, can be used from age 7.
Behavioral/Observational Tools
The FLACC Scale (Face, Legs, Activity, Cry, Consolability) is used for ages 2 months to 7 years and for nonverbal patients. Each category is scored 0-2 for a total of 0-10. A revised FLACC is validated for children with cognitive impairment. The NIPS (Neonatal Infant Pain Scale) is used for preterm and term neonates. The CRIES Scale assesses neonatal postoperative pain. The COMFORT Scale is appropriate for sedated or ventilated children in the PICU.
Assessment Principles
Pain should be assessed at every encounter as the "5th vital sign" using a developmentally appropriate tool applied consistently. Reassessment after intervention should occur at 30-60 minutes. Parental report supplements but does not replace the child's self-report when available. For children with developmental disabilities, behavioral tools should be used alongside input from caregivers who know the child's baseline.
<image>Visual display of age-appropriate pain assessment tools showing the Wong-Baker FACES scale for young children, the FLACC behavioral scale for preverbal or nonverbal patients, and the Numeric Rating Scale for older children and adolescents, with recommended age ranges for each</image>
Non-Pharmacologic Strategies
Non-pharmacologic approaches include distraction (child life specialists, bubbles, videos, music, virtual reality), comfort positioning (parent holding in "comfort holds" rather than restraint, skin-to-skin for infants), and sucrose with pacifier for neonates and infants under 6 months undergoing minor procedures (0.5-2 mL of 24% sucrose on the pacifier or tongue 2 minutes before the procedure, working through endogenous opioid release). Swaddling reduces procedural distress in infants. Guided imagery and relaxation breathing work well for school-age children and adolescents. Cold spray and vibration devices (such as the Buzzy device combining vibration with ice) reduce IV insertion pain. It is critical to understand that non-pharmacologic methods are additive to pharmacologic analgesia, not substitutes for it.
Topical Anesthetics
EMLA (eutectic mixture of lidocaine 2.5% and prilocaine 2.5%) is applied at 1-2 g per site under occlusive dressing with an optimal onset of 60 minutes. Duration is 1-2 hours after removal. There is a risk of methemoglobinemia with excessive application, especially in neonates, and it is contraindicated in infants under 37 weeks or those receiving methemoglobin-inducing agents.
LMX (liposomal lidocaine 4%) requires no occlusive dressing and has a 30-minute onset. It is available over the counter. J-tip is a CO2-powered needle-free jet injection of 1% lidocaine with onset in 1-3 minutes, making it excellent for IV insertion when time is limited.
LET gel (lidocaine 4% + epinephrine 0.1% + tetracaine 0.5%) is applied to open wounds for 20-30 minutes and provides effective anesthesia for laceration repair without injection. It must not be used on end-arteriolar areas (digits, penis, ears, nose) due to epinephrine-mediated vasoconstriction.
Systemic Analgesics
Non-Opioid Analgesics (First-Line for Mild-Moderate Pain)
| Agent | Dose | Route | Frequency | Max Daily Dose | Notes |
|---|---|---|---|---|---|
| Acetaminophen | 15 mg/kg | PO/PR/IV | q4-6h | 75 mg/kg/day or 4 g/day | No anti-inflammatory effect |
| Ibuprofen | 10 mg/kg | PO | q6-8h | 40 mg/kg/day or 2.4 g/day | Age ≥6 months; avoid in dehydration/renal disease |
| Ketorolac | 0.5 mg/kg | IV/IM | q6h | 15-30 mg/dose | Limit to 5 days; potent NSAID |
Acetaminophen is dosed at 15 mg/kg PO/PR every 4-6 hours (maximum 75 mg/kg/day or 4g/day). The IV formulation (15 mg/kg for ages 2 and older, weight 10 kg and above) provides rapid onset but has no anti-inflammatory effect. Ibuprofen at 10 mg/kg PO every 6-8 hours (maximum 40 mg/kg/day or 2.4 g/day) provides anti-inflammatory, analgesic, and antipyretic effects. It is safe in children 6 months and older but should be avoided in dehydration, renal insufficiency, and active bleeding. Ketorolac at 0.5 mg/kg IV/IM (maximum 15-30 mg) is a potent NSAID excellent for acute pain from renal colic, fractures, and post-operative settings, but should be limited to 5 days maximum.
