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South Australian Paediatric Clinical Practice Guidelines 

Acute Pain Management and 
Opioid Safety in Children 

  Department for Health and Wellbeing, Government of South Australia. All rights reserved.  

INFORMAL COPY WHEN PRINTED  Page 1 of 30 

OFFICIAL 

Note:
This guideline provides advice of a general nature.  This statewide guideline has been prepared to promote and 
facilitate standardisation and consistency of practice, using a multidisciplinary approach.  The guideline is based 
on a review of published evidence and expert opinion.  
Information in this statewide guideline is current at the time of publication.  
SA Health does not accept responsibility for the quality or accuracy of material on websites linked from this site 
and does not sponsor, approve or endorse materials on such links. 
Health practitioners in the South Australian public health sector are expected to review specific details of each 
patient and professionally assess the applicability of the relevant guideline to that clinical situation. 
If for good clinical reasons, a decision is made to depart from the guideline, the responsible clinician must 
document in the patient s medical record, the decision made, by whom, and detailed reasons for the departure 
from the guideline. 
This statewide guideline does not address all the elements of clinical practice and assumes that the individual 
clinicians are responsible for discussing care with consumers in an environment that is culturally appropriate and 
which enables respectful confidential discussion. This includes: 

  The use of interpreter services where necessary, 
  Advising consumers of their choice and ensuring informed consent is obtained, 
  Providing care within scope of practice, meeting all legislative requirements and maintaining 

standards of professional conduct, and  
  Documenting all care in accordance with mandatory and local requirements 

 
Explanation of the aboriginal artwork: 
The aboriginal artwork used symbolises the connection to country and the circle shape shows the strong relationships amongst families and the aboriginal culture. 
The horse shoe shape design shown in front of the generic statement symbolises a woman and those enclosing a smaller horse shoe shape depicts a pregnant 
woman. The smaller horse shoe shape in this instance represents the unborn child. The artwork shown before the specific statements within the document 
symbolises a footprint and demonstrates the need to move forward together in unison. 

     

 

 

 

 

 

 
 
 
 
 
The term  Aboriginal  is used to refer to people who identify as Aboriginal, Torres Strait Islanders, or both Aboriginal and Torres Strait 
Islander.  This is done because the people indigenous to South Australia are Aboriginal and we respect that many Aboriginal people prefer the 
term  Aboriginal .  We also acknowledge and respect that many Aboriginal South Australians prefer to be known by their specific language 
group(s). 

 Cultural safety enhances clinical safety.  

To secure the best health outcomes, clinicians must provide a culturally safe health care 
experience for Aboriginal children, young people and their families. Aboriginal children are 
born into strong kinship structures where roles and responsibilities are integral and 
woven into the social fabric of Aboriginal societies. 

Australian Aboriginal culture is the oldest living culture in the world, yet Aboriginal people 
currently experience the poorest health outcomes when compared to non-Aboriginal 
Australians. 
 
It remains a national disgrace that Australia has one of the highest youth suicide rates in 
the world.  The over representation of Aboriginal children and young people in out of 
home care and juvenile detention and justice system is intolerable. 
 
The cumulative effects of forced removal of Aboriginal children, poverty, exposure to 
violence, historical and transgenerational trauma, the ongoing effects of past and present 
systemic racism, culturally unsafe and discriminatory health services are all major 
contributors to the disparities in Aboriginal health outcomes. 
 
Clinicians can secure positive long term health and wellbeing outcomes by making well 
informed clinical decisions based on cultural considerations. 
 



Acute Pain Management and  
Opioid Safety in Children 

 South Australian Paediatric Clinical Practice Guidelines 
 

 

 
INFORMAL COPY WHEN PRINTED  Page 2 of 30 

OFFICIAL 
 

Purpose and Scope of PCPG 
In addition to information on analgesic options for children, this guideline delineates the 
responsibilities of medical nursing staff related to the section of appropriate medication, its 
administration and the monitoring of children receiving analgesia.  

Doses and monitoring requirements in this guideline refer to analgesic doses.  For procedural 
sedation refer to organisational guidelines. 

Table of Contents 
Purpose and Scope of PCPG                         .  .. 2 
Abbreviations                                .  .. 3 
Principles of Acute Pain Management                     .   4 
Pain Assessment Tools   .                           .5 
Opioid Safety                                  ... 6 
Slow / Modified / Controlled Release Opioids                    ... 7 
Opioid Weaning                                 .. 8 
Discharge of Paediatric Patients on Opioid Analgesia               .   8 
Patients Requiring Special Consideration and Closer Monitoring             9 
Monitoring and Observation                             10 
Minimum Observations Following Opioid Administration              ...  11 
Management of Opioid Related Side Effects                    ... 12 
Paracetamol   .                            .   .15 
Non-steroidal Anti-inflammatory Drugs (NSAIDs)                   .. 16 
Tramadol   .                                ... 18 
Oral Opioid   Immediate Release                         . 20 
Oral Opioid   Slow Release (SR) / Modified Release (MR) / Controlled Release (CR) 
and Long-Acting   .                             .. 21 
Intravenous Opioid   Bolus                            . 22 
Subcutaneous (SC) and Intramuscular (IM) Opioid   Intermittent             23 
Intranasal Fentanyl                               .. 23 
Transdermal Opioid                               . 24 
Additional Adjuvant Medications                           25 

Muscle Relaxant: Diazepam                          . 25 
Clonidine   .                               . 25 
Amitriptyline   .                               25 
Gabapentin   .                              . 25 
Pregabalin   .                              ... 25 

Intravenous Opioid / Analgesic Infusions / Nurse Controlled Analgesia (NCA)        26 
Patient Controlled Analgesia (PCA)                         . 28 
References   .                               ... 29 
Acknowledgements   .                           .  29 
Document Ownership &amp; History   .                        30 
 



Acute Pain Management and 
Opioid Safety in Children 

South Australian Paediatric Clinical Practice Guidelines 

INFORMAL COPY WHEN PRINTED Page 3 of 30 

OFFICIAL 

Abbreviations 
ED Emergency Department 

g grams 

ICU Intensive Care Unit 

IV Intravenous 

Kg kilograms 

MAD Mucosal Atomiser Device  

Mg Milligrams 

mL milliliters 

NCA Nurse Controlled Analgesia 

NSAIDs Non-steroidal anti-inflammatory drugs 

PBS Pharmaceuticals Benefit Scheme 

PCA Patient Controlled Analgesia 

PO Per oral 

QID Quarter in die (four times a day) 

Sedation score 1 Awake, alert 

Sedation score 2 Easy to rouse 

Sedation score 3 Easy to rouse, difficulty staying awake 

Sedation score 4 Difficult to rouse (severe respiratory depression) 

SNRIs Serotonin noradrenaline reuptake inhibitors 

SpO2 Oxygen saturation measure by pulse oximetry 

SR Slow release 

SS Sedation score 

SSRIs Selective serotonin reuptake inhibitors 

TDS Ter die sumendum (three times a day) 

WCHN Women s and Children s Health Network 



Acute Pain Management and  
Opioid Safety in Children 

 South Australian Paediatric Clinical Practice Guidelines 
 

 

 
INFORMAL COPY WHEN PRINTED  Page 4 of 30 

OFFICIAL 
 

Principles of Acute Pain Management 
? The assessment and management of pain requires consideration of all of the 

biopsychosocial aspects of pain 

? The goal of effective pain management is to keep the patient comfortable so that they can 
achieve their goals, e.g. deep breathing and coughing, mobilising, sleeping and playing 

? Initiate appropriate non-pharmacological interventions to support patient comfort through 
distraction or play e.g. reading, movies, music, craft, relaxation techniques 

? Analgesics should be given by the simplest method possible and at the lowest dose to 
achieve the desired analgesic effect 

? Oral administration should be used as soon as the patient can tolerate oral intake 

? Multimodal analgesia describes the concurrent use of different classes of analgesic 
medications in order to maximise analgesia and minimise side effects.  If clinically 
appropriate, medications most commonly used as components of multimodal analgesia 
include paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), opioids, tramadol, 
clonidine and low dose ketamine infusion 

? The optimal use of simple analgesics helps reduce opioid use so the risk of opioid related 
side effects is minimised 

? Initial treatment of acute pain with oral opioids should use immediate-release opioids on a 
PRN basis 

