Guide to Pain Management in Low-Resource Settings

Case report 2 (“postoperative pain in the 
neonate”)
Joyce, a 7-day-old newborn baby, was operated on for 
esophageal atresia. Now the nurse reports that the child 
seems to be in great pain. How can you assess and treat 
the pain in this child?
Th
  e baby suff ers from acute postoperative pain. 
Evaluate the pain with help of a pain rating scale for ne-
onates and infants (e.g., NIPS). After major surgery you 
should expect moderate to severe pain. Th
  e baby needs 
very close monitoring in a neonatal intensive care unit. 
Use i.v. morphine for pain management, combined with 
nonpharmacological methods.
Case report 3 (“cancer pain”)
Dhanya, a 10-year-old girl with an incurable meta-
static tumor of the bone who is on oral paracetamol 
(acetaminophen) and codeine, is experiencing increased 
pain. How could you help her? Assess pain with, e.g., the 
Faces pain rating scale. If paracetamol and codeine are 
at maximum dose, a change of opioid is necessary. Stop 
codeine and start oral morphine medication. Continue 
oral morphine on a regular basis at home, after instruct-
ing the parents properly. Th
  ink of opioid side eff ects—if 
not already started, begin prophylactic therapy by giv-
ing preventive remedies. Combine medication with non-
pharmacological methods.
Case report 4 (“neuropathic pain”)
Nasir is a 6-year-old boy suff ering from AIDS. He is 
brought to you by his parents. He is on antiretroviral 
therapy but has severe neuropathic pain in his legs re-
lated to the HIV infection. What would be your fi rst 
line of therapy? Assess pain with, e.g., the Faces pain 
rating scale. Even if neuropathic pain is often declared 
to be “opioid-resistant,” start oral morphine medication 
on a regular basis as fi rst-line therapy, and increase 
the dosage if an additional reduction in pain without 
dangerous medication side eff ects is possible. Try non-
steroidal anti-infl ammatory drugs in addition. Com-
bine medication with nonpharmacological methods. 
If there is no satisfactory pain relief with this regime 
sometimes the use of adjuvants (e.g., gabapentin, tricy-
clic antidepressants, or anticonvulsants) has to be con-
sidered—application of adjuvants should be done by 
experienced pain specialists.
What is the present status of pain 
management in children?
Despite the fact that we understand pediatric pain bet-
ter now, children tend to receive less analgesia than 
adults, and the drugs are often discontinued sooner. Th
 e 
safety and effi
  cacy of analgesic drugs are not well stud-
ied in this age group, and the dosages are often extrapo-
lated from adult studies or pharmacokinetic data. Also, 
the fear of respiratory depression and addiction to opi-
oids are two important issues for reduced usage of these 
potent analgesics in children.
Th
  e major problem in treating pain in children, es-
pecially younger ones, is the diffi
  culty of pain assess-
ment. When we cannot assess pain levels or pain relief 
eff ectively, we are not sure which pain relief measures 
are needed and when. Th
 e other important factor in 
most of the developing countries (where 80% of the 
world’s population lives) is the lack of infrastructure in 
terms of availability of trained nursing staff  or lack of 
drugs and equipment for even simple procedures.
What is the physiology                      
of pain in children?
Right or wrong? Procedures such as circumcision, su-
turing, or other minor operations on young infants can 
be performed without anesthetic or pain medication, 
because children’s nervous systems are immature and 
unable to perceive and experience pain as adults do.
Wrong. Even neonates respond to noxious stimula-
tion with signs of stress and distress. Today, we know 
that a 24-week-old fetus possesses the anatomical and 
neurochemical capabilities of experiencing nocicep-
tion, and related research suggests that a conscious 
sensory perception of painful stimuli is present at these 

Pain Management in Children
257
early stages. Pain means relevant stress in all pediat-
ric patients, and is associated with an inferior medical 
outcome. Lower morbidity and mortality have been re-
ported among neonates and infants who received prop-
er analgesia during and after cardiac surgery. Surgery 
in young infants who are receiving inadequate treat-
ment for pain evokes an outpouring of stress hormones, 
which results in increased catabolism, immunosuppres-
sion, and hemodynamic instability, among other eff ects. 
