Chapter 130

130 

CHAPTER 

Acute Pain Service 

Rita Agarwal and David M. Polaner 

Most hospitals with significant numbers of pediatric surgical 

inpatients have found that it is important to organize and maintain 

an acute pain service (APS). Such a service permits a consistency 

of approach and availability of coverage that is not possible with ad 

hoc care by individual clinicians. An organized service also allows 

the introduction of multidisciplinary personnel that may be 

helpful in expanding the nature of services offered. Clinical 

specialties, such as oncology, neonatology, and pediatric medicine, 

can consult and contribute to the APS as well, thereby expanding 

its reach and scope. It is possible for general hospitals to care for 

pediatric patients with an adult APS, as long as expert consultation 

and input is sought and clear protocols and guidelines are established. 

To do otherwise risks inviting medication and equipment 

errors with a high potential for adverse events. 

SCOPE OF PRACTICE 

Although the primary role of most acute pain services is to order, 

perform, and monitor regional blocks, patient-controlled analgesia 

(PCA), and other analgesics, the management of a variety of painful 

conditions occurring in the hospital setting is becoming 

increasingly important (Table 130–1). 

Acute Postoperative Pain 

The high level of understanding that the anesthesiologist brings 

to bear on opioid and nonopioid analgesics, regional blockade, 

and other modalities of analgesic therapy has produced documented 

improvements in care when an APS model is instituted. 

While routine administration of oral analgesics may be still 

ordered by the operating surgeon, regional blockade, patientcontrolled, 

nurse-controlled, and parent-controlled analgesia 

(PCA and its variants), and continuous opioid infusions can be 

most effectively managed by the APS. 2 Because the APS staff can 

be out of the operating room to see children as needed, inadequate 

analgesia, complications, side effects, and other problems can be 

dealt with in a timely manner. 

Acute Nonoperative Pain 

Outside the perioperative period, oncology and hematology 

patients have the greatest need for analgesics. Both cancer-related 

pain and sickle cell pain are common problems in these children. 

Their pain is often complex, and may involve a combination 

of acute exacerbations superimposed on chronic pain. Their 

spectrum of problems may include neuropathic and complex 

pain problems, opioid tolerance, anxiety, and psychological issues. 

The APS often has greater familiarity with escalating opioid doses, 

converting to different opioids, use of multimodal and polypharmaceutical 

techniques, and psychological and behavioral treatments. 

Other frequent APS referrals are patients with recurrent 

abdominal pain, pulmonary patients with chest pain, patients with 

chronic pancreatitis hospitalized with an acute exacerbation, and 

patients with musculoskeletal pain with or without underlying 

coexisting medical conditions. 

Management of Continuous 

Regional Blockade 

The use of regional analgesic techniques for management of 

postoperative pain, medical (sickle cell crisis, neuropathic, vasoocclusive 

crisis), and traumatic pain has increased dramatically. 

Children often have a fear of needles and/or an inability to cooperate 

but pediatric anesthesiologists have become increasingly 

comfortable placing the majority of these blocks in children who 

are sedated or anesthetized. Both single-shot peripheral nerve 

blocks and continuous catheter techniques have become more 

feasible and popular with the increased use of ultrasound. 3–5 Use 

of standardized (but flexible) sets of postoperative orders for 

medications, monitoring, procedures, and contingencies help 

minimize side effects and problems and improve compliance and 

communication. 

Consultation 

It is not uncommon for an APS to be consulted for a variety of 

patients who are admitted to other services for pain management. 

Examples include the child admitted with idiopathic acute 

abdominal pain who has had an array of inconclusive diagnostic 

tests. Other common examples include patients with extremity 

pain out of proportion to their apparent physical condition, 

patients with acute pancreatitis, headaches, post–dural puncture 

headaches, and children being weaned from large doses of opioids 

or sedatives but who are otherwise ready to be discharged. 6 

ORGANIZATION 

Although the primary goal of most APSs is to manage post - 

operative pain, there are several other functions that must be 

provided by this service (Table 130–2). Therefore, it is logical that 

an anesthesiologist functions as director or codirector of such a 

service. Very little information is available on the organization and 

make up of pediatric pain services. In a survey by McClain and 

colleagues in 2002, more than half of institutions surveyed had

TABLE 130-1. Responsibilities of an APS 

CHAPTER 130 ■ Acute Pain Service 2133 

Regional Analgesia Techniques Opioid Based Analgesia Techniques Consultations for Inpatients 

Continuous epidural infusions 

Follow-up after intrathecal 

opioids 

Continuous peripheral nerve 

block infusions 

Follow-up after single-shot 

peripheral nerve block 

Patient-controlled analgesia (PCA) 

PCA by proxy (nurse- or parent-controlled PCA) 

Continuous opioid infusions 

Weaning schedules for patients on opioids and 

other sedatives 

Intensive care unit patients 

Trauma patients with multiple injuries 

Burn patients 

Hematology/oncology/rheumatology, 

abdominal pain, miscellaneous 

physician-directed pain services. 7 Nurse-directed services had a 

physician advisor. Physician certification in pain management was 

not commonly found among the pediatric APSs. 

Anesthesiologists have a specialized and specific knowledge of 

neurophysiology, pharmacology, anatomy, and pathophysiology, 

and perform many of the techniques used for postoperative care 

in the operating room; they plan intraoperative analgesia regimens 

with an eye towards optimizing postoperative analgesia. Anesthe - 

siolo gists are also excellent liaisons between surgery, nursing, 

pharmacy, and families. However, in many institutions, physicians 

from other specialties (e.g., rheumatology, pediatrics) that have a 

particular interest in pain management function as the APS 

director. 

PERSONNEL 

Each institutions will need to determine an approach that is most 

practical and beneficial given its resources. Certain elements 

should always be present. 

Physicians 

There should be at least one physician with an interest in acute 

pain management involved in the APS. This person may be an 

anesthesiologist, pediatrician, or other pediatric subspecialist 

with an interest in pain management. Additional physicians 

are usually needed to assist with communication, development, 

and institution of policies and procedures, education of nurses, 

physicians, and other health care providers, and day-to-day patient 

management. 

Nurses 

TABLE 130-2. Goals of the APS 

Optimize pain management 

Choose the most appropriate pain assessment tools 

Maximize multimodal approach to pain management 

Minimize and treat side effects of medications 

Develop safe and effective protocols and guidelines 

Educate health care providers, patients, and families 

Monitor outcomes and develop quality improvement programs 

Communicate with surgeons, pediatricians, and other members 

of health care team 

Nurses may serve as the backbone of the service, helping to ensure 

appropriate and timely follow-up of procedures, policies, and 

physician orders. They are often the primary resource for educating 

floor nurses and other health care providers and communicating 

with team members. 