Opioid Analgesics (Moderate-Severe Pain)
| Opioid | Route | Dose | Onset | Duration | Notes |
|---|---|---|---|---|---|
| Morphine | IV/IM | 0.1-0.2 mg/kg (max 5 mg) | 5-10 min IV | 3-4 hours | Standard first-line |
| Morphine | PO | 0.2-0.5 mg/kg | 30-60 min | 3-4 hours | Oral option |
| Fentanyl | IV | 1-2 mcg/kg | 2-3 min | 30-60 min | Short-acting, ideal for procedures |
| Fentanyl | Intranasal (MAD) | 1.5-2 mcg/kg | 10-15 min | 30-60 min | Max 0.5 mL per nostril |
| Oxycodone | PO | 0.1-0.2 mg/kg | 20-30 min | 3-4 hours | Moderate-severe oral pain |
| Codeine | -- | AVOID | -- | -- | FDA-contraindicated <12 years; variable CYP2D6 |
Morphine is given at 0.1-0.2 mg/kg IV/IM (maximum 5 mg initial) or 0.2-0.5 mg/kg PO with onset in 5-10 minutes IV. Fentanyl at 1-2 mcg/kg IV has rapid onset (2-3 minutes) and short duration (30-60 minutes). It is also available intranasally at 1.5-2 mcg/kg using an atomizer (MAD device) with onset in 10-15 minutes, making it excellent for brief painful procedures. Oxycodone at 0.1-0.2 mg/kg PO is appropriate for moderate-to-severe pain when the oral route is suitable. Codeine should be avoided entirely in children due to variable CYP2D6 metabolism; it is FDA-contraindicated in children under 12 years and post-tonsillectomy in those under 18 years due to deaths from ultra-rapid metabolism.
Intranasal Medications (Key Skill for Residents)
Intranasal fentanyl at 1.5-2 mcg/kg via the mucosal atomization device (MAD) is rapid, effective, and non-invasive, with efficacy comparable to IV morphine for acute pain. The maximum volume is 0.5 mL per nostril, necessitating concentrated formulations (50 mcg/mL). Intranasal midazolam at 0.2-0.3 mg/kg provides anxiolysis, while 0.5 mg/kg is used as a procedural sedation adjunct. Intranasal dexmedetomidine at 2-3 mcg/kg provides sedation for non-painful procedures such as MRI. Intranasal ketamine at 3-9 mg/kg provides analgesic-to-dissociative doses with increasing evidence in the pediatric ED.
Adjunctive Agents
Sub-dissociative ketamine at 0.1-0.3 mg/kg IV or 1 mg/kg intranasal provides analgesia without dissociation and is excellent for procedural pain when combined with midazolam. Gabapentin and pregabalin address neuropathic pain in chronic pain conditions. Regional anesthesia and nerve blocks are increasingly used in pediatric EDs, including fascia iliaca blocks for femur fractures and digital nerve blocks.
<image>Illustration of the mucosal atomization device (MAD) technique for intranasal medication delivery showing proper positioning of the atomizer in the nostril, recommended volumes per nostril, and a comparison table of intranasal fentanyl, midazolam, ketamine, and dexmedetomidine with doses and indications</image>
Procedural Sedation
Levels of Sedation (ASA Continuum)
The ASA sedation continuum includes minimal sedation (anxiolysis, with response to verbal commands and unaffected airway), moderate sedation (depressed consciousness with response to purposeful stimulation and usually maintained airway), deep sedation (not easily aroused, may require airway intervention, responds to repeated or painful stimulation), and general anesthesia (unarousable, usually requiring airway intervention). The critical concept is that children can progress unpredictably from one level to the next, so the provider must always be prepared for one level deeper than intended.
Pre-Sedation Assessment
ASA physical status classification guides patient selection, with Class I-II being ideal candidates and Class III or higher requiring anesthesiology consultation. A focused history covers medical conditions, medications, allergies, and prior sedation or anesthesia complications. ASA fasting guidelines specify 2 hours for clear liquids, 4 hours for breast milk, 6 hours for infant formula and light meals, and 8 hours for full meals. For emergency procedures, fasting status does not prevent sedation if the procedure is urgent; the aspiration risk must be balanced against clinical need. Airway assessment evaluates mouth opening, neck mobility, and tonsillar hypertrophy.
Common Sedation Agents
| Agent | Route/Dose | Onset | Duration | Provides | Ideal Use |
|---|---|---|---|---|---|
| Ketamine | 1-2 mg/kg IV; 3-5 mg/kg IM | 1-2 min IV; 5 min IM | 15-40 min | Dissociation, analgesia, amnesia | Fracture reduction, laceration repair, abscess I&D |
| Propofol | 1-2 mg/kg IV bolus | 30-60 sec | 5-10 min | Sedation only (no analgesia) | Brief procedures; requires advanced airway skills |
| Midazolam | 0.05-0.1 mg/kg IV; 0.5 mg/kg PO; 0.2-0.3 mg/kg IN | 1-2 min IV; 15-30 min PO | 30-60 min | Anxiolysis, amnesia (no analgesia) | Adjunct with opioid for moderate sedation |
| Nitrous oxide | 50-70% inhaled | 2-5 min | Immediate offset | Anxiolysis, mild analgesia | Laceration repair, IV insertion, fracture reduction |
| Dexmedetomidine | 1-2 mcg/kg IN; 0.5-1 mcg/kg IV | 15-30 min | 60-90 min | Sedation (no respiratory depression) | MRI, CT, EEG (non-painful procedures) |
Ketamine at 1-2 mg/kg IV (onset 1-2 minutes, duration 15-30 minutes) or 3-5 mg/kg IM (onset 5 minutes, duration 20-40 minutes) provides dissociative anesthesia with analgesia, amnesia, and immobility. It uniquely maintains protective airway reflexes, spontaneous breathing, and hemodynamic stability. It is ideal for fracture reduction, laceration repair, abscess drainage, and burn debridement. Side effects include emergence reactions (less common in young children, reduced with midazolam co-administration in adolescents), hypersalivation (treated with glycopyrrolate or atropine), emesis, and rarely laryngospasm (less than 1%). Contraindications include age under 3 months (relative), active psychosis, and conditions with elevated ICP (relative and debated).
