15.3 Pediatric Pain Assessment & Primary Care Pain Management
Key Takeaways
- Match the scale to the child: FLACC for infants and nonverbal children, faces for many preschoolers, numeric when the child understands numbers
- Start with nonpharmacologic measures — ice, elevation, distraction, sucrose in infants — plus acetaminophen 10–15 mg/kg and ibuprofen 5–10 mg/kg
- Typical teaching is no ibuprofen under 6 months and no aspirin because of Reye syndrome; FDA teaching is to avoid codeine and tramadol in children
- Chronic amplified musculoskeletal pain, headache, and abdominal pain are biopsychosocial problems — do not start opioids
- Night pain that wakes the child, fever, or weight loss is infection or malignancy until proven otherwise; severe sickle cell pain is an emergency
Pain is clinical category #13 on the CPNP-PC outline. Domain II is a valid score in a child who cannot always talk. Domain III is nonpharmacologic care plus the right milligram-per-kilogram analgesic, and the judgment not to start a child on opioids for chronic amplified pain. Hip infection and SCFE are 15.1. Concussion and overuse are 15.2. Hematology owns sickle cell disease long-term; you own the emergency when pain is severe.
Quick Answer: FLACC for infants and nonverbal children, faces for many preschoolers, numeric when the child understands numbers. Separate acute from chronic. Nonpharm: ice, elevation, distraction, sucrose in infants. Acetaminophen 10–15 mg/kg, ibuprofen 5–10 mg/kg; typical teaching no ibuprofen under 6 months; no aspirin (Reye). FDA: avoid codeine and tramadol in children. Chronic amplified MSK, headache, and abdominal pain: biopsychosocial, no opioids. Night pain that wakes + fever/weight loss → malignancy or infection. Severe sickle cell pain is an emergency.
Assessment: match the tool to development
Pain is what the child — or a validated observational tool — reports. It is not what the busy clinic hopes. Choose the scale by developmental ability, not by which laminated card is closest to the sink.
| Tool | Who | How |
|---|---|---|
| FLACC (Face, Legs, Activity, Cry, Consolability) | Infants, toddlers, nonverbal children, many children with significant developmental disability | Each domain 0–2; total 0–10 |
| Faces (Wong-Baker or Faces Pain Scale–Revised) | Many preschool and early school-age children who can point to a face | Self-report |
| Numeric 0–10 | Children who understand numbers (often around 8 years and older — confirm, do not assume) | Self-report |
| Vital signs and behavior | Everyone as context | Tachycardia and crying are not a scale; do not skip FLACC or self-report |
Reassess after an intervention. A FLACC of 8 after vaccines that falls to 2 after sucrose plus acetaminophen is data. Do not hand a 0–10 numeric scale to a 10-month-old. Do not use FLACC as your only tool for a 16-year-old who can self-report. Caregiver estimate supplements the score; it does not replace a tool the child can use.
Acute versus chronic
Acute pain has a tissue reason you can name: otitis, fracture, burn, postoperative, vaccine, sprain, sickle cell vaso-occlusion. Treat the cause and treat the pain together. Withholding analgesia "so you do not mask the abdomen" is not a license to ignore a child's pain after the surgical decision is already made.
Chronic pain lasts beyond expected healing (often taught as more than 3 months) or is recurrent: amplified musculoskeletal pain, chronic daily headache, functional abdominal pain. Most of this in primary care is nociplastic/amplified pain plus sleep, school, and family load — not an opioid deficiency. Acute-on-chronic flares still get a history for red flags before you escalate drugs.
Nonpharmacologic care is first-line, not decoration
- Ice and elevation (rest and compression as appropriate) for sprain, contusion, and overuse flare. Ice is not for an acute septic joint you have not referred.
- Distraction, positioning, caregiver presence, and honest preparation for procedures — not surprise restraint.
- Oral sucrose (and breastfeeding, non-nutritive sucking, swaddling) for infant procedural pain such as vaccines and heel sticks, with topical anesthetic when indicated.
- Heat for some muscle spasm after you have excluded infection.
- For chronic pain: sleep restoration, graded activity and physical therapy, cognitive behavioral therapy, and school re-entry. Those are treatment. They are not what you offer after a year of negative MRIs.
If the only plan you write is "ibuprofen PRN" for a child missing school with widespread pain and a normal exam, you did not manage chronic pain.
