A difficult balance

Dealing with children’s pain is complex and not just a matter of assessing and treating them like a small adult

When it comes to children’s pain management, the accurate assessment of pain is paramount for appropriate and effective treatment.

However, “Assessing pain in children can be tricky,” explains associate professor Rebekah Moles, lecturer of pharmacy practice at the University of Sydney.

“When questioning a child about their pain, try to use their words like ‘ouch’, ‘sore’, and ‘hurt’. Remember that just because an infant may not be able to communicate doesn’t mean they don’t have pain.

“You may need to use more than just questions to try to find out if there is pain and what the severity is. Pain rating scales are very useful tools. Commonly used scales are the numeric scale where a child is asked to rate their pain on a scale of 1–10 with 10 being the worst pain. These scales can be useful for children that are a little older (aged 8 years plus) that can understand number values.

“For younger children (aged 3–8 years), the faces scale has been used extensively. Yet, parents also need to observe their child’s behaviour. Sometimes children in pain will be very withdrawn, whereas others may be disruptive, so parents need to note changes from their normal behaviour.”

Certainly, it’s easier to assess pain in older children as they can verbalise their pain and its severity. However, common non-verbal cues that might indicate a child is experiencing some sort of pain include:

  • crying or screaming;
  • pulling a face;
  • changes in their sleeping or eating patterns;
  • becoming quiet and withdrawn (or the opposite); and
  • refusing to move, or being unable to get comfortable.

It’s worth noting that numerous studies have highlighted the fact that behavioural indicators of pain alone may not provide an accurate assessment of children’s pain. A parent’s assessment of their child’s pain may be skewed by misconceptions about how children express pain, which may ultimately affect how they manage the pain.

A study by Alison Twycross, published in the Journal of Child Health Care in 2015, identified a number of misconceptions about how children express pain.

According to the findings:

  • almost 50% of parents believed children always report their pain to their parents;
  • more than a third (38%) of parents agreed children always express pain by crying or whining;
  • 22% of parents agreed that children exaggerate pain;
  • 20% of parents indicated that children complain about pain to get attention; and
  • approximately 20% of parents believe children experiencing pain report it immediately and that children in pain do not have trouble sleeping.

For pharmacists, this knowledge may encourage them to actively seek out and address parents’ underlying attitudes and beliefs about pain in an attempt to facilitate more appropriate and effective pain management.

Managing mild pain

Unmanaged pain, even in the instance of mild pain, can cause undue anxiety and stress for a child and his or her parents. As such, prompt, short-term symptomatic relief is the usual course of action.

Paracetamol and ibuprofen are the most commonly used over-the-counter analgesics for treating mild to moderate pain in children. Yet, it’s important to advise parents that these medicines do not treat the underlying cause of pain; they simply relieve the symptom.

Pharmacists can also educate parents and caregivers on the variations between each medicine.

This includes the different ways in which each drug works, onset, potential side effects and appropriate dosing.


  • can be used to treat mild to moderate pain and fever;
  • has a minimal effect on inflammation;
  • is the active ingredient in a number of OTC products for children (consideration must be given to this fact, particularly if other medicines are being administered);
  • is suitable for infants from 1 month of age or a body weight of 4kg and over;
  • is available in drops, suspensions, tablets and suppositories; and
  • is usually dosed every 4–6 hours, but not more than 4 times a day.


  • is a non-steroidal anti-inflammatory used to treat mild to moderate pain and fever;
  • can reduce inflammation;
  • is similarly effective in treating pain in children as paracetamol;
  • OTC products containing ibuprofen as the active ingredient are approved for use in children from 3 months of age or with a body weight of 6kg and over;
  • is usually dosed every 6–8 hours but not more than 3 times a day; and
  • relief from pain and/or fever is usually experienced within 15 minutes of taking ibuprofen orally.

Advising on appropriate dosing

Professor Moles says, “Paracetamol or ibuprofen are effective analgesics for mild pain, as well as for the pain associated with fever, when given in the appropriate dose.

“Doses are based on the child’s weight over and above age in children in healthy weight ranges, so getting the dose right is important. It’s best to use a syringe to measure doses to be even more accurate.

“Additionally, both medicines have different dosing intervals, so it’s important to educate and remind parents on how often you can dose.”

She adds, “Pharmacists can be very helpful in helping parents get the doses right. A petite child might need a dose that would often be associated with younger children, but it’s based on body mass. A larger child might need doses that are commonly associated with older children.

