1. Paediatric Guidelines for the Management of Acute and Post-operative Pain. Paracetamol + NSAID + Strong Opioid 1. PARACETAMOL PLUS 2. NSAID ie Ibuprofen or Diclofenac CONSIDER 3. Patient Controlled Analgesia (PCA) -via dedicated cannula or anti-reflux valve. Add 1mg/kg of morphine and make up to a final volume of 50mls with NACL. 20mcg/kg bolus, (1ml bolus) lockout 5mins. PCA to be prescribed by anaesthetist. OR 3. IV Morphine bolus Add 1ml of 10mg/ml morphine ampoule to 9mls NaCl 0.9%. 0-1month 25microgram/kg 1-3months 50microgram/kg >3months 100microgram/kg Monitor Respiratory rate and SPO 2 for all children receiving IV morphine bolus or PCA. Paracetamol + NSAID +/- Weak Opioid 1. PARACETAMOL PLUS 2. NSAID: Ibuprofen or Diclofenac PLUS CONSIDER 3. Weak Opioid e.g. MORPHINE ORAL Possible alternatives to Oramorph include: DIHYDROCODEINE (from 1y, avoid in adenotonsillectomy or airway surgery) OR >12years CODEINE (Contraindicated in children <18years old with obstructive sleep apnoea undergoing ENT surgery) OR >12y TRAMADOL Simple analgesic PARACETAMOL Oral, rectal or IV Mild Pain 1-3 Moderate Pain 4-6 Severe Pain 7-10 Non- Pharmacological Distraction techniques, play, sucrose. Heat, ice therapy. Family involvement. Patient positioning. Splinting of fractures. Regular assessment of pain should be carried out using appropriate tools i.e. VAS, FACES, F.L.A.C.C. C. Haining, S. Russell 2014

2. Paediatric Dosage Guidelines for the Management of Acute and Post-operative Pain The doses below apply to short-term use in otherwise healthy children. See BNF for cautions. Weak Opioid MORPHINE ORAL 0-1month 80 microgram/kg 4hrly. 1-3 months 100 microgram./kg 4hly 3-6months 150 microgram/kg 4hly 6-12 months 200 microgram/kg 4hly >1year 200-300 microgram/kg 2-4hrly, max per dose 10mg. 100-200 microgram/kg 2-4hly as substitute for oral codeine OR DIHYDROCODEINE Oral 1-4y 0.5 mg/kg (max 30mg) 4hrly >4y 0.5 – 1 mg/kg (max 30mg) 4hly OR >12years CODEINE Oral 1mg/kg (max 60mg) 4hly maximum daily dose 240mg in 24 hrs for maximum 3days (Contraindicated in children <18years old with obstructive sleep apnoea undergoing ENT surgery and in children where breathing may be compromised) OR >12y TRAMADOL Oral or IV 50-100mg 4-6hrly Max daily dose 400mg Strong Opioid Morphine PCA or Morphine IV Bolus (see over) Note: morphine bolus usually single dose, re-prescribe if repeat. Simple analgesic PARACETAMOL Oral or Rectal >3months: 15mg/kg 4hrly, routinely up to max four doses per day. Max 75mg/kg/day (max 4g) Consider loading dose 20mg/kg oral or 30-40mg/kg pr >12y provided >50kg: 1g four times a day (no loading dose) IV CONSULTANT PRESCRIPTION ONLY 10-50kg: 15mg/kg 4-6hrly Max daily dose 60mg/kg i.e. four doses per day. >50kg 1gramme 4-6hrly Max daily dose 4grammes. No loading dose IV. +/- NSAID: ibuprofen or diclofenac IBUPROFEN Oral 1-6months 5mg/kg 6hrly. >6months 5-10mg/kg 6-8hrly maximum daily dose 30mg/kg/day Preferred dose for acute pain 10mg/kg tds DICLOFENAC oral or rectal, >6months 1mg/kg 8hrly maximum 150mg/day C. Haining, S. Russell 2014