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| CLINICAL PRACTICE GUIDELINES |
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| Year : 2021 | Volume
: 22
| Issue : 2 | Page : 120-128 |
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Indian association of paediatric anaesthesia advisory for pain management in neonates and preverbal children
Anju Gupta1, Indu Mohini Sen2, YR Chandrika3, Gita Nath4, Elsa Varghese5
1 Department of Anesthesiology, Pain and Critical Care, All India Institute of Medical Sciences, New Delhi, India
2 Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Association and Research, Chandigarh, India
3 Department of Pediatric Anesthesia, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
4 Department of Anaesthesia and Intensive care, Rainbow Children's Hospital, Hyderabad, Telangana, India
5 Indian Association of Paediatric Anaesthesiologists, Hyderabad, Telangana, India
| Date of Submission | 13-Jan-2021 |
| Date of Decision | 05-Mar-2021 |
| Date of Acceptance | 28-Mar-2021 |
| Date of Web Publication | 29-Sep-2021 |
Correspondence Address:
Dr. Indu Mohini Sen
Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Association and Research, Chandigarh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/TheIAForum.TheIAForum_4_21
In the past, management of pain in neonates was regarded as unnecessary, with the belief that neonates have an immature nervous system and do not perceive pain. Later studies confirmed that neonates certainly do feel pain, though they lack the inhibitory mechanisms that modulate excruciating stimuli, unlike in older children. Repeated painful encounters experienced in the newborn period are associated with poor cognitive and motor development by 1 year of age. Pain in preverbal infants and children is also poorly recognized and often undertreated. Neonates and preverbal children cannot verbally communicate their pain and discomfort but express them through specific behavioral, physiological, and biochemical responses. Several pain measurement tools have been developed for young children as surrogate measures of pain. To achieve optimum postoperative or procedural pain relief, easily understandable tools and a multimodal treatment module should be tailor-made for each health-care facility that cares for neonates and young infants. The aim of this advisory is to outline key concepts of pain assessment in neonates and preverbal children and suggest a rational approach to its management by all anesthesiologists, pediatricians, nursing staff, and other medical personnel caring for these children. The Indian Association of Paediatric Anaesthesia (IAPA) convened an online meeting in April 2020 to formulate the advisory on pain management in neonates and preverbal children under the chairmanship of Dr. Elsa Varghese, President IAPA, and members of the guideline committee. After several such meetings and revisions using feedback from IAPA members, the final guidelines were released in October 2020 on the IAPA website.
Recommendations: Pain relief should generally be accomplished with a combination of nonpharmacologic approaches and pharmacologic techniques in a stepwise tiered manner by escalating type and dose of analgesia with anticipated increases in procedural pain. Nonpharmacological distraction measures may be sufficient for minor needle procedures like vaccination and venipuncture and may be offered as a first step and to complement other pain management remedies. An interdisciplinary approach involving pharmacologic, cognitive-behavioral, psychologic, and physical treatments should be employed whenever feasible.
Keywords: Neonatal pain assessment, pediatric pain management, preverbal children
How to cite this article:
Gupta A, Sen IM, Chandrika Y R, Nath G, Varghese E. Indian association of paediatric anaesthesia advisory for pain management in neonates and preverbal children. Indian Anaesth Forum 2021;22:120-8 |
How to cite this URL:
Gupta A, Sen IM, Chandrika Y R, Nath G, Varghese E. Indian association of paediatric anaesthesia advisory for pain management in neonates and preverbal children. Indian Anaesth Forum [serial online] 2021 [cited 2023 Jun 4];22:120-8. Available from: http://www.theiaforum.org/text.asp?2021/22/2/120/326976 |
| Introduction | |  |
Advances in obstetrics and neonatology have greatly improved the survival rate of neonates, including preterm and very preterm infants. As a consequence, an increasing number of neonates, especially premature babies and young children with congenital defects undergo painful diagnostic and therapeutic interventions. In the past, management of pain in neonates was regarded as unnecessary, with the belief that neonates have an immature nervous system and do not perceive pain.[1] Till the end of the 1970s, there was no systematic research into pain management in children. Later studies confirmed that neonates certainly do feel pain, though they lack the inhibitory mechanisms that modulate excruciating stimuli, unlike in older children.[2] By 20-week postconceptual age (PCA), a functional pain system has developed and a fetus is able to mount a stress response to pain N-methyl-D-aspartate receptor-mediated windup and central sensitization is in fact more pronounced in neonates.[3]
Exposure to recurring pain-related stress in early life is known to have short- and long-term unfavorable sequelae.[3],[4] These include physiologic instability, altered neurodevelopment, learning deficits, poor adaptive behavior, and diminished pain threshold. All these can modify a child's subsequent physiologic response to painful or nonpainful stimuli. Repeated painful encounters experienced in the newborn period are associated with poor cognitive and motor development by 1 year of age.[5],[6]