It is thought that younger children may even experi-
ence higher levels of distress during painful procedures 
than older children, because they tend to cope with pain 
more behaviorally.
Do children become accustomed 
to chronic pain or repeated        
painful procedures?
No. Children exposed who are given repeated pain-
ful procedures often experience increasing anxiety and 
perception of pain. Th
 erefore, especially children ex-
periencing chronic or repeated pain, such as in tumor 
diseases or HIV, have a high demand for accurate pain 
management.
Is pain in children with HIV or 
cancer always related directly         
to the disease?
No, not always. In HIV, between 20% and 60% of HIV-
infected pediatric patients have pain daily. Pain in HIV 
not only reduces quality of life, but is also associated 
with more severe immunosuppression and increased 
mortality, and therefore, it should be treated with care. 
Pain not directly related to the HIV infection can be 
caused by (1) adverse drug eff ects, e.g., peripheral neu-
ropathy, drug induced pancreatitis or abdominal pain 
from vomiting (a common side eff ect of zidovudine), (2) 
invasive medical procedures (it has been estimated that 
20–25% of HIV-positive patients will require surgery 
during their illness), (3) opportunistic infections such as 
esophageal candidiasis, herpes zoster, pneumonia (e.g., 
Pneumocystis carinii, Cytomegalovirus, or Cryptococ-
cus), or tuberculosis infections, and (4) additional ma-
lignancy. For cancer in children additional pain mainly 
occurs from (1) surgery, (2) chemotherapy, and (3) ra-
diation therapy. Children undergoing surgery for exci-
sion of a primary tumor experience postoperative pain. 
Chemotherapeutic agents used can also be a cause of 
pain during treatment. Vincristine, a plant alkaloid, is 
most commonly associated with peripheral neuropa-
thies, characterized by dysesthetic pain that presents 
as a burning sensation, causing pain upon light con-
tact with the skin. Mucositis is a common side eff ect of 
chemotherapy, often seen in children receiving anthra-
cyclines (e.g., daunorubicin), alkylating agents (e.g., cy-
clophosphamide), antimetabolites (e.g., methotrexate), 
and epipodophyllotoxins (e.g., VP-16). Radiation thera-
py to the head and neck area is associated with severe 
mucositis in children. Postradiation pain may occur in 
certain body regions, caused by skin reactions, fi brosis 
or scarring of connective tissues, and secondary injury 
to nerve structures. Other treatment-related side eff ects 
that cause pain include abdominal pain from vomiting, 
diarrhea, constipation, and infections such as typhlitis, 
cellulitis, or sinusitis.
Barriers to eff ective                        
pain management
Do children become addicted to opioids      
more easily than adults?
Opioids are no more dangerous for children than they 
are for adults, when appropriately administered. Th
 e 
prevalence of physical dependence (defi ned as an in-
voluntary physiological eff ect of withdrawal symptoms 
noted following abrupt discontinuation of opioids, or 
administration of a narcotic antagonist such as nalox-
one) on opioids in children is comparable to that in 
adults. If opioids are given regularly in high doses for 
more than a week, do not stop medication abruptly. 
Slow tapering of the opioid is recommended to pre-
vent withdrawal symptoms. As a rule of thumb, re-
duce the opioid to 3/4 of the previous dose over each 
24-hour periods (e.g., day 1: 100 mg/d, day 2: 75 mg/d, 
day 3: 55 mg/day, day 4: 40 mg/d). Sometimes tapering 
may last 1–2 weeks. If seizures occur during tapering, 
treatment with diazepam (i.v. 0.1–0.3 mg/kg every 6 
hrs) is recommended.
Is respiratory depression a common problem  
in opioid-treated children?
