Neonatal and Pediatric Pain Management Opioid Stewardship

Especially in institutions with limited pediatric pain services, it is imperative to describe the appropriate management of pain and pharmacotherapy options that are effective and safe in pediatric patients, write the authors of a new review of literature and guidelines.

“The management of acute pain in neonates and pediatric patients should be a priority for all practitioners caring for these patients,” the authors write in the article published in the American Journal of Health-System Pharmacy on October 1. “Use of age-appropriate pain assessment tools and understanding of the mechanisms of action and roles in therapy of various nonopioid and opioid therapies can help optimize treatment of pain in neonatal and pediatric patients.”

Opioid stewardship strategies include use of nonpharmacologic therapies, the use of nonopioid medications and adjuvant medications (such as gabapentin and steroids), and opioid rotation, according to the Pediatric Pharmacy Advocacy Group’s recommendations regarding pharmacists’ role in the management of chronic pain and opioid stewardship in the children.

Optimizing use of nonopioid pharmacologic agents such as acetaminophen and ibuprofen can help augment pain relief and minimize opioid requirements, the authors write. “It is important to identify whether the pain can be treated with adjuvant medications in conjunction with opioids,” they write. 

In addition, nonpharmacologic therapy can supplement pharmacologic pain relief. Nonpharmacologic treatment options in neonates include nonnutritive sucking, with or without sucrose use; swaddling or facilitated tucking; and kangaroo care, a method of care that emphasizes holding the naked or partially dressed child against the bare skin of a parent. In infants and children, music therapy, distraction, and parenteral comfort are nonpharmacologic therapies that can help relieve pain and anxiety.

Upon initiation of pharmacotherapy, it is imperative to communicate expectations of pain relief and provide education about when to use pain medications to the patient and caregivers. Opioid therapies for acute pain should focus on initially using the lowest effective doses and using immediate-release formulations.

Pediatric patients who require long-term therapy for persistent pain may benefit from extended-release formulations, the authors write. Prolonged pain management may be required in patients with sickle cell disease, limb pain, and complex regional pain syndrome.

To decrease the adverse effects and minimize opioid dose escalation in these patients, opioid rotation or opioid switching can be recommended. “When inadequate pain control occurs, switching to another opioid on a set schedule can be beneficial. This practice is not routinely recommended for use in all patients on long-term opioid therapy, and conversion and cross-tolerance should be considered when prescribing the new opioid,” the authors write.

The World Health Organization (WHO) recommends a two-step pain treatment algorithm based on pain severity. The first-step strategy for pain management recommends nonopioid pharmacologic agents. The second-step strategy recommends strong opioids as the treatment of choice for moderate to severe pain.

The WHO first-step strategy for pain management recommends nonopioid pharmacologic agents, acetaminophen and ibuprofen, for patients three years and older. For patients under 3 years old, only acetaminophen is generally recommended. 

Although WHO recommends the use of ibuprofen in patients more than three months of age, in the US, the use of the drug is confined to patients more than six months of age due to the safety concerns of gastrointestinal and renal adverse effects, the authors write

Acetaminophen is one of the most commonly used analgesics in the management of mild pain, both as a single agent and in combination products. In pediatric patients the recommended maximum daily dose of acetaminophen is 75 mg/kg, not to exceed the adult recommended maximum of 4,000 mg. 

Although used infrequently compared to acetaminophen and ibuprofen, other nonopioid analgesics used for pain in pediatric patients include ketorolac (another NSAID, recommended for the short-term management of moderate to severe pain). Ketorolac use should not exceed five consecutive days due to a risk of gastrointestinal bleeding similar to that in adults. 

There are also several other contraindications to ketorolac use, such as cerebrovascular bleeding and preexisting high risk of bleeding.