? Recommended doses provide a starting point but may require adjustment according to 
individual response.  Balance analgesic effects with adverse effects, especially sedation 

? For opioid naive individuals, the initial PRN dose of immediate release opioid should be 
weight-based.  Clinicians should obtain expert advice or consult the literature when 
providing analgesia for obese children.  Doses may need to be adjusted according to age, 
including gestational age for neonates, ideal body weight or co-existent liver or renal 
impairment.  For patients transitioning from intravenous Patient Controlled Analgesia (PCA) 
or opioid infusion/Nurse Controlled Analgesia (NCA), PRN dose can be guided by their 
previous intravenous opioid requirements.  Intermittent dosing permits treating acute pain in 
a targeted way, which is variable, changes with activity and improves with time as the 
patient recovers 

? It is safer to administer a lower dose and titrate up to achieve the desired analgesic effect 

? Assess the patient s comfort and ensure their level of sedation is safe prior to 
administration of opioid medications.  Refer to Pain Assessment Tools section to help 
recognise the patients level of comfort 

? Pain should be assessed and documented every one to four hours when the patient is 
receiving interventions for pain and then as required.  The patient should be reassessed at 
the time of peak effect of the drug related to route of administration 

? Recognise that increasing discomfort to a level out of proportion to the 
trauma/surgery/illness may indicate a change in clinical condition that requires review by 
the treating team 

? Even in an acute pain setting, psychological and social aspects need to be addressed 
concurrently with medical and pharmacological approaches such as analgesics.  Pre-
operative anxiety, catastrophising, depression or other mental health issues can amplify or 
confuse a patient s expression of discomfort.  Addressing these is important in treating 
acute pain adequately 



Acute Pain Management and  
Opioid Safety in Children 

 South Australian Paediatric Clinical Practice Guidelines 
 

 

 
INFORMAL COPY WHEN PRINTED  Page 5 of 30 

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International Association for the Study of Pain 

Pain Assessment Tools 
FLACC Pain Score (behavioural)  
Suggested age group: term neonates   7 years and for older children who are non-
verbal 
Instructions: 

1. Rate patient in each of the five measurement categories 
2. Add together   total score between 0 and 10 
3. Document total pain score 

 

 

Faces Pain Scale - Revised 
Suggested age group: 4 years and older. 
Patients have an option of 6 faces to select across a pain scale 0-10. 

 

Translation options available online: https://www.iasp-pain.org/resources/faces-pain-scale-revised/#download  
 

Verbal Numerical Rating Scale 
Suggested age group: adults and children 6 years and older.                               
                                    
 
 
 
 
 
 

 

Visual Analogue Scale 
Suggested age group: 6 years and older 
Patient marks their pain intensity along a 10cm line from  no pain  to  worst pain  which is then 
measured with a ruler. 

 Scoring 
Categories 0 1 2 

Face No particular 
expression or smile 

Occasional grimace or 
frown, withdrawn, 
disinterested 

Frequent to constant frown, 
clenched jaw, quivering chin 

Legs Normal position or 
relaxed Uneasy, restless, tense Kicking or legs drawn up 

Activity Lying quietly, normal position, moves easily 
Squirming, shifting back 
and forth, tense Arched rigid or jerking 

Cry No cry (awake or 
asleep) 

Moans or whimpers, 
occasional complaints 

Crying steadily, screams or 
sobs, frequent complaints 

Consolability Content, relaxed 
Reassured by occasional 
touching, hugging or 
talking, distractible 

Difficult to console or 
comfort 

No 
pain 

Worst 
possible 

pain 




Acute Pain Management and  
Opioid Safety in Children 

 South Australian Paediatric Clinical Practice Guidelines 
 

 

 
INFORMAL COPY WHEN PRINTED  Page 6 of 30 

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Opioid Safety 
? Opioid medications are the primary medications administered to patients with moderate to 

severe nociceptive pain. 

? Safe use of opioid medications requires knowledge of: 

o opioids available 
o formulations available 
o routes of administration 
o management of potential side effects 
o specific patient observation and monitoring. 

? Ensure that care is provided in an environment with pre-checked oxygen and suction . 

? Naloxone should always be available in areas where opioid medications are administered. 

? As a result of the individual variability of response following opioid administration, close 
observation is required for all patients over the period of peak concentration of the 
medication - this will depend on the specific medication used and the route of 
administration   refer to Minimum Observations following Opioid Administration section 

? Opioid analgesia should not be administered unless the patient has a sedation score 
less than 2 (is easy to rouse to voice or light touch and able to maintain eye opening and 
eye contact for &gt;10 seconds). 

? Document in  Pharmacy/Additional Information  space on the National Standard Medication 
Chart only give if sedation score &lt; 2 or only give if SS&lt;2 

? Prescriptions for immediate release oral opioids with a dose range allows the nurse to 
provide analgesia based on individual response to treatment.   

? Prolonged use of opioids can result in tolerance, requiring greater doses if the cause of 
pain does not diminish over time.  Opioid rotation should be considered with a reduction in 
the equianalgesic dose of the new medication. 

? Opioid-induced hyperalgesia is where increasing doses of opioids paradoxically lead to 
increased pain sensitivity (hyperalgesia) rather than analgesia.  Treatment options for 
suspected opioid-induced hyperalgesia include dose increase (to rule out tolerance), opioid 
dose decrease or cessation, changing to non-opioid analgesics or using multimodal 
analgesia for opioid-sparing . 

 
 
 
 

 
 
 
  

? Recommended analgesic doses in this procedure are for opioid naive patients. 

? Recommended doses are for routine analgesic use.  Refer to organisational procedure 
for management of opioid medications used in conjunction with sedative medications 
for procedural pain relief. 



Acute Pain Management and  
Opioid Safety in Children 

 South Australian Paediatric Clinical Practice Guidelines 
 

 

 
INFORMAL COPY WHEN PRINTED  Page 7 of 30 

OFFICIAL 
 

Slow / Modified / Controlled Release Opioids 
? Slow/modified/controlled release opioids are not recommended for use in acute pain 

management. 

? After careful consideration and opportunity to assess the patients response to immediate 
release opioids, slow release opioids may be considered in a previously opioid-naive 
patient on a temporary basis for post-operative or post-traumatic prolonged pain states. 

? Always tick the SR (slow release) box on the National Standard Medication Chart when 
prescribing for inpatients. 

? Document in  Pharmacy/Additional Information  space on the National Standard Medication 
Chart only give if sedation score &lt; 2 or only give if SS&lt;2 

? In acute pain, daily opioid requirements may vary considerably.  The dose should be 
assessed frequently and adjusted appropriately. 

? Not all pain is opioid responsive.  If excessive sedation develops (a warning sign of 
impending respiratory depression) but pain is still present, non-opioid analgesics should be 
considered.  Slow-release opioids in this scenario add further complexity and risk. 

? The plan to wean and cease slow/modified/controlled release opioids is the responsibility of 
the person/medical team who initiated it.  The need for discharge opioids should be 
assessed based on the inpatient use and anticipated ongoing requirements.  Timely formal 
communication with other appropriate medical staff and/or the patient s general practitioner 
about weaning and discontinuation should be completed.  Appropriate instructions about 
opioid weaning should be given to the patient/carers by the treating team and pharmacy. 

? Patients already taking opioids prior to admission are already tolerant and physically 
dependent on that opioid.  After independent confirmation of the medication and dose, their 
slow-release opioid should be continued.  The patient s acute pain should be treated using 
multimodal analgesia including titration with PRN immediate release opioids.  Their opioid 
requirements are likely to be greater than for those who are opioid na ve. 

Prescribing slow/modified/controlled release opioids for acute pain management 

Prescribing these medications may be restricted to certain prescriber groups.  At WCHN these 
medications must only be prescribed by: 

o Acute Pain Service (APS) 
o Chronic Pain Service 
o Palliative Care 
o Other Consultant medical officer staff experienced in the prescribing of slow release 

opioids. 

 
 

 
  



Acute Pain Management and  
Opioid Safety in Children 

 South Australian Paediatric Clinical Practice Guidelines 
 

 

 
INFORMAL COPY WHEN PRINTED  Page 8 of 30 

OFFICIAL 
 

Opioid Weaning 
If patients have received regular or high doses of opioids for more than one week, weaning will 
be required before cessation to avoid opioid withdrawal. 

