Pediatric Pain Management Guidelines

First‑Line Non‑Opioid Analgesics

Acetaminophen should be dosed at 10–15 mg/kg every 4–6 hours (maximum daily dose limited by weight) as the primary analgesic for children; codeine is contraindicated in anyone < 18 years. [1][2]
Ibuprofen is recommended at 10 mg/kg per dose (or 400–600 mg for older children) every 6–8 hours; clinicians must monitor for antiplatelet activity, gastrointestinal irritation, and renal effects. [3][2]
When ibuprofen is unavailable, naproxen or other NSAIDs may be substituted using equivalent weight‑based dosing. 3

Opioid‑free recovery is feasible for many pediatric surgeries and should be the goal whenever possible. 1
If opioids are required, employ the lowest effective dose with careful titration and avoid codeine and tramadol in all children < 18 years per FDA guidance. [2][1]
Morphine: start 0.1 mg/kg IV; repeat 0.05 mg/kg after 30 min if needed; maximum single dose 10 mg. Small, titrated doses provide analgesia without compromising the trauma exam. [3][2]
Fentanyl: start 1 µg/kg IV; give ~30 µg every 5 min as needed; rapid onset makes it useful in emergencies. Transmucosal and intranasal routes give comparable analgesia, though intranasal may cause nasal mucosa burning. [3][2]
Hydromorphone: start 0.015 mg/kg IV (or 1 mg); repeat 1 mg after 15 min if pain persists; typical range 1–1.5 mg per dose. 3
Oral oxycodone‑acetaminophen combinations may be used when the oral route is feasible; acetaminophen‑codeine combos must be avoided because of unpredictable metabolism and higher side‑effect risk. [3][4]
For moderate pain, scheduled (around‑the‑clock) dosing is preferred over PRN administration. 2

Lidocaine: maximum 7 mg/kg with epinephrine, 4.4 mg/kg without; reduce dose by 30 % in infants < 6 months. For topical airway use, limit to 5 mg/kg (ideal body weight) for procedures ≤ 2 h (or 4 mg/kg in infants < 6 months). Solutions > 4 % must not be used in children. [5][6]
Bupivacaine: maximum 3 mg/kg with epinephrine, 2.5 mg/kg without. Long‑acting agents provide 180–600 minutes of analgesia. 5
In case of local anesthetic systemic toxicity, have 20 % lipid emulsion ready (1.5 mL/kg bolus over 1 min). 5

An opioid‑sparing regimen should combine enteral non‑opioid analgesics, IV non‑opioid agents, and regional/neuraxial techniques. Coordination between surgeons and anesthesiologists is essential for appropriate patient selection. 1
Distraction techniques are especially effective for infants and young children. 2
Parental presence during procedures reduces pain and anxiety. 7
Apply topical anesthetic agents before intramuscular injections and venipuncture to lessen procedural discomfort. 2

Opioid administration requires continuous monitoring of vital signs, oxygen saturation, and sedation level. 2
Local anesthetic toxicity vigilance is mandatory; resuscitation equipment and lipid emulsion must be immediately available. 5
After airway topicalization with lidocaine, maintain NPO status for at least 1 hour (longer if aspiration risk is high). 6
Pre‑operative counseling should set realistic pain‑management expectations and provide consistent messaging across the peri‑operative team. 1
When prescribing opioids, discuss potential adverse events, appropriate response actions, secure storage, and proper disposal of unused medication. 1

Infants < 6 months: reduce amide local‑anesthetic doses by 30 % (e.g., lidocaine 4 mg/kg for topical airway use). Standard weight‑based acetaminophen dosing applies with close monitoring. [5][6]
Renal insufficiency: dose‑adjust gabapentin and pregabalin according to creatinine clearance; use NSAIDs cautiously due to renal toxicity risk. [8][9]2
Underweight children: calculate drug doses using ideal body weight and consider lower maximum lidocaine dose (≈ 4 mg/kg). 6

After swish‑and‑spit use, keep the patient nil‑per‑os (NPO) for 15–60 minutes to maximize mucosal contact; analgesic effect of topical agents typically lasts less than 15 minutes. 10

When lidocaine is required for airway topicalization (not routine mouthwash), the recommended maximum dose is 5 mg/kg ideal body weight for procedures ≤2 hours, or 4 mg/kg for infants under 6 months, underweight children, or those with hepatic disease. [10][11]
For a child weighing roughly 24 kg, the absolute maximum lidocaine dose is about 120 mg (equivalent to 24 mL of a 0.5 % solution or 12 mL of a 1 % solution); concentrations greater than 4 % should never be used in pediatric patients. 10
Lidocaine’s elimination half‑life is 90–120 minutes and is prolonged in infants younger than 6 months and in children with liver impairment. 10

Swallowing lidocaine‑containing mouthwash must be strictly avoided, as gastrointestinal absorption can lead to severe systemic toxicity, including seizures and cardiac arrhythmias. 10
All local anesthetic doses should be calculated using ideal body weight, not actual body weight, particularly in overweight children. [10][11]
When lidocaine is administered by multiple teams (e.g., medical and surgical), the total dose must be documented clearly to prevent cumulative overdose. [10][11]