Physician’s Assistants and 

Advanced Practice Nurses 

Physician’s assistants or advance practice nurses can assist with 

more efficient functioning of an APS. As the demand on physicians 

increases, the physician’s assistant or advanced practice nurse 

can help with much of the daily management of these patients with 

input from the APS physicians. 

PAIN ASSESSMENT 

Pain is a subjective experience, and neonates, infants, and young 

children do not have the ability or vocabulary to describe their 

pain. Older children with developmental delays have similar 

limitations. In the past this has lead to under treatment and 

confusion. There are now many measurement instruments available 

that have extensively studied and validated in children of 

different ages, developmental abilities, and cultures. However, the 

sheer number of scales can add to the confusion of comparing the 

efficacy of treatment modalities. The APS’s first task is to determine 

which scales or evaluation tools work best within their 

institution and to work with nursing to ensure timely and accurate 

use of these scales. Appendix 1 provides some examples of commonly 

used assessment tools. 

MODALITIES 

Pharmacodynamics and pharmacokinetics of medication vary 

with age and development. Hepatic enzyme systems and renal 

clearance are not mature in neonates, and may lead to the 

accumulation of drugs or their metabolites. Children from 2 to 

6 years of age have more-rapid drug clearance that can require 

more frequent dosing. There are differences in body composition 

that change with age. 8 Neonates have greater total body water 

content than older children and adults, a higher percentage of 

highly perfused tissue (e.g., brain, heart), and decreased plasma 

binding proteins such as albumin and alpha-1 acid glycoprotein. 

These variations can make neonates more susceptible to toxicity 

and adverse side effects. (See Chapters 17 and 18) 

Nonopioid Analgesics 

The nonopioid analgesics are a heterogeneous group of drugs 

that exert their effect by inhibiting peripheral prostaglandin 

production. The majority of these medications are administered

2134 PART 6 ■ Specific Considerations 

orally, although rectal and parenteral preparation of some are 

available. 8 

Acetaminophen (paracetamol) is the most commonly used 

mild analgesic in children. It has a well-established safety profile 

and can be used by itself for mild pain 9 or as an adjuvant for 

moderate to severe pain. It has few contraindications and few drug 

interactions. It is not an anti-inflammatory drug and so lacks the 

adverse events associated the nonsteroidal anti-inflammatory 

drugs (NSAIDs). The primary mechanism of action is on centrally 

mediated cyclooxygenases and has weak peripheral effects. 10 An 

overdose of acetaminophen can result in hepatic injury or failure. 

Acetaminophen is available as both an oral and rectal preparation. 

An intravenous form of the pro-drug propacetamol has been 

available in Europe for many years. It has the advantages of a more 

rapid onset, opioid sparing, and minimal side effects; however, 

it causes burning at the site of injection in a large number of 

patients. Recently, an intravenous form of acetaminophen has 

been developed that has decreased side effects and appears to be 

as effective as propacetamol. 11,12 In a multi-institutional study, 

intravenous infusions of acetaminophen reduced the morphine 

requirements after major orthopedic surgery by one third. 13 

NSAIDs are cyclooxygenase (COX) inhibitors. There are 

several isoforms of the COX enzymes. COX-1 is constitutive and 

is present and protective in the gastrointestinal (GI) mucosa, the 

brain, the kidneys, and on platelets. Inhibition of COX-1 subtypes 

by NSAIDs can therefore result in gastric irritation, decreased 

renal blood flow, and inhibition of platelet adhesion. COX-2 

enzymes are inducible and primarily expressed after an inflammatory 

insult. They are found in great concentration in the brain 

and spinal cord. Arachidonic acid, which is metabolized by COX 

enzymes to prostaglandin-G2, is the primary precursor to the 

various prostanoids, which are responsible for pain and inflammation 

and also appear to play a role in central sensitization. 

Although most available NSAIDs for use in children are COX-1 

inhibitors, COX-2 (coxib) drugs, which are more selective and act 

peripherally and centrally to modulate inflammation and pain, are 

also available in oral dosage forms suitable for larger children and 

in intravenous form (ketorolac). They exhibit a lower incidence 

of GI bleeding and renal insufficiency. Doses for commonly used 

nonopioid medications are listed in Table 130–3. 

Ketorolac is the only currently available intravenous NSAID in 

the United States (intravenous diclofenac is available in the United 

TABLE 130-3. Dosage Guidelines for Commonly 

Used Nonopioid Drugs 

Drug Dose and Route Maximum Dose 

Acetaminophen 

Aspirin* 

Ibuprofen 

Naproxen 

Ketorolac 

Celecoxib 

Indomethacin 

10–15 mg/kg q3–4h p.o 

40 mg/kg loading rectal 

dose followed by 

20 mg/kg q6h 

15 mg/kg I.V. up to 

1 gm/dose q6h 

10–15 mg/kg q3–4h p.o 

10 mg/kg q6–8h p.o 

5 mg/kg b.i.d p.o 

0.5 mg /kg q6h mg 

2–4 mg/kg b.i.d. 

0.3–1 mg/kg q6h 

p.o. = per os; q = every; b.i.d = twice a day. 

*rarely used in pediatrics 

100 mg/kg/day 

4000 mg in adults 

4000 mg 

2400 mg 

1500 mg 

30 mg 

150 mg 

TABLE 130-4. Common Side Effects of Nonopioid 

Analgesics 

Drug 

Acetaminophen 

Aspirin* 

COX-1 inhibitors 

Ibuprofen 

Naproxen 

Ketorolac** 

Indomethacin 

COX-2 inhibitor 

Celecoxib 

Kingdom and Europe). It is reported to have potency similar to 

that of 0.1 mg/kg of morphine. Ketorolac has been shown to 

decrease renal blood flow and inhibit renal prostaglandins. It has 

caused acute, although usually reversible, renal failure in both 

pediatric and adult patients. 14,15 As a result of these and other case 

reports and of animal data, it is probably prudent to limit the use 

of ketorolac to 48 to 72 hours. If needed for longer courses of 

therapy, renal function should be monitored. Ketorolac seems 

to have a greater impact on intraoperative and postoperative 

bleeding compared to other NSAIDs, particularly in tonsillectomy 

patients. 16 Ketorolac has been shown to be a superior treatment 

for bladder spasms as compared to opioids. 17 Common side effects 

for the nonopioid analgesics are listed in Table 130–4. 

