Pediatric Pain Management Research Articles

A paediatric pain assessment and management survey at Rahima Moosa Mother and Child Hospital, Johannesburg, South Africa.

Painful experiences are common in the paediatric inpatient population. Immaturity and cognitive impairment may preclude clear description of such experiences, and requests for analgesia when needed. Methods of pain assessment and guidelines for treatment in the paediatric population are well established, but are not widely used. Limited data suggest that the situation is similar in South Africa (SA). To review the assessment and management of pain in SA medical paediatric inpatients. The primary objective was to determine the proportion of children who receive analgesia where indicated. The secondary objectives were to determine the prevalence of pain, at presentation and among admitted patients, whether pain evaluations were performed and pain treated, and the adequacy of such treatment. A prospective cross-sectional survey of medical paediatric inpatients at Rahima Moosa Mother and Child Hospital (RMMCH) in Johannesburg, SA, was conducted. The tool used for data collection was specifically designed for the study, with sections for demographic data, patient or caregiver interview, and chart review. Pain assessments were done using the revised Face, Legs, Activity, Cry, Consolability Scale and the Neonatal/Infant Pain Scale. The analysis consisted of descriptive statistics of epidemiological data and comparative statistics using grouped variables, with the level of significance set at p<0.05. The sample consisted of 74 children, aged between 3 days and 4 years. Male patients accounted for 58% of the cohort. The prevalence of pain at admission was 73% (n=53). Eight percent (n=6) of the study sample had pain evaluation at admission, and only 1 child had been evaluated for pain within the preceding 24 hours. Of the 74 patients reviewed, 10% (n=7) received appropriate analgesia. Paracetamol was given to 31% of patients (n=23), either for pyrexia or for an undocumented indication. More than half of the study sample (59%; n=44) received no analgesia. The presence of pain, both by caregiver report (p=0.62) and by pain score (p=0.074), was not associated with the administration of analgesia. Pain in the paediatric population at RMMCH was found to be common, but it was seldom assessed, and validated pain scores were rarely used. The result was inadequate pain management in all the four domains of assessment, intervention, reassessment and ongoing management.

Utilization of Pediatric Standing Orders by Triage Nurses in a Free-Standing Emergency Department.

Pediatric pain-related complaints continue to be a common presenting factor of most emergency departments (EDs). Studies have shown that several barriers in assessing and treating pediatric pain exist, including nursing knowledge regarding appropriate pain level assessment. This quality improvement study aimed to provide and evaluate specific education regarding pediatric pain management for free-standing ED triage nurses to expedite medication administration during the triage phase of an ED visit. This pre/post-test intervention study was used to measure whether the education provided to nurses working in a primarily adult patient free-standing ED increased the utilization of triage standing orders related to pediatric pain management. Paired sample t-tests results indicated a statistically significant increase (p = .000) in the percentage of patients that received pain medication during the triage phase of an ED visit after specific education was provided to triage nurses. Free-standing ED triage nurses are more likely to follow and implement triage standing orders if education explicitly related to pain management in pediatric patients has been provided. Pediatric pain management education should be revisited annually to re-educate nurses on the importance of early interventions.

Virtual Reality (VR) in Medicine: A Systematic Review of Current Applications of VR and Potential Applications to Pediatric Orthopaedic Surgery

BACKGROUND One of the most interesting emerging trends in healthcare is the use of virtual reality (VR) as a modality for pediatric pain management—with additional applications including anxiety, fear, and other strong emotions related to healthcare states. VR has been used for pain relief in chronic pathologies such as sickle cell disease, during procedures like blood draws, and post-operatively. In orthopaedics, bone pin and cast removal are common clinical procedures that are associated with anxiety and discomfort, especially in pediatric populations. Virtual reality may serve a purpose as a distraction to reduce the anxiety and fear that patients experience during those procedures. In this review, we aim to report the state of VR as it applies to pediatric healthcare and make recommendations for areas of future exploration, such as in orthopaedic surgery. Methods A systematic search query was conducted in the databases PubMed and Embase using the terms “virtual reality” AND “pediatrics” AND “pain.” Between both databases, 303 articles were returned. Titles and abstracts were reviewed to screen for relevant articles and duplicate articles were eliminated, resulting in the final inclusion of 76 articles in a summary table. Results Immersive VR was used in 64% of studies (n=49) and Gameplay VR was used in 25% of the studies (n=19). Most VR use occurred during the medical procedure (n=56). The most common application of VR to date has been pain (n=67), followed by anxiety (n=45), and then fear (n=12). The most common conditions that VR was used for were venipuncture (n=26), burn wound care (n=13), surgical procedures (n=11), and dental procedures (n=9). Conclusions While heavily reported on, procedures such as venipuncture and wound care are not the only potential application for VR intervention. Given the favorable findings of pain, anxiety and fear reduction in other areas, we recommend continuing to explore the use of VR in orthopaedic settings, such as bone pin and cast removal. There may be further benefit from VR use in fracture reduction and post-operative pain management. The potential for VR to improve clinical experiences for patients is yet to be fully appreciated and uncovering applications in new areas of medicine will help to benefit a greater patient population.