? Infants of opioid dependent mothers who develop Neonatal Abstinence Syndrome   refer to 
High Risk Patients section 

? Following prolonged opioid administration during intubation and ventilation  

? Following prolonged opioid analgesia: 

o often occurs when the patient has ongoing analgesic need 
o the duration and dose of opioid treatment will influence the rate and frequency  

of weaning 
o if weaning is to continue at home, it is important that the patient/carers fully 

understands the process, including signs and symptoms of opioid withdrawal. 

? When ready for discharge from hospital, the ward pharmacist can develop weaning 
instructions in a Medication Profile for the patient/carers. 

 

Discharge of Paediatric Patients on Opioid Analgesia 
? Prescription of opioid analgesia for patients discharged from hospital needs to be 

undertaken with caution due to the risk of abuse, misuse and diversion, adverse effects, 
interactions with other medication, impairment of driving and increased risk of falls 

? If opioid analgesia is considered appropriate for discharge, limit the quantity supplied to the 
clinically appropriate amount 

? Reinforce the education of the patient/family and provide written information 

? Discuss safe storage of the medications at home to ensure they will be kept out of reach of 
children 

? Advise patients/parents to return any unused opioid medication to their local pharmacy for 
safe disposal 

  



Acute Pain Management and  
Opioid Safety in Children 

 South Australian Paediatric Clinical Practice Guidelines 
 

 

 
INFORMAL COPY WHEN PRINTED  Page 9 of 30 

OFFICIAL 
 

Patients Requiring Special Consideration and Closer Monitoring 
Some patients have a higher than usual risk of over sedation and respiratory depression.  
Safety can be improved through avoidance of concurrent sedatives or opioids by other routes, 
awareness of comorbidities posing extra risk and by careful dosing.  These patients require 
special consideration when prescribing and administering opioids with vigilant monitoring 
before and after doses are given.   

High Risk Patients 
? Pre-existing respiratory co-morbidities, including: 

o ex-premature infants 
o airway obstruction, asthma, chronic respiratory conditions e.g. cystic fibrosis 
o sleep apnoea or increased potential for sleep apnoea e.g. cerebral palsy, craniofacial 

disorders, muscular dystrophy 
o limited neck mobility 
o obesity. 

? Those receiving concurrent sedative medications, including benzodiazepines and sedating 
antihistamines e.g. promethazine. 

? Pre-existing conditions e.g. liver or renal impairment or concurrent medications which 
reduce drug metabolism or excretion. 

? Previous adverse reaction to opioid medications. 

Infants 
? Opioid medications have a prolonged half-life with increased risk of opioid accumulation in 

infants under 6 months of age and ex-premature infants up to 6 months corrected age. 

? Infants less than 12 months require special consideration of monitoring and dosing if 
opioids are administered by any route   refer to Minimum Observations following Opioid 
Administration section. 

? Discuss appropriate opioid doses with a consultant from Anaesthesia, Emergency 
Department, Intensive Care Unit or medical consultant if they are competent in appropriate 
assessment and dosing. 

Pregnant women/newborn infants 
? When opioids are administered to pregnant women, consideration must be given to the 

potential effect on the fetus. 

? Naloxone is not routinely used in neonatal resuscitation although may be ordered by 
neonatal staff.  In such instances, the newborn infant requires monitoring in the Special 
Care Baby Unit for 4-6 hours to monitor for recurrent respiratory depression.  Medical 
review is required prior to leaving the unit. 

Opioid tolerant mothers/infants 
? It is harmful for the fetus if an opioid dependent mother ceases opioids abruptly during 

pregnancy.  Newborn infants of opioid dependent mothers who develop Neonatal 
Abstinence Syndrome require monitoring, Neonatal Abstinence Syndrome scores and, if 
appropriate, an opioid weaning protocol. Refer to South Australian Perinatal Practice 
Guideline   Infants of Drug Dependent Women and South Australian Neonatal Medication 
Guideline - Morphine. 

? Naloxone is contraindicated in newborn infants born to opioid dependent mothers.  Acute 
opioid withdrawal can result in rapid onset of withdrawal symptoms including convulsions 

? For opioid-tolerant adult patients who are being treated by an outside agency for opioid 
dependence, refer to Medical Management of Patients at Risk of Opioid Withdrawal Clinical 
Guideline. 









Acute Pain Management and  
Opioid Safety in Children 

 South Australian Paediatric Clinical Practice Guidelines 
 

 

 
INFORMAL COPY WHEN PRINTED  Page 10 of 30 

OFFICIAL 
 

Monitoring and Observation 
Opioid analgesia should not be administered unless the patient has a sedation score 
less than 2 - is easy to rouse to voice or light touch and able to maintain eye opening and eye 
contact for &gt;10 seconds. 

Monitoring is mandatory for all patients receiving opioid infusions, Nurse Controlled Analgesia, 
Patient Controlled Analgesia, sedative agents for procedural sedation, high dose oral opioids 
and standard dose oral opioids if the patient has any risk factors that increase sedation and 
respiratory depression. 

More frequent observations may be required depending on clinical status, treating team orders 
and/or post-operative assessment. 

Patients are at their most vulnerable when: 

? The medication is at its peak concentration for the route of administration. 

? They are taking concurrent sedating medications. 

? The pain stimulus is removed e.g. wound dressing completed, hernia reduced, chest drain 
removed. 

In certain circumstances there may be exceptions to monitoring of the patient and pump, such 
as palliative care.  These decisions should be made in consultation with the treating team, 
palliative care and/or the Acute Pain Service and be documented in the Medical Record. 

Minimum monitoring: 

? Continuous cardio-respiratory monitoring for all: 

o ex-premature infants up to 6 months corrected age 
o full term infants up to 2 months of age. 

? Continuous pulse oximetry for all: 

o high risk children   refer to High Risk Patients section 
o full terms infants 2   12 months of age. 

  



Acute Pain Management and  
Opioid Safety in Children 

 South Australian Paediatric Clinical Practice Guidelines 
 

 

 
INFORMAL COPY WHEN PRINTED  Page 11 of 30 

OFFICIAL 
 

Minimum Observations Following Opioid Administration 
? This applies when given for routine analgesia.  When given in higher doses and/or in 

conjunction with sedatives   refer to organisational procedure.  

? Does not apply to opioid weaning programs such as Neonatal Abstinence Syndrome. 

ROUTE OBSERVATIONS 

Oral opioids 

Observe 1 hour post administration for analgesic effect and side effects. 
Record sedation score and pain score plus additional observations if any 
signs of respiratory compromise or over sedation. 

 Age &lt; 12months   see Infants alert below  
Intramuscular / 
subcutaneous 

opioids 
Not recommended 

for general 
paediatric use 

Subcutaneous Fentanyl: Record pre and 15 minutes post each dose 
administration: respiratory rate, heart rate, SpO2, sedation score and pain 
score. 

Morphine: Record pre and 30 minutes post each dose administration: 
respiratory rate, heart rate, SpO2, sedation score and pain score. 

Intravenous bolus 
Record pre and 5, 15 and 30 minutes post administration: 

  respiratory rate, heart rate, SpO2, sedation score and pain score. 
Continuous oximetry recommended and mandatory for infants &lt; 12 months. 

Intranasal fentanyl 
Record pre and 10 and 30 minutes post administration: 

  respiratory rate, heart rate, SpO2, sedation score and pain score. 
Observe for 45 minutes from last dose. 

Opioid infusions, 
Patient Controlled 

Analgesia 

Observations as per organisational procedure. 

Mandatory for all patients: continuous pulse oximetry   record respiratory 
rate, heart rate, SpO2, sedation score and pain score hourly. 

 Age &lt; 12 months   see Infants alert below 
INFANTS 

Require smaller doses + longer observation 
 

Discuss doses with Anaesthetic, Medical, ED, ICU or Neonatal Consultant for infants less 
than 12 months of age 

 

Opioids administered via any route require minimum cardio-respiratory monitoring as below 
Record respiratory rate, heart rate, SpO2, sedation score and pain score at least hourly for duration 

of monitoring or more frequently depending on route as per above observations 
Age Minimum duration of monitoring 

Ex-premature infant up to 6 months 
corrected age 

(older if persisting respiratory issues) 
12 hours post opioid or last apnoea/brady 

Full term infant: Birth - 2 months 8 hours 

Full term infant:  2 - 6 months 
(pulse oximetry monitoring may be sufficient) 4 hours 

6   12 months 
(pulse oximetry monitoring may be sufficient)  2 hours 



Acute Pain Management and  
Opioid Safety in Children 

 South Australian Paediatric Clinical Practice Guidelines 
 

 

 
INFORMAL COPY WHEN PRINTED  Page 12 of 30 

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Management of Opioid Related Side Effects 
Opioids have the potential to cause itch, startles, urinary retention, constipation, nausea and 
vomiting, sedation and respiratory depression.  These are side effects rather than allergic 
reactions and are usually dose related for each individual.  Refer to Recognising and 
Responding to Clinical Deterioration clinical guideline when clinically appropriate. 

