Clinical Feature

Journal of Perioperative Practice

2019, Vol. 29(1 & 2) 10–17
Assessing pain in children in the ! The Author(s) 2018
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DOI: 10.1177/1750458918780109
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Michelle Bennett

Abstract
Pain assessment and management in children is challenging for a number of reasons. This paper aims to identify these
challenges and highlight strategies for effective pain assessment and management in children in the perioperative setting.

Keywords
Pain / Neonate / Infant / Child / Young person / Paediatric / Perioperative / Pain assessment / Pain management

Provenance and Peer review: Unsolicited contribution; Peer reviewed; Accepted for publication 2 March 2018.

Introduction have access to extensive resources, information and

Pain assessment is widely recognised as a complicated
and challenging aspect of caring for children of all ages,
from neonates to young people, in any clinical setting.
Numerous publications and textbooks are available
encompassing the complexities of this topic (APAGBI
2008, 2012, Brahmbhatt et al 2012, DH 2003, RCN
2009, Twycross & Williams 2014). If pain is not assessed
and managed promptly and effectively the child may go
on to develop long-term psychological as well as physical
consequences (Bentley 2014, Wong et al 2012).
This paper aims to identify some of the challenges of
pain assessment in the perioperative setting, review
pain assessment tools available to help address these
challenges and explore current pain management
strategies. For the purposes of this paper the term 'child'
will encompass the age range of neonate to adolescents
(young people).
Children are different: Pain perception and
cognitive development
Pain is a very personal experience and each individual's
physical, emotional, cognitive and behavioural
experiences will influence their perception of pain
(Twycross & Williams 2014). Therefore, a holistic
approach is needed when planning pain management
strategies. This is particularly the case for children, as
psychological and environmental factors can have a
more significant effect on a child's perception of pain
(Twycross & Williams 2014, Wong et al 2012).
Poor assessment of children's pain is a real cause for
concern, especially as healthcare professionals today
advanced techniques such as patient-controlled
analgesia (PCA) and nurse-controlled analgesia (NCA)
and regional analgesia (Wong et al 2012). The reasons
for this have been extensively examined in the literature
and key barriers to effective pain assessment and
management have emerged (summarised in Box 1)
(Asadi-Noghabi et al 2014, De Freitas et al 2014,
Stinson & Jibb 2014).
Cognitive development of the child and its
influence on their pain experience
Children are not miniature versions of adults. The
different stages of their physical and cognitive
development will influence how neonates, infants,
children and young people respond and interpret painful
experiences (Wong et al 2012). It is important to handle
these situations appropriately as this might be the
child's first contact with healthcare professionals. A
positive experience in childhood may prevent fear and
anxiety associated with pain into their adult life.
Neonates and infants
For many years it was believed that infants did not feel
pain, as their nerve sheaths are immature and not
Nottingham Children’s Hospital, Nottingham University Hospitals NHS
Trust, Queen’s Medical Centre, Nottingham, UK
Corresponding author:
Michelle Bennett, Clinical Nurse Specialist Children’s Pain Management,
Children’s Pain Team, Nottingham Children’s Hospital, Room EE1836,
E floor East Block, Nottingham University Hospitals NHS Trust, Queen’s
Medical Centre, Nottingham NG7 2UH, UK.
Email: michelle.bennett2@nuh.nhs.uk
10
Box 1 Barriers to effective pain assessment
and management
• Limitations in drug licensing for children (challenges with
obtaining ethical approval, safeguarding the child’s rights
and safety and effective communication when recruiting
for drug trials).
• The influence of the different cognitive stages of devel-
opment on the child’s perception of pain.
• The difficulty in accurately assessing pain in preverbal and
non-verbal children (eg infants and children with spe-
cial needs).
• Healthcare professionals’ own beliefs and attitudes
towards pain.
• The lack of research and training undertaken in
this population.
• Myths and misconceptions that still surround children’s
pain including:
– Infants cannot feel pain because of their immature
nervous system.
– Active children are not in pain.
– Sleeping children cannot be in pain.
– Opioids cause respiratory depression and addiction.
– A child’s pain can always be detected by behavioural
and physiological signs.
