PAEDIATRIC ANALGESIA GUIDELINES

V5.1

JUNE 2017
 Table of Contents

1.  Introduction .................................................................................................................3 

2.  Purpose of this Policy/Procedure ............................................................................. 3 
3.  Scope ........................................................................................................................... 3 
4.  Definitions / Glossary ................................................................................................. 3 
5.  Ownership and Responsibilities ............................................................................... 3 
6.  Standards and Practice .............................................................................................. 4 
6.1 Hints and Tips ...................................................................................................... 4 
6.2.  Guidelines for Paediatric Analgesia ...................................................................... 5 
6.3.  Guidance for the use or oral sucrose solution prior to minor painful procedures in
babies under 4 months ..................................................................................................... 6 
6.4.  Intranasal Diamorphine (Ayendi) ........................................................................... 7 
6.5.  IV Morphine Infusion ............................................................................................. 8 
6.6.  Morphine Patient Controlled Analgesia (PCA) ...................................................... 9 
6.7.  Morphine Nurse Controlled Analgesia (NCA)...................................................... 10 
6.8.  Fentanyl Infusion and PCA ................................................................................. 11 
6.9.  Paediatric Recovery ............................................................................................ 13 
6.10.  Epidurals ............................................................................................................. 14 
6.11.  Management of Leg Weakness with Epidurals ................................................... 16 
6.12.  Mean Values for weight, height and gender by age ............................................ 17 
7.  Dissemination and Implementation ........................................................................ 18 
8.  Monitoring compliance and effectiveness ............................................................. 18 
9.  Updating and Review ............................................................................................... 18 
10.  Equality and Diversity .............................................................................................. 18 
10.3.  Equality Impact Assessment ............................................................................... 18 
Appendix 1. Governance Information ............................................................................ 19 
Appendix 2. Initial Equality Impact Assessment Form ................................................. 21 

Paediatric Analgesia Guidelines

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1. Introduction
1.1. This policy has been drawn up to ensure that Paediatric patients within the
Trust receive appropriate pain relief.
1.2. This version supersedes any previous versions of this document.

2. Purpose of this Policy/Procedure

2.1. The purpose of this policy is to inform all staff of the appropriate analgesia
regimes for paediatric patients.

3. Scope
3.1. This policy applies to anyone who looks after children within RCHT.

4. Definitions / Glossary
4.1.
PCA- Patient Controlled Analgesia
NCA- Nurse Controlled Analgesia
TTO- Tablets to Take Out
NSAID- Non Steroidal Anti-Inflammatories
IV- Intravenous

5. Ownership and Responsibilities

5.1. The Acute Paediatric Pain Service is responsible for the development,
management and implementation of this policy/procedure.

5.2.
 Dr Julian Berry
 Medicines Practice Committee
 Acute Paediatric Pain Service
 Anaesthetists (Paediatric)
 Clinical staff members

Paediatric Analgesia Guidelines

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6. Standards and Practice
6.1. Hints and Tips
Hints and Tips
(Not for use with children under 3 months of age)
PROTOCOLS ON EPMA
Whenever possible use a pre-prescribed weight-based EPMA protocol:
 PAED PERI- For children going to theatre.
 PAED PAIN- For inpatient analgesia
 FEMUR CHILD- For children admitted with a fractured femur.
Paracetamol
 Orally is rapidly absorbed from the small bowel, almost 100% bioavailability, and has a
similar onset time to IV preparation.
 IV dose will result in higher plasma and effect site concentrations1
 Rectally uptake is slower and more variable; doses of 20mg/kg are often not therapeutic
and take 2-4 hrs to reach therapeutic concentrations2. Therefore PR 40mg/kg followed by
20mg/kg doses are recommended
Always go for oral dosing first, as the cost of rectal and IV preparations are comparable and are 10
times greater than oral.
NSAIDs: Ibuprofen and Diclofenac
 NSAIDs ‘‘opioid-sparing’’ effect of 30–40%3
 Only 2% with asthma have a deterioration in lung function when given aspirin, only 5% of
those patients have a cross sensitivity to other NSAIDS therefore risk is low.
 In orthopaedic procedures benefits outweigh the risks of reduced bone healing in most
cases. Avoid if non-union or scoliosis surgery4.
 Cochrane review has demonstrated that there is no increase in bleeding post tonsillectomy
 Diclofenac: No longer routinely used in Paediatrics.
Codeine Phosphate and Oramorph
 Codeine should only be used to relieve acute moderate pain in children older than 12 years
and only if it cannot be relieved by other painkillers such as Paracetamol or Ibuprofen
alone.
A significant risk of serious and life-threatening adverse reactions has been identified in
children with obstructive sleep apnoea who received codeine after tonsillectomy or
adenoidectomy (or both). Codeine is now contraindicated in all children younger than 18
years who undergo these procedures for obstructive sleep apnoea5
 Oramorph should be used at doses of 100 - 300 micrograms/kg max 4 hourly for in-patient
analgesia.
 If TTOs are required they should be prescribed as 50-100 micrograms/kg max 6 hourly.
Ensure that simple analgesia doses are appropriate and given regularly before adding
Oramorph.
Opiates
 In Paediatrics morphine PCA provides superior analgesia to the intramuscular route or to
continuous infusion of morphine, with comparable outcome to epidural morphine.6
 See intravenous opiate guidelines

