Pediatric pain: neonates, children and adolescents

Children feel pain at least as readily as adults, and neonates show adult-like pain processing. Avoid codeine and tramadol in young children and after tonsillectomy, treat sickle cell crises fast, and treat pediatric CRPS with rehabilitation.

1. Newborns process pain like adults. In an fMRI study, noxious stimulation activated 18 of the 20 brain regions active in adults, including sensory and affective areas, at lower stimulus intensities, implying a lower threshold for nociceptive brain activity ¹.
2. Codeine and tramadol: contraindicated in two groups. FDA labels contraindicate both in children under 12 and in anyone under 18 for pain after tonsillectomy or adenoidectomy, because of deaths and respiratory depression, often in ultrarapid CYP2D6 metabolizers ²³.
3. Post-tonsillectomy pain: nonopioids. The AAO-HNS guideline recommends ibuprofen, acetaminophen or both for pain control after tonsillectomy ⁴.
4. Sickle cell crisis: speed matters. ASH recommends analgesia within 1 hour of emergency department arrival and reassessment every 30 to 60 minutes, with individualized opioid dosing; subcutaneous or intranasal routes help when IV access is delayed ⁵.
5. Add NSAIDs, avoid steroids, in sickle cell pain. ASH suggests a short 5- to 7-day NSAID course added to opioids and suggests against corticosteroids for acute pain ⁵.
6. Pediatric CRPS is treated with rehabilitation. Exercise and physical therapy are the cornerstones, within an interdisciplinary program that includes cognitive behavioral therapy; invasive treatments have only weak evidence ⁶.

A child who "always needs codeine" after tonsillectomy is the patient at risk: ultrarapid metabolizers form morphine fast, which is why the contraindication exists ².

• Only the amygdala and orbitofrontal cortex failed to activate in newborns in the fMRI study ¹.
• Infant spinal withdrawal reflexes are larger and longer than in adults ¹.
• The tonsillectomy contraindication covers all patients under 18, not just those under 12 ²³.
• In children, ASH dosing should follow an individualized, patient-specific plan when available ⁵.
• Gradually increasing aerobic activity is described as the gold-standard therapy for pediatric CRPS ⁶.
• Sucrose reduces procedural pain from single events such as heel lance, venipuncture and intramuscular injection in preterm and term infants ⁷.
• No optimal sucrose dose has been identified, and repeated use needs more study ⁷.
• Psychological therapies are an integral part of interdisciplinary treatment for pediatric CRPS ⁶.

• Assuming neonates feel less pain because they cannot report it, and skipping procedural analgesia ¹.
• Prescribing codeine to a 15-year-old after tonsillectomy because the under-12 limit no longer applies ².
• Using invasive sympathetic procedures first-line in pediatric CRPS ⁶.
• Withholding opioids from a child in a sickle cell crisis until laboratory results return ⁵.