Opioids 

Side Effects 

No anti-inflammatory effect 

Overdose results in hepatic toxicity 

Antiplatelet effects 

Associated with Reye syndrome in children 

Gastrointestinal irritability 

CNS—confusion, dizziness, headache 

Cardiac—premature closure of patent 

ductus arteriosus, increased risk of 

myocardial infarction in adults 

Pulmonary—bronchospasm, RAD 

Gasrotintestinal—nausea and vomiting, 

dyspepsia, diarrhea, gastric ulcers, 

bleeding, irritable bowel syndrome 

Renal—salt and water retention, interstitial 

nephritis, ATN, nephritic syndrome, 

HTN, decreased renal filtration, renal 

failure, hypokalmia 

Increased myocardial infarction in adults 

All of the above can occur 

COX = cyclooxygenase; RAD = reactive airway disease; ATN = acute tubular 

necrosis; HTN = hypertension. Adapted from Anderson CTM, Polaner DM. 

Pediatric pain management. In: Holtzman RS, Mancuso TJ, Polaner DM, editors. 

A Practical Approach to Pediatric Anesthesia. Philadelphia, PA: Wolters 

Kluwer/Lippincott William & Wilkins; 2010, p. 152–169. 

*Rarely used in children. 

**Limit use to 72 hours. 

Opioids provide stronger pain relief than nonopioid analgesics, 

but also may have more significant side effects. There are several 

opioid receptors and subtypes, primarily the mu (µ) (named 

because it is morphine-like), kappa (κ) and delta (δ) receptors. 

These receptors are found primarily in the brain and spinal cord, 

although some exist in the peripheral nerve cells and other sites. 

Commonly used medications may be agonists or partial agonists 

at the opioid receptors. Antagonist of these receptors will reverse 

all or some of the effects in a dose dependant manner. Morphine 

is the “gold standard” for opioids, and potency of the other opioids 

is commonly expressed in morphine equivalents in order to enable


TABLE 130-5. Common Side Effects of Opioids 

Respiratory depression 

Nausea and vomiting 

Pruritus 

Sedation, dysphoria, hallucinations 

Constipation 

Urinary retention 

Hyperalgesia 

Chest wall rigidity, myoclonus, bronchoconstriction 

comparisons between drugs. Opioids all have common side 

effects, although the severity and incidence may differ with the 

different types of drugs and from person to person. Common side 

effects are listed in Table 130–5. 

All opioids have to reach their target site by either direct action 

(epidural or intrathecal) or via the blood stream. In order for drugs 

to reach the CNS, they need to cross the blood–brain barrier. The 

blood–brain barrier may be more immature in neonates and young 

infants. The cytochrome P450 systems in the liver are required to 

metabolize many of the commonly used opioids prior to excretion. 

The liver and P450 system do not reach mature levels until 3 to 

6 months of age. The clearance of morphine is 3 to 5 times slower 

in infants younger than 6 months of age. This difference can lead 

to accumulation and increase in side effects. Children younger 

than 6 months of age should be closely monitored when they are 

started on opioids. Opioids can be administered by a variety of 

routes, including orally, intravenously, transdermally, subcutaneously, 

intramuscularly, transbuccally, and intranasally. The most 

commonly used routes in the APS patient are oral, intravenous, 

and occasionally transdermal. The intramuscular and subcutaneous 

routes are rarely used in children. 

Oral Opioids 

Oral opioids have traditionally been considered “weaker” analgesics, 

but the development of new more potent agents challenges 

that concept. Since many drugs are available in multiple formulations 

(with/without acetaminophen, immediate action/sustained 

release) and have limited data in children, careful consideration 

of the risks and benefits of each must be taken. Commonly used 

oral opioids in children include hydrocodone and oxycodone. 

Other opioids that are available in an oral form include morphine, 

hydromorphone, methadone, tramadol, and transbuccal fentanyl. 

Morphine is available in several oral forms. The immediate 

onset form, available in both tablet and elixir preparations, has an 

effective duration of action of 3 to 4 hours and due to bioavailability 

issues is usually dosed at about three times the intravenous 

dose. Sustained release preparations are also available, with a 

duration of action of about 8 to 12 hours. Available dosage preparations 

limit the use of this form to children over about 20 kg. 

The sustained release preparation has less utility in the management 

of acute postoperative pain, but can be utilized for children 

whose operations, such as Nuss bar insertions for pectus excavatum, 

produce pain of longer duration. Like sustained release 

oxycodone (discussed below) this drug requires less time and 

difficulty to titrate to steady state than methadone. 

Codeine is a traditionally prescribed oral opioid, but is actually 

a pro-drug that has to be metabolized to morphine in the liver. 

Ten percent to 15% of people are unable to effectively demethylate 

codeine to its active form and will therefore experience limited or 

no analgesia. 18 A small percentage of patients are extensive 

demethylators and convert a much higher amount to the active 

form, thereby risking toxicity. Because of these problems, codeine’s 

use is discouraged. 

Unlike codeine, hydrocodone and oxycodone seem to have a 

lower incidence of nausea and vomiting and do not require 

metabolism to have their effect. They are available in both an elixir 

or tablet form, often in a fixed combination with acetaminophen. 

It is always prudent with fixed combinations to calculate the 

amount of acetaminophen being administered, particularly when 

doses need to be escalated, to avoid acetaminophen toxicity. 

Oxycodone is also available as a sustained release formulation that 

is especially useful for pain of prolonged duration. 19,20 It has a 

relatively rapid onset, little peak effect, and duration of action of 

about 12 hours. Because it is not made in a pediatric-specific 

preparation, its use is generally limited to children weighing more 

than 30 to 40 kg and may be given in combination with its short 

acting form to provide both basal analgesia and rescue doses for 

episodes of acute increased pain. 

Meperidine (pethidine) should not be used for repeated dosing 

in children because the risk of neurologic side effects from its 

metabolite normeperidine. Other useful oral opioids are described 

in Table 130–6. 

Parenteral Opioids 

Parenteral opioids are used when the patient is unable to take oral 

medications. Although the oral route can be equally effective even 

after major surgeries, the rapidity of analgesic onset via the 

parenteral route may make it preferable in some circumstances, and 

patient-controlled analgesia techniques (PCA) may permit improved 

titration of drug to need. The APS may spend a significant 

portion of their time assessing, caring for, and managing these 

patients. Several modes of administration are common in pediatric 

patients. These include intermittent I.V. doses, continuous infusions, 

and patient controlled analgesia. The advantages and 

disadvantages of each technique are listed in Table 130–7. Although 

continuous infusions are commonly used in the intensive care unit 

and intermittent dosing may be used to treat intermittent pain, PCA 

is most commonly employed by the APS for a variety of patients. 

