Clinical Review

Pain management and sedation for children in the emergency department

BMJ 2009; 339 doi: (Published 30 October 2009) Cite this as: BMJ 2009;339:b4234
  1. Paul Atkinson, consultant in emergency medicine ,
  2. Adam Chesters, specialty registrar in emergency medicine,
  3. Peter Heinz, consultant in paediatric medicine
  1. 1Emergency Department, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge CB2 0QQ
  1. Correspondence to: P Atkinson Paul.atkinson{at}

    Summary points

    • Ensure that children do not experience prolonged or additional pain when presenting for emergency medical care; use a composite assessment tool to assess pain at triage

    • Aim to provide effective analgesia at the first attempt—use the appropriate drug, dose, and route; if possible choose painless modes of delivery (nasal route, flavoured syrups)

    • Reassess pain scores frequently to ensure that analgesia is effective and allow enough time for it to work

    • Use pharmacological and non-pharmacological modalities to manage pain

    • Avoid the “routine” use of unnecessary painful invasive procedures

    • Use topical, local, and regional anaesthesia along with appropriate safe procedural sedation to avoid further pain

    Children commonly present for emergency care with painful conditions and injuries. Further painful, distressing, or unpleasant diagnostic and therapeutic procedures may be necessary during the visit. Emergency clinicians are expected to provide safe and effective analgesia and sedation for children, and provision of such analgesia is a primary audit standard of the College of Emergency Medicine.1 We provide an overview of published evidence to help clinicians assess, manage, and minimise pain in children presenting to hospital.

    Sources and selection criteria

    We searched Medline, PubMed, and the Cochrane database for evidence from systematic reviews and clinical trials. We searched websites of major international royal colleges and colleges of paediatrics and emergency medicine for published guidelines. We also used our personal experience of practice. Search terms used included “pain”, “analgesia”, “sedation”, “children”, and “emergency”.

    How is acute pain best assessed in children?

    The assessment of pain is a core feature of most international triage systems. National guidelines suggest that children with moderate or severe pain should be triaged as urgent and should wait no longer than 20 minutes for administration of adequate analgesia.1

    Several methods of assessment have been validated for assessing the severity of pain (table 1).2 The ability to indicate the presence of pain …

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