Guide to Pain Management in Low-Resource Settings

Pain management
What drugs can be used for eff ective              
pain control in children?
Local anesthetics for painful lesions in the skin or mu-
cosa or during painful procedures, e.g., lidocaine, TAC 
(tetracaine, adrenaline [epinephrine], cocaine) or LET 
(lidocaine, epinephrine, and tetracaine).
Analgesics for mild to moderate pain (such as 
post-traumatic pain and pain from spasticity), e.g., 
paracetamol (acetaminophen) or nonsteroidal anti-in-
fl ammatory drugs (e.g., ibuprofen or indomethacin).
Opiates for moderate to severe pain not respond-
ing to treatment with analgesics, e.g., codeine (moderate 
pain, alternatives are dihydrocodeine, hydrocodone, and 
tramadol) and morphine (moderate to severe pain; al-
ternatives are methadone, hydromorphone, oxycodone, 
buprenorphine, and fentanyl).
Note: aspirin is not recommended as a fi rst-line an-
algesic because it has been linked with Reye’s syndrome, 
a rare but serious condition aff ecting the liver and brain. 
Especially avoid giving aspirin to children with chicken 
pox, dengue fever, and other hemorrhagic disorders.
In neonates and infants up to 3 kg body weight, 
opioids alone have been shown to be eff ective  drugs 
for treatment of moderate to severe pain. For mild to 
moderate pain therapy, use nonpharmacological meth-
ods, and a formula of 30% sucrose with a pacifi er. Local 
anesthetics can be used for wound care (see Table 7 for 
frequently used drugs and their dosage regimes.)
What do the pain management terms “by the 
ladder,” “by the clock,” “by mouth,” and “by the 
child” mean?
Pain management in children should follow the WHO 
analgesic stepladder (“by the ladder”), be administered 
on a scheduled basis (“by the clock,” because “on de-
mand” often means “not given”), be given by the least 
invasive route (“by mouth”; whenever possible give pain 
medication orally and not by i.v. or i.m. injection), and 
be tailored to the individual child’s circumstance and 
needs (“by the child”).
What nonpharmacological methods can 
be used to relieve pain, fear, and anxiety                  
in children?
If the child and parents agree and if it helps, the follow-
ing additional methods (for local adaption) can be com-
bined with pain medications.
•  Emotional support (whenever possible allow par-
ents to stay with their child during any painful 
procedures).
• Physical methods (touch, including stroking, 
massage, rocking, and vibration; local application 
of cold or warm; controlled deep breathing).
•  Cognitive methods (distraction, such as singing 
or reading to the child, listening to the radio, play 
activities, or imagining a pleasant place).
Table 1
Clinical bedside pain assessment scale
No pain   
Child can cough eff ectively
Mild pain  
Child can breathe deeply but cannot cough without distress
Moderate pain  
Child can breathe normally but cannot cough or take a deep breath without distress
Severe pain  
Child is distressed even during normal breathing
Table 2
Parental assessment scale
No pain  
Playful, comfortable in bed, no discomfort in turning over, calm face, when crying  
 
 
 
easily comforted by parents
Mild 
 
Complains of discomfort at the site of surgery on movement
Moderate 
Facial grimace present, pain and discomfort at site of surgery on movement
Severe   
Persistent crying and restlessness, pain even without movement