PCA has become a routine and popular technique for providing 

analgesia with a minimum of side effects. 21 Most developmentally 

normal children older than 5 years of age who do not 

have any physical limitations that prevent them from operating 

the device can successfully operate PCA. A microprocessorcontrolled 

pump allows the physician to set dose and frequency at 

which a dose of the drug is delivered. A background infusion can 

be used with the demand dose to maintain an even blood level. 

A larger bolus dose is usually provided for the nurse to administer 

prior to potentially more painful procedures (getting up to walk 

for the first time, physical therapy) or for rescue from inadequate 

analgesia. Although studies in adults indicate the use of background 

infusions to be unnecessary and to increase side effects, 

the data in children are conflicting. Early studies by Doyle and 

colleagues indicate that a background infusion is associated with 

better sleep in the first 24 hours after lower abdominal surgery, 

while this could not be confirmed by Kelly et al. 22,23 

PCA by proxy is designed to allow younger, sicker, and developmentally 

or physically impaired patients to benefit from PCA 

technology. A family member or nurse is designated as the proxy


TABLE 130-6. Commonly Used Oral Opioids in Children 

Approximate Potency 

Drug Dose Relative to I.V. Morphine* Comments 

Morphine 

Codeine 

Hydrocodone 

Oxycodone 

Hydromorphone 

Methadone 

Fentanyl (oral 

transmucosal dose) 

Tramadol 

Oxymorphone 

0.3 mg/kg q3–4h 

0.5–1 mg/kg q4–6h 

0.1 mg/kg q3–4h 

0.1–0.15 mg/kg 

0.04–0.08 mg/kg q4–6h 

0.2 mg/kg q6–12h 

10–15 µg/kg q4h 

1–2 mg/kg q4–6h 

0.03 mg/kg q4–6h 

2–3:1 

12:1 

1–3:1 

1–3:1 

0.8:1 

2:1 (acute) 

100:1 

4:1 

30:1 

Hepatic metabolism, renal excretion 

Pro-drug, must be converted to morphine 

for effect 

Usually founding combination with 

acetaminophen 

With or without acetaminophen 

Sustained release tab is dosed q12h 

Minimal renal excretion, safe for patients 

with renal insufficiency. Long-acting oral 

formulation available for adult chronic 

pain patients 

Long half-life causes accumulation after 

2–3 days requiring longer dosing intervals 

Short half-life, effective for short painful 

procedure or breakthrough pain 

Partial agonist 

Both immediate release and extended 

release available 47 

No studies in children 

q = every. 

and activate the button for additional demand doses of pain 

medication. There have been several fatalities associated with both 

PCA and PCA by proxy in adults, although none have been 

reported in children. The Joint Commission on Accreditation of 

Healthcare Organizations (JCAHO) issued a “Sentinel Alert” 

alerting the medical community to potential dangers of PCA by 

proxy. 24 Two retrospective studies in children, however, 25,26 have 

confirmed that although the PCA by proxy is often used in 

younger patients or patients with greater comorbidities, the 

incidence of adverse events is similar to that of PCA. Krane, in an 

excellent editorial, emphasizes that the key points to making PCA 

by proxy safe in children are: careful patient selection, careful 

monitoring including electronic monitoring, and setting specific 

triggers (pain scores) for activating the button. 27 At the Children’s 

Hospital of Denver, we have added detailed education programs 

for both nurses and family members, stressing the importance of 

never activating the PCA demand dose when the patient is 

sleeping or sedated. 

TABLE 130-7. Advantages and Disadvantages of Parenteral Modes of Opioid Administration 

Advantage 

Disadvantage 

Intermittent administration 

Continuous infusions 

Patient-controlled analgesia 

(PCA) 

PCA by proxy 

Cheap 

Easy to administer 

Works well when pain is intermittent 

Effective in ventilated patients, infants, and small 

children 

Drugs can be titrated and boluses for 

breakthrough can be prescribed 

On-demand, individualized small doses at 

intervals determined by patient 

Lockout prevents dosing before peak effect of 

previous dose 

Oversedation minimizes patients ability to 

demand too many doses 

With appropriate training, patient selection and 

protocols, parent or nurse can provide superior 

analgesia to scheduled intermittent dosing 25 

Safe and effective when done correctly 

Peak and valley blood levels 

Increased incidence of side effects 

Inadequate periods of analgesia when 

pain is continuous 

Requires a nurse to administer, leading 

to delays in analgesia 

Requires careful monitoring for side 

effects 

Under- or overtreatment may be difficult 

to avoid 

Costly equipment required 

Pump malfunction rare but possible 

Easier to divert or overuse medications 

since nursing intervention not required 

with each dose 

Requires education and follow-up 

May still have higher incidence of 

respiratory events 26

TABLE 130-8. Commonly Used Doses of Parenteral Opioids 


Intermittent Bolus Continuous Patient-Controlled 

Drug or Loading Dose Infusion Analgesia Dosing 

Morphine 

Fentanyl 

Hydromorphone 

Methadone 

50–100 µg/kg q2–4h 

0.5–2 µg/kg q1–2h 

15 ug/kg 

0.1 mg/kg q6–12h 

10–40 µg/kg/h 

0.5–2 µg/kg/h 

2–6 ug/kg/h 

N/A 

Demand dose: 10–20 µg/kg 

Infusion: 0–20 µg/kg 

Bolus: 50–100 µg/kg q2–4 hrs 

Lockout: 6–10 mins 

Demand dose: 0.1–0.2 µg/kg 

Infusion: 0.1–0.2 µg/kg/h 

Bolus: 0.5–1 µg/kg q1–2h 

Lockout: 6–8 min 

Demand dose: 1.5–3 µg/kg 

Infusion: 1.5–3µg/kg/h 

Bolus: µg/kg q1–2h 

Lockout: 6–8 min 

N/A 

Regional Analgesia 

Regional analgesia in children has become increasingly popular. It 

is safe, adaptable and effective. For many APSs, the majority of 

their time will be spent assessing, monitoring, and troubleshooting 

patients with regional anesthesia. 