1
Morton, N S.(2007) Arch Dis Child Educ Pract Ed 92: ep14-ep19
2
Anderson, B J. (1998) What we don’t know about Paracetamol in children. Paediatric Anaesthesia ;8:451–60
3
Kokki, H. (2003) Non steroidal anti-inflammatory drugs for postoperative pain: a focus on children. Paediatric Drugs; 5:103–23.
4
Ippokratis Pountos, Theodora Georgouli, Giorgio M. Calori, and Peter V. Giannoudis (2012). Do Nonsteroidal Anti-Inflammatory Drugs
Affect Bone Healing? A Critical Analysis. The Scientific World Journal, Volume 2012, Article ID 606404.
5
MHRA (2013) Drug safety update. MHRA; Volume 6, Issue 12.
6
Morton, N. (1997) Paediatric Patient Controlled Analgesia. Paediatric Perinat Drug Ther; 1:9–13.
Paediatric Analgesia Guidelines
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 6.2. Guidelines for Paediatric Analgesia

Guidelines for Paediatric Analgesia

(NOT FOR USE IF UNDER 3 MONTHS)

Whenever possible use a pre-prescribed weight-based EPMA protocol: ‘Paed Pain (ward), ‘Paed Peri’ (theatre) or
‘Femur Child’ (# femur in ED).
Adequate and regular dosing is essential. Use the oral route if pain is not severe. Use parenteral administration if the
drug can only be used this way or if enteral administration has failed or ineffective.
 Prescribe ONE drug from each colour only.
 If more than two IV opiate doses are required, consider IV infusion/PCA/NCA with guidelines.
Contact Paediatric Pain Team on bleep 2283 (office hours) or Senior Anaesthetic Trainee (bleep3513) for advice
or help.
DRUG ROUTE DOSE ESCALATING
ANALGESIA

Suspension- 120mg/5ml 20mg/kg 6 hourly PO/PR for 48 hours

Paracetamol 250mg/5ml
Tablets- 500mg Then reduce to
Soluble tablets- 500mg
Suppositories- 60, 120, 250, 500mg 15/mg/kg 6 hourly

Maximum daily dose 75mg/kg, not exceeding

4g / day
ONLY TO BE PRESCRIBED IF
Intravenous ORAL ROUTE NOT AVAILABLE <10kg- 7.5mg/kg 6 hourly
Paracetamol >10kg- 15mg/kg 6 hourly
50mls- 500mg >50kg- 1g max 6 hourly
100mls- 1g

Ibuprofen Suspension- 100mg/5ml 3-6months- 5mg/kg 8 hourly PO

Tablets- 200, 400mg >6 months- 10mg/kg 8 hourly PO

Maximum daily dose 30mg/kg or 1.2g

Oramorph- 10mg/5ml Orally

Morphine Tablets- 10, 20mg <12 months- 50 micrograms/kg 4 hourly
Injection- 10mg/ml >12 months- 100-300 micrograms/kg 4 hourly

Intravenous-
<6 months 100 micrograms/kg 6 hourly
>6 months 100 micrograms/kg 4 hourly

TTO’s of Oramorph-
>12 months- 100 micrograms/kg 6 hourly
If OSA/altered respiratory drive-
50micrograms/kg 6 hourly
INTRANASAL- ONCE ONLY
Diamorphine Intranasal spray- See separate guideline on intranet
720micrograms/spray intranetanaestheticguidelinespaediatric pain
1600micrograms/spray

RESPIRATORY DEPRESSION
 Give oxygen, contact paediatric or ITU consultant. Consider PERT call.
 < 12 years- Naloxone 10micrograms/kg IV bolus and repeat if necessary. If no response, give subsequent doses of 100
micrograms/kg (max 2mg)
> 12 years- Naloxone 100micrograms IV bolus and repeat if necessary. If no response, give subsequent doses in
increments of 100micrograms every 2 minutes if required (max dose 10mg).

