TABLE 50.1 Factors Possibly Contributing to Increased Awareness of and Treatment of Pain in Infants and Children
typically composite pain scores consisting of behavioral parameters such as facial grimacing, posture, and crying combined with more objective data such as heart rate, blood pressure, and oxygen saturation. Pain ratings may be erroneous in critically ill infants because sepsis, hypotension, respiratory failure, and other conditions will change many of the physiologic and behavioral parameters in composite pain scales. The CRIES; Face, Legs, Activity, Cry, and Consolability (FLACC) scales; and the Premature Infant Pain Profile have been validated for infants and premature infants.11,12,13
term infants and children. Rectal dosing can be used for children who are unable to tolerate oral dosing, although absorption of rectal dosing can be variable.35 Maximal concentration after rectal dosing occurs at approximately 2 to 3 hours. Typical rectal dosing is 30 to 45 mg/kg initially, followed by 20 mg/kg every 6 hours.32,34 In 2010, the U.S. Food and Drug Administration (FDA) approved the use of intravenous acetaminophen. Peak plasma concentration is reached in 15 minutes following infusion and data show improved pain control with use of the intravenous, with opioid sparing effect.36,37,38 There is a role for use of the intravenous form in children who are both nothing by mouth (NPO) and nothing by rectum (NPR), as well as situations where children are NPO alone, given that rectal dosing can lead to discomfort, fear, or anxiety in children beyond infancy.
preventing long-term postoperative pain, although the incidence of persistent postoperative pain in this demographic is not clearly known. It is reasonable to consider use of ketamine in children, particularly in those with difficult to control pain or a history of chronic opioid use. The data for use in adults is well-established and thus is an area that can be further explored in pediatrics.
TABLE 50.2 Dosing Guidelines for Nonopioid Analgesics
results in analgesia and reduced hyperalgesia as well as partially reversing tolerance to opioids.85
TABLE 50.3 Initial Dosing Guidelines for Opioids