Propofol at 1-2 mg/kg IV bolus followed by 50-150 mcg/kg/min infusion is ultra-short acting with rapid onset and recovery. It provides no analgesia and must be combined with an analgesic for painful procedures. Risks include apnea, hypotension, and injection site pain. It requires advanced airway skills and is typically used by emergency medicine or anesthesiology providers.
Midazolam at 0.05-0.1 mg/kg IV, 0.5 mg/kg PO, or 0.2-0.3 mg/kg IN provides anxiolysis and amnesia without analgesia. It is often combined with fentanyl for moderate sedation. Respiratory depression risk exists, especially when combined with opioids. The reversal agent is flumazenil at 0.01 mg/kg IV.
Nitrous oxide at 50-70% in oxygen via demand valve or continuous flow mask provides anxiolysis and mild analgesia with rapid onset (2-5 minutes) and recovery. It is ideal for laceration repair, IV insertion, and fracture reduction with local or regional anesthesia. Contraindications include impaired consciousness, bowel obstruction (gas expansion), and pneumothorax.
Dexmedetomidine is an alpha-2 agonist providing sedation without respiratory depression at 1-2 mcg/kg IN or 0.5-1 mcg/kg IV over 10 minutes. It is ideal for non-painful procedures requiring immobility (MRI, CT, EEG) but has slower onset and recovery. Side effects include bradycardia and hypotension.
Monitoring During Sedation
Required monitoring includes continuous pulse oximetry, continuous capnography (which detects hypoventilation before desaturation occurs), heart rate and blood pressure every 5 minutes, direct observation of respiratory effort, and a dedicated sedation nurse providing 1:1 monitoring.
Recovery and Discharge
Patients should be monitored until baseline mental status, protective reflexes, and hemodynamic stability are restored. Discharge criteria include age-appropriate responsiveness, stable vital signs, adequate hydration, and a capable escort. Written discharge instructions should cover activity restrictions and indications to seek care.
Clinical Pearls
Intranasal fentanyl is a game-changer for pediatric acute pain, providing efficacy equivalent to IV morphine without requiring IV access; the MAD device should be used in every painful presentation before IV access is obtained. Topical anesthetics should be applied proactively for any anticipated needle procedure because no child should experience avoidable needle pain. Ketamine is the workhorse of pediatric procedural sedation, uniquely maintaining airway reflexes while providing excellent conditions, with emergence reactions being rare in young children. Capnography during sedation detects respiratory depression 30-60 seconds before pulse oximetry changes and should be standard. Codeine should be avoided in all children as it has no role in modern pediatric practice. Child life specialists are invaluable team members and should be involved early for procedural preparation and distraction.
<image>Comparison chart of procedural sedation agents in pediatrics showing ketamine, propofol, midazolam, nitrous oxide, and dexmedetomidine with columns for dose, onset, duration, advantages, disadvantages, and ideal clinical scenarios</image>
Key Controversy: Opioid Prescribing in Pediatric Pain
Post-surgical and acute opioid prescribing in children has come under scrutiny amid the opioid epidemic. Adolescents prescribed opioids after surgery have increased risk of persistent opioid use. The AAP and surgical societies advocate for the lowest effective dose, shortest duration (3-5 days), multimodal analgesia, and safe storage and disposal counseling. However, undertreating pain also has consequences including chronic pain development, psychological trauma, and healthcare avoidance. Best practice involves individualized prescribing, clear expectations, scheduled non-opioids as the foundation, opioids as rescue only, and follow-up for pain reassessment.
References
- Krauss B, Green SM. Procedural Sedation and Analgesia in Children. Lancet. 2006;367(9512):766-780.
- Coté CJ, Wilson S. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures. Pediatrics. 2019;143(6):e20191000.
- Fein DM, et al. Intranasal Fentanyl for Acute Pain in Children in the ED. Pediatr Emerg Care. 2017;33(3):227-231.
- Green SM, et al. Clinical Practice Guideline for Emergency Department Ketamine Dissociative Sedation. Ann Emerg Med. 2011;57(5):449-461.
- AAP Committee on Psychosocial Aspects of Child and Family Health. The Assessment and Management of Acute Pain in Infants, Children, and Adolescents. Pediatrics. 2001;108(3):793-797.
- Miech R, et al. Prescription Opioids in Adolescence and Future Opioid Misuse. Pediatrics. 2015;136(5):e1169-e1177.