FIRST-LINE ANTI-EMETIC
Ondansetron Intravenous 0.1mg/kg 8 hourly Can cause severe constipation.
See BNFC for Orally <4 years- 2mg 8 hourly May be ineffective in opioid induced nausea
alternatives >4 years- 4mg 8 hourly and vomiting.
CONSIDER ENTONOX FOR PROCEDURAL PAIN RELIEF

Paediatric Analgesia Guidelines

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 6.3. Guidance for the use or oral sucrose solution prior to minor
painful procedures in babies under 4 months

Indication for use

 In conjunction with non-nutritive sucking, oral sucrose solution can relieve pain in neonates
during minor procedures such as venepuncture, heel prick, cannulation, intramuscular
injections, subcutaneous injection, lumbar puncture etc.
 Sucrose is only effective when given orally, directly onto the infant's tongue.
 There is no analgesic effect if sucrose is given directly into the stomach via a nasogastric
tube.

 Breast feeding is more efficacious than sucrose.

 The efficacy and safety of repeated doses/maximum doses is not known.

Contraindications
 Necrotising enterocolitis.

 Suspected hyperglycaemia.

 Do not use in ventilated or paralysed babies.

Dose
 Must be prescribed on their drug chart.

 Ideally, obtain consent from the parent to use.

 The dose is administered onto the baby’s tongue approximately 2 minutes prior to the
procedure. After administration the baby should be given a dummy or comforter to suck on
as this can potentiate the analgesic effect of sucrose. The effect may last for approximately
10 minutes.

Preterm neonates <3kgs 0.5-1ml of 24% sucrose 4 times a day

solution
Term neonates > 3kgs 1-2ml of 24% sucrose 6-8 times a day
solution

There is no data regarding repeated doses or long term effects of using sucrose.

Holsti, L. and Grunau, R.E. (2010) Considerations for using sucrose to reduce procedural pain in
preterm infants, Pediatrics, 125(5) pp 1042-1047.

Stevens, B., Yamada, J., Lee, G. and Ohlsson, A. (2013) Sucrose for analgesia in newborn infants
undergoing painful procedures, Cochrane Database of Systematic Reviews; Cochrane Neonatal
Group, DOI: 10.1002/14651858.CD001069.pub4

Paediatric Analgesia Guidelines

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 6.4. Intranasal Diamorphine (Ayendi)

Indications
 First line treatment of severe pain in a child without IV access e.g.
Clinically suspected limb fractures
Painful dressings/burns
Procedural pain
 Intranasal Diamorphine is usually effective within 5-10 minutes but allow 20 minutes
for maximum pain control. Analgesic effect lasts for up to 4 hours.
 Oxygen saturation monitoring will be required once Diamorphine has been
administered and for 1 hour post administration.
 Ensure that intravenous access is obtained as soon as possible.
 Ensure that supplementary analgesia is prescribed (see coloured paediatric
analgesia dosing guideline) e.g. Paracetamol and NSAIDs.
 Naloxone must be prescribed (see coloured paediatric analgesia dosing guideline).
 *Child less than 12kg weight (unlicensed) only to be administered by a senior doctor.
Contraindications
 Nasal trauma or epistaxis.
 Decreased conscious level or head injury
 Allergy to opiates.
Dose schedule
 Dosing is based on weight
 Preparation and administration-
Reconstitute, if required and date the bottle. Attach pump and nasal tip, remove
green collar and prime with 8 sprays.
Subsequent doses- Remove the green safety collar. Attached new nasal tip and
before use prime using 2 sprays.
Administer the required number of sprays (alternate nostrils).
Discard the used nasal tip and replace the green safety collar.
 CD register- Record both the wastage from priming and the number of sprays in the
register.

NB AFTER RECONSTITUTION THE BOTTLE MUST BE DISPOSED OF AFTER 14 DAYS.

WEIGHT OF CHILD APPROX AGE TOTAL NUMBER TOTAL DOSE

OF SPRAYS DELIVERED

720micrograms/spray 10-30kg

*10-11.9kg 1- <2 years 1 720micrograms

12- < 18kg 2-5 years 2 1.44mg
18- < 24kg 5-8 years 3 2.16mg
24- <30kg 8-10 years 4 2.88mg

1600micrograms/spray 30kg- 50kg

30- <40kg 10-14 years 2 3.2mg

40- 50kg 14-15 years 3 4.8mg

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 6.5. IV Morphine Infusion

IV Morphine infusion

 Any patient requiring a morphine infusion with complex medical or surgical needs requires
paediatric HDU.
 Early discussion with Paediatric Consultant on call required before commencing case.
 Young infants require reduced doses.
 Prematurely-born neonates and infants must be discussed with a consultant anaesthetist.