Hospitalized Children With Limited English Proficiency: The Strive to Improve Analgesia.

Hospitalized Children With Limited English Proficiency: The Strive to Improve Analgesia.

Pediatric Pain and Pain Management After Ambulatory Plastic Surgery: Trends in the Age of Opioid Awareness.

Overprescribing by physicians has been shown to be a major contributor to the opioid epidemic. Although pediatric ambulatory plastic surgery patients are commonly prescribed opioids for postoperative pain control, there is a lack of evidence for their necessity. This study aimed to investigate the role of prescribed narcotics in the ambulatory pediatric plastic surgery setting. All assenting patients/guardians, ages 0 to 17 years, who underwent an ambulatory plastic surgery procedure by 1 attending surgeon from March 2018 to March 2019, were asked to participate in the study. A questionnaire was distributed at the first postoperative visit to interrogate postoperative pain, management, and narcotic use. A total of 95 patients/guardians completed the questionnaire. Seventy-eight percent (74) of patients picked up the narcotic medication, with 33% (31) taking at least 1 dose of narcotics, and only 9% (9) taking 4 or more doses. Patients overall found no difference in efficacy of the narcotics versus nonprescription analgesics (3.93/5 and 4.31/5, P = 0.11). Age was a significant predictor, with older patients requiring more narcotics (odds ratio, 1.12; 95% confidence interval, 1.02-1.24; P = 0.019). The type of surgery a patient underwent was not a significant predictor of the amount of narcotic used. Few patients knew how to properly dispose of the excess narcotics, with almost 50% still having it stored in their homes. This study demonstrates that the majority of pediatric ambulatory plastic surgery patients do not require narcotic pain medications and experience adequate pain relief with over-the-counter analgesics. Importantly, education on proper disposal of narcotic medications may be a simple, yet effective target to decrease opioid availability for abuse.

Postural Orthostatic Tachycardia Syndrome (POTS): Characteristics of Youth Enrolled in an Outpatient Interdisciplinary Pediatric Chronic Pain Program