(APAGBI 2008, RCN 2009, Twycross & Williams 2014)
insulated with myelin, resulting in slow impulse
transmission. However, substantial evidence has now
demonstrated that an infant's pain impulses are still
present but pass more slowly up to the brain (Wong et al
2012). Infants (aged less than one year) have also been
found to have a full complement of neurons in the cortex
by 20 weeks' gestation and can therefore perceive pain.
They may even perceive pain more acutely because the
descending mechanism, present in adults, that
dampens down pain transmission, is immature (Asadi-
Noghabi et al 2014).
Pain inflicted on a neonate (aged less than 28 days) may
increase sensitivity to pain and have potentially
damaging effects on brain development (Asadi-Noghabi
et al 2014, Carter & Simons 2014, Walker 2014).
Research has also demonstrated that neonates exposed
to frequent painful procedures become sensitised over
time, developing a lower pain threshold and heightened
pain behaviours and responses during subsequent
painful events, even years later (Bentley 2014, Walker
2014, Wong et al 2012).
These data indicate that children have pain memory and
that inadequately treated pain can result in detrimental
long-term effects throughout childhood and perhaps into
adulthood (Carter & Simons 2014). If pain is poorly
managed during a first admission to hospital, even in
the neonatal period, this can increase the pain
perceived by the child in the future, reduce their
compliance with medical advice and potentially have a
Journal of Perioperative Practice 29(1 & 2)
negative impact on relationships with healthcare
professionals (WHO 1998). Therefore, it is important to
know the child's pain history, which may also have some
influence on the anxiety expressed by the parents.
Preschool children
Preschool children are one of the most difficult groups to
manage. They may see pain as a punishment and 'hate'
the healthcare professional who appears to be inflicting
pain by hitting out or biting (Twycross & Williams 2014).
Toddlers will not be able to see the connection between
treatment and relief of pain, for example giving an
unpleasant tasting medicine that will make the pain in
their arm better. These children need their parents to be
present, but parents also need to be supported in the
perioperative setting as they can be anxious and
distressed themselves.
School-aged children
These children have vivid imaginations which can be
used to distract them for short periods of time. How they
react to painful situations and the pain words used are
learned behaviours from their family, which are
influenced by culture, society or religious beliefs. It is
important to find out the pain words for each child. For
example, a 'headache' can become a pain word applied
to any part of the child's body as they may have heard
adults say they have a headache and need a pain relief
tablet. School-aged children are able to describe how
they feel, relate to pain physically and specify location in
terms of body parts and internal organs (Twycross &
Williams 2014).
Adolescents (now commonly referred to as
young people)
A young person, like younger children, needs time to
gain the healthcare professional's trust and
opportunities to discuss fears preoperatively. Young
people need information about their condition and to be
given treatment choices where applicable, especially if
they have chronic conditions (Twycross & Williams
2014). Young people may revert back to a previous
cognitive level and want their parents with them. They
also need to know that it is 'O.K.' to be cross or cry and
that they do not need to put on a brave face, but to tell
you if it hurts.
Children with communication difficulties
Most children can communicate in some way, whether it
is through sign language or behavioural cues. Each child
will need individual assessment preoperatively,
documenting their normal responses to pain and the
usual interventions that the parent or carer may use to
relieve pain (Stinson & Jibb 2014).
Bennett
Children with complex disabilities are sometimes
hypersensitive to bright lights and noise and may
become very agitated, so the environment may need to
be adjusted. The involvement of the parent or carer is
vital in this group of children.
Pain assessment
Key practice points
The key points to keep in mind when dealing with
children in pain are as follows:
• Wherever possible, self-reporting should be used to
promote most accurate pain assessment.
• Use an appropriate validated and reliable pain
assessment tool in conjunction with observing
behavioural and physiological signs of pain.
• Treat every child and family individually and remem-
ber that the family are partners in the pain assess-
ment process and their involvement should
be secured.
• Document pain assessment and management
measures taken.
• Reassess regularly and liaise with colleagues regard-
ing further options (eg anaesthetist, children's pain
team and medical staff).
(Based on Baker and Wong QUESTT principles of pain
assessment (1987))
Without accurate pain assessment and evaluation, pain
cannot be managed effectively. Whilst self-report of pain
is the gold standard of pain assessment, many children,
including premature infants, neonates, toddlers with
limited vocabulary, the critically ill and children with a
cognitive impairment, are unable to verbally
communicate their pain (Brahmbhatt et al 2012,
Verghese & Hannallah 2010). Therefore, physiological
and behavioural indicators of pain are often used to
supplement self-report.