The majority of regional blocks are placed under deep sedation 

or general anesthesia, so it is of utmost importance for the APS to 

determine the efficacy of the block as soon as possible. The need 

for additional medication and potential complications should be 

considered. The APS will usually check dermatomes (in the case 

of an epidural) or sensation in the affected region, check for motor 

function, and assess the child for pain. The availability of multiple 

combinations of local anesthetics, opioids, and adjuvant agents 

for epidural use can allow the establishment of different physiologic 

effects. One must counterbalance the benefit of less 

motor blockade with higher-concentration local anesthetics 

against the potential disadvantage of breakthrough pain with low 

TABLE 130-9. Advantages and Disadvantages of 

Regional Analgesia 

Advantages 

Decreased stress response 

Improved analgesia 

Improved gastrointestinal 

function 

Earlier return to oral 

intake 

Less sedation 

Attenuation of phantom 

limb sensations and pain 

May decrease blood loss 

in vascular surgery cases 

Can decrease the incidence 

of thromboembolic 

phenomenon in high 

risk patients 

Disadvantages 

Takes time and skill to place 

Infection or bleeding at site 

Partial or patchy analgesia 

Leaking or bleeding catheters 

Motor block 

Nausea and vomiting, pruritus, 

urinary retention and respiratory 

depression may still occur 

with the use of epidural opioids 

Rare nerve injury 

concentration agents. Similarly, a multimodal approach adding 

central neuraxial opioids may enhance analgesia but at the 

potential risk of increasing nausea, pruritus, and respiratory 

depression, and alpha agonists may prolong analgesia but also may 

produce more sedation. 28 

Ambulatory Nerve Blocks 

Continuous peripheral nerve blocks (CPNBs) have been shown 

to treat pain more effectively than systemic analgesics and may 

cause fewer side effects than epidural analgesic techniques. 29 

Single-shot peripheral nerve blocks have been commonly used in 

both pediatric and adult practices; however, the advent of 

ultrasound has made placing these blocks easier, safer, and more 

effective. 30,31 Dadure et al. found CPNBs using elastomeric pumps 

to be safe and easy to place in a small sample of children. 32 Two 

hundred twenty-six CPNB catheters were placed in children aged 

4 to 18 years, 112 of whom were discharged home. 33 They received 

2 to 12 mL of dilute solutions of either bupivacaine or ropivacaine; 

side effects occurred in 2.8% of patients and were minor. The 

authors credit their success to strict protocols that were developed, 

frequent follow-up with patients by the APS, and education of all 

the families and nurses in the postanesthesia care unit and on the 

surgical floors. The education focused on the infusion pumps, 

monitoring, and clinical recognition of potential complications 

TABLE 130-10. Epidural Dosing—Continuous Infusions— 

Guidelines 

Agents Concentration Infusion 

Bupivacaine 0.075%–0.125% 0.15–0.4 mL/kg/h 

Ropivacaine 0.075 % 0.2% 0.15–0.4 mL/kg/h 

Fentanyl 2–5 µg /mL 0.5–1 µg/kg/h 

Morphine (PF) 10 µg /mL 2–10 µg/kg/h 

Hydromorphone 3–5 µg/mL 0.3–2 µg/kg/h 

Clonidine 0.5–1 µg/mL 1–4 µg/kg/h 

The maximum infusion rates should not exceed 0.5 mg/kg/h of bupivacaine or 

ropivacaine in children and 0.25 mg/kg/h in neonates. When different concentrations 

of local anesthetic solutions are used, the mg/kg/h and mL/kg/h 

maximum dose should be recalculated.


related to both the perineural catheters and the local anesthetic. 

Follow-up included frequent phone calls assessing pain, need for 

opioids, sedation, and potential complications. 

EDUCATION OF FLOOR 

NURSES AND PARENTS 

Survey and studies reveal that pain is still sometimes inconsistently 

and inadequately treated. 34,35 Staff in-services and informational 

hand-outs can improve assessment and treatment. Interestingly, 

a recent survey showed that pediatric nurses’ attitudes and knowledge 

about pain were related not only to their degree of experience 

but also their involvement in professional nursing societies 

and nursing committees. 36 Ellis et al. showed that comprehensive 

programs could improve pain management in children, and of 

particular importance was the presence and support of the APS 

nurse(s) and team. 37 

Educating parents is as important as educating nurses. Parents 

frequently receive fragmented and unclear information regarding 

their children’s postoperative pain management techniques. 38 In a 

survey by Tait and Voepel-Lewis, one third of parents had no idea 

of the risks of their child’s postoperative pain management. 

SURGEONS AND PLANNING FOR 

POSTOPERATIVE ANALGESIA 

It is important to communicate with the surgeon when deciding 

on the modality for postoperative analgesia. One must know the 

nature of the operation, the planned duration of the hospital stay, 

and any special requirements that the surgeon may have in mind 

for postoperative care and management. Since many operations 

will have a somewhat regimented postoperative care plan, it is 

TABLE 130-11. Troubleshooting Common Epidural 

Problems 

Problem 

Inadequate pain 

relief 

Persistent motor 

block 

Pruritus and/or 

vomiting 

Diagnosis and Treatment 

Confirm position and patency of catheter 

Assess dermatomes if possible 

Consider bolus (calculate toxic dose) 

Change concentration or composition of 

epidural solution 

Small additional doses of opioids or other 

analgesics are commonly required in 

young children to improve overall 

“comfort” 

Epidurogram can help diagnose catheter 

problems 

Stop infusion for 1 hour and resume at 

lower concentration 

If no improvement after several hours 

consider magnetic resonance imaging 

to rule out epidural hematoma 

Nalbuphine 0.05 mg/kg q4h 

Naloxone infusion 0.25–0.5 ug/kg/h 48 

Decrease infusion if patient has good pain 

control 

Ondansetron 

both efficient and practical to develop analgesic care plans to 

complement the operation and the surgeon’s preferences. By 

working with the surgeon, a cooperative plan for postoperative 

analgesia that incorporates the expertise of the anesthesiologist 

can be decided upon in advance and implemented as a routine for 

a given procedure. Standardization of these care plans (with the 

obvious ability to make alterations based on the clinical circumstance) 

will help ensure consistency of care and avoid errors. 

Criteria that are particularly important to consider include: 

● 

● 

● 

● 

What is the duration of the patient’s stay after surgery? Will the 

patient be admitted overnight, for several days, or be discharged 

home from the PACU? If a same day procedure is planned, for 

example, the use of central neuraxial opioids is contraindicated. 

Neural blockade with a long acting local anesthetic may work 

well in that situation, and ambulatory continuous regional 

blockade is becoming more commonly used for procedures of 

the extremities. 

What is the expected duration of pain? For procedures that are 

expected to have prolonged analgesic needs during recover, the 

use of long acting oral opioids such as sustained release preparations 

may be considered and instituted early. 