Itch 
Opioid-induced itch is primarily on the face and chest 

? Maximise opioid sparing analgesia 

? There is some evidence that a 5-HT3 receptor antagonist, such as ondansetron, decreases 
the incidence and severity of opioid-induced itch 

? If itch is distressing and/or impacting on sleep and recovery, consider change of opioid or 
change from intravenous to oral route if clinically appropriate 

? Non-pharmacological measures e.g. cool face cloths 

? Low dose naloxone may be titrated to effect to relieve opioid-induced itch following 
therapeutic doses without affecting analgesia 
o dosage: 1 microgram/kg/dose - repeat after 30 minutes if required 

Startles 
Occurs most often in infants and young children 

? Maximise opioid sparing analgesia 

? If startles are distressing and/or impacting on sleep and recovery, consider change of 
opioid or change from intravenous route to oral route if clinically appropriate 

Urinary Retention 
? Maximise opioid sparing analgesia 

? Use appropriate strategies to encourage urination 

? Consider other reasons for urinary retention/lack of urinary output 

? Escalate to treating team as per clinical escalation guidelines 

Constipation 
? Monitor bowel function 

? Consider regular stool softeners and stimulant laxatives for patients receiving regular 
opioids 

? Avoid bulk-forming laxatives in opioid induced constipation. 

  





Acute Pain Management and  
Opioid Safety in Children 

 South Australian Paediatric Clinical Practice Guidelines 
 

 

 
INFORMAL COPY WHEN PRINTED  Page 13 of 30 

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Post-operative / Opioid Induced Nausea and Vomiting 
 

 

Considerations when managing post-operative nausea and vomiting 
? Limit/cease oral intake 

? Hydrate patient (IV fluids) 

? Minimise activity 

? Encourage rest/sleep 

? Reassure 

? Manage discomfort 

? Maximise opioid sparing analgesia 

? If concern about opioid related nausea and vomiting, consider change of opioid or change 
from intravenous to oral route of administration if clinically appropriate 

? Review to exclude other reasons for persistent nausea and vomiting 

? Many patients receive antiemetics in theatre   check intra-operative anaesthetic chart 

? Ondansetron can cause prolongation of the QT interval. Use with caution in patients who 
have pre-existing prolongation of the QT interval, are taking other medications which may 
increase the QT interval or have risk factors for a prolonged QT interval. 

  

 
 

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Ondansetron 
Dose: refer to  

Australian Medicines 
Handbook   

Children s Dosing 
Companion 

  
IV/oral 8 hourly 

 
 

Not within 8 hrs of 
intraoperative dose 

Cyclizine 
Dose: refer to 

Australian 
Medicines 

Handbook   
Children s Dosing 

Companion 
 

IV 8 hourly 
 

 
 

Droperidol 
Dose: refer to 

Australian 
Medicines 

Handbook   
Children s Dosing 

Companion 
 

IV 8 hourly 
 

Do not prescribe 
for children less 
than  2 years old  

Dexamethasone 
Dose: refer to 

Australian 
Medicines 

Handbook   
Children s Dosing 

Companion 
 

IV single dose only 
 

Not within 24 hrs of 
intraoperative dose  

 

 






















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Opioid Safety in Children 

 South Australian Paediatric Clinical Practice Guidelines 
 

 

 
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Sedation indicating Potential Respiratory Depression 
The best clinical indicator for potential respiratory depression is increasing sedation 

1. Check respiratory rate, depth and SpO2 
2. Stimulate the patient 
3. Administer oxygen and initiate other resuscitation measures as clinically appropriate 
4. If patient is on a PCA or opioid infusion, put the pump on hold 
5. Escalate to a medical officer or Medical Emergency Response as clinically indicated 
6. If observations stable, including respiratory rate and SpO2: 

? continue continuous oximetry until sedation resolves 
? restart PCA or opioid infusion at a lower rate once sedation score &lt; 2 and pain 

score ? 3. 

? If patient using oral or IV bolus opioid administration, ask the treating team or the Acute 
Pain Service, if involved, for a review of the analgesia including dosage before the next 
dose is required. 

? Naloxone may be necessary following review by an anaesthetist or Medical Emergency 
Response team. 

Naloxone for Reversal of Opioid Action   acute opioid overdose or sedation due 
to therapeutic use 
? Naloxone may be necessary following review by an anaesthetic, ED or ICU specialist. 
? Naloxone is short-acting (20-60 minutes) and therefore is shorter acting than most opioids.  

Observe the patient closely for any recurrence of sedation following the last naloxone 
dose for a minimum of: 
o 4 hours for short-acting opioid such as immediate release formulations 
o 24 hours for long-acting opioid such as slow/controlled/modified release formulations 

or methadone. 
Dosage: 

? Paediatrics: refer to Australian Medicines Handbook   Children s Dosing Companion 

o Contraindicated in newborn infants born to opioid dependent mother: risk of rapid 
onset of withdrawal, including seizures (link to South Australian Perinatal Practice 
Guideline   Infants of Drug Dependent Women). 

 

 






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Opioid Safety in Children 

 South Australian Paediatric Clinical Practice Guidelines 
 

 

 
INFORMAL COPY WHEN PRINTED  Page 15 of 30 

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Paracetamol 

Age Dose Preparation 
Indication and 

additional 
information 

Paracetamol 
Neonate 

Refer to South Australian Neonatal Medication 
Guideline - Paracetamol 

 

Mild to moderate 
pain 

 

May be used as a 
component of 

multimodal 
analgesia 

 

May be given in 
conjunction with 
ibuprofen if no 

contraindications for 
NSAID 

 

See below for 
relative 

contraindications/ 
considerations and 

indications for 
intravenous use 

 

Birth (at term)  
   

1 month  
(44 weeks post 
conceptual age) 

 

&gt;1 month 
(44 weeks post 
conceptual age) 

 

 
 

Refer to Australian 
Medicines Handbook   

Children s Dosing 
Companion 

 
 

Give PR only with 
parental consent  

 
 
 

 
 

Oral (liquid):  
 

250 mg/5mL 
*check specific bottle 

 
Oral (tablets):  

 

500 mg 
 

Rectal (suppository): 
30 mg* 
60 mg* 
125 mg 
250 mg 
500 mg 

*WCHN manufactured 
product 

 
Injection: 

 

1 g/100mL 
 

 

 

 

 

 

 

 

 
 

Relative contraindications/considerations when ordering paracetamol 
Refer to Australian Medicines Handbook   Children s Dosing Companion 

 

Indications for intravenous use 
? Current SA Medicines Formulary restriction: when other forms of paracetamol are inappropriate 

  patients MUST be nil by mouth 
? Not tolerating oral intake 
? Rectal route not available e.g. rectal surgery, oncology 
? Rectal route refused or inappropriate 
? As soon as the oral or rectal routes are available, intravenous route should be changed 
 

 










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Opioid Safety in Children 

 South Australian Paediatric Clinical Practice Guidelines 
 

 

 
INFORMAL COPY WHEN PRINTED  Page 16 of 30 

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Non-steroidal Anti-inflammatory Drugs (NSAIDs) 
Dose reduction required for renal or severe hepatic impairment 

Dose Preparation 
Indication and 

additional 
information 

Ibuprofen 
 

Mild to moderate 
pain, especially 
in relation to an 
inflammatory 
process 
 
Administer oral 
preparations 
with food or milk 
*single dose may 
be given without 
food/milk 
although this 
may cause mild 
stomach irritation 
 
May be used as 
a component of 
multimodal 
analgesia 
 
May be given 
with paracetamol 
 
See below for 
relative 
contraindications/ 

   considerations 

 
Refer to Australian Medicines Handbook   

Children s Dosing Companion 
 
 
 