Postural Orthostatic Tachycardia Syndrome (POTS) is a common form of orthostatic intolerance that affects about 3,000,000 people in the United States. For youth, significant functional impairment is noted, especially related to school attendance, limited participation in social and physical activities, and lower quality of life. Although previous research highlights the unique challenges for youth with chronic pain, fewer studies have focused on the clinical presentation of pediatric patients with POTS. This study aimed to explore characteristics of youth with POTS presenting to an interdisciplinary pediatric chronic pain program. Twenty-nine adolescents (14.7 +/- 1.7 years; 79% female) diagnosed with POTS presenting with their caregiver to an initial visit at an interdisciplinary pediatric chronic pain management program at a large Northeastern children's hospital in the United States were asked to complete questionnaires assessing demographic and pain characteristics, pain acceptance, and functional impairment and anxiety (PROMIS; t-scores). Number of visits within the program were gathered from medical record. Youth were primarily Caucasian/White (86.2%), Other (6.9%), AAPI (3.4%) and Mixed Race (3.4%). Youth reported overall low pain acceptance (M=34.1, SD=9.3), moderate anxiety (M=57.1, SD=13.1) and high pain interference (M=63, SD =7.4). Caregivers reported observing moderate anxiety (M=59.1, SD =11.5) and high pain interference (M=65.1, SD=4.6) for youth. Adolescents were observed to attend a wide range of visits within the program, including medical (1.7 +/- 2.5), physical therapy (3.4 +/- 4.9), occupational therapy (.5 +/- 1.7), and psychology (4.3 +/- 3.6). Less is known about youth with POTS who present for treatment. Additionally, youth with POTS meet with multiple doctors before receiving a diagnosis leading to disparities in access to treatment and the type of treatment that is received. Data here highlights that youth with POTS are experiencing significant impairment and more research targeting this population is necessary to improve outcomes. Postural Orthostatic Tachycardia Syndrome (POTS) is a common form of orthostatic intolerance that affects about 3,000,000 people in the United States. For youth, significant functional impairment is noted, especially related to school attendance, limited participation in social and physical activities, and lower quality of life. Although previous research highlights the unique challenges for youth with chronic pain, fewer studies have focused on the clinical presentation of pediatric patients with POTS. This study aimed to explore characteristics of youth with POTS presenting to an interdisciplinary pediatric chronic pain program. Twenty-nine adolescents (14.7 +/- 1.7 years; 79% female) diagnosed with POTS presenting with their caregiver to an initial visit at an interdisciplinary pediatric chronic pain management program at a large Northeastern children's hospital in the United States were asked to complete questionnaires assessing demographic and pain characteristics, pain acceptance, and functional impairment and anxiety (PROMIS; t-scores). Number of visits within the program were gathered from medical record. Youth were primarily Caucasian/White (86.2%), Other (6.9%), AAPI (3.4%) and Mixed Race (3.4%). Youth reported overall low pain acceptance (M=34.1, SD=9.3), moderate anxiety (M=57.1, SD=13.1) and high pain interference (M=63, SD =7.4). Caregivers reported observing moderate anxiety (M=59.1, SD =11.5) and high pain interference (M=65.1, SD=4.6) for youth. Adolescents were observed to attend a wide range of visits within the program, including medical (1.7 +/- 2.5), physical therapy (3.4 +/- 4.9), occupational therapy (.5 +/- 1.7), and psychology (4.3 +/- 3.6). Less is known about youth with POTS who present for treatment. Additionally, youth with POTS meet with multiple doctors before receiving a diagnosis leading to disparities in access to treatment and the type of treatment that is received. Data here highlights that youth with POTS are experiencing significant impairment and more research targeting this population is necessary to improve outcomes.

Comparing the surgical management of acute paediatric scrotal pain between adult urologists and general surgeons in the UK: an observational study.

Acute scrotal pain is a common paediatric surgical emergency. Assessment and timely exploration are required to rule out testicular torsion (TT) and prevent unnecessary morbidity. A retrospective observational cohort study was carried out at two district general hospitals in the UK for boys aged ≤16 years presenting with acute scrotal pain between January 2014 and October 2017 managed by adult general surgery (AGS) at one hospital and adult urology (AU) at the other. Some 565 patients were eligible for inclusion (n=364 AGS, n=201 AU). A higher proportion of patients underwent surgical exploration at AGS compared with AU (277/346 (80.1%) vs 96/201 (47.8%); p<0.001). Of those who underwent exploration, 101/373 (27.1%) had TT, of whom 25/101 (24.8%) underwent orchidectomy and 125/373 (33.5%) had torted testicular appendage. There was no statistically significant difference in rates of orchidectomy between AGS (19/68, 27.9%) and AU (6/33, 18.2%) with testicular salvage rates of 72.1% and 81.8%, respectively (p=0.334). Patients were twice as likely to be readmitted at AGS as at AU (28/346 (8.1%) vs 8/201 (4.0%); p=0.073). Although intraoperative findings were similar between adult general surgeons and urologists, there were significant differences in surgical management, with a higher rate of surgical exploration by general surgeons. Testicular salvage and 30-day postoperative morbidity rates at both institutions were acceptable but the readmission rate was high at 6.6%. It is not known why there is a heterogeneity in management of acute scrotal pain between specialist centres, and further prospective investigations are warranted.

