The use of opioids to treat pain in infants and children presents challenges. First, with rare exceptions, opioids have not been labeled for use in individuals under 18 years of age. There is a dearth of quality studies on pharmacokinetics, pharmacodynamics, safety, and clinical effectiveness. Acute pain problems in pediatrics have many characteristics in common with adult presentations. Persistent, recurrent, and chronic pain in infants, children, and adolescents are often qualitatively different from chronic pain problems in adults. Treatment approaches may vary accordingly.
Assessment
- Review medical history, including records from previous providers, when available. Be sure to elicit family history of chronic pain syndromes.
- Perform a physical exam to determine diagnosis, baseline function, and pain.
- Carefully assess the degree of injury and the normal healing expectations regarding pain and improved function. Determine the need for opioids versus non-opioid therapies (see Acute Pain section in this document).
Non-Opioid Treatment
- Describe the nature of the injury or disease to the patient and the parent. Be sure to describe the expected course of recovery and convey that some pain is to be expected and that activity and exercise can often provide some pain relief and may improve healing.
- Explain that OTC or over-the-counter pain medications can be highly effective, and be sure they understand dose and frequency recommendations.
- Patients who experience pain extending beyond the expected time of recovery should be reevaluated.
Opioid Treatment
- Only those who understand the differences in pharmacokinetics and pharmacodynamics between children and adults should prescribe opioids for pediatric patients.
- Opioids should be avoided for the vast majority of chronic non-cancer pain in children and adolescents as evidence of safety and efficacy is lacking.
- Opioids are indicated for a small number of persistent, painful conditions, including those with clear pathophysiology and when an endpoint to usage may be defined, such as post-surgical pain and trauma (including burns). Every attempt should be made to limit opiate use to fewer than seven days.
- Opioids may be indicated for some chronic conditions where there is no definable endpoint (like osteogenesis imperfecta or epidermolysis bullosa) or for end-of-life care. Such patients are best treated in a specialty-care setting.
- Put safety first when prescribing opioids to younger patients. Limit the total dispensed and educate parents about dosing, administration, storage and disposal to minimize risks of diversion or accidental ingestion. Adolescents should undergo similar screening for risk of substance-use disorder that one would conduct with adults.
Tools for Adolescents
- Screening tools for substance abuse: ORT, SOAPP-R
- Screening tools for co-occurring mental health conditions: PHQ-9, GAD-7
- Prescription Drug Monitoring Program
- Age and developmentally appropriate screening tools for children such as NIPPS, FLACC, or Bieri-Modified
