The heat of the moment: managing children with pain or fever

Clinical
By
Tara de Koning
-
child pain

A child presenting with pain and/or fever can be a source of distress for any parent or carer. Community pharmacists can provide invaluable advice and support.

Pain and fever in children

Acute pain or fever is common in children. Pain occurs as a result of injury, illness, teething and necessary medical procedures.1

Fever is a rise in body temperature above 38°C and is a natural response to infection. Medicines are not always needed to relieve fever in a child. Most infants and children can tolerate low-grade fever (38°–38.5°C), and often respond to clear fluids such as water, and comfort.1,2

How do you assess pain in children?

While older children can explain where the pain is located and how they feel, there are many validated tools for assessing pain in younger children.1

Parents are ideally placed to assess their child’s pain, noting any deviations to their normal behaviour.1,3

Assessment of pain in children is done using self-reporting scales, observation and physiological assessment. The most commonly used are the scales with faces, which are used extensively in children aged 3 to 8 years.1

The first tool to assess pain in children was the Faces Pain Scale, developed in 1990. This allowed a child to point to the face that represented the level of pain being experienced and a numerical value and pain level was allocated to that face.1 This scale was later revised and renamed the Faces Pain Scale-Revised (FPS-R) which can be downloaded at bit.ly/2oinR3Y

A tool more commonly used in practice was one developed by Wong. This tool is useful for children 3 years and older. It uses a set of cartoon illustrations and as the pain level increases the series of facial expressions changes from a smile to a very sad face with tears1. It is accessible at wongbakerfaces.org/

The FLACC scale assesses the Face, Legs, Activity, Cry and Consolability and provides a score of 0–2 for behaviour in each of the five categories.1

Information on the FLACC scale is available at bit.ly/2InIuCN

The numeric scale can be useful for children 8 years or older. The child is asked to rate their pain on a scale of 1–10 with 10 being the worst pain.3

Over-the-counter medicines for children with pain or fever

If medicines are needed in children with pain or fever, first-line treatment of mild to moderate pain and fever is ibuprofen or paracetamol. Aspirin should not be used in children because of the risk of Reye’s syndrome.1,2,4 Over-the-counter (OTC) liquid preparations of paracetamol are frequently used in children,5 and is suitable for infants from birth. Paracetamol is most commonly prescribed for fever.1,2,4

Ibuprofen is the most commonly used non-steroidal anti-inflammatory drug (NSAID) for the treatment of inflammation, mild-to-moderate pain and fever in children. It is the only NSAID approved for use in children aged ≥3 months with a body weight of 6kg and over.1,2,3

There is large consensus that ibuprofen should be used as an antipyretic only in children not responding to paracetamol.2

Meta-analyses have shown that paracetamol and ibuprofen have similar safety and tolerability profiles for children with fever.1,3,4

Evidence shows that alternating between paracetamol and ibuprofen is not recommended for fever but may be beneficial for pain.2,4

Ibuprofen – considerations

Dehydration plays an important role in triggering renal damage with ibuprofen, so ibuprofen should not be given to children with diarrhoea and vomiting, with or without fever.2

Studies have shown that the risk of ibuprofen-sensitive asthma is low (around 2%).1

Paracetamol – considerations

Paracetamol is one of the most common agents of unintentional poisoning in young children and is a major cause of paediatric acute liver failure.5

Many children’s medicines contain paracetamol and there is an increased risk of accidental overdose if carers give different medicines for different reasons (pain, sleep, fever) due to a perception there are different ingredients involved.1

Should I recommend food when taking ibuprofen?

With both paracetamol and ibuprofen, the risk of gastrointestinal (GI) bleeding is low (one study reported 7.2 per 100,000 for ibuprofen).1,2,6

The perceived association of NSAIDs and GI adverse effects can result in the advice to take ibuprofen with food or fluid such as milk. This may have a consequence for children with pain or fever who may feel too unwell to eat.1

In fact, food delays the achievement of peak levels of NSAIDs and therefore impacts on efficacy, leading to the suggestion that ibuprofen be taken on a fasting stomach to achieve a more rapid onset of action.1

Counselling for caregivers

Community pharmacists are well placed in providing advice to parents/carers of children with pain or fever to address knowledge gaps about the safe administration of paracetamol and potential adverse events associated with overdose.5

Advise the parent/carer on the following:

  • Document the weight of the child as the daily dose of medications are based on weight. If a child is obese, ideal body weight should be used.2–4
  • Keep a diary of the time each medicine was given, what the ingredient was, and what dose to avoid accidental overdose.2–4
  • Note the mandatory warnings with paracetamol preparations and advise parents/carers to check the ingredients of all medicines to reduce the risk of administering multiple doses of paracetamol.1,4
  • The maximum daily dose of paracetamol and the risk of liver toxicity, and that there are no early signs of hepatotoxicity.1,3,4
    • An Australian survey showed parents/ caregivers had gaps in knowledge regarding the maximum daily dose of children’s paracetamol, dosing intervals, or that liver toxicity could result from overdose.5
  • Paracetamol comes with two different formulations, and to choose the correct formulation for their child’s age.3
  • Both paracetamol and ibuprofen should not be given for more than two consecutive days without seeing a doctor.3,4
  • Use a syringe to measure doses to be accurate, particularly when small doses are required.3
  • Non-pharmacological interventions are just as important as pharmacological interventions. Non-pharmacological interventions include:3
    • diversion and distraction – using music, chat, and technological devices
    • controlled breathing – blowing bubbles or focusing on breath
    • touch – massage, stroking, rocking
    • imagination – reading books or using guided imagery.

WHEN TO REFER TO A DOCTOR

The following circumstances require referral to a doctor:3

  • the child is not responding to analgesia
  • there is an obvious medical condition requiring treatment (e.g. broken bones)
  • the cause of pain is unknown
  • prolonged high temperature
  • analgesia overdose is suspected

A more comprehensive list is available at the Royal Children’s Hospital Melbourne website at www.rch.org.au/kidsinfo/fact_sheets/Fever_in_children/

References

  1. Guest Author. Children’s pain and fever management. AJP E-mag 2018. At: ajp.com.au/lessons/childrens-pain-and-fever-management
  2. De Martino M, Chiarugi A, Boner A, et al. Working towards an appropriate use of ibuprofen in children: an evidence-based appraisal. Drugs 2017;77(12):1295–1311. At: www.ncbi.nlm.nih.gov/pmc/articles/PMC5529476/
  3. Philpott L. A difficult balance. AJP E-mag 2019. At: ajp.com.au/features/a-difficult-balance/
  4. NPS MedicineWise. Treating my child’s pain or fever – paracetamol or ibuprofen? 2017. At: nps.org.au/consumers/treating-my-child-s-pain-or-fever-paracetamol-or-ibuprofen
  5. Mullan J, Burns P, Sargeant D. Caregivers’ knowledge about children’s paracetamol. J Pharm Pract Res 2018. At: onlinelibrary.wiley.com/doi/full/10.1002/jppr.1431
  6. Walsh P, Rothenburg SJ, Bang H. Safety of ibuprofen in infants younger than six months: A retrospective cohort study. PLoS ONE 2018;13(6):e01994932018. At: www.ncbi.nlm.nih.gov/pubmed/29953460