 The current pump to use is a PCAM pump with the handset removed. It should be
programmed with the background as ml/hr with no bolus.

 Ensure adequate loading dose of 100 micrograms/Kg.

 A continuous infusion will provide a relatively steady state.

 Rate can be adjusted to pain score.

 Must have naloxone prescribed (see coloured paediatric analgesia dosing guideline).

 Please complete yellow paediatric pain audit form to ensure follow-up.

TO MAKE INFUSION

 Dose: 1mg/kg morphine made up to 50ml with normal saline.

 Maximum dose is 50mg of morphine in 50mls of saline

Example For a 20kg child, use 20mg morphine and dilute to 50ml with normal saline.
20mg divided by 50ml = 0.4 mg/ml (or 400 micrograms/ml).

Results in 1ml/hr = 400 micrograms/hr or 20 micrograms/kg/hr.

Infusion
regimes 0-1 months: maximum of 5 micrograms/kg//hour = max 0.25mL/hour
1-3 months: maximum of 10 micrograms/kg/hour = max 0.5mL/hour
Over 3 months: maximum of 40 micrograms/kg/hour = max 2mL/hour

Maximum infusion rate should be 2ml/hr, which is equal to 40 micrograms/kg/hr.

ALARIS PCAM pump setup

 Pumps are kept in recovery, need drug keys to unlock. Keys for PCA machines are kept
together with the controlled drug keys by the nurse in charge.

 Select protocol C; Paediatric Morphine protocol.

 The default is set to 200 micrograms/ml, this needs adjusting depending on weight:

o The micrograms/ml concentration is the child’s weight divided by 50.

o Go to modify protocol, scroll to Drug Concentration and alter
o To set rate, scroll down to continuous and alter the rate in mls.

Paediatric Analgesia Guidelines

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 6.6. Morphine Patient Controlled Analgesia (PCA)

Indications for use

 For use in 4 years and above, usually have the ability to understand and push the button.

 Need adequate loading dose to gain child’s confidence in PCA

 Loading dose: 100 micrograms/kg. This can be repeated if required.

 May need a background infusion for the first 24hrs.

 Must prescribe naloxone (see coloured paediatric analgesia dosing guideline).

 Bolus: press bolus button, then code, then enter amount.

 Please complete yellow paediatric pain audit form to ensure follow-up.

Drawing up a Morphine PCA

 Dose: 1mg/kg morphine made up to 50ml with normal saline.

 Gives a final concentration of 20 micrograms/kg/ml.

 Maximum dose is 50mg of morphine in 50mls of saline

Example 20kg child = 20mg of morphine in 50ml.

Gives 0.4mg per ml,= which is 400 micrograms/ml
BACKGROUND (IF 6 micrograms/kg/hour (0.3ml/hr).
USED)
BOLUS 1ml over 1minute, 20 micrograms/kg.

LOCKOUT 5 minutes.

ALARIS PCAM pump setup

 Pumps are kept in recovery, keys for PCA machines are kept together with the controlled
drug keys by the nurse in charge.

 Select protocol C; Paediatric Morphine protocol.

 The default is set to 200 micrograms/ml, this needs adjusting depending on weight:

o The micrograms/ml concentration is the child’s weight divided by 50.

o Go to modify protocol, scroll to Drug Concentration and alter.

o To set rate, scroll down to continuous and alter the rate in mls

Paediatric Analgesia Guidelines

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 6.7. Morphine Nurse Controlled Analgesia (NCA)

Indications for use

 For children under 6 years or those incapable of using a PCA.

 Use with constant background, and allows bolus for breakthrough and procedures.

 Use on paediatric HDU only. Early discussion with Paediatric Consultant on call required
before commencing case.

 Avoids delay with increasing background alone.

 Must prescribe naloxone (see coloured paediatric analgesia dosing guideline).

 Please complete yellow paediatric pain audit form to ensure follow-up.

Drawing up a Morphine NCA

 Dose: 1mg/kg Morphine made up to 50ml with normal saline, example as above for
morphine.

 Maximum dose is 50mg of morphine in 50mls of saline

BACKGROUND 10-20micrograms/kg/hr = 0.5-1ml/hr.