Respiratory depression is a serious and well-known side 
eff ect of opioids; however, it rarely occurs in children 
when opioids are administered appropriately. As chil-
dren develop a tolerance to the analgesic eff ect of opioids, 
they often develop a tolerance to an initial respiratory 

258
Dilip Pawar and Lars Garten
depressant eff ect as well. Th
  e most common opioid side 
eff ect is constipation, not respiratory depression. It is im-
portant to note that pain acts as a natural antagonist to 
the analgesic and to the opioid side eff ects of respiratory 
depression. However, opioid analgesics should be given 
cautiously if the age is less than 1 year. Opioids are not 
recommended for babies aged less than 3 months, unless 
very close monitoring in a neonatal intensive care unit is 
available, as there is higher risk of respiratory depression 
and low blood pressure.
When can children be treated at home           
with oral opioids?
With proper instruction, the administration of oral 
opioids by parents at home is safe. Parents have to be 
taught that oral opioids are strong pain killers and have 
to be given to their child as prescribed. Frequency and 
regularity are important to prevent the return of the 
pain, and this has to be made clear. Parents have to be 
prepared for opioid side eff ects (nausea and drowsi-
ness, which usually go away after a few days and do 
not come back; constipation always occurs). Preven-
tive remedies such as dried papaya seeds or a laxative 
such as senna at night should always be given. Parents 
should be told to contact a health worker if (1) the 
pain is getting worse (the dose may be increased), (2) 
an extra dose of oral opioid was given to the child, (3) 
drowsiness comes back, or (4) the dose was reduced. 
Opioid medication MUST NOT be stopped suddenly, 
because severe withdrawal symptoms may occur. All 
instructions should be written out clearly (Fig. 1).
Pain assessment
How is pain assessed?
Th
  e visual analogue scale (VAS) is the gold standard for 
assessment of pain in adults. Th
  e traditional scale is a 
10-cm (100-mm) scale with markings at 1-cm intervals 
from 0 to 10. Zero denotes “no pain” and 10 denotes 
“excruciating pain.” Th
  e patient is asked to identify the 
mark on the scale that corresponds to his/her degree of 
pain. Th
  is VAS has been found to be eff ective in chil-
dren from 5–6 years on. Younger children present a 
real challenge, and the VAS has been modifi ed for ease 
of comprehension of children by incorporating facial 
expressions at either end or at intervals in the scale. In 
a 10-step ladder scale with a toy, a child is asked how 
many steps the toy would be able to climb if it had the 
same degree of pain. All these scales have been used for 
children 3–5 years of age (Fig. 2).
Besides perception of pain, a noxious stimulus 
produces other physiological and behavioral changes, 
which are more marked in children and maybe utilized 
to assess pain. Th
  e most common changes are:
1) Facial expression with certain degree of pain 
(CHEOPS, Oucher, Facial)
2) Heart rate
Fig. 1. Medication instructions (from: World Health Organization. Palliative care: symptom management and end-of-life care.
Interim guidelines for fi rst-level health workers. World Health Organization; 2004. Reprinted with permission.)

Pain Management in Children
259
3) Respiratory rate
4) Body movements and crying (AIIMS, FLACC, 
OPS)
5) Crying is also the ultimate expression of the 
non-pain-related needs of a child such as hunger, 
thirst, anxiety, or parental attention. Th
 ese factors 
should be carefully excluded before considering crying 
as a sign of pain.
Do children express their pain                                 
in the same manner as adults?
No, they do not. Due to developmental diff erences, pain 
expression varies among diff erent pediatric age groups. 
1) Infants may exhibit body rigidity or thrash-
ing, may include arching, exhibit facial expression of 
pain (brows lowered and drawn together, eyes tightly 
closed, mouth open and squarish), cry intensely/loudly, 
be inconsolable, draw knees to chest, exhibit hypersen-
sitivity or irritability, have poor oral intake, or be un-
able to sleep. 
2) Toddlers may be verbally aggressive, cry in-
tensely, exhibit regressive behavior or withdraw, exhibit 
physical resistance by pushing painful stimulus away af-
ter it is applied, guard painful area of body or be unable 
to sleep. 
3)  Preschoolers/young children may verbalize inten-
sity of pain, see pain as punishment, exhibit thrashing of 
arms and legs, attempt to push a stimulus away before 
it is applied, be uncooperative, need physical restraint, 
cling to a parent, nurse, or signifi cant other, request 
emotional support (e.g., hugs, kisses), understand that 
there can be secondary gains associated with pain, or be 
unable to sleep. 
