Nelson Textbook of Pediatrics 22nd Edition — Chapter 93 | Table 93.12: CDC Practice Guideline for Prescribing Opioids for Pain (2022) — for acute, subacute, and chronic pain (excluding sickle cell, cancer, palliative care). Table 93.16: Medications for Pediatric Chronic Pain (tricyclic antidepressants, SNRIs, gabapentin, pregabalin).
🌐 paeds.online — Pakistan's Pediatric Platform| Recommendation | Key Points |
|---|---|
| Non-opioid therapies first | Maximize non-pharmacologic and non-opioid pharmacologic therapies before opioids for acute/subacute/chronic pain. |
| Immediate-release opioids | When opioids initiated, use immediate-release (not ER/LA) preparations. |
| Lowest effective dosage | Prescribe lowest effective dosage. Avoid increasing dosage above levels with diminishing returns. |
| Duration for acute pain | Prescribe no greater quantity than needed for expected duration of severe pain (often 3-7 days). |
| Follow-up within 1-4 weeks | Evaluate benefits and risks within 1-4 weeks of starting or escalating therapy. |
| Assess risk for harms | Evaluate risk for opioid-related harms; discuss with patient. Offer naloxone when risk factors present. |
| Prescription Drug Monitoring Program (PDMP) | Review PDMP data before prescribing and periodically during therapy. |
| Tapering | If benefits do not outweigh risks, gradually taper to lower dosage or discontinue. Do not taper abruptly unless life-threatening. |
| Avoid concurrent benzodiazepines | Use particular caution when prescribing opioids and benzodiazepines together (increased risk of overdose). |
| Treat opioid use disorder | Offer evidence-based medications (buprenorphine, methadone) for opioid use disorder. |
| Medication Class | Drug (Starting Dose) | Indications / Comments |
|---|---|---|
| Tricyclic Antidepressants (TCAs) | Amitriptyline 0.1-0.25 mg/kg qhs (max 0.5-1 mg/kg) Nortriptyline 0.1-0.25 mg/kg qhs | Neuropathic pain, migraine, functional abdominal pain. Obtain ECG (QTc <450 msec). Side effects: sedation, dry mouth, constipation. |
| SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors) | Duloxetine: 13-17 yrs: 30-60 mg daily Venlafaxine: 0.75-1.5 mg/kg/day (off-label) | Neuropathic pain, fibromyalgia. Duloxetine FDA-approved for fibromyalgia in adolescents. Monitor blood pressure. |
| Gabapentin | Initial: 2-5 mg/kg/day tid Max: 35-50 mg/kg/day (up to 1800-3600 mg/day) | Neuropathic pain, CRPS, chronic headache. Sedation, dizziness. Renal adjustment needed. |
| Pregabalin | Initial: 2.5 mg/kg/day divided bid-tid Max: 600 mg/day | Neuropathic pain, fibromyalgia. Twice daily dosing. Side effects similar to gabapentin. |
| Topiramate | 0.5-1 mg/kg/day titrate up to 3-6 mg/kg/day | Migraine prophylaxis (12-17 yrs approved). Weight loss, cognitive dulling. |
| Clonidine | 5-25 mcg/kg/day divided q8h | Neuropathic pain, sleep disturbance. Monitor BP, sedation. |