Are there specific needs for postoperative assessment? The surgeon 

operating near a neural plexus may have concerns about 

motor and sensory function that might preclude the use of regional 

analgesia, or may wish for the patient to ambulate early, 

mandating very low concentrations of local anesthetics to avoid 

motor blockade. 

Will the patient be able to take oral medications immediately, or 

will regional or parental drugs be required? 

EXPECTANT/EMERGENT 

MANAGEMENT OF COMPLICATIONS 

There are certain untoward side effects that can be anticipated for 

the various analgesic modalities. Understanding the nature and 

incidence of these effects can help the physician chose the most 

appropriate analgesic technique for a given patient and situation. 

Furthermore, anticipating some of these problems can permit the 

APS to develop protocols to mitigate their manifestations and 

increase the efficiency of how they are managed. 39 Two recent large 

prospective audits from the United Kingdom, one on epidural 

anesthesia and a second on opioids, have demonstrated the great 

degree of safety that these modalities enjoy in children, but also 

point out the nature of risk and complications. 40 

Regional Analgesia and Local Anesthetics 

Excessive motor block is the most common untoward effect of 

regional analgesia. The primary risk is weakness of an extremity 

and injury to an unprotected limb. Lack of movement can produce 

a pressure injury. Skin necrosis or pressure sores can develop, or 

pressure on a peripheral nerve, especially if located adjacent to a 

boney prominence, can result in sensory or motor neuropathy. 

Careful monitoring of motor function and padding and positioning 

of an affected limb can prevent such potentially serious 

complications should motor weakness be detected. The local 

anesthetic concentration must be reduced or the infusion stopped 

until the motor block resolves. Assessment with the Bromage 

Score (Table 12) should be performed at regular intervals when 

the nurse measures the vital signs. New onset of dense motor block


TABLE 130-12. Modified Bromage Score for Assessing 

Motor Blockade 

Score: 0 1 2 

Motor 

response 

in a patient with an epidural infusion may be a sign that the 

catheter has eroded through the dura into the subarachnoid space. 

Local anesthetic toxicity can be prevented by careful attention 

to drug dosing. Maximal infusion rates for bupivacaine should not 

exceed 0.5 mg/kg/h. Although there is an increased margin of 

safety with levoenantiamer amides such as ropivacaine or 

levobupivacaine, the authors recommend using similar limits for 

those drugs. Infants younger than 6 months of age are especially 

at risk of local anesthetic accumulation and toxicity due to their 

decreased levels of alpha-1 acid glycoprotein; their maximal 

infusion rate should be reduced by about 25% and a levoenantiamer 

should be used instead of racemic bupivacaine. Alternatively, 

2,3 chloroprocaine, an ester local anesthetic with little risk 

of accumulation, may be used instead of an amide. 41,42 

Early signs of local anesthetic toxicity include restlessness and 

somnolence. CNS irritability may herald the onset of seizures, 

which can rapidly be followed by cardiovascular collapse. Treatment, 

in addition to stopping the infusion and the institution of 

supportive measures, is immediate infusion of 1 mL/kg of 20% 

intravenous lipid emulsion, with additional 1 mL/kg doses (up to 

3 mL/kg) until the child is stabilized. 43–45 

Inadequate analgesia demands investigation. This is especially 

so if the block appeared to be working previously. Possible 

explanations include dislodgement of the catheter, misplacement 

of the catheter, inadequate infusion volume, inappropriate catheter 

placement for the analgesic need, and inappropriate choice of 

drug. Anatomic variations may also produce inadequate analgesia, 

for example, unilateral epidural blockade due to septation of the 

epidural space. It is never appropriate to simply increase the 

infusion rate unless it can be clearly demonstrated that the catheter 

is in the correct location. Injection of a small volume of nonionic 

contrast into the catheter can visually confirm its location. 

Catheter dislodgement should be suspected when a previously 

effective regional block suddenly is ineffective. These small 

catheters are often difficult to secure. The authors suggest the use 

of a clear adhesive dressing in conjunction with an adhesive agent 

such as Mastisol or tincture of benzoin. The catheter should be 

looped under the dressing to provide a strain relief so that if it is 

pulled on it will tend to shorten the loop rather than directly pull 

on and dislodge the catheter from its insertion site. We also 

recommend that the site of entry always be visible. This permits 

inspection of the position of the catheter (they commonly have 

centimeter markings) and of the skin for signs of infection. The 

vast majority of infections probably originate at the insertion site, 

and signs of local infection are grounds for catheter removal. 46 

Opioids 

No evidence of 

motor block, 

able to lift 

extremity to 

gravity 

Able to move 

extremity, but 

cannot sustain 

lift against 

gravity 

Unable to 

move 

extremity 

These drugs can produce several undesirable effects that can be 

troubling even when mild. Either small doses of nalbuphine, a 

mixed agonist–antagonist (0.05 mg/kg/dose q4h), or low-rate 

infusions of naloxone (0.25–1 µg/kg/h) have been shown to be 

effective in combating the various side effects of both central 

neuraxis and systemic opioids. Except for the histamine-induced 

pruritus caused by systemically-administered morphine, we 

usually prefer to use an opioid antagonist as our initial therapy for 

opioid side effects. 

Respiratory depression occurs to some degree with all opioids. 

Close monitoring of mental status, respiratory rate, and respiratory 

depth is mandatory when parenteral or central neuraxial 

opioids are administered. Pulse oximetry, while useful and 

encouraged, is not a panacea because desaturation is a relatively 

late sign. Impedence respirometry, the technology employed by 

most cardiorespiratory monitoring devices, measures chest wall 

excursion, not actual aeration, and may register an adequate 

respiratory rate when a child’s airway is partially obstructed and 

alveolar ventilation is impaired. Thus, close and frequent nursing 

observation is mandatory for these patients and cannot be 

supplanted by electronic devices. 

With central neuraxial administration, respiratory depression 

is more common with the hydrophilic compared with lipophilic 

opioids. Since the lipophilic drugs cross cell membranes more 

readily and bind to receptors in the substantia gelatinosa of the 

spinal cord, rostral spread is less likely with fentanyl than with 

morphine or hydromorphone, but still may occur, especially with 

higher doses or in susceptible patients. Delayed respiratory 

depression is especially a risk with intrathecal (and even epidural) 

morphine, and may not present until 10 to 16 hours after the initial 

administration of the drug. 

Nausea and vomiting can be produced by any opioid via any 

route. It can be treated with the usual antiemetic therapies such as 

5-HT3 antagonists (ondansetron), or by more directed approaches 

using opioid antagonists described above. 

