Pain and Non-Pain Symptom Assessment and Management
Assessment first
Self-report is the gold standard when the child can report. Use age-appropriate tools: FLACC for infants and young children, Wong-Baker faces for preschool and early school age, and numeric scales for older children. For nonverbal or cognitively impaired children, use observational tools plus knowledge of baseline behavior, and treat reported pain.
Pain management principles
Use multimodal analgesia: non-opioids, opioids, adjuvants, and non-pharmacologic methods. The WHO ladder is adapted for children. Avoid codeine (contraindicated under age 12 and after tonsillectomy or adenoidectomy under 18 because of ultrarapid CYP2D6 metabolism) and avoid tramadol in young children and meperidine because of neurotoxic metabolites. Morphine is a standard strong opioid. Prescribe scheduled dosing plus breakthrough doses at roughly 10–15% of the total daily dose. When rotating opioids, reduce the equianalgesic dose by about 25–30% for incomplete cross-tolerance. Prescribe bowel prophylaxis, anticipate nausea, and monitor sedation and respiratory rate. Naloxone reverses opioid-induced respiratory depression but must be titrated in palliative patients.
Non-pain symptoms
Dyspnea: opioids are first-line; oxygen helps only if hypoxemic. Nausea: match antiemetic to mechanism (constipation, chemotherapy, raised intracranial pressure, vestibular, gastric stasis). Secretions: glycopyrrolate or scopolamine; avoid deep suction. Constipation: polyethylene glycol prophylaxis. Delirium and agitation: look for reversible causes and use haloperidol or quetiapine cautiously. Neuropathic pain: add gabapentin or a tricyclic rather than escalating opioids alone.
Traps
Under-treating because of addiction fears; confusing dependence, tolerance, and addiction; using codeine or tramadol; giving oxygen for dyspnea without hypoxemia; escalating opioids for neuropathic pain without adjuvants; failing to prescribe laxatives; assuming a nonverbal child cannot have pain.
Worked example
A 7-year-old on morphine 10 mg every 4 hours has 6/10 pain. Total daily dose is 60 mg; a breakthrough dose is 6–10 mg every hour as needed. Add polyethylene glycol, reassess, and add gabapentin if pain is neuropathic.