Pain in preverbal infants and children is also poorly recognized and often undertreated. A large observational study from the Netherlands reported only 34% of neonates received some analgesia before painful procedures.[7] A landmark study by Mather and Mackie highlighted the pathetic state of pain management in older children. The authors observed that 75% of children studied had significant pain on the day of surgery and 13% reported severe pain.[8]
Neonates and preverbal children cannot verbally communicate their pain and discomfort but express them through specific behavioral, physiological, and biochemical responses. Several pain measurement tools have been developed for young children as surrogate measures of pain.[9] Consequences of acute pain include acute increases in blood pressure, heart rate, intracranial pressure, and fall in arterial oxygen saturation. These changes in cerebral perfusion and blood flow may be associated with an increased risk, especially in preterm infants of intraventricular hemorrhage and periventricular leukomalacia. It is, therefore, essential to assess, detect, and document the presence of pain and to implement appropriate and timely therapeutic interventions.[10]
Recognizing the deplorable state of pain assessment and management in children, more so in preverbal children because of the difficulty in assessment of pain severity in this group and the lacunae in knowledge and understanding of the pain management in this population, the Indian Association of Paediatric Anaesthesia (IAPA) convened an online meeting to formulate the advisory on pain management in neonates and preverbal children under the chairmanship of Dr. Elsa Varghese, President IAPA and members of the guideline committee in April 2020. After several such meetings and revisions using feedback from IAPA members, the final guidelines were released in October 2020 on the IAPA website.
Applicability
The aim of this advisory is to outline key concepts of pain assessment and suggest a rational approach to its management in neonates and preverbal children. The methods of assessment described can be used by anesthesiologists, pediatricians, nursing staff, and other medical personnel caring for these children.
Definition of pain
In 2020, the International Association for the Study of Pain (IASP) has defined pain as “An unpleasant sensory and emotional experience associated with or similar to that connected with actual or potential tissue damage.” This definition needs to be broadened for neonates and preverbal children, to include behavioral and physiologic indicators.
| Pain Relief Issues in Neonates and Preverbal Children | | |
General principles
Formulation and implementation of a uniform pain management program for small children has several advantages. It can improve understanding, help recognize the presence of pain, the remedies available, and the importance of initiating adequate pain control measures. Assessment of pain at regular intervals should be included as a fifth vital sign, after a painful procedure.[9],[10],[11] To achieve optimum postoperative or procedural pain relief, easily understandable tools and a multimodal treatment module should be tailor-made for each health-care facility that cares for neonates and young infants. Important components of the program should include:
- Specifying the frequency of pain evaluation and measurement depending on the clinical context
- Active involvement of parents and health-care providers. Cooperation can be achieved by being receptive to their views about their child's behavioral cues of pain and stress. This will help parents be proactive and enhance their coping skills
- A baseline pain evaluation of all children with painful conditions during the preanesthetic evaluation. Preoperative discussions should include what to expect in the postoperative period, the basis for pain evaluation, and therapeutic interventions available
- Postoperatively, pain parameters should be documented at 15-min intervals until optimal analgesia is achieved
- Reassessment of pain should be done 30 min after administration of rescue analgesic to establish its effectiveness
- After discharge from the postanesthesia care unit to the ward, a minimum of 4th hourly assessments can be continued for 48 h postoperatively for major surgical procedures.
- For children on mechanical ventilation, pain assessment can be documented by nursing staff. They should also document the child's state of consciousness (e.g., fully awake/sleeping comfortably and sedated/paralyzed). The attending intensivist should perform an independent assessment and plan further management.
- All analgesic interventions and their efficacy should be documented.
- Any special concerns should also be documented at the time of scoring and the team should ensure that the handover to the person in the next shift includes pain assessment and management to provide continuity of care.
| Causes of Inadequate Perioperative Pain Management in Preverbal Children | | |
- Pain assessment in preverbal children is subjective with considerable interobserver variability. On the other hand, using multidimensional observational tools can also be time-consuming and difficult, as is pinpointing the exact location of the noxious stimulus
- There is a diverse range of confounding factors responsible for the physiological changes in the perioperative period
- Undertreatment may also be due to a fear of side effects of potent opioid analgesics, e.g., depressed levels of consciousness, respiratory depression, cardiovascular collapse, and drug dependence
- Pain management is often left to the discretion of surgical and medical residents, and factors such as lack of time or interest as well as lack of knowledge of pediatric analgesic pharmacology may lead to under- or overmedication.
