Case of the Month #25: Procedural pain management in children by Dr Eveline Matthews

Published: 28/02/2023

Management Plan

Shiferaw and colleagues evaluated the literature for pharmacological and non-pharmacological methods of paediatric procedural burn pain management in a recent review (7). Gillum and colleagues focused on non-pharmacological management options (6).

Pharmacological Management

Pharmacological management of ward-based procedural pain management requires adequate analgesia while maintaining the child’s safety i.e. conscious with an appropriate respiratory drive.

Table 1 describes analgesic agents used in paediatric procedural sedation. Opiates are essential in acute procedural pain management. Route and dose must be guided by the child, their pain scores and the intervention/ procedure that will take place. Inhaled Nitrous Oxide/Oxygen (Entonox) is a useful adjunct to opioid procedural analgesia due to its excellent safety profile and high rates of patient and parent satisfaction (8). In patients with high opiate requirements, the addition of Ketamine can be advantageous as it does not suppress respiratory drive and sedative side effects are minimal at analgesic doses.

Class Drug Route Dose Onset
Side Effects
Opiates Opiates PO 100-200mcg/kg 20-30 Respiratory depression, sedation, dizziness, nausea
IV 20mcg/kg (titrated to effect, this can most safely be administered using a Nurse Controlled Analgesia pump) Titrated to effect
Fentanyl Intranasal


0.75-1mcg/kg for subsequent doses if required

Nitrous Oxide Entonox (02/N20) Inhaled Titrated to effect Rapid onset Dizziness, nausea, dry mouth
NMDA Antagonist Ketamine IV 0.1-0.3mg/kg 5-10 Sedation,
PO 0.5mg/kg 20-30

Table 1: Procedural analgesic agents

Anxiolytic agents can be useful in children displaying high levels of procedural anxiety and fear (Table 2). This is summarised in Heikal and Grant’s publication on anxiolytic agents in paediatrics (9). It is crucial that these agents are used in conjunction with an effective analgesic plan and not as a substitution for adequate pain relief. The additive effect of benzodiazepines to opiates have been well described. Standard monitoring should be used routinely and appropriately trained staff with experience in procedural sedation. α2-agonists have a synergistic effect with opiates, potentially reducing the required opiate dose and they do not supress the respiratory drive, which can be useful in ward based paediatric procedural pain management.

Class Drug Route Dose Onset
Side Effects
Benzodiazepines Midazolam Buccal 0.3mg/kg
(max 10mg)
15-20 Sedation, hypnosis, amnesia, respiratory depression (particularly associated with opiate co-administration)
  PO 0.25-0.5mg/kg (max 20mg) 30-45
Temazepam (children >40kg) PO


α2-agonists Clonidine PO 2-4mcg/kg (max 200mcg) 45

bradycardia, hypotension,
dry mouth

IV 1-2mcg/kg (max 150mcg) 5-15
Dexmedetomidine Intranasal
1-4mcg/kg (max 100mcg) 45

Table 2: Procedural anxiolytic agents

Non-Pharmacological Management
Extensive evidence supports the use of non-pharmacological, distraction-based therapies in relieving anxiety and reducing procedural pain. Gillum and colleagues published a recent systematic review of 15 RCT on their use in paediatric burns dressing management reporting a reduction of pain by a weight mean of 19.7% (6). 

  1.  Child Life Therapy: Child Life Therapy or Play Therapy harnessing distraction-based interventions is frequently used for intravenous cannulation, induction of anaesthesia and emergency department procedures. One RCT in paediatric burns first dressing change reported an 11.7% reduction in pain.  
  2. Virtual Reality (VR): 6 RCT reported a weighted mean of 34.3% reduction in procedural pain. High levels of VR engagement and enjoyment increased distraction and correlated with a reduction in anxiety levels.
  3. Multi-Modal Distraction Technology: Ditto (Diversionary Therapy Technologies) is a handheld device which uses sensory and educational input to provide distraction during procedures. The systematic review reports a weighted mean on 23.9% pain reduction. One study found those that used the device required fewer dressing changes, suggesting improved would healing with effective pain management.
  4. Computer tablets: While the review found no statistically significant difference in patient reported pain scores, there was a significance in nurse recorded pain scores. The authors suggest that given the low cost and readily available nature of these devices, they should be an adjunct to pharmacological management where the other non-pharmacological therapies described are not available.

Parental pain management education can be beneficial in decreasing parental peri-procedural anxiety. Dr Christine Chambers’ parental education “It Doesn’t Have to Hurt” is an excellent resource to empower parents advocating for their child’s acute pain management(10).