Physiological indicators
Changes such as increased heart rate and blood
pressure, tachypnoea, reduced oxygen saturation levels
and palmar sweating would all be considered to be
physiological indicators of pain (see Box 2) (RCN 2009,
Stinson & Jibb 2014). However, it is important to
remember that these indicators must be seen in context
as changes can also be signs of fear and anxiety and
can have many other causes, for example pyrexia,
dehydration, medication.
Even if the physiological indicators of pain diminish, pain
may still be present as the body's response to pain
adapts after a period of time. For all these reasons,
physiological indicators should always be used in
11
Box 2 Physiological indicators of pain
• tachycardia
• bradycardia (neonates and infants)
• hypertension
• tachypnoea
• apnoea (neonates and infants)
• desaturation (neonates and infants)
• palmar sweating (neonates)
• elevated blood glucose
• pallor.
Box 3 Behavioural indicators of pain
Changed behaviour Irritability
Unusual posture Screaming
Reluctance to move Aggressiveness
Disturbed sleep Crying
Grimacing Increased clinging
Loss of appetite Restlessness
Sobbing Lethargy
Lying 'scared stiff’ Guarding the area
Pulling away Withdrawal
combination with other methods of assessment (APAGBI
2012, RCN 2009).
Pain behaviours which are used by nurses to assess
pain in children include restlessness, grimacing, head
shaking, drawing up knees, generalised restless body
movements and withdrawing limbs from painful stimuli
(see Box 3). Combining behavioural assessment with
changes in vital signs is more indicative than using one
method alone. However, it is important to note that pain
behaviours may not always be evident. A child's pain
behaviours can be modified by several factors including
fear, sleep deprivation, cultural background and the
environment. A child may also react to pain by becoming
quiet and withdrawn.
Each child's behaviour needs to be assessed individually
as they may behave differently when recovering from a
general anaesthetic for example. The initial assessment
can be carried out with their family as part of their
admission to hospital and documented at this point.
Pain assessment tools
There are numerous different pain assessment tools
available for children of different ages and cognitive
ability. The APAGBI (2008), RCN (2009) and Royal
College of Paediatrics and Child Health (RCPCH 2001)
have made evidence-based recommendations.
Behavioural and physiological scales are used for infants
and children who are unable to verbally communicate.
12
There are many visual scales for school-aged children to
assess quality and quantity of pain experienced. Young
people often prefer the visual analogue scale of 1–10.
As there are so many tools available, a small selection of
tools should be chosen for the perioperative setting so
that the children can choose from them and the
healthcare professional can become familiar (see Box 4
for examples). Local policies and guidelines should be in
place to guide clinical practice and to identify the tools to
be used to ensure consistency in pain assessment
throughout the institution.
Pharmacological pain management
The APAGBI (2008) Good practice in postoperative and
procedural pain guidelines provided evidence-based
recommendations for numerous specific surgical
procedures in neonates and children and is an
invaluable resource. The guidelines include general
principles and good practice points based on the
principles of pre-emptive, synergistic pharmacological
pain management (see Box 5) in combination with non-
pharmacological measures. This is supported by the
recent clinical practice guideline, Recommendation 6,
from the American Pain Society (Chou et al 2016).
Box 4 Pain assessment tools suitable for the periopera-
tive setting
Premature infants and neonates
Behavioural
Premature Infant Pain Profile (McNair et al 2004)
Crying, Requires increased oxygen administration,
increased vital signs, Expression, sleeplessness (CRIES)
(Krechel & Bildner 1995)
COMFORT scale (Ambuel et al 1992)
Children and young people without a cognitive impairment
Self-report
FACES Pain Scale (Wong & Baker 1988). Valid for 3–18
year olds
Faces Pain Scale-Revised (Hicks et al 2001) Valid for 4–12
year olds
Behavioural
Face, Legs, Activity, Cry and Consolability (FLACC)
(Merkel et al 1997). Valid for 1–18 year olds
Children and young people with a cognitive impairment
Behavioural
Non-Communicating Children’s Pain Checklist-
Postoperative Version (Breau et al 2003). Valid for 3–19
year olds
Paediatric Pain Profile (Hunt et al 2004). Valid for 1–18
year olds
Revised FLACC (Malviya et al 2006). Valid for 4–19
year olds
(cited in APAGBI (2012) and Voepel-Lewis et al (2010))
Journal of Perioperative Practice 29(1 & 2)
Best practice when considering any pharmacological
pain management strategy is a combination of
medications as recommended by the World Health
Organization analgesic pain ladder (1998) (see Box 6).