| Pain Assessment Tools | | |
Several pain assessment tools (PATs) are available for neonates and preverbal children, and the choice should be based on the pediatric subgroup and the type of pain (acute, postoperative, or chronic persistent).[9],[10],[11],[12] Ethnic and cultural background and language-related factors may influence the expression and assessment of pain. PATs are either unidimensional (based on a single parameter) or multidimensional (dependent on a combination of physiologic, behavioral, and other accessory parameters, e.g., gestational age and present age).[13],[14]
Types of physiologic and behavioral responses indicating pain
Physiologic parameters include heart rate, heart rate variability, blood pressure, breathing pattern, respiratory rate, oxygen saturation, vagal tone, intracranial pressure, skin color, pupillary size, and palmar sweating.[3],[4]
Behavioral responses include crying patterns, facial expressions, sleep patterns, hand and body movement, behavioral state changes, muscle tone, and consolability.[4],[13],[14] In neonates and infants, specific facial features such as eye squeeze, brow bulge, nasolabial furrows, and open-squared mouth are associated with acute pain [Figure 1] and commonly utilized PATs for acute pain in preverbal children are listed in [Table 1]. | Table 1: Pain scales used for measuring acute pain in neonates and preverbal children
Click here to view |
The modified pain assessment tool
The modified PAT (mPAT) is an observational, multidimensional, multicomponent pain assessment scale that was designed specifically for postoperative pain in neonates and has been validated for neonates of 24 weeks PCA to full-term neonates.[15] The mPAT is a revision of the previous PAT score devised by Hodgkinson et al. in 1994[16] and later modified by O'Sullivan et al. in 2016.[17]
The maximum score is 20, a higher score representing a greater level of pain. A score of >10 signifies severe pain and the need for opioids in combination with nonopioids and other nonpharmacological measures. For an intubated child on muscle relaxants, the total score is out of 10, since only the physiological indicators of pain can be recorded. Special considerations should be noted in the mPAT score, e.g., altered physiological response in children on inotropes or altered color in neonates with anemia or congenital heart disease which may be considered noncontributory to pain assessment.[18],[19] In these cases, deviations from the child's baseline status should be recorded in the mPAT score.
The specific parameters of the mPAT scale are shown in [Table 2].
Future perspectives of pain assessment
Ongoing research aims to add objectivity to PATs using measurable endpoints to assess pain. The purported endpoints include serum or salivary cortisol measurements, neuroimaging tests (near-infrared spectroscopy or functional magnetic resonance imaging), neurophysiologic tests (heart rate variability, amplitude-integrated encephalography), and changes in skin conductance.[9],[13],[14] These parameters may potentially reflect pain and stress and are being investigated in both acute and persistent pain. However, as of now, none of these have been shown to have sufficient reliability or universal clinical applicability to be considered as “the gold standard” (as the results are not real time and may be affected by other confounding factors).
| Pain Management Plan | | |
Pain relief should generally be accomplished with a combination of nonpharmacologic approaches and pharmacologic techniques in a stepwise tiered manner by escalating type and dose of analgesia with anticipated increases in procedural pain. An individualized multimodal pain management approach should be chalked out before the conduct of anesthesia or medical procedures. Preemptive analgesia with systemic analgesics and central neuraxial and peripheral nerve blocks instituted before surgical incision and continued perioperatively greatly reduce postoperative analgesic requirements. Treatment plans can be modified depending on the surgical procedure performed and on perioperative hemodynamic fluctuations. The following pain management approach can be used as a guide to individual clinical judgment. If facilities are available, it is preferable to collaborate with the multidisciplinary pain management team.
General principles recommended for pain management in the neonates and young children include:
- Nonpharmacologic comfort measures should be offered as a first step and to complement systemic pain relief[11],[12]
- Analgesics should be titrated based on comprehensive pain assessment including perioperative documentation of trends
- For mild to moderate pain, nonopioid analgesics, i.e., acetaminophen and ibuprofen are recommended by the WHO for children who are >3 months old. For infants aged <3 months, acetaminophen is generally recommended[5]
- For moderate to severe pain, opioid drugs along with nonopioid analgesics are generally prescribed[5],[13],[15]
- For the first 48 h after surgery, analgesics should preferably be administered by continuous infusion or at regular time intervals rather than by a need-based approach.[12],[13]
| Nonpharmacologic Interventions Which May Alleviate Pain and Stress: Step I | | |
There are several nonpharmacological or nursing control measures that are beneficial in reducing pain scores in the neonatal population.[20],[21],[22] These include:
- Limiting environmental stressors by lowering light and noise intensity
- Limiting handling of the baby to facilitate undisturbed sleep by encouraging cluster nursing care
- Kangaroo care
- Facilitated touch and gentle massage
- Encourage breastfeeding when appropriate
- Use pacifiers to encouraging nonnutritive sucking
- Swaddling, positioning with facilitated tucking to minimize movement
- Psychological interventions (distraction techniques [music and videogames or cartoons for nonverbal infants], cognitive behavior therapy, and hypnosis), relaxation, and physical therapies
- Oral sucrose and glucose feeds.