 
 

 

 

Oral (liquid):  
 

100 mg/5mL 
 

Oral (tablets):  
 

200 mg 
400 mg 

Diclofenac 
 

Refer to Australian Medicines Handbook   
Children s Dosing Companion 

 
 
 
 

 

 

Suppositories: 
 

12.5 mg 
25 mg 
50 mg 
100 mg 

 
Give rectal only with 

parental consent  
 

Oral (tablets): 
 

25 mg 
50 mg 

No liquid preparation 
available 

  Celecoxib 
 

  Selective COX-2 Inhibitor 
 

   

 

May be given 
without regard for 
timing of meals 

 

100   200 mg 
oral twice daily 

 
Multiple doses (up to 14 days) for patients  

&gt; 12 years of age and &gt; 40kg  
AND  

who can take oral medicines but are not tolerating 
food (alternative to parecoxib) 

 

 

Oral (capsules): 
 

100 mg 
200 mg 

 

  

  
 

Do not give to infants &lt; 3 months of age 

 
 

Do not give to infants &lt; 6 months of age 







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Parecoxib 
 

Selective COX-2 Inhibitor 
 
 

 

 

1 mg/kg 
IV once daily 

 
Maximum dose: 40 mg/dose 

 
paediatric surgical patients  

? 2 years of age 
 

Multiple doses (up to 3 further doses in the post-
operative setting) for children ? 2 years of age on 

recommendation of the 
WCH Acute Pain Service only 

 
No further NSAID for at least 12 hours 

 

Injection:  
 

40 mg 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 
 

 

 

Relative contraindications/considerations when ordering NSAIDs 

? Hypovolaemia, dehydration, prolonged lack of oral intake   NSAIDs may reduce renal function 
and cause acute renal impairment (prostaglandins are important in maintaining renal blood flow 
when circulating blood volume is decreased) 

? Pre-eclampsia 
? Pregnancy 
? Renal disease 
? Severe hepatic impairment 
? NSAID/Aspirin induced Asthma   NSAIDs may increase risk of bronchospasm.  If trialled 

previous NSAID with no issues   may be used.  If not previous trial of NSAID   suggest use. 
? Bleeding/clotting disorder   non-selective NSAIDs may increase risk of bleeding (anti-platelet 

effect) 
? Likelihood of surgical intervention within 48 hours   particularly if there is a significant risk of 

post-operative bleeding and in people requiring critical haemostasis 
? History of gastrointestinal bleeding, ulceration or inflammatory bowel disease 
? Recent neurosurgical/transcranial procedure 
? Ear, Nose &amp; Throat surgery (consult with surgeon) 
? Cardiovascular disease or increased cardiovascular risk is present 
? Known hypersensitivity reaction 
? Rectal administration contraindicated in: inflammatory bowel disease, surgery or 

inflammatory conditions of the rectum, anus or sigmoid colon and most oncology patients 
 

 



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Opioid Safety in Children 

 South Australian Paediatric Clinical Practice Guidelines 
 

 

 
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Tramadol 
Dose reduction required for renal or severe hepatic impairment. 

It is not recommended to prescribe Tramadol to outpatients   seek expert advice. 
 

Dose Preparation 
Indication and 

additional 
information 

Tramadol   Immediate Release 
 

Moderate pain 
 

May be used as an 
analgesic in its own right 
or as an opioid sparing 
agent 
 
Reputation for nausea 
but well tolerated by 
many, especially children 
 
Report tachycardia, 
tremor, sedation or 
agitation to treating team 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

See below for 
relative 
contraindications/ 
considerations 

 

Refer to  
Australian Medicines Handbook   

Children s Dosing Companion 
 
 
 
 

 
 
 

 

Oral (capsules):  
 

50 mg 
 

For doses other than 50 mg or  
100 mg orally, disperse contents of 

capsule: 
50 mg made up to 10mL in water 

= 5 mg/mL 
 

Injection: 
 

100 mg/2mL 
 
 
 

 

Tramadol   Slow Release 
 

Minimum patient weight: 25kg 
Refer to Australian Medicines 

Handbook 
Always tick the SR box on the 

National Standard Medication Chart 
when prescribing for inpatients 

 
 
 
 
 
 

Time to peak concentration:  
10-12 hours after 1st dose 

 

Duration of effect: 12 hours 

 

Oral (tablets):  
 

50 mg 
100 mg 

 
 
 
 
 

 

  
Do not give to infants 
&lt; 12 months of age 

 

If prescribing SR + immediate 
release tramadol for 

breakthrough, do not exceed 
maximum recommended daily 

dose 

Tablets must not be crushed, 
cut or chewed 

When ordering for 
discharge: 

 

  Patient must have 
tolerated a dose 
during current 
admission 

 
  Order a clinically 

appropriate 
quantity 

 
  Dispersing of 

capsules requires 
specific caregiver 
education from a 
pharmacist  

 

 

Tramadol drops not 
recommended for children 

 







Acute Pain Management and  
Opioid Safety in Children 

 South Australian Paediatric Clinical Practice Guidelines 
 

 

 
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Relative contraindications/considerations when ordering tramadol 

Do not use for the following patients: 
? History of seizures or a recognised risk for seizures as it may lower seizure threshold 
? Concurrently taking selective serotonin reuptake inhibitors (citalopram, dapoxetine, 

escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline) and serotonin and noradrenaline 
reuptake inhibitors (desvenlafaxine, duloxetine, venlafaxine)   risk of serotonin toxicity 

? Received pethidine in the last two days 
? Received moclobemide in the last two days 
? Received monoamine oxidase inhibitors (phenelzine, transylcypromine) in the last 14 days. 

Use with caution: 

? Tramadol is metabolised to an active metabolite by CYP2D6; variable metabolism may result 
in toxicity or reduced effect 

? In patients who are taking warfarin - may increase anticoagulant effects 
? In patients who are taking tricyclic antidepressants (amitriptyline, clomipramine, dosulepin 

(dothiepin), doxepin, imipramine, nortriptyline) especially at higher doses 
? Carbamazepine - may reduce tramadol s activity 

          
  

 



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Opioid Safety in Children 

 South Australian Paediatric Clinical Practice Guidelines 
 

 

 
INFORMAL COPY WHEN PRINTED  Page 20 of 30 

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Oral Opioid   Immediate Release 
Dose reduction required for renal or severe hepatic impairment 

Dose Preparation Routine observations 
Indication and 

additional 
information 

Oxycodone   Oral 
 

Refer to Australian Medicines 
Handbook   Children s Dosing 

Companion* 
 
 
 
 
 
 
 
 
 

 
 
 
 
 
 
 

 
 

 

Oral (liquid):  
 

1 mg/mL 
 

Oral (tablets):  
 

5 mg 
 

 

Observe at 1 hour for 
analgesic effect and 
side effects 

 
 
 
 
 

 

 

Moderate   severe 
pain if oral route 
available 
 

Oral opioid of choice 
for children 
 

Document on 
medication chart: 
only give if sedation 
score &lt; 2 (only give if 
SS&lt;2) 
 

Consider minimising 
supply quantity on 
discharge 

Morphine   Oral 
 

Refer to Australian Medicines 
Handbook   Children s Dosing 

Companion* 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Oral (liquid):  
 

5 mg/mL 

 

Observe at 1 hour for 
analgesic effect and 
side effects 
 

 

 

 

 

 

 
 

 

Moderate   severe 
pain if oral route 
available 
 

Morphine liquid is 
less palatable than 
oxycodone 
 
Document on 
medication chart: 
only give if sedation 
score &lt; 2 (only give if 
SS&lt;2) 
 

Larger doses may 
be ordered as a 
component of 
procedural 
analgesia   refer to 
organisational 
procedure for dosing 
&amp; monitoring 

*Immediate release opioids may occasionally be used at regular (scheduled) intervals or shorter 
intervals than those stated above with Acute Pain Service advice 

  
For infants &lt; 12 months of age 

or concerns re. respiratory 
depression   consult with 

Anaesthetic, Medical, ICU, ED 
or Neonatal Consultant 

  
*For infants &lt; 12 months of age 

or concerns re. respiratory 
depression   consult with 

Anaesthetic, Medical, ICU, ED 
or Neonatal Consultant 

 

  
 

Special monitoring 
precautions for 

infants &lt; 12 
months of age - 

refer to Minimum 
Observations  

  
 