BOLUS 10-20 micrograms/kg = 0.5-1ml per bolus.

LOCKOUT 20- 30 minutes.

ALARIS PCAM pump setup

 Pumps are kept in recovery, need drug keys to unlock. Keys for NCA/PCA machines are
kept together with the controlled drug keys by the nurse in charge.

 Select protocol C; Paediatric Morphine protocol.

 The default is set to 200 micrograms/ml; this will need adjusting, depending on weight:

o The micrograms/ml concentration is the child’s weight divided by 50.

o Go to modify protocol, scroll to Drug Concentration and alter.

o To set rate, scroll down to continuous and alter the rate in mls

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 6.8. Fentanyl Infusion and PCA
FENTANYL PCA TO BE PRESCRIBED BY SENIOR CLINICIAN ONLY
 Indicated for morphine intolerance; nausea and vomiting; poor renal function
 Paediatric protocol up to 40 kg. Above 40kg use adult protocol included below
 If patient BMI>30 calculate an ideal body weight using patient height-50th centile weight
chart (see page 17 or BNFc back page).

FENTANYL INFUSION <40kgs

(renal impairment or those with significant side effects to morphine)

 Dose: 50 micrograms/kg Fentanyl made up to 50ml with normal saline (max 40kg).

 Gives a final concentration of 1 microgram/kg/ml.

 Must prescribe naloxone (see coloured paediatric analgesia dosing guideline).

 Please complete yellow paediatric pain audit form to ensure follow-up.

Example For a 20kg child use 50 micrograms/ml Fentanyl and draw up 20mls (ie 2 large 500
micrograms amps), dilute with normal saline to 50ml: 1000 micrograms divided by
50ml = 20 micrograms/ml.
Maximum dose 50mls (i.e. 5 large 500microgram ampoules).

Results in 1ml/hr = 1 microgram/kg/hr.

Range is 0.5-2ml/hr = 0.5-2micrograms/kg/hr.

FENTANYL PCA <40kgs

(renal impairment or those with significant side effects to morphine)

 Dose: 50micrograms/kg Fentanyl made up to 50mls with Normal Saline (max 40kg).

 Gives a final concentration of 1 microgram/kg/ml.

 Must prescribe naloxone (see coloured paediatric analgesia dosing guideline).

 Please complete yellow paediatric pain audit form to ensure follow-up.

Example 20kg patient draw up 20ml of 50micrograms/ml for a (= 2 large

500microgram/10ml vials) and dilute with normal saline to 50mls.

BACKGROUND (IF 0.5ml/hr on 1st-2nd post op day.

USED)
BOLUS 0.5ml over 1 minute, 0.5 microgram/kg.

LOCKOUT 10 minutes.

4 HOURLY 12mls in 4 hours.

MAXIMUM DOSE

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 ALARIS PCAM pump setup

 Pumps are kept in recovery, need drug keys to unlock. Keys for NCA/PCA machines are
kept together with the controlled drug keys by the nurse in charge.

 Select protocol E; Paediatric Fentanyl protocol.

 The default is set to 10 micrograms/ml; this will need adjusting, depending on weight:

o The micrograms/ml concentration is1 microgram/kg/ml.

o Go to modify protocol, scroll to Drug Concentration and alter.

o To set rate, scroll down to continuous and alter the rate in mls

FENTANYL PCA >40KGS

(renal impairment or those with significant side effects to morphine)

 500micrograms Fentanyl (=10mls neat fentanyl) made up to 50mls with Normal saline
 There is no per kilogram calculation
 Dose: 10micrograms/ml

BOLUS 1ml

LOCKOUT 5 minutes

4 HOURLY 50mls (500micrograms) in 4 hours

MAXIMUM DOSE

ALARIS PCAM pump setup

 Pumps are kept in recovery, need drug keys to unlock. Keys for NCA/PCA machines are
kept together with the controlled drug keys by the nurse in charge.

 Select protocol B; Fentanyl protocol.

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 6.9. Paediatric Recovery

Use of IV Fentanyl post operatively in children < 50kgs

Indication for use

 Acute post operative pain score >5.

 Rapid relief of moderate to severe pain relief.

 Provides immediate pain relief, lasts approx. 20 minutes.

 Ensure oxygen available. Monitor for respiratory depression, sedation and itch

 If patient BMI>30 calculate an ideal body weight using patient height-50th centile weight
chart (see page 17 or BNFc back page).