“If, however, a pharmacist is giving advice for a caregiver of a child that is obese, at this stage ‘ideal’ body weight should be used to work out the most appropriate dose.

Studies have shown that paracetamol is one of the most common medicines taken by children in an accidental overdose. Widespread causes of paracetamol overdose include too frequent administration, co-administration with other medicines containing paracetamol and prolonged administration of regular paracetamol doses (for a period of up to 24 days).

Given that dosing error is a key cause of preventable poisoning, pharmacists can make a point of reminding and encouraging parents and carers to carefully follow dosing instructions using the enclosed measurement aid.

According to NPS Medicinewise, “Evidence suggests that healthcare providers should encourage parents and carers to use an appropriately marked oral syringe to measure liquid medicines, particularly when small doses are recommended.”

It also states that when recommending paracetamol, for the purpose of pain relief in children under 12 years of age, there are a number of advice points that can be discussed.

  • Paracetamol comes in different formulations and strengths for different ages. It’s important to choose the correct paracetamol product for the child’s age.
  • Parents or carers should keep track of all medicines that are given to the child. This helps prevent accidental overdose through co-administration of medicines that contain paracetamol.
  • There is a potential for liver damage with misuse and overdose of paracetamol, and there are no early signs of hepatotoxicity.
  • The recommended dose of paracetamol for children is based on ideal body weight (15mg/kg).
  • The maximum recommended dosage for children, which is 15mg/kg every 4–6 hours to a maximum of 1 gram, and no more than 4 doses in a 24-hour period, should never be exceeded.

When looking at parent’s attitudes towards children’s pain and analgesic use, Twycross found that almost 47% of parents thought pain medications work best when saved for when the pain is quite bad. Similarly, 37% of parents believed that the less often analgesics are administered the better they work.

Moles says, “Knowing mums’ and dads’ attitudes towards pain relief is important to make sure the child will get the right doses at the right intervals for short-term use.

She adds, “Analgesics are important for moderate to severe pain relief. Post-op is a very reasonable time to use an analgesic to help with pain, and for many children a couple of days of medicines might be all they need, if the right doses are delivered.”

Of course, it’s also important to recognise red flags for referral. Moles says the following circumstances would warrant referral:

  • the child is not responding to analgesia;
  • there is an obvious medical condition requiring treatment (e.g. broken bones);
  • the cause of pain is unknown;
  • there is prolonged high temperature (more than 48 hours);
  • an overdose of analgesia is suspected.

Non-pharmacological pain management

Despite being ‘medication managers’, pharmacists also have a vital role to play in advising on the evidence-based non-pharmacological strategies for managing pain.

Emerging evidence supports the role of non-pharmacological interventions to alleviate pain. Not only are these techniques useful in instances where children must undergo regular procedures, but also in more general settings, such as when administering immunisations.

Non-pharmacological techniques include:

  • diversion and distraction—using music, chat, and technological devices;
  • controlled breathing—blowing bubbles or focusing on breath;
  • touch—massage, stroking, rocking; and
  • imagination—reading books or using guided imagery.

“Once the severity of pain is established, treatment options can be looked at. Play and physical methods to assist children with their pain are just as important as pharmacological interventions,” says Moles.

“Heat packs or cold packs, as well as distraction through playing, can help take the little one’s mind off the pain. No one should be just relying on medicines.”



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1 Comment

  1. Karalyn Huxhagen

    I am often faced with cases of children with severe damage requiring pain relief. This school holidays was no different with skiing accidents and normal play accidents bringing in children in severe distress. The regulations for the use of codeine in children under 12 years does not seem to have filtered into prescribing guidelines as we are seeing many Rxs for children under 12 for Panadeine Forte and Pain Stop.

    For many of these cases the use of appropriate support aids would have given a great deal of support and comfort. The lack of understanding on how to fit aids such as moon boots, clavicle support bandaging and slings including ensuring the child can move without abrasion and rubbing is a very large problem. I know there are not enough occupational therapists to be in each ED 24 hrs a day 7 days a week BUT surely post review -normally three days after the accident surely an OT review should be a primary requirement.

    We were promised during the Opioid Taskforce review that upskilling GPs and emergency department staff would be a primary outcome of the changes. It is not only about better prescribing of medication but it is certainly about improved management techniques for post trauma and post injury.

    I am heart broken when I see inappropriately fitted moon boots and clavicle supports causing more pain and discomfort and sometimes causing more injury. We are missing the easy fixes for all paients in pain especially children.

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