Pain Management in Children
263
•  Prayer (the family’s practice must be respected).
•  Traditional practices that are helpful and not 
harmful. (Health professionals should get to 
know what can help in the local setting.)
Another important point is to give children and 
family members proper information about the mecha-
nisms and appropriate treatment of pain, to help them 
better cope with the situation and encourage better 
compliance with recommended care. For neonates and 
infants up to 3 months old, oral glucose/sucrose (e.g., 
0.5–1 mL glucose 30%) given orally 1–2 minutes be-
fore the painful procedure, in combination with paci-
fi ers  off ered to the baby during the painful procedure, 
are eff ective for reducing procedure-related pain from 
injections or blood sampling. All these methods are “ad-
ditionals” and should not be used in place of analgesic 
medications when they are necessary.
What routes of administration are used           
for pharmacotherapy?
Non-parenteral route
Th
  e most commonly used nonopioid analgesic in chil-
dren is paracetamol (acetaminophen). Th
 e traditionally 
recommended dose is the antipyretic dose, which is too 
conservative for pain relief. Th
  e current recommenda-
tion is an oral dose of 20 mg/kg followed by 15–20 mg/
kg every 6–8 hours, or a rectal dose of 30–40 mg/kg 
followed by 15–20 mg/kg every 6 hours. Th
  e total dai-
ly dose for either route should not exceed 90–100 mg/
kg/day in children and 60 mg/kg/day in neonates. Th
 is 
maximum daily dose should not be given longer than 48 
hours in infants under 3 months, and not longer than 
72 hours in children over 3 months old. If a suppository 
is used, it should not be cut, because drug distribution 
might be uneven. Multiple suppositories can be used 
to obtain the desired dose. Th
  e use of paracetamol sup-
positories given for analgesia has to be seen very criti-
cally, because in studies rectal absorption was shown 
to be slow and erratic with substantial variability, es-
pecially in neonates and infants. Often, rectally applied 
paracetamol does not provide therapeutic drug serum 
levels. If paracetamol is used, the oral route should be 
the fi rst choice.
Nonsteroidal anti-infl 
ammatory drugs (NSAIDs) 
such as ibuprofen and ketorolac can be used. Ibuprofen 
(10–20 mg/kg orally) provides eff ective relief for mild 
pain. Ketorolac rectal suppositories have been found to 
be useful in children with a narrow therapeutic margin 
for opioids. NSAIDs can aff ect bleeding time and should 
be used with caution in adenotonsillectomy.
Tramadol hydrochloride, a mild opioid (with only 
partial opioid receptor agonist activity), is available for 
oral and rectal administration in children. It is absorbed 
rapidly (within less than 30 minutes), and the concen-
tration profi le supports an eff ective clinical duration in 
the region of 7 hours. Transmucosal, intraoral, or intra-
nasal opioids might become an interesting alternative 
for breakthrough pain in children, since they generally 
accept this form of application well.
Parenteral route
Th
  e traditional route of parenteral administration used 
to be intramuscular, which should be avoided nowadays 
because of the fear, anxiety, and distress it produces in 
children. A subcutaneous route might be an alternative 
in those cases where venous access is diffi
  cult.
What is the role of opioids?
Opioids are the fi rst line of systemic therapy in moder-
ate to severe pain, with morphine being the most fre-
quently used. Morphine has been intensively studied in 
children. Serum levels of 10–25 μg/kg have been found 
to be analgesic after major surgery in children. A steady 
static serum level of 10 μg/mL can be achieved in chil-
dren for moderate perioperative pain with a morphine 
hydrochloride infusion of 5 μg/kg/h in term neonates 
(8.5 μg/kg/hr at 1 month, 13.5 μg/kg/hr at 3 months, 
18.0 μg/kg/hr at 1 year, and 16.0 μg/kg/hr at 1–3 years 
of age). For the use of morphine and fentanyl in the pe-
diatric patient, and especially in neonates and infants, 
no strong correlation between dose/serum plasma levels 
and analgesic eff ects has been shown, due to the high 
variability in individual opioid metabolism. For that 
reason it is advisable not to rely on specifi c dose recom-
mendations, but use the “WYNIWYG” concept: “what 
you need is what you get.” Titration of the medication is 
recommended to identify the patient’s individual opioid 
dose for proper pain relief.
Total body morphine clearance is 80% of adult val-
ue at 6 months of age. Morphine clearance is higher in 
infants than adults, primarily because of higher hepatic 
blood fl ow and the active alternative sulfation pathway.
Fentanyl can be used as a substitute for morphine 
in children who have hemodynamic instability and who 
cannot tolerate histamine release. In neonates, fentanyl 
has a prolonged elimination half-life compared to mor-
phine. In children older than 1 year, clearance is similar 