Dose

 0.25micrograms/kg per dose

 Dose can be repeated every 15minutes up to a maximum 4 doses (1microgram/kg in 1
hour)

Practice points

 Ensure supplementary analgesics (Paracetamol, NSAIDs) are prescribed regularly on

prescription chart.

 If prolonged post-op pain likely, in addition consider morphine administration in recovery

and ensure IV and oral preparations prescribed on ward chart.

 Must have naloxone prescribed (see coloured paediatric analgesia dosing guideline).

 Must have anti-emetics prescribed (see coloured paediatric analgesia dosing guideline).

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 6.10. Epidurals

Indications for use

 Children require larger volume with lower concentrations of opiate to block dermatomes.

 Bolus loading dose in theatre should be 0.5-1.0ml/kg of 0.25% Levobupivicaine.

 Continuous infusion rates of around 0.4mg/kg/hr are effective for children > 3 months.

 Maximal dose of Levobupivicaine in children is 2.5mg/kg.

 Must have naloxone prescribed (see coloured analgesia dosing guideline).

 All patients should have a urethral catheter.

 Must have working cannula in-situ at all times.

 Please complete a yellow paediatric acute pain audit form to ensure follow-up.

Infusion

Strength 0.125% Levobupivicaine + 2mcg/ml Fentanyl

Rate 0.2-0.4ml/kg/hr

Example  For a 10kg child the rate would be 2-4ml/hr

 2-4ml/hr = 2.5mg – 5mg of Levobupivicaine/hr
= 4-8 micrograms of Fentanyl/hr
 Always check the dosing is appropriate for the child in front of
you.

McKinley Pump Setup

 Keys for epidural machines are kept together with the controlled drug keys by the nurse in
charge.
 After switching on enter code

 First prime the line through the pump.

 Then select protocol depending on strength of epidural mix.

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PROBLEM
Infusion rate too low
Catheter not in epidural
space, or kinked
Child may have full bladder
Patchy Block
Witnessed catheter
disconnection from filter.
Un-witnessed catheter
disconnection from filter.
SIDE EFFECTS
Ventilatory Depression
Pruritus/ Urinary retention
Local anaesthetic toxicity.
Signs and symptoms:
Dizziness, blurred vision,
decreased hearing, tingling in
mouth and lips, restlessness,
tremor, hypotension, bradycardia,
arrhythmias, seizures, sudden loss
of consciousness.
Leg weakness/ motor block
DENSE MOTOR BLOCK IS
ABNORMAL!
Paediatric Analgesia Guidelines
Trouble Shooting for Epidurals
ACTION
 On-call should give a bolus dose of epidural mixture and
increase rate.
 Bolus dose is 0.25ml/kg of 0.25% Levobupivicaine, e.g. 0.25
x 20kg = 5mls of 0.25%.
 A bolus of epidural mix can also be given, 0.25mls/kg. Press
and hold bolus, enter code, then amount, MAX 10ml.
 Check catheter site for leakage.
 Consider removing and replacing with PCA.
 Regular review of site.
 Consider catheterisation.
 Consider top-up in correcting position.
 Remove and replace with PCA.
 Clean the end of the catheter with 2% Chlorhexidine, allow
drying and holding the catheter with a sterile swab, cut the
catheter with a sterile scissors approximately 2 – 3 cm and
insert into the filter.
 Epidural will require removal. If in doubt contact the Acute
Pain Team or 1st Call Anaesthetist
Side effects
TREATMENT
Oxygen.
Naloxone
 Should be prescribed for all patients receiving IV or
neuraxial opioids (opioid delivered into the brain and
spinal cord).
 <12 years 10 micrograms/kg and repeat if no response
 12-18years 3 micrograms/kg and repeat
 If no response repeat 100 microgram every 2mins
 Consider infusion 5-20micrograms/kg/hr and contact
Consultant
Naloxone
1 micrograms/kg (NB small dose, care in drawing up)
STOP infusion, contact Senior Anaesthetic Trainee bleep
3513 as an emergency.
Local anaesthetic rescue boxes are located in:
General and trauma recovery.
Eden Ward
ITU
Stop infusion, monitor sensory and motor block every 15
minutes, contact on call anaesthetist or pain team, the
concern is epidural haematoma.
See flow chart on next page.
Page 15 of 23
 6.11. Management of Leg Weakness with Epidurals

Contact the
Increasing leg weakness? Paediatric Pain
Motor block score 3 or 4 Team or Senior
Anaesthetic Trainee
Yes bleep 3513 to inform
Routine them of the situation
observations

Switch epidural
Yes infusion off

Recommence
epidural Reassess leg
infusion strength every
30 minutes

Yes

Patient Leg strength

Yes
comfortable? improving?

