Authors' objectives:

This study aims to determine the safety, effectiveness and cost effectiveness of the commonly used pharmacological and non-pharmacological modalities of pain management in paediatric populations.

Authors' results and conclusions: 1.Pharmacological agents; Acetaminophen (Paracetamol) There is sufficient evidence to show that there is minimal risk of developing toxic reactions to acetaminophen when used at therapeutic doses. Acetaminophen is hepatotoxic with inappropriate/excessive dosing, impaired liver function and when ingested with other hepatotoxic drug. Rectal administration of acetaminophen may produce high peak drug levels. There is good evidence on the effectiveness of paracetamol in providing acute post-operative pain control in various surgical procedures, whether given pre-operatively or in the immediate post-operative period. Rectal acetaminophen has not been to be effective in controlling pain satisfactorily. Evidence also shows that combining paracetamol with other analgesics like codein, diclofenac, ibuprofen or rofecoxib does not provide superior pain control compared to using paracetamol alone. Non-steroidal anti-inflammatory agents (NSAIDs) There is sufficient evidence to show that ibuprofen, diclofenac, ketorolac and ketoprofen are reasonably safe. Nausea and vomiting are common side effects. These drugs may also cause mild to severe homeostasis defects peri-operatively. There is also evidence that they are effective in relieving pain in immediate post-operative period and during recovery for various ophthalmic, ear, nose and throat surgical procedures that are administered through various routes i.e. oral, intravascular, intramuscular, rectal or topical. Opoids Evidence shows that opoids can cause hypotension and respiratory depression in high doses. Fentanyl has been found to cause fewer side-effects compared to morphine. There is sufficient evidence to show that opiods are potent analgesics for moderate to severe pain. Their sedative and analgesic effects are dose dependent. There is sufficient evidence that morphine and fentanyl are effective for relief of moderate to severe pain post-operatively in various surgical procedures like ophthalmic, ENT, cardiac procedures, and procedures carried out during the neonatal period. Evidence also shows that the synthetic opiod, fentanyl, is 100 times more potent than morphine, and is effective for out-patient procedural care either in the outpatient setting or emergency department, due to its rapid onset and short duration of action. It is also effective for acute pain relief by administration through transmucosal and intra-nasal routes. Patient controlled analgesia has also been found to be effective for the management of moderate to severe pain post-operatively in older children and adolescents. Local anaesthetic agents Most evidence indicates that Lidocaine-prolocaine cream, is safe as topical analgesia for pain associated with circumcision and medical procedures such as venepuncture. However, there is a risk of methemoglobinemia particularly in premature infants as well as term infants aged less than 3 months. It is also effective for reducing pain during circumcision but the evidence of its effectiveness for analgesia in medical procedures is inconclusive. 2.Non-pharmacological modalities; There is evidence that skin-to-skin contact is a safe intervention against pain in the newborn, but there is insufficient evidence on its effectiveness. As for the other behavioural interventions, there is insufficient evidence on their effectiveness. There is limited evidence on the effectiveness of cognitive behavioural interventions to reduce pain stimuli. 3.Other modalities; Evidence shows that sucrose is a safe to be used with minimal side effects. It is an effective intervention against procedural pain in the term newborn. There is some evidence that glucose is a safe intervention against pain associated with minor procedures in neonates, but findings on its effectiveness were inconclusive. There is insufficient evidence of effectiveness of artificial sweetener against pain. 4.Assessment tools There are several pain assessment tools that can be used to measure pain in the different age groups i.e. preterm infants, neonates, infants and children. Children's families, especially parents, are important in identifying children's behaviour in response to painful stimuli though these may not be as accurate as that of the child.

Authors' recommendations: Pharmacological agents like acetaminophen, NSAIDs like ibuprofen, diclofenac, ketorolac and ketoprofen, and opiods like fentanyl are safe and effective analgesics for use in various surgical procedures that produce mild, moderate and severe painful stimuli. However, the side effects of these need to be taken into consideration with constant monitoring carried out. Pain assessment tools taking into consideration parents' assessment and/or child's self-report can be used to measure pain.

Authors' methods: Systematic review

Project Status: Completed

URL for project: http://www.moh.gov.my/

Year Published: 2006

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: Malaysia

Organisation Name: Malaysian Health Technology Assessment Unit

Contact Address: Health Technology Assessment Unit, Medical Development Division, Ministry of Health Malaysia, Level 21, PERKIM Building, Jalan Ipoh, 51200 Kuala Lumpur, Malaysia. Tel: 603 4045 7781, Fax: 603 4045 77 40

Copyright: Malaysian Health Technology Assessment Unit (MHTAU)