A Philosophical Approach to Pediatric Analgesia

Pediatric pain is consistently undertreated in the ED, despite evidence that repeated painful stimuli can lead to hyperalgesia and allodynia. A practical approach starts with multimodal analgesia, treating the underlying condition, and delivering meds by the least painful route possible.

Principles of pediatric analgesia

• Undertreated pediatric pain: Children with clearly painful conditions receive analgesia less often than adults; in one fracture review, 53% of children were treated versus 73% of adults, underscoring a persistent ED care gap.
• Pain memory consequences: Repeated painful stimuli in children can amplify future pain responses, with hyperalgesia and allodynia as the key long-term concern rather than a brief procedural upset.
• Three-part analgesia framework: The core strategy is multimodal analgesia, treatment of the underlying pathology, and choosing the least painful route first, a bedside mindset shift we lay out in the episode.
• Assume pain in nonverbal kids: If an injury or procedure would hurt a verbal patient, treat the nonverbal child as if it hurts too; under-recognition is a bigger error than overcalling pain in this setting.
• Avoid unnecessary procedures: Nasogastric tubes and catheterized samples can be among the most painful interventions, so the better analgesic move is often deciding not to do a low-yield procedure at all.

Medication choices and routes

• Morphine over codeine: Morphine is the preferred opioid because it is active as given, while codeine is a prodrug with CYP2D6 variability that led to an FDA black box warning in patients under 18.
• Headline morphine dosing: A practical starting dose for morphine is 0.1 mg/kg, then titrate to comfort rather than stopping at a token first dose.
• Intranasal fentanyl role: Intranasal fentanyl can provide meaningful pain relief in about 10 to 15 minutes, making it especially useful when you expect a single-dose analgesic plan.
• Route-specific drug performance: Intranasal delivery is not interchangeable across agents; fentanyl performs well, ketamine is erratic, and oral midazolam is often better tolerated despite a slower onset. We get into the route nuances in the chapter.
• Multimodal nonopioid backbone: Acetaminophen and ibuprofen should anchor many plans, with escalation to morphine, ketamine, or a nerve block when the injury and severity justify it.

Procedural pain and distress reduction

• Sucrose is not analgesia: Oral sucrose may reduce distress, but it has not been shown to provide analgesia in patients able to report pain, so it should not replace proven pain control.
• Topical anesthetic timing: Topical anesthetic only helps if you give it enough time to work; rushing the procedure is a common reason otherwise good local pain control fails.
• Infant LP local anesthesia: Infants do need local anesthetic for lumbar puncture; EMLA and careful lidocaine infiltration with the smallest practical needle make the procedure less traumatic.
• Lidocaine with epinephrine: For lumbar puncture anesthesia, lidocaine with epinephrine may lower the risk of a traumatic tap, a small technical pearl with outsized procedural payoff.
• Distress modulation tools: Covering the child’s eyes, using videos or music, and reframing equipment with child-friendly language can meaningfully reduce distress alongside analgesics. We share the bedside phrasing in the episode.