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General Principles

Analgesia is the diminution or elimination of pain in the conscious patient.

  • Even neonates demonstrate behavioral and hormonal changes in response to painful procedures.

  • Children do not have to understand the meaning of pain to communicate pain or to experience it.

  • Preemptive analgesia may decrease postinjury opioid requirements


Observational-Behavioral Measures

  • Useful in infants and toddlers (who do have physiologic and behavioral responses to pain, such as increased heart rate, blood pressure, respiratory rate, crying, flushing, facial expressions, and body movements)

  • Example: FLACC (Face, Leg, Activity, Cry, Consolability) Behavioral Pain Scale (Merkel SI, et al. The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatr Nurs 1997;23:293–297.)


  • The OUCHER scale combines numeric and faces scales, making it appropriate for young children (available at

  • Wong–Baker FACES scale: The child is asked to point to the face that best represents his/her own pain (available at

  • Verbal numeric pain rating: Useful in developmentally normal children 6–7 years of age (or older). Pain is rated from 0 to 10 (0 is no pain and 10 is the worst pain imaginable).


  • Distraction, music, play

  • Acupuncture, massage, and hypnosis are other methods of analgesia; these usually require trained practitioners.



  • 2.5% lidocaine/2.5% prilocaine

  • Apply to intact skin; complete anesthesia in 60–90 minutes

  • Use for blood drawing/IV placement, bone marrow aspiration, lumbar puncture in nonemergent settings

  • May use LMX, which is topical lidocaine only; it has a faster onset, with anesthesia in 30 minutes.

  • Contraindications: Methemoglobinemia (avoid EMLA) in children less than 1 month of age


  • Used for dermal lacerations; may apply to open wound

  • Contraindicated in areas supplied by end arteries (digits, pinna, nose, penis).

Viscous Lidocaine

  • For older children who can expectorate

  • Combine with diphenhydramine and aluminum hydroxide, magnesium hydroxide (e.g., Maalox) in equal parts (1:1:1) to create “magic mouthwash” (can exclude lidocaine if mouth sores create a concern for systemic absorption)

  • Usual dose: 15 mL of undiluted mixture to “swish and spit” (not swallow); maximum dose is 4.5 mg/kg of body weight or 300 mg of lidocaine component (up to every 3 hours). Smaller amounts work well.

Lidocaine Jelly

  • Used for nasogastric tube placement and urethral catheterizations

Injectable Local Anesthetic

  • Buffer with 1 mL (1 meq/mL) sodium bicarbonate (NaHCO3) per 9 mL lidocaine or 0.1 mL NaHCO3 per 10 mL bupivacaine to reduce pain associated with injection.

  • Enhance efficacy and duration by using in combination ...

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