Chapter 38: Pain and Palliative Care

Pain assessment (FLACC, Faces, NIPS) · WHO analgesic ladder · Opioids (morphine, fentanyl) · Adjuvant drugs · Non‑pharmacological · Palliative care principles · Symptom control (dyspnea, nausea, agitation) · Communication · End‑of‑life · Bereavement
🩺 Core principles: Pain is the 5th vital sign. WHO ladder: step 1 (non‑opioid), step 2 (weak opioid), step 3 (strong opioid). Regular around‑the‑clock dosing. Palliative care: holistic, multidisciplinary, support for child and family. Breakthrough pain: immediate‑release opioids.

📘 Pain & Palliative Care Summary

🩺 Pain assessment tools
Neonates: NIPS, CRIES. Infants: FLACC (Face, Legs, Activity, Cry, Consolability). 3-7 years: Faces Pain Scale, OUCHER. >7 years: Visual Analog Scale (VAS), Numeric Rating Scale.
📈 WHO Analgesic Ladder
Step 1: Non‑opioids (paracetamol, ibuprofen). Step 2: Weak opioids (codeine – caution, tramadol). Step 3: Strong opioids (morphine, fentanyl, oxycodone). Adjuvants for neuropathic pain (gabapentin, amitriptyline).
💊 Opioid principles
Morphine: dose 0.05-0.1 mg/kg IV/PO; titrate. Fentanyl: 0.5-2 μg/kg. Side‑effects: constipation (prophylactic laxatives), nausea, sedation, respiratory depression. Naloxone for reversal.
🧘 Non‑pharmacological
Distraction, relaxation, massage, hypnosis, cognitive behavioral therapy. Essential in pediatric pain management.
🤝 Palliative care principles
Active total care of child and family. Physical, psychological, social, spiritual. Not just end‑of‑life. Advanced care planning, symptom control, coordination.
🫁 Symptom control
Dyspnea: opioids (morphine, fentanyl), oxygen, non‑invasive ventilation. Nausea: ondansetron, metoclopramide. Agitation: benzodiazepines, antipsychotics. Seizures: midazolam.
🗣️ Communication & EOL
Honest, empathetic, age‑appropriate disclosure. Advance care plan. Decision to withdraw life support: multidisciplinary, shared with family. Bereavement support.
📊 Key points: Breakthrough pain: extra dose (10-20% of daily morphine dose). Methadone for neuropathic pain. Palliative care improves quality of life, may prolong survival.

🔍 Approach to pain and palliative care

1
Pain assessment – Use age‑appropriate validated tool (FLACC, Faces, VAS). Ask child if possible. Re‑assess after intervention.
2
WHO ladder stepwise – Start with paracetamol/ibuprofen. Add weak opioid if moderate pain. Switch to strong opioid for severe or progressive pain.
3
Opioid titration – Start low, go slow. Around‑the‑clock with breakthrough doses. Monitor for sedation, respiratory depression.
4
Non‑pharmacological & adjuvants – Distraction, massage. Gabapentin/amitriptyline for neuropathic pain. Laxatives for opioid‑induced constipation.
5
Palliative care domains – Physical, psychological, social, spiritual. Advanced care planning, family meetings. Bereavement follow‑up.

📋 Stepwise management of pain & palliative symptoms

1
Mild pain (step 1) – Paracetamol 15 mg/kg PO/PR q4-6h (max 75 mg/kg/24h). Ibuprofen 10 mg/kg q6-8h (max 40 mg/kg/d).
2
Moderate pain (step 2) – Codeine (caution – poor metabolizers, avoid <12y post‑tonsillectomy). Tramadol 1-2 mg/kg q6h. Continue non‑opioids.
3
Severe pain (step 3) – Oral morphine 0.2-0.3 mg/kg q4h (immediate release) or long‑acting. IV morphine 0.05-0.1 mg/kg. Fentanyl patch for stable pain.
4
Breakthrough pain – Immediate release opioid (10-20% of daily morphine equivalent). Dose every 1-2h as needed.
5
Refractory symptoms at EOL – Continuous subcutaneous infusion (syringe driver): morphine + midazolam + glycopyrrolate. Consider sedation for intractable distress.
⚡ Palliative care pearls: Regular opioid dosing prevents pain cycling. Constipation: stimulant (senna) + stool softener (docusate). Methadone effective for neuropathic pain but high risk of accumulation.

🧠 Reflex prompts – pain & palliative care

😣 Pain scale for preverbal child?
FLACC (Face, Legs, Activity, Cry, Consolability).
📈 WHO ladder step 3 drug?
Morphine, fentanyl, oxycodone.
💊 Opioid reversal agent?
Naloxone 0.1 mg/kg IV/IM.
💩 Most common opioid side‑effect?
Constipation (prophylactic laxatives essential).
🤝 Four domains of palliative care?
Physical, psychological, social, spiritual.
🫁 First‑line drug for dyspnea in palliative care?
Opioids (morphine/fentanyl).