Pain Management in Children

by on June 11, 2012

in Uncategorized


Q: I do not want to use painkillers when my 4 month old son gets his immunizations. Are there alternative options?

A: Many years ago it was not standard practice to provide analgesia to infants when they were immunized. As experts learned more and more about pain control and how, in some cases, babies develop a memory for the inflicted pain, the tide shifted.

Oral sucrose solutions are effective analgesic measures. Usually a 2ml solution of 24 % oral sucrose gets administered a few minutes prior to getting a needle (It is a solution which contains 240mg of sugar per milliliter) For many babies it works well.

In the May 2012 edition of Pediatrics, researchers from the Section of Academic Pediatrics at the Children’s Hospital at Norfolk, Virginia, published data where they compared the value of physical nonpharmacological interventions with sucrose

The latter method involved the so-called 5 S’s. (Swaddling, side/stomach position, shushing where a clinician leans close to a baby’s ear and whispers a shushing noise, swinging and sucking)The study involved 230 babies at ages 2 and 4 months respectively. The group where the 5 S’s were used showed decreased pain scores when compared with the sucrose group.

The authors concluded that the 5 S methods appear to be a viable, nonpharmacological option for babies to be used as analgesia during vaccinations.

Dr Moshe Ipp, a Toronto community Pediatrician, was recognized recently in London, Ontario by the Canadian Pediatric Society (CPS) at their Annual Meeting, for his work in the field of pain management associated with vaccinations. His work was published in Pediatrics and Child Health, the official publication of the CPS. The CPS considered Dr Ipp and his colleague’s publication as one that stood out in terms of changing the way doctors practice pediatrics. His research is now incorporated in the Canadian clinical practice guidelines

Pain in very young children is highly complex, subjective and difficult to research.

In research done on babies who were circumcised without analgesia, it appeared that these babies developed a memory for pain later in life. They were more sensitive to the pain associated with getting future needles.

Complicating matters further is the fact not all babies and children experience pain the same way. There are racial and gender differences.

Doctors from the Cincinnati Children’s Hospital investigated the influence of race on postoperative pain perception, opioid (morphine) requirements, and opiate side-effects. They studied pain in patients who underwent a tonsillectomy or adenoid-tonsillectomy.

Two scales to assess pain were used. The first scale, the Numerical Rating Scale (NRS), simply used numbers between 0 and 10 to subjectively describe the severity of the pain. The other method, FLACC, involved looking at the child’s facial expression, leg movements, activity, crying and consolability. The FLACC scale is thought to be more objective.

The authors concluded that Black children had higher postoperative pain and that Caucasian children had higher incidences of opioid-related adverse effects. They are calling for better personalized pain control—meaning more morphine for Black children and awareness that Caucasian children are more prone to have postoperative side-effects from morphine.

The bottom line is that pain management in adults is far advanced compared to children, but that research is moving clinicians who care for children in the right direction.  Much more needs to be done and genetic factors may play a bigger role than previously realized.

For example, a recent study suggested that people with red hair are more sensitive to the same amount of pain compared to others in the population. This study involved only adults, but if you have a red haired child, it is something to keep in mind—even though research has not confirmed that yet.

For more information on the 5S method of soothing a baby, see a  book by Dr Harvey Karp, a Los Angeles pediatrician, titled The Happiest Baby on the Block (Bantam Books, 2003) or visit Dr Karp’s website

Dr. Nieman is a community pediatrician and has cared for kids since 1983. Since 2003, he has written on children’s health ( He is married to a family doctor, a father of four children, a marathon runner and the co-founder of Calgary’s Pediatric Weight Clinic.

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