Experience of Pediatric Chronic Pain for Gender Expansive and Cisgender Patients

Sex differences in chronic pain are well documented. However, very little research has examined the experience of chronic pain in gender-expansive youth, a population who experience significant healthcare disparities. This study examined characteristics of pain and psychosocial correlates in gender-expansive and cisgender patients seen for evaluation and treatment of chronic pain. Participants included 48 youth (16 gender-expansive, 32 matched cisgender; M=16.28 years) with chronic pain seen in an interdisciplinary pediatric pain management clinic. Independent samples t-tests were conducted comparing pain, pain-related cognitions, internalizing symptoms, and sleep difficulties between groups. Correlations were conducted for each group; differences in the strength of the correlations were evaluated using Fisher's r to z transformation. Patients reported moderate pain intensity (M=4.98), moderate functional disability (M=28.64), and decreased quality of life (M=42.84). The most common pain diagnosis was fibromyalgia. Cisgender patients reported significantly poorer sleep onset (p=.044). Differences in pain intensity trended toward significance with cisgender patients reporting greater pain (p=.095). Internalizing symptoms trended toward significance with gender-expansive patients reporting greater anxiety (p=.089) and depression (p=.086). There were no significant differences in functional disability, symptom severity, quality of life, or pain-related attitudes and beliefs. For both gender-expansive and cisgender patients, lower quality of life was associated with greater symptom severity and greater pain-related injustice (ps<.05). Of note, these correlations were significantly stronger for gender-expansive patients. Gender-expansive and cisgender patients with chronic pain experienced functional disability and poor quality of life. Results should be interpreted with caution given the small sample size, however, preliminary evidence suggests internalizing symptoms may be of particular importance when treating chronic pain in gender-expansive youth, whereas sleep concerns and pain intensity may be greater in cisgender youth. These results have the potential to influence clinical practice, treatment, and future research for gender-expansive youth receiving treatment for chronic pain.

Postoperative Pain in Children

Postoperative pain is an acute pain that starts with surgical trauma and gradually decreases with healing of the tissue. The mechanism of pain perception in the pediatric population is different and poorly understood. Difficulties in defining and grading pain in pediatric patients also complicate treatment. Postoperative pain management in children should be planned with a multidisciplinary and multimodal approach. In this article, it is aimed to review up-to-date information on pediatric postoperative pain management.

Chronic pain-related consultations to the emergency department of children with complex pain conditions: A retrospective analysis of healthcare utilization and costs

Background There is limited information regarding the effects of pediatric chronic pain management on the number and cost of chronic pain-related emergency department (ED) consultations. Aim This retrospective study aimed to evaluate the number and costs of chronic pain-related ED consultations of children and adolescents with chronic pain conditions at the Montreal Children’s Hospital (MCH) (Canada). Methods Charts of patients followed by the Edwards Family Interdisciplinary Center for Complex Pain (CCP) of the MCH between April 2017-December 2018 were reviewed. ED consultations, specialist consultations, medication prescriptions, hospital admissions, and outpatient consultation referrals were assessed for the period of one year before and after the patients’ first consultation with the CCP. Associated costs were also calculated. Results One-hundred-sixty-eight patients were included in the analysis. Fifty-one percent of them consulted the ED and had 151 chronic pain-related ED consultations within one year before their initial CCP consultation. In the year following their first CCP consultation, 52 patients (31%) consulted the ED, of which 24 consultations were chronic pain-related (84% reduction). There was an 81% reduction in the costs associated with chronic pain-related ED consultations within the year after CCP management. In addition, there was a significant reduction in ED interventions within the year after CCP management, though no change in medication prescriptions, hospital admissions, or subspecialist consultations. Conclusion Children and adolescents with chronic pain conditions had less chronic pain-related ED consultations within one year after the first evaluation by an interdisciplinary center for complex pain contributing to reduced ED costs.

Low-dose ketamine infusions reduce opioid use in pediatric and young adult oncology patients.

Ketamine is an NMDA-receptor antagonist with analgesic and opioid-sparing properties. Although well studied in adults, more robust evidence supporting ketamine's use for pediatric pain management is needed. This retrospective study evaluates ketamine's opioid-sparing effectiveness in pediatric and young adult oncology and hematology patients. Continuous ketamine infusions administered for pain management between 2010-2020 were reviewed. Data including demographic characteristics, oncology/hematology and pain diagnoses, concurrent pain medications, and ketamine infusions' dose and duration were collected. Opioid consumption data based on delivery via patient-controlled analgesia were collected 1 day before (D1), all days during (cumulatively named D2), and 1 day after (D3) ketamine infusions and calculated as morphine-equivalent doses (mg/kg/day). Data were reported for the entire study group as well as for distinct oncology and end-of-life categories, and short-term acute pain circumstances which included vaso-occlusive crises in hematology patients. Side effects were reviewed. Significantly lower daily opioid consumption was noted in the oncology group, while decreases were not significant in the end-of-life group and in the overall study population. The acute pain group did not show an opioid reduction associated with the ketamine infusions. A largely tolerable side-effect profile was observed, with no differences among each group's incidence. Ketamine infusions were associated with significantly reduced opioid consumption for oncology patients. The opioid-sparing effects of ketamine may vary according to clinical diagnoses and circumstances of use. Overall, low-dose ketamine infusions present an acceptable safety profile in pediatric and young adult patients; nevertheless, individual risks and benefits should be considered.