4) School-age children may verbalize pain, use 
an objective measurement of pain, be influenced by 
cultural beliefs, experience nightmares related to pain, 
exhibit stalling behaviors (e.g., “Wait a minute” or “I’m 
not ready”), have muscular rigidity such as clenched 
fi sts, white knuckles, gritted teeth, contracted limbs, 
body stiff ness, closed eyes, or wrinkled forehead, en-
gage in the same behaviors listed for preschoolers/
young children, or be unable to sleep. 
5) Adolescents may localize and verbalize pain, 
deny pain in the presence of peers, have changes in 
sleep patterns or appetite, be infl uenced by cultural be-
liefs, exhibit muscle tension and body control, display 
regressive behavior in the presence of the family, or be 
unable to sleep.
Can you assess pain intensity in children          
by just looking at their behavior?
As every child has individual strategies of coping with 
pain, behavior can be very nonspecifi c  for  estimation 
of pain levels. For example, a school-age girl may spend 
hours playing normally with a toy. At fi rst sight, you 
may think she is happy and not in pain. But this could 
be her behavioral expression for coping with pain (by 
distracting her attention from pain and attempting to 
enjoy a favorite activity). Th
  ough a child’s behavior can 
be useful, it can also be misleading. Using a pain rat-
ing scale and looking at physiological indicators of pain 
(changes in blood pressure, heart rate, and respiratory 
rate) in addition is recommended.
Are children able to tell you                                     
if and where they hurt?
Studies have shown that children as young as 3 years of 
age are able to express and identify pain with the help of 
pain assessment scales, accurately. Children are able to 
point to the body area where they are experiencing pain 
Fig. 2. Adapted pain intensity scales (left: pain ladder, right: modifi ed VAS-scale).

260
Dilip Pawar and Lars Garten
or draw a picture illustrating their perception of pain. A 
widely used and appropriate pain assessment scale is the 
Faces pain rating scale (recommended for children age 3 
years and older) (Fig. 3).
Do children always tell you                               
when they are in pain?
Even when they have adequate communication skills, 
there are some reasons children may not report pain. 
Children may be frightened of (1) talking to doctors, 
(2) fi nding out they are sick, (3) disappointing or both-
ering their parents or others, (4) receiving an injection 
or medication, (5) returning to hospital or delaying dis-
charge from hospital, (6) having more invasive diagnos-
tic procedures, or (7) having medication side eff ects. 
And after all, children just may not think it is necessary 
to tell health professionals about their pain. Th
 us, par-
ents should always be asked for their observations re-
garding the child’s situation. So even in children whose 
cognitive development should allow them to report 
pain, a combination of (1) questioning the child and 
parents, (2) using a pain rating scale, and (3) evaluating 
behavioral and physiological changes is recommended.
How can you assess pain                                            
in infants and toddlers?
Parents, caregivers, and health professionals are con-
stantly challenged to interpret whether the distressed 
behaviors of infants and children, who cannot self-
report, represent pain, fear, hunger, or a range of other 
perceptions or emotions. A range of behavioral distress 
scales for infants and young children have been devised. 
Facial expression measures appear to be the most useful 
and specifi c in neonates. Typical facial signs of pain and 
physical distress in infants are: (1) eyebrows lowered 
and drawn together; (2) a bulge between the eyebrows 
and vertical furrows on the forehead; (3) eyes sightly 
closed; (4) cheeks raised, nose broadened and bulging, 
deepened nasolabial fold; and (5) open and squarish 
mouth (Fig. 4).
Th
  e FLACC Scale (Fig. 6) is a behavioral pain 
assessment scale for use in nonverbal patients unable to 
provide reports of pain. It is used for toddlers from 1 to 
3–4 years of age and for cognitively impaired children of 
any age). Each of the fi ve categories is scored from 0–2, 
which results in a total score between 0 and 10.
