Oral drugs for moderate, acute nociceptive pain in children 1 year or older

The oral route of administration is preferred for moderate, acute nociceptive pain in children; if the oral route is not appropriate, see Approach to managing moderate, acute nociceptive pain. Paracetamol and an NSAID may provide adequate pain relief in some children for moderate, acute nociceptive pain; however, an immediate-release opioid is often required¹.

In children, morphine and oxycodone are preferred to other opioids for moderate, acute nociceptive pain. Do not use modified-release opioids for acute pain because they cannot be safely or rapidly titrated.

There is a risk of dose errors when liquid formulations are used—if a liquid formulation is needed to achieve the required dose or because the child cannot swallow tablets, take care measuring the dose.

There is limited clinical evidence that tramadol is safe and effective in children younger than 18 years, but there is significant experience with its use and it is included in some hospital protocols². Concentrated tramadol drops (100 mg/mL) should not be used in children because dosing errors (confusing the number of drops with the number of mL prescribed) have resulted in accidental overdose and death. Tapentadol should not be used in children because there is insufficient evidence to support its use.

If oral drug regimens are appropriate for moderate, acute nociceptive pain due to an acute illness (eg uncomplicated appendicitis), or following surgery or trauma in children 1 year or older, as a two- or three-drug regimen, use:

paracetamol immediate-release 15 mg/kg (for overweight children, use ideal body weight) up to 1 g orally, 4-to 6-hourly. Maximum 60 mg/kg up to 4 g in 24 hours acute pain, moderate (children receiving oral opioids) paracetamol

PLUS ONE OF THE FOLLOWING NSAIDS

1 ibuprofen 5 to 10 mg/kg (for overweight children, use ideal body weight) up to 400 mg orally, 8-hourly. Maximum 30 mg/kg up to 1.2 g in 24 hours acute pain, moderate (children receiving oral opioids) ibuprofen

OR

2 celecoxib 2 to 4 mg/kg (for overweight children, use ideal body weight) up to 100 mg orally, 12-hourly. Maximum 8 mg/kg up to 200 mg in 24 hours acute pain, moderate (children receiving oral opioids) celecoxib

OR

2 naproxen 5 mg/kg (for overweight children, use ideal body weight) up to 500 mg orally, 12-hourly. Maximum 10 mg/kg up to 1 g in 24 hours acute pain, moderate (children receiving oral opioids) naproxen

PLUS (if pain is not expected to be relieved with paracetamol plus an NSAID) ONE OF THE FOLLOWING OPIOIDS

1 morphine immediate-release 0.1 to 0.15 mg/kg (for overweight children, use ideal body weight) up to 10 mg orally, 4-hourly if required. Use the lower end of the dose range for children treated in the community or if the child has risk factors for opioid-induced ventilatory impairment (eg recent airway surgery, tonsillectomy or adenoidectomy, sleep apnoea, concomitant sedative drugs)³ acute pain, moderate (children) morphine

after each dose, wait 1 hour then assess the patient for signs of opioid-induced ventilatory impairment (using sedation score and respiratory rate)⁴ and determine whether pain relief is adequate. Subsequent management depends on whether the patient is treated in the community or in hospital

OR

1 oxycodone immediate-release 0.05 to 0.1 mg/kg (for overweight children, use ideal body weight) up to 5 mg orally, 4-hourly if required. Use the lower end of the dose range for children treated in the community or if the child has risk factors for opioid-induced ventilatory impairment (eg recent airway surgery, tonsillectomy or adenoidectomy, sleep apnoea, concomitant sedative drugs) acute pain, moderate (children) oxycodone

after each dose, wait 1 hour then assess the patient for signs of opioid-induced ventilatory impairment (using sedation score and respiratory rate)⁵ and determine whether pain relief is adequate. Subsequent management depends on whether the patient is treated in the community or in hospital.

If tramadol is considered appropriate as an alternative to morphine or oxycodone (eg in a hospital with a protocol for use), use:

tramadol immediate-release 0.5 to 1 mg/kg (for overweight children, use ideal body weight) up to 100 mg orally, 6-hourly if required. Maximum 4 mg/kg up to 400 mg in 24 hours. Use the lower end of the dose range for children treated in the community or if the child has risk factors for opioid-induced ventilatory impairment (eg recent airway surgery, tonsillectomy or adenoidectomy, sleep apnoea, concomitant sedative drugs)⁶ ⁷. acute pain, moderate (children) tramadol

¹ There is no universal definition of moderate acute pain. The definition used in these guidelines may differ to definitions used by other organisations (including the Therapeutic Goods Administration) and literature. Return

² The Society for Paediatric Anaesthesia in New Zealand and Australia have published recommendations for the use of tramadol in children [URL].Return

³ At the time of writing, immediate-release morphine tablets are not available on the Pharmaceutical Benefits Scheme (PBS) for this indication. See the PBS website for current information.Return

⁴ If the patient cannot be monitored (eg is being treated with oral opioids at home), they should be educated about opioid-induced ventilatory impairment and how to safely use an opioid for acute pain at home; see How to use an opioid for acute pain at home.Return

⁵ If the patient cannot be monitored (eg is being treated with oral opioids at home), they should be educated about opioid-induced ventilatory impairment and how to safely use an opioid for acute pain at home; see How to use an opioid for acute pain at home Return

⁶ Concurrent use of tramadol with other serotonergic drugs increases the risk of serotonin toxicity (see Drugs most commonly associated with serotonergic toxidrome for drugs associated with serotonin toxicity).Return

⁷ Concentrated tramadol drops (100 mg/mL) should not be used in children because dosing errors (confusing the number of drops with the number of mL prescribed) have resulted in accidental overdose and death. For alternative formulation options for children with swallowing difficulties, see the Don’t Rush to Crush Handbook, published by the Society of Hospital Pharmacists of Australia [URL].Return