Pruritus is a common and unpleasant side effect, and except 

in the case of systemically administered morphine, is generally not 

caused by histamine release but rather is thought to be centrally 

mediated via the µ receptor. We generally prefer to treat with an 

opioid antagonist or a mixed agonist–antagonist. Antihistamines 

such as diphenhydramine (0.5 mg/kg) can be used for patients 

on systemic morphine, but their potential for sedation must be 

born in mind in these patients who are already receiving CNS 

depressants. 

QUALITY ASSURANCE 

AND IMPROVEMENT 

In order to improve the performance of APS practices, it is 

important to track both efficacy and complications. These data 

should be reviewed at regular intervals in order to detect trends. 

It is similarly important for the APS to place daily progress notes 

in the patient’s chart in order to communicate management 

decisions and clinical findings to the entire patient care team. 

REFERENCES 

1. Miaskowski C, Crews J, Ready LB, et al. Anesthesia-based pain services 

improve the quality of postoperative pain management. Pain. 1999;80: 

23–29. 

2. Lonnqvist PA, Morton NS. Postoperative analgesia in infants and 

children. Br J Anaesth. 2005;95:59–68. 

3. Marhofer P, Frickey N. Ultrasonographic guidance in pediatric regional 

anesthesia. Part 1: theoretical background. Paediatr Anaesth. 2006;16: 

1008–1018.


4. Mariano ER, Ilfeld BM, Cheng GS, et al. Feasibility of ultrasound-guided 

peripheral nerve block catheters for pain control on pediatric medical 

missions in developing countries. Paediatr Anaesth. 2008;18:598–601. 

5. Marhofer P. Vertical infraclavicular brachial plexus block in children: a 

preliminary study. Paediatr Anaesth. 2005;15:530–531; author reply 531. 

6. Yaster M, Kost-Byerly S, Berde C, Billet C. The management of opioid 

and benzodiazepine dependence in infants, children, and adolescents. 

Pediatrics. 1996;98:135–140. 

7. Finley GA, McGrath PJ, Chambers CT. Bringing Pain Relief to Children: 

Treatment Approaches. Totowa, NJ: Humana Press, 2006. 

8. Berde CB, Sethna NF. Analgesics for the treatment of pain in children. 

N Engl J Med. 2002;347:1094–1103. 

9. Bhatt-Mehta V, Rosen DA. Management of acute pain in children. Clin 

Pharm. 1991;10:667–685. 

10. Remy C, Marret E, Bonnet F. State of the art of paracetamol in acute pain 

therapy. Curr Opin Anaesthesiol. 2006;19:562–565. 

11. Moller PL, Juhl GI, Payen-Champenois C, Skoglund LA. Intravenous 

acetaminophen (paracetamol). comparable analgesic efficacy, but better 

local safety than its prodrug, propacetamol, for postoperative pain after 

third molar surgery. Anesth Analg. 2005;101:90–96. 

12. Hernandez-Palazon J, Tortosa JA, Martinez-Lage JF, Perez-Flores D. 

Intravenous administration of propacetamol reduces morphine consumption 

after spinal fusion surgery. Anesth Analg. 2001;92:1473–1476. 

13. Sinatra RS, Jahr JS, Reynolds LW, et al. Efficacy and safety of single and 

repeated administration of 1 gram intravenous acetaminophen injection 

(paracetamol) for pain management after major orthopedic surgery. 

Anesthesiology. 2005;102:822–831. 

14. Buck ML, Norwood VF. Ketorolac-induced acute renal failure in a 

previously healthy adolescent. Pediatrics. 1996;98:294–296. 

15. Witting MD. Renal papillary necrosis following emergency department 

treatment of migraine. J Emerg Med. 1996;14:373–376. 

16. Gunter JB, Varughese AM, Harrington JF, et al. Recovery and complications 

after tonsillectomy in children: a comparison of ketorolac and 

morphine. Anesth Analg. 1995;81:1136–1141. 

17. Park JM, Houck CS, Sethna NF, et al. Ketorolac suppresses postoperative 

bladder spasms after pediatric ureteral reimplantation. Anesth Analg. 

2000;91:11–15. 

18. Fagerlund TH, Braaten O. No pain relief from codeine...? An introduction 

to pharmacogenomics. Acta Anaesthesiol Scand. 2001;45:140–149. 

19. Czarnecki ML, Jandrisevits MD, Theiler SC, et al. Controlled-release 

oxycodone for the management of pediatric postoperative pain. J Pain 

Symptom Manage. 2004;27:379–386. 

20. Blumenthal S, Min K, Marquardt M, Borgeat A. Postoperative intravenous 

morphine consumption, pain scores, and side effects with perioperative 

oral controlled-release oxycodone after lumbar discectomy. Anesth Analg. 

2007;105:233–237. 

21. McDonald AJ, Cooper MG. Patient-controlled analgesia. an appropriate 

method of pain control in children. Paediatr Drugs. 2001;3:273–284. 

22. Kelly JJ, Donath S, Jamsen K, Chalkiadis GA. Postoperative sleep disturbance 

in pediatric patients using patient-controlled devices (PCA). 

Paediatr Anaesth. 2006;16:1051–1056. 

23. Doyle E, Harper I, Morton NS. Patient-controlled analgesia with low dose 

background infusions after lower abdominal surgery in children. Br J 

Anaesth. 1993;71:818–822. 

24. The Joint Commission. Patient controlled analgesia by proxy. Sentinel 

Event Alert. 2004;33:1–2. 

25. Anghelescu DL, Burgoyne LL, Oakes LL, Wallace DA. The safety of 

patient-controlled analgesia by proxy in pediatric oncology patients. 

Anesth Analg. 2005;101:1623–1627. 

26. Voepel-Lewis T, Marinkovic A, Kostrzewa A, et al. The prevalence of and 

risk factors for adverse events in children receiving patient-controlled 

analgesia by proxy or patient-controlled analgesia after surgery. Anesth 

Analg. 2008;107:70–75. 

27. Krane EJ. Patient-controlled analgesia. proxy-controlled analgesia? Anesth 

Analg. 2008;107:15–17. 

28. Ansermino M, Basu R, Vandebeek C, Montgomery C. Nonopioid additives 

to local anaesthetics for caudal blockade in children: a systematic 

review. Paediatr Anaesth. 2003;13:561–573. 

29. Capdevila X, Ponrouch M, Choquet O. Continuous peripheral nerve 

blocks in clinical practice. Curr Opin Anaesthesiol. 2008;21:619–623. 

