Clinical update

Pain management in children

Summary and nursing implications of the latest updates to clinical practice.

Summary and nursing implications of the latest updates to clinical practice.

Picture: Getty

Essential facts

In a three-year study published in 2012, the National Pain Audit found that 8% of children in the UK experience severe pain.

Pain is often misunderstood, undiagnosed and untreated, especially in children. Reasons may include difficulties in assessing severity, with children not appearing to be distressed or having difficulty communicating their pain. 

What’s new?

The Royal College of Emergency Medicine (RCEM) has published best-practice guidance on managing pain in children, adapted and updated from its 2013 guideline.

The guidance includes a number of recommendations, including that recognising and alleviating pain in ill or injured children should be a priority. This process should start at triage and be monitored throughout each child’s time in an emergency department (ED). It should end by ensuring adequate analgesia is provided at, and where appropriate beyond, discharge.

The guidance says healthcare professionals caring for children should also pay attention to factors that may be distressing them, including unfamiliar environments and people, parental distress and fear relating to the severity of injury.

The RCEM says it is essential that all staff involved in patient care should be trained in pain relief for children to ensure quality and timely management.

Signs and symptoms

Signs that a child may be in pain include changes in behaviour, appearance, levels of activity and vital signs.

Language, ethnicity and cultural factors may influence the expression and assessment of pain.

The RCEM guidance includes a tool for assessing acute pain in children in the ED. The tool allocates children to one of four pain categories: no pain, and mild, moderate or severe pain. To help assessment, the tool uses faces ranging from happy to crying, with associated behaviour and examples of injuries, from a bump on the head to appendicitis. 

How you can help your patient

Be vigilant for any indication of pain. Listen carefully for a child’s reports of pain and behavioural clues, including facial expressions, limb movements, body posture, crying, verbalisation, restlessness, undue quietness and guarding pressure on a painful area.

Parents may be able to help you understand the language their children use to describe their symptoms and pain. But keep in mind that, although often helpful, parents’ views may be distorted by their understandable concerns about their child’s suffering.

Use a validated pain assessment tool that suits the age and cognitive ability of individual children. If a child cannot communicate pain, use a tool that incorporates physiological and behavioural indicators.

Assess, record and re-evaluate pain at regular intervals. Ask other members of the team, particularly play specialists, to help distract children in pain.

Expert comment


Jason Gray O’Connor is paediatric emergency nurse consultant at Brighton and Sussex University Hospitals NHS Trust

‘While it’s great that this guidance keeps the importance of managing pain in children on the radar for clinicians in emergency departments, for me it is quite basic and represents a missed opportunity.

‘I would like to have seen something about the assessment of pain in pre-verbal children and also those who have special or complex needs. They are vulnerable to injuries and have a higher pain threshold, and we need to be particularly sensitive to their presentation at hospital.

‘It is important that nurses administer pain relief at triage, rather than wait for it to be prescribed by medics. Although this can be done through patient group directions, a lot of departments are still not doing it.

‘Positive aspects of the guidance include its emphasis on timely administration of analgesia, which is crucial, and the importance of reassessing pain using validated tools.’

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