264
Dilip Pawar and Lars Garten
to adults, but in neonates it is almost twice as long as 
in adults. An infusion rate of 1–4 μg/kg/hr usually pro-
vides adequate analgesia in children.
For remifentanil, which may only be used intraop-
eratively, adequate analgesia is achieved with a loading 
dose of 1 μg/kg/hr followed by maintenance infusion of 
0.25 μg/kg/min. Alfentanil is eff ective at a dose of 50 μg/
kg followed by an infusion of 1 μg/kg/min. While pethi-
dine (meperidine) has been used clinically for many 
years, it should not be used in continuous infusions any 
longer, as it can produce seizures in children.
What are some ways to reduce opioid              
side eff ects?
Th
  e following methods can be tried by “trial and er-
ror” to reduce opioid side eff ects: (1) dose reduction, (2) 
change of opioid (e.g., from codeine to morphine), (3) 
change of route of administration (e.g., from oral to i.v.), 
and (4) symptomatic therapy (e.g., preventive remedies 
or a laxative for constipation).
What is the maximum dose of morphine         
per day?
Th
  ere is no maximum dose of morphine. If an addition-
al reduction in pain without dangerous medication side 
eff ects is possible with an increased dose, it is indicated. 
Titration of the medication is recommended to identify 
the patient’s individual opioid dose for proper pain re-
lief. If tolerance develops after some time, the dose will 
need to be increased to maintain the same degree of 
pain relief.
What are parenteral nonopioid analgesics        
to consider?
Th
  ere has been a resurgence of interest in ketamine, an 
NMDA-receptor antagonist, for its analgesic properties. 
A dose of 0.1–0.5 mg kg i.v. has been found to provide 
eff ective intraoperative pain relief. Ketorolac has suf-
fi cient analgesic potency for most day care cases and 
maybe supplemented initially by parenteral tramadol. 
No evidence for the eff ectiveness and safety of these 
drugs in neonates and infants has been published.
Is it possible to use patient-controlled  
analgesia (PCA)?
A PCA device is an infusion pump with the facility to 
deliver a top-up dose whenever the patient feels the 
need of it. In the pediatric patient, PCA use is pos-
sible at beginning school age (over 5 years). In children 
less than 5 years old, a “parent-controlled” or “nurse-
controlled” analgesia could be an alternative to PCA. 
Th
  e pump can be programmed to prevent delivery of 
toxic doses by using a lockout interval and a maximum 
hourly dose. Morphine is the usual drug of choice. Th
 e 
patient bolus delivers 10–25 μg/kg. A basal rate of con-
tinuous infusion of 10–20 μg/kg maximum might be ad-
ministered with a lockout interval of 6–12 minutes. In 
children, a background infusion might be helpful dur-
ing sleep and it does not seem to increase the total dose. 
Patient-controlled regional analgesia is also possible. It 
has been found to be eff ective in popliteal and fascia ili-
aca blocks as well as in epidural blocks. One should re-
member, though, that the lockout interval in these cas-
es should be longer than 30 minutes because the time 
needed for the bolus dose to be eff ective is longer.
Regional and local anesthesia
What is the therapeutic value of regional blocks 
in children?
In recent years, there has been a resurgence in the pop-
ularity of regional blocks in children because of their 
effi
  cacy in providing good pain relief. Regional blocks 
hold the key to provision of good pain relief in diffi
  cult 
situations as they are simple to use, easy to learn, and 
cost-eff ective. Th
  ey provide profound analgesia, and lo-
cal anesthetics, such as lidocaine (lignocaine) and bupi-
vacaine, are available even in the least affl
  uent countries. 
Commonly used blocks in children are given in Table 3.
Table 3
Common regional blocks practiced in children
Caudal epidural    
 
Hernia repair, orchidopexy, urethro   plasty,  circumcision
Lumbar epidural   
 
All upper and lower abdominal surgery, thoracotomy
Ilioinguinal/iliohypogastric  
Hernia repair
Dorsal nerve of penis   
 