Special monitoring 
precautions for 

infants &lt; 12 
months of age - 

refer to Minimum 
Observations 









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Opioid Safety in Children 

 South Australian Paediatric Clinical Practice Guidelines 
 

 

 
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Oral Opioid   Slow Release (SR) / Modified Release (MR) / 
Controlled Release (CR) and Long-Acting        

Slow release opioids are not recommended for acute pain management    
refer to Slow/Modified/Controlled Release Opioids section 

  Oxycodone Slow Release 
(Oxycontin  SR) 

 

Non-formulary   not stocked at the WCH* 
*available on Statewide Formulary   at WCH can be prescribed for continuing therapy while 

inpatient on recommendation of WCH Pain Service  
Tramadol Slow Release 
Refer to Tramadol section 

Methadone 
Long-acting 

  Specialised modality   seek expert advice  

Dose Preparation Routine observations 
Indication and 

additional information 

Morphine SR 
(MS Contin ) 

  Specialised modality   seek expert advice  
 

 

Refer to Australian 
Medicines Handbook   

Children s Dosing 
Companion 

 

Time to peak concentration:  
3-4 hours after 1st dose 
 

Duration of effect: 12 hours 
 
 

 

 

Oral (sachets):  
20 mg made up to 

10 mL water 
= 2 mg/mL 

 

Oral (tablets):  
5 mg 
10 mg 
15 mg 
30 mg 
60 mg 

 

 

Observe for and 
report excessive 
sedation, 
especially at 
commencement 
of therapy or with 
dose increase 

 

 

Moderate   severe pain 
At WCH, must only be 

prescribed by: 
  Acute Pain Service 

(APS) 
  Chronic Pain Service 
  Palliative Care 
  Other Consultant 

medical officer staff 
experienced in the 
prescribing of slow 
release opioids 

 

Document on medications 
chart: only give if sedation 
score &lt;2 (only give if 
SS&lt;2) 

         
?  
?  
 

 

  
 

refer to 
Minimum 

Observations Tablets must not 
be crushed, cut 

or chewed 

? Practice Points when ordering Morphine SR (MS Contin ). 
? Consider dose reduction in renal or hepatic impairment. 
? It takes 2-3 days to reach steady state following commencement. 
? Breakthrough analgesia should be ordered PRN if used for analgesia. 
? Can be used within an opioid weaning process, opioid tolerance or opioid rotation. 
? In most instances, slow release or long-acting doses should be administered even when 

patients are fasting prior to a general anaesthetic. 
? Tick the SR box on the medication chart when prescribing these medications. 
 

 
 

 







Acute Pain Management and  
Opioid Safety in Children 

 South Australian Paediatric Clinical Practice Guidelines 
 

 

 
INFORMAL COPY WHEN PRINTED  Page 22 of 30 

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Intravenous Opioid   Bolus        
Morphine: consider dose reduction in renal or hepatic impairment 
Fentanyl: consider dose reduction in renal impairment 
? Single dose intravenous bolus opioids have a role in the management of short term 

moderate-severe pain or incident related pain 
? If regular bolus doses are required, the use of PCA, NCA or opioid infusions should be 

considered if available in your organisation using organisational procedures 
 

Dose Preparation Routine observations 
Indication and 

additional 
information 

Morphine   Intravenous 
 

Record pre and 5 
minutes, 15 minutes 
and 30 minutes post 
administration: 
respiratory rate, heart 
rate, SpO2, sedation 
score and pain score 
 
Continuous oximetry 
recommended for all 
and mandatory for 
infants  
&lt; 12 months of age 

 
 
 
 
 
 
 
 
 
 
 

If given in conjunction 
with sedative agents 
for procedural pain, 
refer to organisational 
procedure for 
personnel &amp; 
monitoring 

 
 
  

 

Single dose:  
moderate   severe pain 
or incident related pain 
 
If regular bolus doses 
are required, the use of 
PCA or opioid infusion 
should be considered 
 
 Pain Protocols  for use 
ONLY in Emergency 
Department and Post 
Anaesthetic Care Unit by 
accredited staff following 
local organisational 
guidelines 
  
 

Larger IV doses may 
be ordered as a 
component of 
paediatric procedural 
analgesia refer to 
organisational procedure 
for dosing &amp; monitoring 
 
Document on medication 
chart: only give if 
sedation score &lt; 2 (only 
give if SS&lt;2) 

 

Refer to  
Australian Medicines Handbook   

Children s Dosing Companion 
 

 

 
 
 
 
 
 
 

Titrate dose according to 
response and sedation 
 

Time to peak concentration:  
20 minutes 
 

Duration of effect: 2-4 hours 

 

Injection: 
10 mg/mL 

 

Fentanyl   Intravenous 
 

Refer to  
Australian Medicines Handbook   

Children s Dosing Companion 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
Time to peak concentration:  
3-5 minutes 
 

Duration of effect:  30-60 minutes 

 

Injection: 
50 microgram/mL 

 
Infants &lt; 12 months of age: 
special dosing precautions - 

consult with Anaesthetic, Medical, 
ICU, ED or Neonatal Consultant 

 
Infants &lt; 12 months of age: 
special dosing precautions - 

consult with Anaesthetic, Medical, 
ICU, ED or Neonatal Consultant 

  
 

Special monitoring 
precautions for 

infants &lt;12 
months of age - 

refer to Minimum 
Observations  







Acute Pain Management and  
Opioid Safety in Children 

 South Australian Paediatric Clinical Practice Guidelines 
 

 

 
INFORMAL COPY WHEN PRINTED  Page 23 of 30 

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 Subcutaneous (SC) and Intramuscular (IM) Opioid   Intermittent     

Intranasal Fentanyl 

Dose Preparation Routine Observations 
Indication and 

additional 
information 

Fentanyl   Intranasal 
Refer to  

Australian Medicines 
Handbook   Children s 

Dosing Companion 
 

 
 
 
 
 
 
 
 
 
 

 
 
 
 

Time to therapeutic level:  
10 minutes 

 
Duration of effect: 

30-60 minutes 
 

Injection: 

50 microgram/mL 

Prior to 
administration and 
10 minutes following 
each dose: 

heart rate, 
respiratory rate, 
SpO2, pain score 
and sedation score 

Patient must be 
observed for 45 
minutes following 
last dose and until 
they have returned 
to their pre-analgesic 
level of functioning 

If used with a 
sedative agent as a 
component of 
paediatric 
procedural 
analgesia   refer to 
organisational 
procedure for 
additional monitoring 

Severe pain 

May be used as 
initial analgesia or 
procedural pain 
management e.g. 
fractures requiring 
plaster application 
or wound 
exploration 

Do not use if the 
patient has an altered 
conscious state, head 
injury or if they have 
upper respiratory or 
nasal tract infection 
as absorption can be 
altered 

Document on 
medication chart: 
only give if sedation 
score &lt; 2 (only give 
if SS&lt;2) 

Administration 
Use a Mucosal Atomiser Device  (MAD) and a 3mL syringe 

1. Draw up more than required dose 
2. Attach MAD to the syringe 
3. Prime syringe to correct dose - this eliminates dose errors from 0.09mL dead space in 

atomiser 
4. Position the patient, if able, sitting up with head tilted back at a 45o angle 
5. Deliver fentanyl into single nostril   the volume may be equally divided into both 

nostrils, especially if large volume 

Morphine   Subcutaneous / Intramuscular 
Fentanyl - Subcutaneous 

  Not recommended for general paediatric use  

 
Infants &lt; 12 months of age: 
special dosing precautions - 

consult with Anaesthetic, 
Medical, ICU, ED or 
Neonatal Consultant 






Acute Pain Management and  
Opioid Safety in Children 

 South Australian Paediatric Clinical Practice Guidelines 
 

 

 
INFORMAL COPY WHEN PRINTED  Page 24 of 30 

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Transdermal Opioid 
 Not recommended for acute pain management  

Refer to organisational procedures for management of patches 

Dose Available sizes Routine Observations 
Indication and 

additional 
information 

Fentanyl   Transdermal 
Buprenorphine - Transdermal 

  Specialised modality   seek expert advice  
 

 

If converting from parenteral or oral 
opioid analgesic medication:  
starting dose can be estimated using 
the total opioid requirement in the 
previous 24 hours using an 
equianalgesic table or Opioid 
Calculator available from ANZCA 
Faculty of Pain Medicine website  
or app store 
 