No
No

Contact Paediatric Pain More than 4 hours

Team or on call since stopping
anaesthetist to assess epidural infusion?
patients analgesia

Yes

Suspect an epidural haematoma?

Contact Paediatric Pain Team 2283 or Senior

Anaesthetic Trainee bleep 3513

An epidural haematoma has to be evacuated

within 8 hours of the onset of symptoms for
your patient to have the best chance of
recovery of neurological function. DO NOT
DELAY.

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 6.12. Mean Values for weight, height and gender by age

The table below shows the mean values for weight, height and gender by age; these values have
been derived from the UK-WHO growth charts 2009 and UK1990 standard centile charts, by
extrapolating the 50th centile, and may be used to calculate doses in the absence of actual
measurements. However, the child’s actual weight and height might vary considerably from the
values in the table and it is important to see the child to ensure that the value chosen is
appropriate. In most cases the child’s actual measurement should be obtained as soon as possible
and the dose re-calculated.

Age Weight Height

kg cm

Full term neonate 3.5 51

1 month 4.3 55

2 months 5.4 58
3 months 6.1 61
4 months 6.7 63
6 months 7.6 67

1 year 9 75
3 years 14 96
5 years 18 109
7 years 23 122

10 years 32 138
12 years 39 149
14 year-old boy 49 163

14 year-old girl 50 159

Adult male 68 176
Adult female 58 164

BNF for Children 2016-2017

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7. Dissemination and Implementation
7.1. This policy will be disseminated to all staff via email and publication on the
Document Library. Any new version of this policy will be re circulated and all
relevant staff made aware of the updates.

8. Monitoring compliance and effectiveness

Element to be Adherence to the published RCHT guidelines
monitored
Lead Dr. Julian Berry
Acute Paediatric Pain Service
Tool Regular audit of the acute paediatric pain service is undertaken by
the lead clinician along with weekly review of complicated cases.
Frequency see above
Reporting The committee reviewing the audit will be the anaesthesia
arrangements directorate. Cases will be discussed at audit meetings and the
details will be recorded in the minutes.
Acting on As above
recommendations The audits/recommendations will also be shared with Child Health
and Lead(s) through the children’s business and audit group.
Change in Required changes to practice will be identified and actioned within
practice and a month. A lead member of the team will be identified to take each
lessons to be change forward where appropriate. Lessons will be shared with all
shared the relevant stakeholders

9. Updating and Review

9.1. This document will be reviewed and updated in June 2020.

9.2. Any revision activity is to be recorded in the Version Control Table as part of
the document control process.

10. Equality and Diversity

10.1.This document complies with the Royal Cornwall Hospitals NHS Trust service
Equality and Diversity statement which can be found in the 'Equality, Diversity &
Human Rights Policy' or the Equality and Diversity website.

10.2.Royal Cornwall Hospitals NHS Trust is committed to a Policy of Equal

Opportunities in employment. The aim of this policy is to ensure that no job
applicant or employee receives less favourable treatment because of their race,
colour, nationality, ethnic or national origin, or on the grounds of their age, gender,
gender reassignment, marital status, domestic circumstances, disability, HIV
status, sexual orientation, religion, belief, political affiliation or trade union
membership, social or employment status or is disadvantaged by conditions or
requirements which are not justified by the job to be done. This policy concerns all
aspects of employment for existing staff and potential employees.

10.3. Equality Impact Assessment

10.4. The Initial Equality Impact Assessment Screening Form is at Appendix 2.

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Appendix 1. Governance Information
Document Title Paediatric Analgesia Guidelines

Date Issued/Approved: June 2017

Date Valid From: June 2017

Date Valid To: June 2020

Directorate / Department Dr Julian Berry

responsible (author/owner): Consultant Paediatric Anaesthetist

Contact details: 01872 252800

This guidance is to inform all staff of the appropriate

Brief summary of contents
analgesia regimes for paediatric patients.