Fig. 3. Faces Pain Rating Scale. Original instructions: Explain to the 
person that each face is for a person who feels happy because he has 
no pain (hurt), or sad because he has some or a lot of pain. Face 0 
is very happy because he doesn’t hurt at all. Face 1 hurts just a little 
bit. Face 2 hurts a little more. Face 3 hurts even more. Face 4 hurts 
a whole lot. Face 5 hurts as much as you can imagine, although you 
don’t have to be crying to feel this bad. Ask the person to choose 
the face that best describes how he is feeling. Brief word instruc-
tions: Point to each face using the words to describe the pain inten-
sity. Ask the child to choose face that best describes their own pain 
and record the appropriate number. Continuous use of a pain assess-
ment scale for monitoring the eff ectiveness of pain therapy is recom-
mended. (From: Whaley LF, Wong DL. Nursing care of infants and 
children, 3rd ed. St Louis: Mosby; 1987. Reprinted with permission.)
Fig. 4. Facial expression of physical distress and pain in the infant. 
(From: Wong DL, Hess CS. Wong and Whaley’s clinical manual 
of pediatric nursing, 5th ed. St Louis: Mosby; 2000. Reprinted 
with permission.)

Pain Management in Children
261
Neonatal/Infant Pain Scale (NIPS)
Pain Assessment
Score
Facial Expression
0—Relaxed muscles
1. Grimace
Restful face, neutral expression.
Tight facial muscles, furrowed brow/chin/jaw (negative facial expression—
nose, mouth, and brow).
Cry
0. No Cry
1. Whimper
2. Vigorous Cry
Quiet, not crying.
Mild moaning, intermittent.
Loud scream; rising, shrill, continuous (note: silent cry may be scored if 
baby is intubated, as evidenced by obvious mouth and facial movements).
Breathing Patterns
0. Relaxed
1. Change in Breathing
Usual pattern for this infant.
Indrawing, irregular, faster than usual; gagging; breath holding.
Arms
0. Relaxed/Restrained
1. Flexed/Extended
No muscular rigidity; occasional random movements of arms.
Tense, straight arms; rigid and/or rapid extension/fl exion.
Legs
0. Relaxed/Restrained
1. Flexed/Extended
No muscular rigidity; occasional random movements of legs.
Tense, straight legs; rigid and/or rapid extension/fl exion.
State of Arousal
0. Sleeping/Awake
1. Fussy
Quiet, peaceful sleeping or alert.
Alert, restless and thrashing. 
Fig. 5. Neonatal/Infant Pain Scale (NIPS). An example of an evaluated pain rating scale for neonates and in-
fants. Th
  e maximum score is 6; a score greater than 3 indicates pain. (From: Lawrence J, et al. Th
 e development 
of a tool to assess neonatal pain. Neonatal Nets 1993;12:59–66.)
Pain Assessment
Score
Facial Expression
0–
1–
2–
No particular expression or smile.
Occasional grimace or frown, withdrawn, disinterested.
Frequent to constant quivering chin, clenched jaw.
Legs
0–
1–
2–
Normal position or relaxed.
Uneasy, restless, tense.
Kicking, legs drawn up.
Activity
0–
1–
2–
Lying quietly, normal position, moves easily.
Squirming, shifting back and forth, tense.
Arched, rigid or jerking.
Cry
0–
1–
2–
No cry (awake or asleep).
Moans or whimpers, occasional complaint.
Crying steadily, screams or sobs, frequent complaints.
Consolability
0–
1–
2–
Content, relaxed.
Reassured by occasional touching, hugging or being talked to, distractible.
Diffi
  cult to console or comfort.
Fig. 6. Th
  e FLACC scale. (From: Merkel S, et al. Th
  e FLACC: a behavioral scale for scoring postoperative pain 
in young children. Pediatr Nurse 1997;23:293–7. Copyright 1997 by Jannetti Co. University of Michigan Medi-
cal Center.)

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Dilip Pawar and Lars Garten
Are simple bedside assessment tools available?
In the clinical practice of the All India Institute of Medi-
cal Sciences (AIIMS) in New Delhi, a clinical bedside 
pain assessment scale and a parental assessment scale 
have been developed (Tables 1 and 2), which have prov-
en helpful even with illiterate parents.