Combining analgesics (multi-modal analgesia) blocks
pain transmission at several points of the pain pathway.
This method of management has a synergistic effect
whereby the overall analgesic effect can be superior to
Box 5 Pharmacological pain management. Summary taken
from APAGBI 2008
• The paediatric anaesthetist is responsible for initiating
suitable postoperative analgesia and liaising with
patients and their families/carers, surgeons and other
members of the team providing postoperative care in
order to ensure that pain is assessed and appropriate
ongoing analgesia is administered.
• Children should not be discharged from the recovery
area until satisfactory pain control is established and
ongoing analgesia is available.
• All health professionals caring for neonates and children
postoperatively should have appropriate educational
input including an awareness of the general principles of
pain assessment and pain management in children.
• Postoperative analgesia should be appropriate to the
child’s developmental age, surgical procedure and clini-
cal setting in order to provide effective and safe, suffi-
ciently potent and flexible pain relief with minimal
side effects.
• Postoperative pain should be assessed frequently, the
frequency depending on the surgical procedure and the
child’s individual needs.
• Analgesic prescribing and combination should be suffi-
ciently flexible to allow for inter-individual differences in
the response to analgesics and the variation in the
requirement for pain relief that occurs during the
postoperative period.
• Analgesics should be used in combination unless there
are specific contraindications, for example: opioids,
local anaesthetics, non-steroidal anti-inflammatory
drugs (NSAIDs) and paracetamol can be given in con-
junction, not exceeding maximum recommended doses.
Box 6 Postoperative pharmacological pain management
• local anaesthetics (epidural infusion, caudal block,
regional block, local wound infiltration, topical
cream/gel)
• neuraxial analgesics, for example ketamine and clonidine
(added to local anaesthetic blocks and epidural or
intravenous infusions)
• opioids, for example morphine, fentanyl (PCA and NCA
and continuous infusions or added to local anaesthetic
blocks and infusions)
• NSAIDs
• paracetamol
(APAGBI 2008, 2012)
Bennett
that of one drug alone (APAGBI 2012, Chou et al 2016,
Verghese & Hannallah 2010).
For example, combining an oral or intravenous opioid
with regular paracetamol and a NSAID such as ibuprofen
or diclofenac sodium is a common method of achieving
balanced analgesia in the immediate postoperative
period (APAGBI 2008, Chou et al 2016). Analgesics
should be prescribed and administered regularly, to
prevent peaks and troughs in serum levels and potential
episodes of 'break-through' pain. In addition,
combination therapy has been shown to have an opioid
sparing effect (APAGBI 2012).
Pre-emptive pain management
As a general principle in pain management, anticipation
and prevention of pain is preferable to attempting to
treat pain after a nociceptive insult has occurred and the
pain pathway triggered. A recent study of the plasticity of
the nervous system and its ability to adapt its thresholds
according to input would suggest that introducing
analgesic agents prior to the first painful stimulus
occurring, such as surgery, can improve the overall pain
management (APAGBI 2008).
Opiate use in neonates and children
Both the World Health Organization (1998) and the
National Service Framework for Children (DH 2003)
highlight that many healthcare professionals are
reluctant to prescribe and administer opioid medications
due to inherent fears regarding opioid side effects and
addiction, and that this is the case in both adults and
children. In fact, respiratory depression is uncommon
(Morton & Arerra 2009).
However, it must be noted that neonates have higher
body water content than that of older children and
adults, immature liver and kidneys, a large extracellular
fluid compartment, slower gastric emptying and less fat
and muscle as a per cent of body weight. All of these
factors contribute to delayed excretion of drugs and lead
to a greater degree of accumulation of some drugs,
including opiates (Verghese & Hannallah 2010).
Neonates and infants also have a naturally higher
number of opioid receptors, with the potential to cause
respiratory depression (Walker 2014). This does not
mean, however, that opioids should be withheld from
this group of patients, just that they should be to be
administered with caution.