Paediatric analgesia, Children’s analgesia

Suggested Keywords:
PCA, NCA, Epidural
RCHT PCH CFT KCCG
Target Audience

Executive Director responsible
Medical Director
for Policy:
Date revised: June 2017
This document replaces (exact
Paediatric Analgesia Guidelines
title of previous version):
Approval route (names of Medical Practice Committee
committees)/consultation: Anaesthetics Governance Leads

Divisional Manager confirming

Dr Nila Cota
approval processes
Name and Post Title of additional
Not Required
signatories
Name and Signature of
Divisional/Directorate {Original Copy Signed}
Governance Lead confirming
approval by specialty and Name:
divisional management meetings
Signature of Executive Director
{Original Copy Signed}
giving approval
Publication Location (refer to
Policy on Policies – Approvals Internet & Intranet  Intranet Only
and Ratification):
Document Library Folder/Sub Paediatrics
Folder Anaesthetics

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 The Association of Paediatric Anaesthetists of
Links to key external standards
Great Britain and Ireland
References included within the document
Related Documents:

Training Need Identified? No, for reference purposes only.

Version Control Table

Version Changes Made by

Date Summary of Changes
No (Name and Job Title)

Dr Julian Berry
July 11 V1.0 Initial Issue
Lead For APPS

Dr Julian Berry
Dec 11 V2.0 Additional guidance introduced.
Lead for APPS

Change of format Dr Julian Berry

Sept 12 V3.0
Update of guidance Lead for APPS

Dr Julian Berry
Sept 13 V3.1 Change in practice regarding Codeine
Lead for APPS

Dr Julian Berry
Jan 15 V4.0 Update of guidance
Lead for APPS

Update of guidance including change of

Diamorphine formulation. Dr Julian Berry
June 17 V5.0
Removal of Diclofenac from coloured Lead for APPS
analgesia chart.

Dr Julian Berry
July 17 V5.1 Change to intranasal Diamorphine priming
Lead for APPS

All or part of this document can be released under the Freedom of Information
Act 2000
This document is to be retained for 10 years from the date of expiry.
This document is only valid on the day of printing

Controlled Document
This document has been created following the Royal Cornwall Hospitals NHS Trust
Policy on Document Production. It should not be altered in any way without the
express permission of the author or their Line Manager.

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Appendix 2. Initial Equality Impact Assessment Form
This assessment will need to be completed in stages to allow for
adequate consultation with the relevant groups.

Name of Name of the strategy / policy /proposal / service function to be assessed

Paediatric Analgesia Guidelines

Directorate and service area: Is this a new or existing Policy?

Anaesthesia/ APPS Existing
Name of individual completing assessment: Telephone:
Sarah Fox 01872 252800
1. Policy Aim* To inform staff of the appropriate analgesia for paediatric patients.

Who is the strategy /

policy / proposal /
service function aimed
at?
2. Policy Objectives* To inform staff of the appropriate analgesia for paediatric patients.

3. Policy – intended  Improve post-operative analgesia for all children

Outcomes*  Standardise care for children

4. *How will you Monitor through audit, incident reporting and case discussions at
measure the governance meetings
outcome?

5. Who is intended to All children who attend RCHT

benefit from the
policy?
6a Who did you Workforce Patients Local External Other
consult with groups organisations

Please record specific names of groups
b). Please identify the
Medicines Practice Committee
groups who have
Anaesthetic Governance
been consulted about
this procedure.
What was the Policy agreed
outcome of the
consultation?

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7. The Impact
Please complete the following table. If you are unsure/don’t know if there is a negative
impact you need to repeat the consultation step.

Are there concerns that the policy could have differential impact on:
Equality Strands: Yes No Unsure Rationale for Assessment / Existing Evidence
Age 

Sex (male, 
female, trans-gender /
gender reassignment)

Race / Ethnic 
communities
/groups

Disability - 
Learning disability,
physical
impairment, sensory
impairment, mental
health conditions and
some long term health
conditions.
Religion / 
other beliefs
Marriage and 
Civil partnership

Pregnancy and 
maternity
Sexual 
Orientation,
Bisexual, Gay,
heterosexual, Lesbian
You will need to continue to a full Equality Impact Assessment if the following have
been highlighted:
 You have ticked “Yes” in any column above and

 No consultation or evidence of there being consultation- this excludes any policies which have
been identified as not requiring consultation. or

 Major this relates to service redesign or development

8. Please indicate if a full equality analysis is recommended. Yes No 

9. If you are not recommending a Full Impact assessment please explain why.

No areas indicated

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Signature of policy developer / lead manager / director Date of completion and submission

Names and signatures of 1. Sarah Fox

members carrying out the 2. Human Rights, Equality & Inclusion Lead
Screening Assessment

Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead
c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa,
Truro, Cornwall, TR1 3HD

This EIA will not be uploaded to the Trust website without the signature of the
Human Rights, Equality & Inclusion Lead.

A summary of the results will be published on the Trust’s web site.

Signed _ ____________

Date ____June 2017____________

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