Barriers and facilitators to out-of-hospital pain management for children

Pain is one of the most common symptoms presented by patients of all ages to ambulance services. While children in pain make up a relatively small proportion of the patients attended by prehospital care services, medical intervention is needed in only 40% of cases. This might go some way to explaining why management of paediatric pain is perceived as poor. Aim: To establish and explore published barriers and facilitators to out-of-hospital pain management for children aged &lt;18 years. Methods: Key search terms were used to search the three databases (CINAHL, MEDLINE and PSYCHInfo) individually and simultaneously. Inclusion and exclusion criteria were applied and 15 papers were identified as meeting the criteria and were subject to data extraction. Results: Three broad themes were identified; organisational factors, patient factors and clinician factors. Conclusion: From considering international systems and aspects of care, it can generally be accepted that the assessment and management of paediatric pain is below what would be expected, and compared with with that for adults, it is sub-optimal. Multiple demographic influences are evident and appear to influence clinician decisions.

Evaluation of Paediatric Postoperative Pain Management among Nursing Staff Working in Tertiary University Hospitals: A multicentre Cross-sectional Study

Evaluation of Paediatric Postoperative Pain Management among Nursing Staff Working in Tertiary University Hospitals: A multicentre Cross-sectional Study

Managing Pain and Discomfort in Children with Cancer.

Approximately 15,600 children are diagnosed with cancer annually. Many of these children have cancer-related pain that improves with cancer treatment, but some develop intractable pain from cancer progression or sequelae from treatment modalities. The purpose of this paper is to provide a critical evaluation of the literature relevant to pain management in children with cancer. We intend to emphasize important and up-to-date findings in pharmacology, interventional pain management, and complementary and alternative medicine. Alternative medications and routes of administration, complementary and alternative medicine techniques, and interventional pain procedures offer possible routes for a multi-pronged pediatric cancer pain management plan, although high-level data is often lacking. To improve pediatric cancer pain management, a multifaceted approach embracing the biopsychosocial model of pain is recommended, incorporating evidence-based pharmacology, complementary and alternative medicine techniques, and if needed, interventional pain procedures.

Clown therapy for procedural pain in children: a systematic review and meta-analysis.

Clown therapy seems effective in reducing procedural pain in children, particularly for older age groups, but due to poor methodological quality and the high risk of bias of the studies included, the results obtained should be considered with caution. •Clown therapy is one of the most used techniques in the non-pharmacological management of acute pediatric pain. • Laughter physiologically stimulates the production of beta-endorphins, substances with an effect similar to opiates. •Clown therapy seems effective in reducing procedural pain and anxiety in children. •The intervention in school-age children or adolescents produces a statistically significant decrease in the symptom.

Pain management in children and young adults with minor injury in emergency departments in the UK and Ireland: a PERUKI service evaluation

BackgroundManagement of acute pain should commence at the earliest opportunity, as it has many short-term and long-term consequences. A research priority of Paediatric Emergency Research in the UK and Ireland...

The perceptions and practices of parents and children on acute pain management among hospitalized children in two Botswana referral hospitals

BackgroundPerceptions and practices of parties in pediatric pain are critical in children's access to adequate acute pain management. The personal factors of the child and parents have been shown to be central to pediatric pain management by the Symptom Management Theory. AimTo describe children and parents/guardians' perceptions (knowledge, attitudes and beliefs) and practices regarding pediatric acute pain management and explain the influence of socio-cultural and environmental factors on those perceptions and practices. MethodsDescriptive cross-sectional survey using modified versions of the American Pain Society Patient Outcome Questionnaire-Revised among parents/guardians and children. ResultsA convenience sample of 275 parents/guardians and 42 children aged 8 to 13 years admitted between date November 2018 and February 2019 to two Botswana tertiary hospitals completed the surveys. Forty-seven percent (n = 129) of parents/guardians reported the child to be in moderate-severe pain, while 38% (n = 16) of children reported pain as moderate-severe at the time of the survey. The children mean scores for cm-APS-POQ-R were 113(33) while parents/guardian's guardians for m-APS-POQ-R were 123(26). The subscales except for the parents/’guardians' pain interference (p = .96) were statistically significant (p = .000), showing adequate knowledge, positive attitudes and high pain intensity for both parents/guardians and children. ConclusionParent/guardians and children reported a high incidence of acute pain, were content with pain management services, and showed adequate knowledge of pediatric pain and its management. The incongruence between the intensity of pain, satisfaction on the adequacy of pain management and knowledge and attitudes demonstrated in this study need further inquiry.