Analgesic techniques
PCA and NCA
A NCA infusion allows the child to receive an immediate
predetermined dose of analgesia to target increased
pain, or prior to painful procedures or episodes, in
addition to the background infusion. The advantages of
13
using an NCA rather than a continuous opioid infusion
are that the programme allows an analgesic regimen to
be prescribed which is more flexible and may provide a
better quality of analgesia.
The system is suitable for preverbal and non-verbal
children (ie neonates, infants, young children, those
critically ill and cognitively impaired) and those without
the physical dexterity to press a PCA button.
PCA has been available for 20 years and has been used
widely for postoperative pain management since its
introduction. PCA is used to deliver self-demand boluses
of medication. PCA has a large range of applications for
managing moderate to severe pain postoperatively
(Chou et al 2016). The child or young person should be
assessed preoperatively to ascertain whether they can
understand the concept of PCA and that they have the
manual dexterity required to push the button.
PCA can engage the child or young person in feeling that
they are a participant in their treatment, giving them
control of their pain management which can empower
them, increase their confidence and help to
reduce anxiety.
Epidural and regional local anaesthetics
Regional anaesthesia has become widely used and
accepted for perioperative analgesia in children usually
as an adjuvant to general anaesthesia (Verghese &
Hannallah 2010). Techniques range from simple
infiltration, blocks of single nerves or plexuses to
neuraxial blocks like spinal and paravertebral blocks
and epidural analgesia (Walker 2014). Regional
anaesthesia modifies the neuroendocrine stress
response, provides profound postoperative pain relief,
insures a more rapid recovery and may shorten
hospital stay.
Peripheral nerve blocks can provide significant pain
relief after many common paediatric procedures. They
can be performed with ease in children and adolescents
using similar equipment to that used in adults but small
bore needles are required. Adequate knowledge of the
relevant anatomy is necessary along with appropriate
indications and knowledge of complications that can
occur. Techniques involving the use of ultrasound
technology can facilitate better placement of nerve
blocks (Ivani & Mossetti 2010, Rapp et al 2005).
A continuous epidural infusion of a local anaesthetic, in
combination with low dose opiate, reversibly blocks pain
transmission along the pain pathway and offers unique
benefits in the relief of acute and perioperative pain
(Bennett & Douglass 2012a). Additional training and
monitoring is required to ensure that staff are
competent to manage patients with an epidural infusion
and this has implications for staffing and skill mix which
14
needs to be considered. An epidural infusion may not be
suitable, for example if the child is allergic to local
anaesthetics, if they have abnormal anatomy of their
spine, local or systemic infection or if they or their
parents refuse consent. Used to its full potential it can
offer children pain-free recovery post-surgery and is
known to reduce postoperative morbidity, particularly in
high-risk patients (eg children with complex needs,
respiratory disease or poor lung function) (APAGBI 2008,
Bennett & Douglass 2012a, Chou et al 2016).
High-quality analgesia with minimal sedation allows
better lung expansion and increases the child's ability to
clear secretions by coughing. In older children and young
people there is a decrease in the risk of deep vein
thrombosis secondary to immobility. The reduced
quantity of opiate drugs required can decrease the
degree of ileus and nausea and vomiting after
abdominal surgery (Bennett & Douglass 2012b).
Epidural analgesia in children does have associated
risks but the incidence of serious complications is less
than 1%, as reported in a national paediatric epidural
audit of 10,000 children and young people over a five-
year period (Llewellyn & Moriarty 2007).
Adjuvant agents
Ketamine has been demonstrated to be a useful
adjuvant to opiates for acute postoperative pain
management (Chou et al 2016). Ketamine is an N-
methyl-D-aspartate (NMDA) antagonist: it opposes the
action of this chemical which is produced naturally in the
body. At sub-anaesthetic doses it has an analgesic effect
as it binds to the receptor sites of NMDA, which inhibits
the transmission of pain impulses from the primary
afferent fibre to the NMDA receptor. It exerts strong
adjuvant analgesic properties by inhibiting the binding of
glutamate to the NMDA-R receptor. As this mode of
action is different from the action of opioid drugs, the
use of ketamine in combination with an opiate can
improve pain relief (APAGBI 2008). Ketamine also has
an opioid-sparing effect which can result in less
escalation of the opiate dose and less incidence of
opiate side effects (Laskowski et al 2011).