It is preferable to choose a slightly 
lower dose and provide 
breakthrough analgesia when 
commencing therapy 
 

Patch size may be titrated depending 
on breakthrough use 

 
 

Fentanyl: 
12 microgram/hr 
25 microgram/hr 
50 microgram/hr 
75 microgram/hr 
100 microgram/hr 

 
 

Buprenorphine: 
5 microgram/hr 

10 microgram/hr 

 

Observe for 
sedation during 
the first 24 
hours of 
therapy or if the 
patch size is 
increased 

 

Predominantly used  
in palliative care, 
oncology or for 
patients requiring a 
few days of 
background opioid 
who are non-
compliant with oral 
medications and have 
no IV access 

Practice Points when ordering transdermal opioids 
? Do not use for opioid na ve patients. 
? The initial patch will take time to reach peak effect and breakthrough analgesia may be required 

during this period. 
? Check with a pharmacist or prescriber that the patch is suitable for cutting. 
? Patients require observation for over sedation during the first 24 hours of therapy or if the patch 

size is increased. 
? Check patch 2-3 times daily and document to ensure patch remains in place. 
? Remove the old patch prior to applying a new patch. 
? Dispose of used patches as per organisational procedure - must be folded over and disposed of 

in a yellow sharps container. 

Time to peak effect of transdermal opioids: 

Drug 
Time to steady state after 
initial patch application or 

dose increase 

Patch 
replacement 

Length of effect 
following patch removal 

Fentanyl 12   24 hours  
(therapeutic at 6 hours) 

Every 3 days 50% wears off over 17 hours 

Buprenorphine Up to 3 days Weekly 50% wears off over 12 hours 





Acute Pain Management and  
Opioid Safety in Children 

 South Australian Paediatric Clinical Practice Guidelines 
 

 

 
INFORMAL COPY WHEN PRINTED  Page 25 of 30 

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Additional Adjuvant Medications 
Muscle Relaxant: Diazepam 
? Muscle spasm may occur following some neurosurgery or orthopaedic surgery/trauma 
? Oral diazepam is the medication of choice 
? If patient is on concurrent opioids or sedating medications, monitor SpO2 following initial 

dose 

     Dosage: Diazepam 
     Refer to Australian Medicines Handbook   Children s Dosing Companion 

Clonidine 
? ?2 adrenoreceptor agonist 
? Has analgesic and sedative properties as well as a role in facilitating opioid weaning 
? Anti-hypertensive   do not give if hypotensive 

o Monitor blood pressure with 1st dose and any subsequent dose increases: 
IV: pre and 30 minutes post administration 
Oral: pre and 1 hour post administration 

? Reduce dose if sedation excessive 
? Regular dosing can be stopped immediately if used for less than 2 weeks 
? If used for more than 2 weeks, wean off regular dose   suggest daily over at least 5 days 

then stop 

Dosage: consider dosage reduction in renal impairment 
Oral / IV clonidine dose: 1-2 micrograms/kg/dose 8 hourly regularly or PRN 

Amitriptyline 
? Tricyclic antidepressant but can be used for the management of neuropathic pain in low 

doses 
? No oral mixture available 

     Dosage: prescribed once per day 2 hours prior to bed time 
     Refer to Australian Medicines Handbook   Children s Dosing Companion 

Gabapentin 
? Anticonvulsant medication but can be used in the management of neuropathic pain 
? Used in post-operative and burn injury for neuropathic pain 
? Not available on PBS for neuropathic pain so not first choice for outpatient care 
? No oral mixture available but the contents of the capsules may be dispersed in 10mL of 

water before administration 

Dosage: consider dosage reduction in renal impairment 
     Refer to Australian Medicines Handbook   Children s Dosing Companion 

Pregabalin 
? Available on PBS for neuropathic pain 
? No oral mixture available 

     Dosage: 
     No paediatric dosing guidelines available  






Acute Pain Management and  
Opioid Safety in Children 

 South Australian Paediatric Clinical Practice Guidelines 
 

 

 
INFORMAL COPY WHEN PRINTED  Page 26 of 30 

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Intravenous Opioid / Analgesic Infusions / Nurse Controlled 
Analgesia (NCA) 

  Specialised modality   seek expert advice  
Opioid infusions and nurse controlled analgesia provide continuous and/or bolus doses of 
opioid/analgesic medication for the management of acute pain to infants, children and older 
patients who are unable to effectively manage patient controlled analgesia. 

Refer to organisational procedure for indications, contraindications, management and specific 
patient monitoring requirements.  The syringe pump should be lockable to prevent accidental 
or intentional tampering. 

Patients receiving opioid infusions require close observations because of the risk of 
accumulation and adverse effects.  Continuous pulse oximetry is mandatory for all patients and 
must continue for at least two hours following cessation of opioid infusion.  As a minimum, 
document respiratory rate, heart rate, SpO2, sedation score and pain score at least hourly. 
 

Infants   additional monitoring 
The physiological immaturity of infants increases their sensitivity to opioids.  Particular attention 
and longer monitoring is required in infants receiving opioid infusion and following cessation of 
opioid infusion   refer to Minimum Observations Following Opioid Administration section 

 

? Morphine - consider dose reduction in hepatic or renal impairment 
? Fentanyl - consider dose reduction in renal impairment 
 

Opioid / Analgesic Infusion standard dosing protocol: 
 

 

  

Infants LESS than 1 year 

Morphine or Oxycodone Fentanyl 

  Add 0.5 mg/kg and dilute to a total volume  
of 50mL with sodium chloride 0.9% 
(10micrograms/kg/mL) 

  Rate: 0   2 mL/hr  
(0   20 micrograms/kg/hr) 
 

  Bolus dose: 1   2mL  
(10   20 micrograms/kg) every 30 minutes PRN 
for breakthrough or intervention pain. 

  Add 10 micrograms/kg and dilute to a total 
volume of 50mL with sodium chloride 0.9% 
(0.2micrograms/kg/mL) 

  Rate: 0   2 mL/hour  
(0   0.4 micrograms/kg/hr)  
 

  Bolus dose: 1   2mL  
(0.2   0.4 micrograms/kg) every 15 minutes 
PRN for breakthrough or intervention pain 



Acute Pain Management and  
Opioid Safety in Children 

 South Australian Paediatric Clinical Practice Guidelines 
 

 

 
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Children 1 year and OVER 

Morphine or Oxycodone Fentanyl 

  Add 0.5 mg/kg (maximum 50mg/50mL) and 
dilute to a total volume of 50mL with sodium 
chloride 0.9% (10 micrograms/kg/mL or less if 
&gt;50kg) 

  Rate: 0   4 mL/hour  
(0   40 micrograms/kg/hr) 

  Bolus dose: 1   3mL  
(10   30 micrograms/kg) every 30 minutes PRN 
for breakthrough or intervention pain. 

  Add 10 micrograms/kg (maximum 
1000micrograms/50mL) and dilute to a total 
volume of 50mL with sodium chloride 0.9% 
(0.2 micrograms/kg/mL or less if &gt;50kg) 

  Rate: 0   4 mL/hour  
(0-0.8 micrograms/kg/hr)  

  Bolus dose: 1   3mL  
(0.2   0.6 micrograms/kg) every 15 minutes 
PRN for breakthrough or intervention pain 

 
Low dose ketamine infusions may be prescribed to provide adjuvant analgesia in order to 
enhance the analgesic effects of opioid medications while acting as an opioid sparing agent 
and in the prevention and treatment of neuropathic pain.  Ketamine may be used prior to and 
after an amputation to try and prevent subsequent phantom pain.  Ketamine may cause 
dysphoric reactions. 

 

  

Ketamine   Low Dose Infusion 

Low dose ketamine infusion may be prescribed to provide adjuvant analgesia in order to 
enhance the analgesic effect of opioid medications while acting as an opioid sparing agent and 
in the prevention and treatment of neuropathic pain. 

  Add 5 mg/kg (maximum 200mg/50mL) and dilute to a total volume of 50mL with sodium 
chloride 0.9% (100 micrograms/kg/mL or less if &gt;40kg) 

  Rate: 0   2 mL/hour (0   200 micrograms/kg/hr) 

  Bolus doses are not to be given outside of PICU 



Acute Pain Management and  
Opioid Safety in Children 

 South Australian Paediatric Clinical Practice Guidelines 
 

 

 
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Patient Controlled Analgesia (PCA) 
  Specialised modality   seek expert advice  

Patient controlled intravenous analgesia (PCA) is a method of pain control that allows patients 
to self-administration analgesia using a programmable device in response to pain or 
anticipated pain.   

