Acute Pediatric Pain Management (6 months-18 years)
Acute Pediatric Pain Management (6 months-18 years)
Can consider either intranasal ketamine or sufentanil.

Sufentanil Intranasal
Ketamine Intranasal

Contraindications to ibuprofen?

Inclusion Criteria
  • Obvious significant pain (source not important)
Exclusion Criteria
  • Hx of high risk airway disease, surgery or tracheostomy
  • Respiratory distress or oxygen requirement
  • Head/mid-face trauma, LOC or mental status changes
  • Toxic appearance

Contraindications to PO?

Contraindications to acetaminophen?

Consultations with physician qualified to manage acute pain

IV access already established?

Contraindications to intranasal fentanyl?

Contraindications to IV morphine?

Still severe pain after 5 min?

Acetaminophen suspension

Qualitative assessment of pain - Wong-Baker FACES or r-FLACC (by any provider - MD, RN, etc.)

Ibuprofen suspension

Morphine injection

>30 kg?

Revised Face, Legs, Activity, Cry, Consolability (r-FLACC) Tool


0 points

1 point

2 points


No particular expression or smile

Occasional grimace/frown; withdrawn or disinterested; appears sad or worried

Consistent grimace or frown; frequent/constant quivering chin, clenched jaw; distressed-looking face; expression of fright or panic


Normal position or relaxed; usual tone & motion to limbs

Uneasy, restless, tense; occasional tremors

Kicking, or legs drawn up; marked increase in spasticity, constant tremors or jerking


Lying quietly, normal position, moves easily; regular, rhythmic respirations

Squirming, shifting back and forth, tense or guarded movements; mildly agitated (e.g. head back and forth, aggression); shallow, splinting respirations, intermittent sighs.

Arched, rigid or jerking; severe agitation; head banging; shivering (not rigors); breath holding, gasping or sharp intake of breaths, severe splinting


No cry/verbalization

Moans or whimpers; occasional complaint; occasional verbal outburst or grunt

Crying steadily, screams or sobs, frequent complaints; repeated outbursts, constant grunting


Content and relaxed

Reassured by occasional touching, hugging or being talked to. Distractible.

Difficult to console or comfort; pushing away caregiver, resisting care or comfort measures

Non-pharmacological actions for pain control

  • Child life involvement
  • Parental involvement
  • Distraction techniques
  • Relaxing / Safe environment

Reassessment of pain level every 30 min

Examples of high risk airway diseases

  • Active obstructive sleep apnea
  • Active pneumonia or airway infection
  • Severe asthma
  • Chronic lung disease
  • Neuromuscular disorders impacting breathing (MD, SMA, etc)
  • Note: many more exist

Can consider either intranasal ketamine or fentanyl.

Fentanyl Intranasal
Ketamine Intranasal

Home - Wong-Baker FACES Foundation

Consultation with physician qualified to manage acute pain.

Reassessment of pain level every 30 min

75% 100% Zoom 125%

Export to PDF