Ketamine has been used in the paediatric population for
some time in the form of caudal administration. More
recently, ketamine has been administered via
continuous sub-anaesthetic infusion or in combination
with a PCA or NCA for postoperative pain management
(Laskowski et al 2011). For more detailed information
about analgesic agents, please refer to the APAGBI Good
practice in postoperative and procedural pain
management (2012).
Non-pharmacological measures
Any measures that help to treat pain and anxiety whilst
reducing the need for pharmacological interventions
Journal of Perioperative Practice 29(1 & 2)
Box 7 Non-pharmacological interventions for the periop-
erative setting
• parental presence
• distraction, for example toys, books, blowing bubbles,
children’s videos, relaxation music
• rocking, stroking, swaddling
• non-nutritive sucking or feeding
• information giving
• choice.
should always be considered to be an essential part of
pain management (DH 2003).
Sensory methods
Sensory methods stimulate A-beta afferent fibres
through pressure, thermoregulation, positioning and
weak electrical currents. They inhibit nociceptive signals
by directly blocking transmission of nociceptor input and
at the same time, activate internal pain-inhibiting
signals (Vessey & Carlson 1996).
Sensory pain management techniques useful in the
perioperative setting would include parental presence,
careful positioning, use of a comforter and nursing with
boundaries (Bentley 2014, Carter & Simons 2014,
Twycross & Williams 2014) (see Box 7). Many babies are
very hungry postoperatively and can be comforted by
non-nutritive sucking or a feed (Asadi-Noghabi et al
2014). Therefore, they should be fed as soon as possible
in recovery if surgery allows, ideally by the mother if
breast fed. Please note that some parents specifically do
not wish their babies to be given bottled water or milk if
they breast feed, so consent should be obtained for this.
Parental presence
Parental presence and participation is of course a vital
component of managing children's pain, especially when
considering psychosocial aspects, as they are familiar
with their child's likes and dislikes, hobbies, home
environment and level of cognition. The parents will
usually also have well-established trusting relationships
with their child (Polkki et al 2001). However, nurses
should not rely on parents too heavily, as they can be
under a great deal of stress themselves. Also, family
members' own experiences, perceptions of pain and
expectations will influence the child and this needs to be
taken into consideration. Despite this, the presence of
parents can provide emotional support and reassurance
and can play an important role in reducing their child's
level of anxiety; nurses have an important role in
supporting parental participation in non-
pharmacological measures for pain relief (Carter &
Simons 2014, Twycross & Williams 2014).
Bennett
Cognitive behavioural therapies (CBTs)
CBTs are combinations of physical and cognitive
activities that alter or suppress painful stimuli.
The effectiveness of these interventions is not easily
explained, but it is partly as a result of the action of
descending pain inhibitors in the nociceptor system (Tse
et al 2002). CBT draws on the patient's tactile, visual,
auditory and kinaesthetic senses and can involve
nurses, parents and carers, environmental factors and
other members of the multidisciplinary team. Several
studies which have examined the effects of CBT in
children and results have been favourable, perhaps
because children naturally use their imagination and
enjoy playing (Polkki et al 2001, Tse et al 2002, Uman
et al 2013). CBT suitable for use in the perioperative
setting would include distraction, toys and games. It is
useful to compile a simple distraction box with toys and
books for children of all ages. A child friendly
environment is also important, with brightly coloured
pictures, posters, mural and toys.
Recovery discharge criteria
Recovery criteria which must be present before
discharge include the following:
• The neonate, infant, child or young person is com-
fortable, with a mild or zero pain score (pain has been
assessed using a pain assessment tool appropriate
for age and development).
• Any medication given has been evaluated for its
effectiveness (eg antiemetic, opioid bolus).
• Local guidelines regarding length of stay in recovery
after an opioid bolus has been given have
been followed.
• Analgesia (both for postoperative pain management
and for discharge in the case of day-case surgery) has
been prescribed.
• Any infusions have been checked by both the recovery
nurse and receiving ward nurse. These include PCA
and NCA opioid infusions and epidural analgesia.
Conclusion
In conclusion, the aim of this paper was to identify some
of the challenges of pain assessment in neonates,
infants, children and young people in the perioperative
setting, to review the pain assessment tools which are
available to help address these challenges and to
explore current pain management strategies. Prior to
discharging the patient, criteria should be met as
detailed above.
The paper has highlighted key practice points with the
aim to equip staff with the knowledge to meet the pain
assessment and management needs of children in their
care in the perioperative setting.
15
No competing interests declared
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