Acutely Painful Presentations

Last modified by Lisa Stromquist on 2017/10/10 17:32

Welcome to the toolkit about how acute presenting pain and distress can be minimized for children. When dosing medications, we suggest you consult your local formulary for specific guidance, as variability exists between centres.  Physical and psychological interventions can be used in all ages.


The majority of healthcare visits in North America are related to pain, and untreated pain has consequences for children. Short-term consequences include pain and distress for the child, parents and healthcare providers, inadequate patient assessment, and slower healing. Long-term consequences include increased sensitivity to pain, healthcare avoidance, social hyper-vigilance and higher levels of anxiety before a medical visit. Expeditious and effective pain care improves patient and caregiver satisfaction, decreases the ‘wind-up’ phenomenon that can exacerbate perceived pain, and optimizes discharge times. 

The purpose of this toolkit is to make the treatment of children’s pain and distress easier in your clinical practice. We have seen these interventions suggested used for the pain and distress associated with otitis media, musculoskeletal injuries, headaches, acute abdominal pain, and other such illnesses and injuries. We strongly urge you to consider utilizing more than one complementary intervention, along with the medications, for children who present to your clinical setting with acute pain. The contents, which have been provided by your clinical colleagues around the country, can help you move these pharmacologic, physical, and psychological interventions into your regular practice, help create a policy for their use in your organization, support clinical education in pain treatment efforts, and provide clinical resources to make these interventions easier to use. Use as many of the resources as you need and modify them to fit your organizational context.

Physical and psychological interventions can also be used in conjunction with pharmacological (ie ibuprofen or opioids) pain management. Links to recommendations and resources for these techniques can be found through the main webpage for the CAPHC acute procedural pain toolboxes


In this kit you’ll find:

  • Family resources, including a brochure to explain to families how opioid medications work, and why you might have to use it.
  • Clinician Resources, including a dosing summary sheet, analgesia dosing handbook, and a pain management algorithm.
  • An example of multiple hospital policies  for the treatment of burns, migraines, and fractures. These exemplars can be used to create your own organizational policies based on your needs and context.
  • Educational PowerPoint presentations developed by your clinical colleagues to support education about measuring and treating acutely painful conditions. These slides can be modified and delivered for your needs and context but please acknowledge the original authors and the CAPHC Pain CoP for their contributions.
  • Videos explaining migraines and applying burn dressings, which can be shared with families or health care providers.
  • Background articles outlining the current best research evidence to support the assessment and treatment of painful presentations. These include general articles, as well as condition-specific articles.

Please note, examples of policies are provided for reference purposes, only. We encourage all users of the toolkit who wish to adopt a similar policy at their institution to review, adapt, and modify the examples, as needed. The providers of these examples do not endorse their use outside of the institution for which it was originally created.

If you have any comments, questions or additions for the box, please contact CAPHC at 

Thank you for supporting the CAPHC Pain Community of Practice’s mission to improve health outcomes for infants and children by reducing pain experienced during medical procedures, healthcare interventions and chronic conditions. 

Family Resources

Podcasts and Apps for Pain Coping

Phone Applications for Mindfulness/Meditation:

  1. Smiling Mind (Free): Guided meditation for ages 7 to adult
  2. Headspace (Free): Guided meditation with animation
  3. Healing Buddies Comfort Kit (Free): Guided practice of skills for pain and nausea

Phone Applications for Anxiety:

  1. Mindshift (Free): Anxiety tracking app that helps people track anxiety triggers and situations

Biofeedback Tools:

  1. Heartmath software:
    • Inner Balance for iPhone
  2. Stress Cards on Amazon

Kaiser Guided Imagery Podcasts
Enter the link below in your browser

    • Click on “Live Healthy”
    • Click on “Podcasts (guided imagery) on bottom left”

Other Websites / Tools:

  1. Pain Management Network – Relaxation Techniques and Mindfulness:


  1. Pain Management for Common Childhood Pain and Injuries - Hospital for Sick Children:  About Kids Health 
  2. Soulagement de la douleur liée aux blessures et auxmaux communs pendant l’enfance - Hospital for Sick Children: About Kids Health
  3. Analgésiques Narcotiques Opiacés - CHU Sainte Justine (When prescribing short-term opioid analgesia, it is advised to suggest the use of stool softeners or laxatives to help avoid constipation, a very common adverse effect t of short-term opioid therapy.)
  4. Narcotic Opiate Analgesics - CHU Sainte Justine (When prescribing short-term opioid analgesia, it is advised to suggest the use of stool softeners or laxatives to help avoid constipation, a very common adverse effect t of short-term opioid therapy.)
  5. Acute Pain Postcard - Holland Bloorview Kids Rehabilitation Hospital
  6. Pain Pain Go Away: Helping Children with Pain (Booklet) - Patrick J. McGrath, G. Allen Finley, Judith Ritchie, and Stephanie J. Dowden (Please note that, as of 2013, Health Canada does NOT support the use of codeine in children <12 years of age)
  7. Mindful Distraction - Dr Bernie Whitaker RN BAppSci(Adv Nur) MNSt. Ph.D
  8. Comforting Your Baby In Intensive Care -  Professor Linda S. Franck
  9. Comfort Holds - Stollery Children's Hospital
Clinical Resources
  1. Stollery Children's Hospital Pain Handbook (2014) - Alberta Health Services 
  2. Stollery Children's Hospital Pain Management Algorithm - Alberta Health Services
  3. RxFiles Cheat Sheet - L Regier BSP BA, B Jensen BSP, B Kessler BSP © (Please note that Health Canada does NOT support the use of codeine in children <12 years of age. Further, all health care professionals performing procedural sedation should have paediatric advanced life support training, and adhere to local patient monitoring guidelines when performing sedation)
  4. Assessment and Management of Pain Third Edition (2013), Clinical Best Practice Guideline, Registered Nurses' Association of Ontario (RNAO) (This is a comprehensive guide to pain assessment in nursing. Please see Appendices E,I, and J for pediatric-specific pain measurement tools, Appendix F for an algorithm-based approach to assessing pain in children, and Appendix N for an excellent summary of strategies for acute pain management in children)
Hospital Policy
Educational PowerPointAssessing Paediatric Pain in the Hospital and Home - Vikram Sabhaney, MD, FRCPC
It Hurts - Treatment of Musculoskeletal Pain - Dr. Samina Ali
Play Away the Pain - Bernadette Sanchez, CCLS
VideosPain Management at Sickkids – Overview of various types of interventions for treatment of  pain
Developed by: The Hospital for Sick Children
Video link:
 Migraine: How it works and how to get it under control!
Developed by: German Paediatric Pain Centre
Video link:
 RANTony  on pain management and assessment
Developed by: Dr. Anthony Crocco
Video link:
 Videos for burn dressing application (French)
Developed by: CHU Ste Justine
Pansement Bactigras
Video link:    
Acticoat pour les brulûres  
Video link:

Background ArticlesBackground article list PDF

Ali et al, Pain Management of Musculoskeletal Injuries in Children Current State and Future Directions, Pediatric Emergency Care  Volume 26, Number 7, July 2010

Agency Medical Directors Group (AMDG), Interagency Guideline on Prescribing Opioids for Pain Third Edition 2015 (*See Part II, pages 22-25 for general opioid use recommendations for acute pain. Not specific to children)

Bailey B, Trottier ED2. Paediatr Drugs. 2016 Aug;18(4):287-301. doi: 10.1007/s40272-016-0181-5. Managing Pediatric Pain in the Emergency Department.

Bailey B, Daoust R, Doyon-Trottier E, Dauphin-Pierre S, Gravel J.Pain. 2010 May;149(2):216-21. doi: 10.1016/j.pain.2009.12.008. Epub 2010 Feb 25. Validation and properties of the verbal numeric scale in children with acute pain.

Bailey B, Gravel J, Daoust R.Pain. 2012 Apr;153(4):839-42. doi: 10.1016/j.pain.2012.01.006. Epub 2012 Feb 4.Reliability of the visual analog scale in children with acute pain in the emergency department.

Bolt P, Barnett P, Babl FE, Sharwood LNArch Dis Child. 2008 Jan;93(1):40-4.Topical lignocaine for pain relief in acute otitis media: results of a double-blind placebo-controlled randomised trial.  reported also  in :

Hartling L, Ali S, Dryden DM, Chordiya P, Johnston W, Plint AC, Stang A, McGrath P, Drendel AL, How Safe Are Common Analgesics for the Treatment of Acute Pain for Children? A Systematic Review, Pain Research and Management Volume 2016, Article ID 5346819,

Jacob R, Shavit I. Emergency Department Pain Management of Acute Abdominal Pain and Acute Appendicitis in Children., Isr Med Assoc J. 2016 Nov;18(11):689-691. Review. PMID: 28466621
Krauss BS, Calligaris L, Green SM, Barbi E., Current concepts in management of pain in children in the emergency department., Lancet. 2016 Jan 2;387(10013):83-92. doi: 10.1016/S0140-6736(14)61686-X. Epub 2015 Jun 18. Review.

Le May S, Ali S, Khadra C, Drendel A, Trottier E , Gouin S, Poonai N, Pain Management of Pediatric Musculoskeletal Injury in the Emergency Department: A Systematic Review, Pain Research and Management Volume 2016, Article ID 4809394,

Murphy A, O'Sullivan R, Wakai A, Grant TS, Barrett MJ, Cronin J, McCoy SC, Hom J, Kandamany N.Cochrane Database Syst Rev. 2014 Oct 10;(10):CD009942. doi: 10.1002/14651858.CD009942.pub2.Intranasal fentanyl for the management of acute pain in children.

Patniyot IR, Gelfand AA Headache. 2016 Jan;56(1):49-70. doi: 10.1111/head.12746.Acute Treatment Therapies for Pediatric Migraine: A Qualitative Systematic Review.
Poonai N1, Paskar D, Konrad SL, Rieder M, Joubert G, Lim R, Golozar A, Uledi S, Worster A, Ali S.Acad Emerg Med. 2014 Nov;21(11):1183-92. doi: 10.1111/acem.12509.Opioid analgesia for acute abdominal pain in children: A systematic review and meta-analysis.

Poonai N1, Bhullar G2, Lin K2, Papini A2, Mainprize D2, Howard J2, Teefy J2, Bale M2, Langford C2, Lim R2, Stitt L2, Rieder MJ2, Ali S2.CMAJ. 2014 Dec 9;186(18):1358-63. doi: 10.1503/cmaj.140907. Epub 2014 Oct 27.Oral administration of morphine versus ibuprofen to manage postfracture pain in children: a randomized trial.

Pope N, Tallon M, McConigley R, Leslie G, Wilson S, Experiences of acute pain in children who present to a healthcare facility for treatment: a systematic review of qualitative evidence, 2017 JBI Database of Systematic Reviews and Implementation Reports DOI: 10.11124/JBISRIR-2016-003029
Created by Lisa Stromquist on 2017/07/19 22:24