Subcutaneous opioids for severe, acute nociceptive pain in children 1 year or older

If oral administration of an opioid is not appropriate (eg prompt analgesia is required, or the child cannot take oral medications or has impaired gastrointestinal absorption), or intranasal or intravenous administration is not available (eg the child is being treated in a non–critical care area), consider subcutaneous opioid administration for severe, acute nociceptive pain. In children, the use of subcutaneous opioids is usually limited to postoperative pain in hospital; ideally, a subcutaneous cannula is inserted intraoperatively because it can be distressing for a young child. For advice on choosing an opioid or the route of administration for severe, acute nociceptive pain, see Approach to managing severe, acute nociceptive pain.

A subcutaneous opioid should be used in addition to paracetamol and an NSAID. If oral paracetamol or an NSAID is not appropriate, see Alternative routes of administration if oral paracetamol or NSAIDs cannot be used.

Oral opioids should be used for ongoing analgesia. If the oral route is not appropriate in children, refer to local protocols—nurse- or patient-controlled analgesia may be considered, seek expert advice.

If a subcutaneous opioid is indicated for a child 1 year or older with severe, acute nociceptive pain, following surgery or trauma, 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 subcutaneous 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 subcutaneous 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 subcutaneous 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 subcutaneous opioids) naproxen

PLUS

morphine 0.05 to 0.15 mg/kg (for overweight children, use ideal body weight) up to 7.5 mg subcutaneously (by slow injection), 2-hourly for a maximum of 3 doses 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, subcutaneous dosing (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.