• See dosing range charts, below. 
• ALL prescriptions MUST be reviewed every 24 hours.

Oral paracetamol

• Paracetamol can be administered by the oral route REGULARLY for the relief of mild to moderate pain and as an adjunct to stronger analgesics in severe pain.
• If the patient has not received any paracetamol in the preceding 24 hours, a loading dose of 20mg/kg (prescribed on the ‘ONCE ONLY’ section of the drug kardex) may be used if necessary, followed by the usual dose. NB this is included in the patient’s total daily dose.
• Do not exceed 1g in a single dose or 4g in 24 hours.
• All Children should be dosed by weight rather than age. If the weight is unknown then follow the dosing by age in the BNF for Children.

Rectal paracetamol

• When the oral and the IV routes are not available, Paracetamol can be administered by the rectal route but dosing can be complex as bioavailability is very variable.
• If the patient has not received any paracetamol in the preceding 24 hours, a loading dose of 30mg/kg may be given followed by the usual dose
• Child 1 month to 18 years 15- 20mg/kg per dose
• Suppositories should not be halved.Doses are adjusted according to the suppository strength available.
• Maximum of 4 doses may be given in 24 hours.
• The maximum daily dose is 75mg/kg/day, up to max of 4g daily (for 5 to 12 years as per BNFc).

IV paracetamol

• When the oral route of administration is unavailable, IV preparations of paracetamol should be considered.
• IV paracetamol is no more potent or effective than oral paracetamol but dosing is reduced in certain circumstances due to a greater potential for toxicity.
• All IV doses should be administered as a slow IV infusion over aminimum of 15 minutesto avoid hypotension.
• Do not exceed 1g as a single dose or 4g in a 24 hour period.
• Consideration should be made to decreasing the maximal dosing further in the presence of hepatic impairment, malnutrition, dehydration and muscle disorders.

NSAIDs may have adverse effects so care should be taken when determining if NSAIDs are suitable for patients and when prescribing/ reviewing therapy. Please check through the list below before prescribing NSAIDs.

Ibuprofen

• Can be administered by the oral route every 6 to 8 hours.
• Dose: 5 mg/kg up to 30 mg/kg/day.
• Preparations:
  
  • Suspension: 100mg/5ml
  • Tablets: 200mg and 400mg

Cautions: see list on NSAID flowchart.

Diclofenac

• If the oral route is not available then DICLOFENAC can be administered by the rectal route. 
• Preparations:
  
  • Suppositories: 12.5mg, 25mg, 50mg

Dosing

Observations

Oral opioids have the same side effects as parenteral opioids and the following need to be carried out:

• Routine post-operative observations: pulse, oxygen saturation levels, respiratory rate, pain score, sedation score and nausea score should be recorded on the observation chart. 
• Assess effects half an hour after each administration of opioid

Oxygen saturation levels less than 94% on air (with no other known cause)

1. Administer oxygen by facemask, commence with 4L/min and titrate until sats >95% and ensure a clear airway.
2. Stay with the child and monitor respiratory rate, sedation and oxygen saturation levels continuously.
3. Contact the On call/duty anaesthetist for further advice.
4. Assess for other causes of hypoxia/sedation.
5. Reduce subsequent dose of opioid by half and assess if the child's pain can be managed with regular paracetamol and/or NSAIDS (oral/rectal).

Respiratory depression

Oral opioids have the same side effects as parenteral opioids and the following need to be carried out:

1. Ensure a clear airway and administer oxygen 4L/min via face mask and titrate until sats >95%.
2. Stay with the child and monitor the respiratory rate, sedation and oxygen saturation levels continuously.
3. Contact the paediatrician and On-call/Duty anaesthetist for further advice.
4. Assess for other causes.
5. Reduce subsequent doses of opioids by half and assess if the child’s pain can be managed with paracetamol and /or NSAIDS.

Severe respiratory depression

1. Ensure a clear airway and administer oxygen face mask, commence with 4L/min and titrate until sats >95%.
2. Contact the paediatrician and On-call/Duty anaesthetist to review urgently.
3. Administer naloxone (10 micrograms/kg IV in increments. Eg: for a 30kg child the maximum dose of naloxone is 300microgram. Give ¼ of the dose and repeat after 1 minute intervals if there is an inadequate response until the maximum dose of naloxone has been given. A naloxone infusion may be required.
4. If the response to naloxone is inadequate then consider other causes.
5. The child must be nursed in the high dependency area until opioids are no longer required. Continuous pulse oximetry must be used.
6. Reduce subsequent doses of opioids by half and assess if the child’s pain can be managed with paracetamol and /or NSAIDS.

Side effect management

Constipation

• Laxatives should be prescribed for any child receiving regular opioids.
• Ensure a high fibre diet and adequate fluid intake
• Assess for other causes

Nausea and Vomiting

• If a child complains of nausea or is vomiting please give the prescribed anti-emetic
• See paediatric post operative nausea and vomiting (PONV) guidelines
• Children receiving regular opioids may require regular prophylactic anti-emetics
• If problem continues despite treatment as per guidelines consider iv fluid therapy to maintain hydration

Itching

• Assess cause. It may not be the opioid, eg, rash with dressings, etc.
• Prescribe antihistamine as required: 
  Chlorphenamine Doses:
  
  • 2 to 6 years 1mg, every 4 to 6 hours. Max 6 mg daily.
  • 6 to 12 years 2mg every 4 to 6 hours. Max 12mg daily.
  • 12 to 18 years 4mg every 4 to 6 hours. Max 24mg daily.

Use Opioids with caution in the following groups of children as they may need a reduced dose and longer dosing interval

• Children with moderate to severe renal impairment.
• Children with moderate to severe liver impairment.
• Children with sleep apnoea, upper airway abnormalities or those at risk of upper airway obstruction.
• Children with severe neurological disorders.

Oxycodone oral solution

Oxycodone oral solution (1mg/ml) can be used as an alternative strong opioid when morphine is contraindicated.  This is not a stock medication and must be ordered in advance through pharmacy.  The dosing regimes in the BNFc are for moderate to severe oncological pain and a 30 to 50% dose reduction may be more appropriate for treatment of moderate post-operative pain.

• Oral morphine 0.2mg/kg, 2 hourly as required.
• If experienced in giving intravenous opioids: control child’s pain with morphine 50 to 100mirogram/kg. Slow intravenous incrementally with appropriate monitoring.
• Alternatively use:
  • Morphine 0.1 to 0.15mg/kg by subcutaneous cannula. See Subcutaneous opioid (Paediatric Guidelines).
  • Or subsequent doses Morphine PCA or infusion (contact Acute Pain Nurse: bleep 1003 or On-call/Duty Anaesthetist)
• Children receiving frequent opioids require oxygen saturation levels, respiratory rate, sedation, pain scores and nausea score.