#154: Ache It ‘Til You Make It: Approach to Pain in Children

October 1, 2025 | By Sam Masur

Audio

Ouch! Overwhelmed by a serious boo boo? In this episode, pediatric anesthesiologist and pain medicine specialist Dr. Emmanuel Alalade (Children’s Hospital of Atlanta) teaches us what to do when Tylenol just won’t cut it. Learn about opioid dosing, procedural nerve blocks, and multimodal approaches to pain from infancy to adolescence. 

Pain Pearls

1. Foundations of pain management in children include (of course) acetaminophen, ibuprofen, and nonpharmacologic strategies. 
2. Opioids can be safely used for short-term severe pain; start low, titrate carefully, and consider adjunctive medications to minimize side effects.
3. For chronic pain, focus on function to guide management.

Pain Show Notes 

Assessing pain

Step 1: Observe the situation

Look for nonverbal cues about how the child is feeling, both from child’s behavior and parent’s behavior. 

Decide whether to do the H&P or treat the pain first. If the child is in distress, treating the pain may help you get a better history and exam.

Pain scales 

The Faces Pain Scale – Revised (FPS-R) is familiar to most people and can be helpful for asking young children about pain. 

Faces Pain Scale – Revised, ©2001, International Association for the Study of Pain

The Face, Legs, Activity, Cry, and Consolability (FLACC) Scale (or revised FLACC for children with cognitive disabilities) is a behavioral scale for scoring pain that relies on observation of behaviors to determine pain.

For verbal children, ask about times they’ve experienced different levels of pain (e.g. “When have you experienced 2 out of 10 pain before? 8 out of 10? When was the worst pain you’ve ever experienced?”) to help contextualize and calibrate the score of their current pain. 

Special populations

Children with developmental delay may not express pain verbally or show typical pain behaviors. Ask an adult who knows the child well about what behaviors they typically use to show that they’re in pain. 

For kids with acute-on-chronic pain (for example, sickle cell pain crisis), asking about what has been successful in the past can be helpful in developing a tailored pain plan.

Treating pain

Nonpharmacologic techniques

Infants: sucrose (“sweeties”), swaddling, white or brown noise, parent’s voice

Toddlers through school-age: Age-appropriate distraction, touch, toys, videos, games, show-and-tell or modeling procedures on dolls or stuffed animals

Older children and teens: Age-appropriate distractions, mindfulness (apps like Headspace or Calm), CBT, biofeedback, acupuncture, massage

Partner with child life and pain psychologists to help figure out what might work best!

The basics

Acetaminophen: 15 mg/kg (up to 650 mg) every 6 hours

Ibuprofen: 10 mg/kg (up to 600 mg) every 6 hours for infants over 6 months old

Don’t be afraid to give therapeutic doses! The dosing instructions on over-the-counter medication packaging are intentionally more conservative, but we can and should give more precise weight-based doses. 

Dr. Alalade recommends staggering doses of each (at least while inpatient) so that the child gets pain medication every 3 hours.

Topical agents

Lidocaine (e.g. EMLA cream) and diclofenac gel can be used for small scrapes and cuts to numb the surrounding skin. They can also be helpful before procedures like lumbar punctures or suturing. 

Opioid medications

Opioids can be a helpful tool to treat short-term severe pain. Side effects include sedation, respiratory depression, nausea, constipation, and itching. Start with the lowest dose and titrate to effect. 

Intranasal: good choice for patients without an IV

• Fentanyl: 1-2 mcg/kg (typically rounded to the nearest 15 mg)

Oral:

• Oxycodone: 0.05 – 0.1 mg/kg

IV:

• Morphine: 0.05 – 0.1 mg/kg (typically rounded to the nearest 2 mg) every 3-4 hours
• Hydromorphone: 10 – 20 mcg/kg every 3-4 hours
• Fentanyl: 1 – 2 mcg/kg

Patient-controlled analgesia (PCA) or nurse-controlled analgesia (NCA):

Hydromorphone: 1-4 mcg/kg/hr basal, 1-4 mcg/kg/hr bolus up to every 10 minutes 

Partial opioid agonists: 

Buprinorphine (either patch or sublingual) can be used in children with chronic pain. 

Expert tips: Dr. Alalade prefers hydromorphone over morphine because it has fewer side effects. He tends to avoid combined acetaminophen/opioid products to allow for alternating dosing. 

Adjunctive medications

Antiemetics and stool softeners are important contributors to a multimodal pain control strategy.

Gabapentin: 5 – 15 mg/kg daily divided in three doses

Gabapentin or pregabalin can help with neuropathic pain, described as “burning” or “stabbing.” Dr. Alalade starts with just an evening dose (5 mg/kg), and then adds additional doses to effect. 

Clonidine: 0.1 mg nightly

Clonidine is helpful in chronic pain and sleep.

Nalbuphine can be used to reduce opioid-related pruritus. 

SNRIs (e.g. duloxetine, venlafaxine) can be helpful for chronic pain in adolescents, but the lack of oral suspension formulations makes it challenging to titrate doses for younger children. 

Low-dose ketamine, dexmedetomidine, and lidocaine infusions can all be used for adjunctive opioid-sparing treatments in severe acute pain.

Expert tip: Adjunctive and multimodal pain strategies are especially important for patients with a history of chronic pain.

Procedural pain management

Regional nerve blocks provide pain relief to the area innervated by that nerve that lasts 8-16 hours. Nerve blocks are NOT the same as local anesthesia (i.e. lidocaine injected into the skin around the incision) done by a surgeon during a procedure. 

Epidurals can provide prolonged pain control over several days in abdominal or lower extremity surgery. 

Enhanced Recovery After Surgery (ERAS) protocols

Some hospitals have developed pediatric Enhanced Recovery After Surgery (ERAS) protocols. These protocols take a comprehensive approach to pre-operative, peri-operative, and post-operative phases of surgery to optimize recovery. Common themes of ERAS protocols include pre-operative pain medication, peri-operative opioid-sparing nerve blocks, and early mobilization after surgery. 

Equity and pain management

Several studies have documented that Black children are less likely to receive timely adequate pain medications, especially opioids, compared to other racial groups. These disparities were presented even when controlling for other variables like severity of injury. Contributing factors might include implicit and explicit racial bias, false beliefs about racial differences in pain experience, and provider-family dynamics. 

Awareness of implicit bias and how it impacts clinical practice is important to improve disparities in care. Dr. Alalade points out that it’s also important to think about how biases against parents can impact a child’s care.

Resources

Society for Pediatric Pain Medicine

The Stanford Pediatric Pain Pocket Reference has dosing of all commonly used pediatric pain medications. 

Goal

Listeners will describe strategies for assessing and managing pediatric pain, including use of pain scales, nonpharmacologic and pharmacologic interventions, and equity considerations, to improve care for children in pain.

Learning Objectives

After listening to this episode, listeners will…

1. Identify appropriate pain assessment tools for children of different ages and developmental abilities, including self-report and behavioral scales.
2. Describe age-appropriate nonpharmacologic strategies to alleviate pain in infants, children, and adolescents.
3. Apply weight-based pharmacologic interventions, including acetaminophen, NSAIDs, opioids, and adjunctive medications, in both acute and chronic pediatric pain.
4. Explain procedural pain management techniques, including regional nerve blocks, epidurals, and ERAS protocols.
5. Recognize potential disparities in pediatric pain treatment and strategies to provide equitable, bias-informed care.

Disclosures

Dr. Alalade reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 

Citation

Lidsky H, Alalade E, Chiu C, Masur S. “#154: Ache It ‘Til You Make It: Approach to Pain in Children”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ October 1, 2025.