30. Ganesh A, Kim A, Casale P, Cucchiaro G. Low-dose intrathecal morphine 

for postoperative analgesia in children. Anesth Analg. 2007;104: 

271–276. 

31. Marhofer P, Sitzwohl C, Greher M, Kapral S. Ultrasound guidance for 

infraclavicular brachial plexus anaesthesia in children. Anaesthesia. 

2004;59:642–646. 

32. Dadure C, Pirat P, Raux O, et al. Perioperative continuous peripheral 

nerve blocks with disposable infusion pumps in children. a prospective 

descriptive study. Anesth Analg. 2003;97:687–690. 

33. Ganesh A, Rose JB, Wells L, et al. Continuous peripheral nerve blockade 

for inpatient and outpatient postoperative analgesia in children. Anesth 

Analg. 2007;105:1234–1242, table of contents. 

34. Barnason S, Merboth M, Pozehl B, Tietjen MJ. Utilizing an outcomes 

approach to improve pain management by nurses: a pilot study. Clin Nurse 

Spec. 1998;12:28–36. 

35. Gimbler-Berglund I, Ljusegren G, Enskar K. Factors influencing pain 

management in children. Paediatr Nurs. 2008;20:21–24. 

36. Rieman MT, Gordon M. Pain management competency evidenced by a 

survey of pediatric nurses’ knowledge and attitudes. Pediatr Nurs. 2007; 

33:307–312. 

37. Ellis JA, McCleary L, Blouin R, et al. Implementing best practice 

pain management in a pediatric hospital. J Spec Pediatr Nurs. 2007;12: 

264–277. 

38. Tait AR, Voepel-Lewis T, Snyder RM, Malviya S. Parents’ understanding 

of information regarding their child’s postoperative pain management. 

Clin J Pain. 2008;24:572–577. 

39. Ellis JA, Martelli B, LaMontagne C, Splinter W. Evaluation of a continuous 

epidural analgesia program for postoperative pain in children. Pain 

Manage Nurs. 2007;8:146–155. 

40. Llewellyn N, Moriarty A. The national pediatric epidural audit. Paediatr 

Anaesth. 2007;17:520–533. 

41. Berde C. Local anesthetics in infants and children: an update. Paediatr 

Anaesth. 2004;14:387–393. 

42. Gunter JB. Benefit and risks of local anesthetics in infants and children. 

Paediatr Drugs. 2002;4:649–672. 

43. Ludot H, Tharin JY, Belouadah M, et al. Successful resuscitation after 

ropivacaine and lidocaine-induced ventricular arrhythmia following 

posterior lumbar plexus block in a child. Anesth Analg. 2008;106:1572– 

1574, table of contents. 

44. Rosenblatt M, Able M, Fischer G, et al. Successful use of a 20% lipid 

emulsion to resuscitate a patient after a presumed bupivacaine-induced 

cardiac arrest. Anesthesiology. 2006;105:217–218. 

45. Weinberg G, Ripper R, Feinstein DL, Hoffman W. Lipid emulsion 

infusion rescues dogs from bupivacaine-induced cardiac toxicity. Reg 

Anesth Pain Med. 2003;28:198–202. 

46. Strafford MA, Wilder RT, Berde CB. The risk of infection from epidural 

analgesia in children: a review of 1620 cases. Anesth Analg. 1995;80: 

234–238. 

47. Gimbel JS. Oxymorphone. a mature molecule with new life. Drugs Today 

(Barc). 2008;44:767–782. 

48. Maxwell LG, Kaufmann SC, Bitzer S, et al. The effects of a small-dose 

naloxone infusion on opioid-induced side effects and analgesia in 

children and adolescents treated with intravenous patient-controlled 

analgesia: a double-blind, prospective, randomized, controlled study. 

Anesth Analg. 2005;100:953–958. 

49. Beyer JE, Denyes MJ, Villarruel AM. The creation, validation, and 

continuing development of the Oucher: a measure of pain intensity in 

children. J Pediatr Nurs. 1992;7:335–346. 

50. Wong DL, Baker CM. Pain in children: comparison of assessment scales. 

Pediatr Nurs. 1988;14:9–17. 

51. Merkel S, Voepel-Lewis T, Malviya S. Pain assessment in infants and 

young children: the FLACC scale. Am J Nurs. 2002;102:55–58. 

52. Bieri D, Reeve RA, Champion GD, et al. The Faces Pain Scale for the selfassessment 

of the severity of pain experienced by children: development, 

initial validation, and preliminary investigation for ratio scale properties. 

Pain. 1990;41:139–150.

Pain Assessment Tools 

1 

APPENDIX 

Poker Chip Tool. Poker Chips represent “pieces of hurt”, the child determines the amount of “hurt” he/she by indicating the number 

of poker chips. 

Word Graphic Rating Scale. 

________________________________________________________________________________________________________ 

No Pain Little Pain Medium Pain Large Pain Worst Possible Pain 

Eland Color Scale. The child uses colors to indicate the areas that 

hurt on a schematic of a child’s body (gender-specific). The child 

is allowed to choose which colors represent mild, moderate, and 

severe pain (or hurt). 

0–10 Scale. As in adults, the child states on a scale of 0–10 what 

level their pain is: 0 = no pain and 10 = worst possible pain. 

Wong Baker Faces Pain Scale. 50 

Oucher Scale. The child is shown photographs of a child with 

different facial expressions ranging from calm and relaxed to 

screaming. The faces are arranged beside a scale and the child 

points to the photograph that represents his degree of pain. 

There are White, African American, and Hispanic Ouchers 

available. 49


Bieri Faces Pain Scale. 52 

FLACC (Facial expression, Legs, Activity, Cry, Consolability) observational pain scale for nonverbal children. This has been validated in 

older children with developmental delays as well as infants. 51 

SCORE 

FACE 

LEGS 

ACTIVITY 

CRY 

CONSOLABILITY 

0=No particular expression or smile 

1=Occasional grimace/frown, withdrawn or disinterested 

2=Frequent/constant quivering chin, clenched jaw 

0=Normal position or relaxed 

1=Uneasy, restless, tense 

2=Kicking, or legs drawn up 

0=Lying quietly, normal position, moves easily 

1=Squirming, shifting back and forth, tense 

2=Arched, rigid or jerking 

0=No cry 

1=Moans or whimpers; occasional complaint 

2=Crying steadily, screams or sobs, frequent complaints 

0=Content and relaxed 

1=Reassured by occasional touching, hugging or being talked to. Distractible 

2=Difficult to console or comfort 

0 

1 

2 

0 

1 

2 

0 

1 

2 

0 

1 

2 

0 

1 

2

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