Circumcision, advancement of prepuce
Axillary  
 
 
Surgery of hand and forearm
Femoral/iliac 
  Th
  igh and femur surgery

Pain Management in Children
265
Note: wound infi ltration can be as good for a hernia, 
or caudal block with bilateral drug administration pro-
viding complete blockade. Epinephrine-containing local 
anesthetics should not be used because the penile artery 
is an end-artery.
Is there a maximum dose of local 
anesthetics  that  is  safe  when  the  drug  is  used                        
for local anesthesia?
Yes. No more than 4 mg/kg of lidocaine without epi-
nephrine, or 7 mg/kg with epinephrine, should be 
used when infi ltrating for local anesthesia. Bupivacaine 
should not exceed 2 mg/kg or 8 mg/day; it is commonly 
used in concentrations of 0.125–0.25% for caudal epi-
dural block (interestingly, 0.5 mg/kg ketamine by the 
same route prolongs the action of bupivacaine for up to 
12 hours). Maximum doses are generally an issue when 
suturing large wounds or when using higher concentra-
tions of local anesthetics.
Helpful tips
1) For painful mouth ulcers, apply lidocaine on 
gauze before feeds (apply with gloves, unless the family 
member or health worker is HIV-positive and does not 
need protection from infection; acts in 2–5 minutes).
2) For suturing, apply TAC (tetracaine, adrenalin, 
cocaine)/LET (lidocaine, epinephrine, and tetracaine) to 
a gauze pad and place over open wounds.
3) Morphine, when administered through the cau-
dal route, is eff ective even for upper abdominal and tho-
racic surgery, and can be eff ective and safe at a dose of 
10 mg/kg through the epidural route.
What regional techniques may be used              
for continuous analgesia?
Compared to neuraxial blocks, peripheral nerve blocks 
with or without catheters have the least complications 
and are popular, especially the axillary, the femoral, 
and the three-in-one-block. Lumbar epidurals can be 
used for a single dose administration, especially when 
caudal block is contraindicated or when the volume 
needed for the caudal block would be close to toxic 
levels. A catheter placed in the epidural space can pro-
vide continuous analgesia for a long period of time (if 
tunneled for periods of more than 1 week). Th
 e cath-
eter can be placed at the lumbar, caudal, or thoracic 
level. Th
  e thoracic level should be used by experienced 
and skilled clinicians only. In children, often the caudal 
route is preferred because it is safest technically due to 
anatomical diff erences, and much easier than in adults. 
Th
  e catheters may even be advanced—always without 
resistance—up to the thoracic segments in infants be-
cause their more compact and globular fat makes it easy 
to pass the catheter. Subcutaneous tunneling of the cau-
dal catheter reduces the rate of bacterial contamination.
Planning an analgesic strategy
It is important to have a plan for pain relief from the 
beginning of the perioperative period until such time 
as the pediatric patient is pain free (see Fig. 7). Factors 
that need to be considered for eff ective planning are 
as follows.
Developmental age
Th
  e chronologic and neurodevelopmental age of the 
patient should be considered. A premature or young 
infant who may have problems with central respiratory 
drive may benefi t from techniques that minimize the 
use of opioids, which have central respiratory depres-
sant drug eff ects. In older infants and toddlers, play 
therapy and the presence of parents have an important 
role in pain relief. Older children may understand the 
concept of a PCA.
Surgical considerations
Th
  e degree of pain is often associated with the type of 
surgery. Th
  e type of surgery often is the deciding fac-
tor in choosing a particular pain relief measure. For 
surgeries in areas that are moved regularly, such as the 
chest and upper abdomen, the pain relief measure re-
quired would be intense. Th
  e patient’s ability to take oral 
medications after surgery is another important factor in 
planning of care.
Educating nurses and parents
A nurse is the fi rst person who faces a child with pain. 
She also is the one who takes care of epidural infu-
sions, i.v. infusions, and PCA devices. It is her respon-
sibility to monitor and coordinate with the surgical 
and the anesthetic team. Her education in pain man-
agement is important. If trained nursing personnel is 
not available or a high-dependency area is not avail-
able, more aggressive methods of pain relief may not 
be safe. Parents provide emotional support to the 
child, and it is important to discuss the plan with the 
parents to elicit their support.