Acetaminophen, ibuprofen, aspirin, and the opioid bans
Weight-based dosing is the exam language. Use mg/kg, a milliliter volume the caregiver can draw, and a maximum daily dose. Confirm the concentration in the bottle — pediatric acetaminophen is commonly 160 mg/5 mL.
| Drug | Typical primary-care dose | Hard stops |
|---|---|---|
| Acetaminophen | 10–15 mg/kg/dose every 4–6 hours; common pediatric max 75 mg/kg/day, not to exceed the adult daily cap (counsel 3,000–4,000 mg/day depending on product labeling) | Hepatotoxicity when families double up with combination cold products |
| Ibuprofen | 5–10 mg/kg/dose every 6–8 hours (10 mg/kg is common for pain or fever) | Typical teaching: do not use under 6 months; caution in dehydration, renal disease, bleeding risk, or a suspected surgical abdomen |
| Aspirin | Not a pediatric analgesic or antipyretic | Reye syndrome with viral illness — do not use |
| Codeine and tramadol | Not for children | FDA: avoid in children (contraindicated under 12 years; additional restrictions after tonsillectomy/adenoidectomy and in higher-risk adolescents). Ultra-rapid CYP2D6 metabolism and respiratory depression are the historic disasters |
Around-the-clock dosing for expected moderate acute pain (after a reduction and cast, after a burn dressing) beats chasing pain every time it spikes. For ordinary fever and minor pain, PRN with a written milliliter plan is enough. Combination cough-and-cold products hide acetaminophen. Do not stack two acetaminophen brands. Do not substitute aspirin "because the fever is high after influenza."
Opioids in primary care are rare, short, and indicated — severe acute injury after the fracture is set, or a hematology-aligned sickle cell plan. They are not for chronic amplified pain, not for growing pains, and not codeine or tramadol "because those are weak opioids." If an opioid is truly needed, choose an agent and a duration you can defend, counsel storage, and schedule follow-up. That still does not make codeine or tramadol acceptable pediatric first-line drugs.
Chronic amplified pain, headache, and abdominal pain
Amplified musculoskeletal pain (including the juvenile fibromyalgia spectrum) is widespread pain, often with allodynia, normal joints, poor sleep, and school absence, in a family searching for the one MRI that will explain everything. Headaches and functional abdominal pain share amplification biology. Teach a biopsychosocial model without accusing the child of faking. Start function: sleep, physical therapy, CBT, a school plan, and simple analgesics when they help function. Do not start opioids. Imaging is for red flags, not a ritual before every CBT referral. Gastroenterology and neurology chapters cover abdominal pain and headache differentials; the pain category wants you to stop the opioid reflex and name the rehab plan.
Red flags and sickle cell pain
| Red flag | Worry | Primary-care action |
|---|---|---|
| Night pain that wakes the child, progressive and focal | Bone tumor, leukemia, osteoid osteoma, infection | Do not label growing pains; examine, labs/imaging, urgent referral |
| Fever plus bone pain or limp | Osteomyelitis, septic joint, leukemia | ED or same-day workup |
| Weight loss, night sweats, pallor, bruising | Malignancy | Urgent |
| Morning stiffness, swollen joint | JIA (rheumatology chapter) | Not growing pains |
| Back pain in a young child | Infection, tumor; spondylolysis in older athletes | Age-inappropriate back pain is never "just sports" without an exam |
Sickle cell disease vaso-occlusive pain is an emergency when severe. Primary care may treat a mild, typical crisis with oral analgesia, hydration, and a hematology plan only if the child is otherwise well and afebrile. Fever in sickle cell is a sepsis emergency (functionally asplenic). Chest pain, hypoxia, neurologic change, priapism, splenic sequestration signs, or uncontrolled pain → ED, not a codeine prescription and a hope. Hematology owns the chronic disease (heme chapter also). You own not sending a screaming, febrile child home.
Exam traps. Numeric scale on an infant. Ibuprofen in a 10-week-old. Aspirin for influenza. Codeine after a fracture or after tonsillectomy-era thinking still lingering as a "mild opioid." Tramadol for three months of abdominal pain. Opioids for amplified musculoskeletal pain. Growing-pains label on night-waking focal pain with fever and weight loss. Treating severe sickle cell pain as routine myalgia.
Clinic close. Score with FLACC, faces, or numbers that match development. Ice, elevation, sucrose, distraction first. Acetaminophen 10–15 mg/kg, ibuprofen 5–10 mg/kg after 6 months, never aspirin, never codeine or tramadol. Chronic amplified pain, headache, and abdominal pain get a biopsychosocial plan, not oxycodone. Night pain that wakes plus fever or weight loss is infection or malignancy until it is not. Severe sickle cell pain goes to the ED.
A 7-year-old needs analgesia after a closed forearm fracture that has been reduced and casted. Which pharmacologic teaching is correct for the CPNP-PC?
You need a pain score for a 10-month-old after a vaccine series and for a 9-year-old with a sprained ankle who understands numbers. Which pairing is correct?
A 10-year-old has had three months of widespread musculoskeletal pain with a normal exam. A second child wakes from sleep with focal bone pain, fever, and weight loss. A third child with sickle cell disease has severe vaso-occlusive pain. What is the correct cluster of plans?