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

The oral route of administration for severe, acute nociceptive pain is preferred for children when prompt analgesia is not required (eg postoperatively when analgesia has been established). Alternative routes of administration should be used if oral absorption is impaired (eg trauma patients). Irrespective of the route of administration used for initial analgesia, oral administration should be used for ongoing analgesia.

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.

For advice on choosing an opioid or the route of administration for severe, acute nociceptive pain, see Approach to managing severe, acute nociceptive pain.

If oral drug regimens are appropriate for severe, acute nociceptive pain due to an acute illness (eg shingles), or following surgery or trauma in children older than 1 year, as a 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, severe (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, severe (children receiving oral opioids) ibuprofen

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, severe (children receiving oral opioids) celecoxib

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, severe (children receiving oral opioids) naproxen

PLUS ONE OF THE FOLLOWING OPIOIDS

1 morphine immediate-release 0.15 to 0.3 mg/kg (for overweight children, use ideal body weight) up to 20 mg orally, 4-hourly if required. Use the lower end of the dose range 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, severe (children) morphine

after each dose, wait 1 hour then assess the child for signs of opioid-induced ventilatory impairment (using sedation score and respiratory rate) and determine whether pain relief is adequate. See Opioid dose titration in hospital for subsequent management, including top-up doses

1 oxycodone 0.1 to 0.2 mg/kg (for overweight children, use ideal body weight) up to 15 mg orally, 4-hourly if required. Use the lower end of the dose range 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, severe (children) oxycodone