Clinical update

Pain management in children

The Royal College of Emergency Medicine has updated its guidance on managing pain in children, saying that recognising and alleviating pain in ill or injured children should be a priority that starts at triage

The Royal College of Emergency Medicine has updated its guidance on managing pain in children, saying that recognising and alleviating pain in ill or injured children should be a priority that starts at triage


Picture: Getty Images

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 its severity, with children finding it hard to communicate their pain or not appearing to be distressed.

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.

It says 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 discharge, and beyond that time where appropriate.

All staff involved in patient care should be trained in pain relief for children to ensure quality and timely management, the guidance says.

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 puts children in one of four pain categories: no pain, or 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

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

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 a 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.

Role of nurses

‘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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