Refer to organisational procedure for indications, contraindications, management and specific 
patient monitoring requirements.  The syringe pump should be lockable to prevent accidental 
or intentional tampering. 

Patients receiving opioid infusions require close observations because of the risk of 
accumulation and adverse effects.  Continuous pulse oximetry is mandatory for all patients and 
must continue for at least two hours following cessation of opioid infusion.  As a minimum, 
document respiratory rate, heart rate, SpO2, sedation score and pain score at least hourly. 

PCA is usually programmed without a background infusion, particularly in opioid na ve patients. 
A background infusion increases the risk of sedation and respiratory depression. 

? Dilute to a total of 50mL with sodium chloride 0.9% 
 
Dosing Protocol: 

 

 

Administration Order: 
 

  Lockout period: 5 minutes   may be adjusted by prescriber according to symptoms  
  Continuous background infusion: rarely required 

o do not consider a background infusion unless sedation score ? 1 i.e. the patient is 
easy to rouse to voice or light touch and able to maintain eye opening and eye 
contact for &gt;10 seconds 

  PCA delivery: stat   may be adjusted by prescriber according to symptoms 
 

Morphine or Oxycodone 
Less than 50kg: 
  Add 1 mg/kg and dilute to a total volume of 50mL with sodium chloride 0.9%  (20 

micrograms/kg/mL) 
  Bolus dose: 1mL = 20 micrograms/kg 
 
50kg or greater: 
  Add 50 mg and dilute to a total volume of 50mL with sodium chloride 0.9%  (1 mg/mL) 
  Bolus dose: 1mL = 1 mg 

Fentanyl 

Less than 50kg: 
  Add 20 micrograms/kg and dilute to a total volume of 50mL with sodium chloride 0.9%  

(0.4 micrograms/kg/mL) 
  Bolus dose: 1mL = 0.4 micrograms/kg 
 
50kg or greater: 
  Add 1000 micrograms and dilute to a total volume of 50mL with sodium chloride 0.9%  

(20 micrograms/mL) 
  Bolus dose: 1mL = 20 micrograms 



Acute Pain Management and  
Opioid Safety in Children 

 South Australian Paediatric Clinical Practice Guidelines 
 

 

 
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References 
1. American Society of Anesthesiaologists 2014,  Practice Guidelines for Acute Pain 

Management in the Perioperative Setting , Anesthesiology, vol. 100, no. 6, pp. 1573-
1581 

2. Australian Medicines Handbook Children s Dosing Companion (online). Australian 
Medicines Handbook Pty  Ltd; 2018 Jan. Available from: https://childrens.amh.net.au/ 

3. Australian Medicines Handbook (online). Australian Medicines Handbook Pty Ltd; 
2018 Jan. Available from: https://amhonline.amh.net.au/  

4. Australian and New Zealand College of Anaesthetists. Australia; 2018 March. Position 
statement on the use of slow-release opioid preparations in the treatment of acute 
pain [cited 2019 May 22]. Available from 
http://www.anzca.edu.au/resources/endorsed-guidelines/position-statement-on-the-
use-of-slow-release-opio   

5. Drugdex Drug Evaluations Micromedex Healthcare Series, accessed 19-03-18 
6. Evelina London Paediatric Formulary, accessed 20-05-21 
7. Ganesh A, Maxwell L 2007,  Pathophysiology and Management of Opioid-Induced 

Pruritis , Drugs, vol. 67, no. 16, pp. 2323-2333 
8. Hayes J, Dowling J, Peliowski A, Crawford M, 2016,  Patient-Controlled Analgesia 

plus Background Opioid Infusion for Postoperative Pain in Children: a systematic 
review and meta-analysis of randomised trials , Society for Paediatric Anaesthesia, 
vol. 123, no. 4, pp. 991-1003 

9. International Association for the Study of Pain, 2021, accessed 14-10-21 
https://www.iasp-pain.org/resources/faces-pain-scale-revised/  

10. Jarzyna D, Jungquist C, Pasero C, Willens J 2011,  American Society for Pain 
Management Nursing guidelines on monitoring for opioid-induced sedation and 
respiratory depression ,  Pain Manag Nurse, vol. 12, no. 3, pp. 118-145 

11. Lien C, Youngwerth J 2012,  Patient-Controlled Analgesia  Hospital Medicine Clinics, 
vol. 1, no. 3, pp. e386-e403 

12. Schug S, Palmer G, Scott D, Halliwell R, Trinca J, APM:SE Working Group of the 
Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine 
(ed.) 2015, Acute Pain Management: Scientific Evidence (4th edition),  ANZCA &amp; FPM, 
Melbourne 

Acknowledgements 
The South Australian Child and Adolescent Health Community of Practice gratefully 
acknowledges the contribution of clinicians and other stakeholders who participated throughout 
this guidelines development process, particularly:  

 
Write Group Lead 
   Dr Laura Burgoyne 
 
Write Group Member 
   Rachel Dineen 
 
South Australian Paediatric Clinical Practice Guideline Reference Group  
  








Acute Pain Management and  
Opioid Safety in Children 

 South Australian Paediatric Clinical Practice Guidelines 
 

 

 
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Document Ownership &amp; History 
Developed by: SA Child &amp; Adolescent Health Community of Practice 
Contact: Health.PaediatricClinicalGuidelines@sa.gov.au 

Endorsed by:  Domain Custodian, Clinical Governance, Safety &amp; Quality 
Next review due:  26/06/2025 
ISBN number:  978-1-74243-907-5 
CGSQ reference:  PCPG004 
Policy history: Is this a new policy (V1)?  N 
 Does this policy amend or update and existing policy?   Y 
 If so, which version? 2 
 Does this policy replace another policy with a different title?  N 
 If so, which policy (title)?   
 
 

Approval 
Date Version 

Who approved New/Revised 
Version Reason for Change 

14/04/22 V2.2 Domain Custodian, Clinical Governance, Safety and Quality 

Minor updates to better support 
paediatric dosing and 
assessment on EMR/Sunrise to 
reflect practice: PCA update to 
50ml total volume, add 
oxycodone infusion/PCA, 
update post-op nausea &amp; 
vomiting list, update paediatric 
Faces Pain Scale 

10/12/20 V2.1 Chair, Child and Adolescent Health Community of Practice 
Minor amendment: ketamine 
infusion dose increase. 

26/06/20 V2 
Lynne Cowan, Deputy CE, 
Commissioning and Performance,  
SA Department for Health and 
Wellbeing 

Formally reviewed in line with 1-
5 year scheduled timeline for 
review. 

03/08/18 V1.1 SA Safety and Quality Strategic Governance Committee 
Minor amendment: tramadol 
dose reduction for children 

02/03/16 V1 SA Safety and Quality Strategic Governance Committee Original 

 



	Purpose and Scope of PCPG
	Table of Contents
	Abbreviations
	Principles of Acute Pain Management
	Pain Assessment Tools
	Opioid Safety
	Slow / Modified / Controlled Release Opioids
	Opioid Weaning
	Discharge of Paediatric Patients on Opioid Analgesia
	Patients Requiring Special Consideration and Closer Monitoring
	Monitoring and Observation
	Minimum Observations Following Opioid Administration
	Management of Opioid Related Side Effects
	Paracetamol
	Non-steroidal Anti-inflammatory Drugs (NSAIDs)
	Dose reduction required for renal or severe hepatic impairment
	Tramadol
	Oral Opioid   Immediate Release
	Oral Opioid   Slow Release (SR) / Modified Release (MR) / Controlled Release (CR) and Long-Acting
	Intravenous Opioid   Bolus
	Subcutaneous (SC) and Intramuscular (IM) Opioid   Intermittent
	Intranasal Fentanyl
	Transdermal Opioid
	Muscle Relaxant: Diazepam
	Clonidine
	Amitriptyline
	Gabapentin
	Pregabalin

	Intravenous Opioid / Analgesic Infusions / Nurse Controlled Analgesia (NCA)
	Patient Controlled Analgesia (PCA)
	References
	Acknowledgements
	Document Ownership &amp; History

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