BNF for Children 2011-2012

BNFC 2011–2012 4.7 Analgesics 199Scopoderm TTS c (Novartis Consumer Health) APatch, self-adhesive, pink, releasing hyoscine approx.1 mg/72 hours when in contact with skin. Net price 2= £4.30. Label: 19, counselling, see belowCounselling Explain accompanying instructions to child andcarer, in particular emphasise advice to wash hands afterhandling and to wash application site after removing, and touse one patch at a time4.7 Analgesics4.7.1 Non-opioid analgesics and compoundanalgesic preparations4.7.2 Opioid analgesics4.7.3 Neuropathic pain4.7.4 Antimigraine drugsThe non-opioid drugs (section 4.7.1), paracetamol andibuprofen (and other NSAIDs), are particularly suitablefor pain in musculoskeletal conditions, whereas theopioid analgesics (section 4.7.2) are more suitable formoderate to severe pain, particularly of visceral origin.Pain in palliative care For advice on pain relief inpalliative care, see p. 17.Pain in sickle-cell disease The pain of mild sicklecellcrises is managed with paracetamol, an NSAID(section 10.1.1), codeine, or dihydrocodeine. Severecrises may require the use of morphine or diamorphine;concomitant use of an NSAID may potentiate analgesiaand allow lower doses of the opioid to be used. Amixture of nitrous oxide and oxygen (Entonox c ,Equanox c ) may also be used.Dental and orofacial pain Analgesics should be usedjudiciously in dental care as a temporary measure untilthe cause of the pain has been dealt with.Dental pain of inflammatory origin, such as that associatedwith pulpitis, apical infection, localised osteitis(dry socket) or pericoronitis is usually best managed bytreating the infection, providing drainage, restorativeprocedures, and other local measures. Analgesicsprovide temporary relief of pain (usually for about 1 to7 days) until the causative factors have been broughtunder control. In the case of pulpitis, intra-osseousinfection or abscess, reliance on analgesics alone isusually inappropriate.Similarly the pain and discomfort associated with acuteproblems of the oral mucosa (e.g. acute herpetic gingivostomatitis,erythema multiforme) may be relieved bybenzydamine (p. 543) or topical anaesthetics until thecause of the mucosal disorder has been dealt with.However, where a child is febrile, the antipyretic actionof paracetamol (p. 200) or ibuprofen (p. 503) is oftenhelpful.The choice of an analgesic for dental purposes should bebased on its suitability for the child. Most dental pain isrelieved effectively by non-steroidal anti-inflammatorydrugs (NSAIDs) e.g. ibuprofen (section 10.1.1). Paracetamolhas analgesic and antipyretic effects but noanti-inflammatory effect.Opioid analgesics (section 4.7.2) such as dihydrocodeineact on the central nervous system and are traditionallyused for moderate to severe pain. However,opioid analgesics are relatively ineffective in dentalpain and their side-effects can be unpleasant.Combining a non-opioid with an opioid analgesic canprovide greater relief of pain than either analgesic givenalone. However, this applies only when an adequatedose of each analgesic is used. Most combinationanalgesic preparations have not been shown to providegreater relief of pain than an adequate dose of the nonopioidcomponent given alone. Moreover, combinationpreparations have the disadvantage of an increasednumber of side-effects.Any analgesic given before a dental procedure shouldhave a low risk of increasing postoperative bleeding. Inthe case of pain after the dental procedure, taking ananalgesic before the effect of the local anaesthetic hasworn off can improve control. Postoperative analgesiawith ibuprofen is usually continued for about 24 to 72hours.Dysmenorrhoea Paracetamol or a NSAID (section10.1.1) will generally provide adequate relief of painfrom dysmenorrhoea. Alternatively use of a combinedhormonal contraceptive in adolescent girls may preventthe pain.4.7.1 Non-opioid analgesicsand compound analgesicpreparationsParacetamol has analgesic and antipyretic propertiesbut no demonstrable anti-inflammatory activity; unlikeopioid analgesics, it does not cause respiratory depressionand is less irritant to the stomach than the NSAIDs.Overdosage with paracetamol is particularly dangerousas it may cause hepatic damage which is sometimes notapparent for 4 to 6 days (see Emergency Treatment ofPoisoning, p. 26).Non-steroidal anti-inflammatory analgesics(NSAIDs, section 10.1.1) are particularly useful for thetreatment of children with chronic disease accompaniedby pain and inflammation. Some of them are also usedin the short-term treatment of mild to moderate painincluding transient musculoskeletal pain but paracetamolis now often preferred. They are also suitable for therelief of pain in dysmenorrhoea and to treat pain causedby secondary bone tumours, many of which producelysis of bone and release prostaglandins (see Prescribingin Palliative Care, p. 17). Due to an association withReye’s syndrome (section 2.9), aspirin should beavoided in children under 16 years except in Kawasakisyndrome or for its antiplatelet action (section 2.9).NSAIDs are also used for peri-operative analgesia (section15.1.4.2).Dental and orofacial pain Most dental pain isrelieved effectively by NSAIDs (section 10.1.1).Paracetamol is less irritant to the stomach than NSAIDs.Paracetamol is a suitable analgesic for children; sugarfreeversions can be requested by specifying ‘sugar-free’on the prescription.For further information on the management of dentaland orofacial pain, see above.4 Central nervous system