Exploring factors affecting the facilitation of nursing students to learn paediatric pain management in Rwanda: A descriptive qualitative study.

Nurse educators and nurse preceptors play a fundamental role in facilitating nursing students' acquisition and utilization of professional competencies. Previous studies about key elements for teaching and learning about pain in nursing education programs include students' personal characteristics and previous experiences; educators' knowledge, skills, and beliefs; learners' exposure to leaders in pain education; and curricular pain content and delivery approaches. These studies were mainly carried out in developed countries, with a context of educational and health care systems different from those of developing countries. The current study explores academics', clinical nurse preceptors', and nursing students' perceptions about factors influencing the facilitation of nursing students' competency for paediatric pain management in Rwanda. A qualitative descriptive exploratory design was used in this study that utilized in-depth interviews with six nurse educators and eight nurse preceptors, and focus group discussions with nineteen senior year nursing students. The study setting included five sites: two academic institutions and three clinical settings. Narratives from participants were transcribed verbatim and analysed using thematic analysis. The analysis yielded six themes describing factors that affected the facilitation of students' learning about paediatric pain management. The themes included student motivation, facilitators' attributes, collaboration between academics and clinicians, nurses' limited autonomy for decision-making regarding PPM practices, shortage of human and material resources, and educational qualification. Knowing these factors is essential as it provides an opportunity to design targeted interventions aimed to enhance the capacity of nurse educators and clinical nurse preceptors involved in teaching nursing students about paediatric pain management.

Mapping the current state of pediatric surgical pain care across Canada and assessing readiness for change

ABSTRACT Background Preventing pediatric chronic postsurgical pain is a patient, parent/caregiver, health care professional, and policymaker priority. Poorly managed presurgical and acute postsurgical pain are established risk factors for pediatric chronic postsurgical pain. Effective perioperative pain management is essential to prevent the transition from acute to chronic pain after surgery. Aims The aim of this study was to identify current pediatric surgical pain management practices and assess health system readiness for change at health care institutions conducting pediatric surgery in Canada. Methods An online survey was completed by 85 multidisciplinary health care professionals (nurses, surgeons, anesthesiologists, allied health) from 20 health institutions in Canada regarding institutional pre- and postsurgical pediatric pain care, specialty pain services, and Organizational Readiness for Implementing Change (ORIC). Results Of all specialty pain services, acute and chronic/complex pain services were most common, primarily with physician and nursing involvement. Alignment to recommended practices for pediatric pre- and postsurgical pain care varied (38.1%–79.8% reported “yes, for every child”), with tertiary/quaternary children’s hospitals reporting less alignment than other institutions (community/regional or rehabilitation hospitals, community treatment centers). No significant differences were reported between health care institutions serving pediatric populations only versus those also serving adults. Health care professional experience/practice was the most reported strength in pediatric surgical pain care, with inconsistent standard of care the most common gap. Participants “somewhat agreed” that their institutions were committed and capable of change in pediatric surgical pain care. Conclusions There is a continued need to improve pediatric pain care during the perioperative period at Canadian health care institutions to effectively prevent the development of pediatric postsurgical pain.

Opioids for Pediatric Pain Management

To study the efficacy and adverse effects of opioids in management of pain in children. A descriptive study was conducted in children aged below 15 years with moderate to severe pain, and response to opioids and adverse effects were assessed at 24, 48 and 72 hours after administration. 100 children (68% males) with median (IQR) age of 6.5 (3.5,10) years were studied. 81% (n=81) children with moderate pain and 78.9% (n=15) with severe pain responded to opioids in 72 hours. Among children with severe pain of non-malignant origin, 80% (n=8) responded in 48 hours compared to 11.1% (n=1) with malignancy and this difference was statistically significant at 24 hours (P=0.005). Of children with severe pain 73.7% (n=14) developed adverse reactions compared to 30.9% (n=25) with moderate pain. Children with moderate-severe pain, either of malignant or non-malignant origin could be managed effectively with opioids without severe adverse effects.