266
Dilip Pawar and Lars Garten
Availability of resources
Limited resources can be defi ned as non-availability of a 
potent analgesic such as morphine or fentanyl, or equip-
ment for drug delivery such as an infusion pump or a 
PCA pump or skilled personnel to perform the proce-
dure and monitor the patient postoperatively. In such 
situations, the strategy should be to devise simple tech-
niques, which do not require precision equipment and 
intensive monitoring in the postoperative period. Th
 ese 
could be as follows:
• Eff ective use of commonly available oral medi-
cations such as paracetamol, NSAIDs, and ket-
amine. Paracetamol and ketamine have been ex-
tensively used in developing countries.
•  Optimum utilization of local anesthetics. Local 
anesthetics can be applied by wound infi ltration, 
prior to incision, before closure, or continuously 
in the postoperative period.
• Th
 e extremely low incidence of complications 
after peripheral nerve blocks should encour-
age using them more often when appropriate. In 
single-injection regional nerve blocks, postopera-
tive analgesia is limited to 12 hours or less. Con-
tinuous peripheral nerve blocks provide an eff ec-
tive, safe, and prolonged postoperative pain relief. 
Th
  ey have been used even in day-care cases up 
to the age of 8 years. If all patients received a re-
gional block intraoperatively, that would obviate 
the need for potent parenteral opioids. Th
 e dura-
tion of analgesia provided by a caudal block can 
be prolonged by addition of other adjuvants.
•  Alternative therapies such as acupuncture analge-
sia might prove to be simple, safe, and economi-
cal.
•  If infusion pumps are not available, a simple pe-
diatric burette can be used for infusion. Th
 e au-
thor’s many years of experience have seen it to be 
safe, if only 2 hours’ worth of the dose is fi lled up 
at any time (even with potent opioids like mor-
phine and fentanyl).
Practical treatment plans                
for a district hospital
Plan 1
A 2 year old child weighing 15 kg is scheduled for her-
nia repair as a day care procedure. Premedication with 
paracetamol 300 mg orally or 600 mg rectally, and after 
induction of anesthesia a caudal or ilioinguinal and ilio-
hypogastric block, followed by wound infi ltration at the 
end of surgery. Two hours after surgery, oral paracetamol 
300 mg or a combination of paracetamol and ibuprofen 
(300 mg) is given 8-hourly until the pain score allows re-
duction or stopping of the medication.
Plan 2
A newborn baby with an anorectal anomaly is scheduled 
for an emergency colostomy. No oral medication is pos-
sible. Th
  e baby can be managed with a spinal subarach-
noidal block with bupivacaine alone. In that case no 
other intraoperative analgesic is needed. In case the baby 
is administered general anesthesia, ketamine (0.5 mg/
kg) and morphine (50 μg/kg) may be administered. For 
premature babies, opioids should be avoided due to im-
mature respiratory function. Although ketamine is used 
in many places, there is no good evidence for the eff ec-
tiveness and safety of this drug in neonates. At the end of 
surgery, wound infi ltration is also used. In the postopera-
tive period, the baby can be given oral paracetamol.
Plan 3
A 5-year-old boy is admitted to the emergency ward 
with acute burns and severe pain. A child with acute 
pain should be managed with available i.v. medication 
such as morphine, ketamine, or tramadol or a combi-
nation of these drugs, along with low-dose midazolam 
to avoid post-traumatic stress, but not for analgesia. 
Once acute pain subsides, oral medication may be initi-
ated with paracetamol 20 mg/kg. Th
  is child will require 
pain medication for physiotherapy, change of dressings, 
or even simple bedsheet changes subsequently. Th
 e child 
and his parents should be prepared with an explanation 
of what is being done. Th
  e pain can be managed with 
oral paracetamol and ketamine (8–10 mg/kg) and i.v. 
ketamine (1 mg/kg). If it comes to surgery, local infi ltra-
tion with local anesthetics of the donor area or a regional 
block would be benefi cial.