Pain

 DO

• Use an age-appropriate measurement tool to measure pain severity.
• In children who are unable (or no longer able) to communicate verbally, use an observational scale such as the comfort scale or the FLACC.

• In nonresponsive children, consider using modified assessment such as NCS-R.
• In children who are unable (or no longer able) to communicate verbally, consider assessing the child's facial expression and other expressions of pain. Include parents' assessment in this assessment.
• Consider additional testing if it has therapeutic implications for the child.

 DO

• Create a calm environment.
• Provide information about causes of pain, treatment options and disease progression.
• Discuss with child and parents what factors influence pain.
• Promote child and parents' autonomy by providing advice on measures they can implement themselves, e.g., posture modification, relaxation exercises, self-medication, etc.
• Involve child and parents as much as possible in the treatment of pain and agree on how care can be given (preferably through the pain passport).
• Discuss what can be done in acute pain and how to continue medication according to schedule.
• Ensure that adequate (dosage) advice and medication are present and think ahead several steps.  
• Engage a paediatric palliative care team or pain team on a low-threshold basis.

• Consider involving an occupational therapist or (paediatric) physical therapist to provide advice to child and parents on postural changes, relaxation options and possible assistive devices.

 DO

• Treat any causes that trigger or exacerbate pain if possible.

• Consider chemotherapy in susceptible malignancies.
• Consider local radiotherapy, for localized pain due to primary tumour or (bone) metastases.
• Consider nuclear therapy, in case of multiple painful bone metastases or if local radiotherapy on the bone metastases is not possible.
• Consider surgery, in pathologic fractures of vertebrae or long pipe bones, ileus or localized pain due to tumour growth.

• Consider the use of complementary therapies.

• Consider the use of psychological therapies for children.

• Consider cognitive behavioural therapy for parents.

 DO

• Administer in mild to moderate pain, paracetamol, ibuprofen or a combination of paracetamol and ibuprofen.

 DO

• Administer morphine as first choice in case of severe pain.

• In severe pain, consider administering opioids in consultation with a paediatric palliative care team and/or pain team, for example fentanyl, hydromorphone, oxycodone, or methadone.

• For specific conditions e.g. inflammation or oedema, consider corticosteroids.
• Consider administration of clonidine or ketamine. Consult with a paediatric palliative care team and/or pain team first.

 DO

• If neuropathic pain is suspected and standard analgesia is not efficient enough, involve a specialist from a paediatric palliative care team and/or pain team.

• In case of neuropathic pain, consider tricyclic antidepressants such as amitriptyline.
• In case of neuropathic pain, consider anticonvulsants such as gabapentin.

• In children with spastic palsy, consider implanting a baclofen pump.
• In children with osteogenesis imperfecta, consider administering bisphosphonates.
• If classical pain management is ineffective or pain is located at a specific site, consult early with an experienced pain team about the possibilities of an invasive pain management technique.

 DO

• Evaluate the effect and side effects of the treatment instituted at the appropriate time, and adjust treatment as needed. Involve child and family in this process.