Skin-to-skin care (with or without sucrose or glucose supplementation) decreases pain scores in preterm and term infants.[23] A meta-analysis of nonpharmacologic nursing control measures used during minor invasive procedures (heel lance, intravenous [IV] catheter insertion, etc.) found that swaddling, facilitated-tucking, and sucking-related interventions were advantageous for preterm neonates.[24] Rocking, holding, and sucking-related interventions were found to be beneficial for term neonates.
Psychological strategies
An increasing appreciation for the need to adequately manage distress and pain during needle procedures is being realized. Strategies of distraction and hypnosis in collaboration with parents can help reduce procedural pain, distress, and fear of needles in children aged 2 years and older undergoing vaccination and venipuncture.[24],[25] Distraction aims to shift attention away from the noxious source using cognitive measures, e.g., blowing bubbles, counting, conversation, music) or behavioral (e.g., videos, toys, and games). The age appropriateness and level of engagement of these interventions are important factors contributing to their efficacy. Although the evidence for these strategies remains low at present, their potential benefits and lack of harm support their clinical use.
Oral glucose and sucrose
Providing oral sucrose while performing mild to moderate painful procedures is commonly used in neonates and infants. However, the correct dose, analgesic effects versus soothing benefits, exact mechanism of action, and long-term outcomes are not known. Glucose has similarly been found effective in reducing response to short-term painful procedures. A meta-analysis of studies on glucose and sucrose has determined that sucrose and glucose are safe and useful for procedural pain management.[26] Literature is lacking on its role in postoperative analgesia.
| Pharmacologic Management: Steps II–V | | |
- Step II: Oral or IV paracetamol and/or nonsteroidal anti-inflammatory drugs (NSAIDs)
- Step III: Topical or subcutaneous infiltration of local anesthetic or particular peripheral nerve blocks/neuraxial blocks
- Step IV: Use of opioids
- Step V: Combination of opioids and other adjuvant analgesic drugs.
Pharmacologic treatment strategies
Systemic pharmacologic agents that reduce neonatal pain and stress include nonopioid analgesics like acetaminophen, NSAIDs like ibuprofen, ketorolac, and diclofenac.[19],[27],[28] In addition, ketamine, local anesthetic, and opioid analgesics (e.g., fentanyl, alfentanil, morphine, etc.) are effective when pain is of greater severity. [Table 4] | Table 4: Commonly used medications for managing pain in preverbal children
Click here to view |
Acetaminophen (paracetamol) is effective for treating to moderate procedural or postoperative pain, but ineffective for acute pain when administered alone.[5] Based on the available evidence, it is recommended to be used as an adjunctive analgesic combined with topical anesthetics or opioid therapy.[23] IV acetaminophen has a useful opioid-sparing action and may reduce the risk of adverse opioid effects. In an opioid-sparing randomized trial design in children undergoing thoracoabdominal surgery, IV acetaminophen decreased the total morphine consumption by 66% without any adverse effects.[29] Opioid-sparing effects were also observed in a retrospective cohort study on postoperative morphine consumption in preterm infants (GA <32 weeks). Minimal opioid-sparing effects have been reported with rectal acetaminophen administered to neonates and infants, possibly due to inadequate rectal absorption.[30]
Route and dose of acetaminophen
Oral dose: 10 mg/kg 6 hourly or 15 mg/kg 8 hourly.
IV acetaminophen doses in preterm neonates are as shown in [Table 3].
The IV dosing schedule for infants and children <2 years of age is 7.5–15 mg/kg/dose every 6 h up to an upper limit of 60 mg/kg/day.
Side effects: In contrast to its use in older children and adults, neonates rarely manifest hepato-renal toxicity with acetaminophen, though vigilance is required in infants with malnutrition or hypoalbuminemia.[31]
Nonsteroidal anti-inflammatory drugs
The combination of NSAIDs with opioids has beneficial opioid-sparing effect, decreasing opioid requirement to about <30%.[32] NSAIDs are avoided in neonates because of the concerns of renal insufficiency, gastrointestinal bleeding, platelet dysfunction, and pulmonary hypertension. Although the WHO proposes the use of ibuprofen in children >3 months of age, these drugs are commonly used only in infants >6 months of age due to the apprehensions about gastrointestinal and renal adverse effects.[5],[13] NSAIDs are be used with caution in children with decreased renal function and hypovolemia.
Acetaminophen and ibuprofen are the standard first-choice analgesics for treating mild pain. The oral dosage of ibuprofen for infants and children is 10 mg/kg every 4–6 h. IV dose is 4–10 mg/kg every 6–8 h. Ketorolac has been used intravenously in the dose of 0.5 mg/kg every 6–8 h in neonates in the postoperative setting, and in infants after adenotonsillectomy.[13] Unlike adults, postoperative ketorolac has not been associated with increased bleeding in pediatric patients. Diclofenac is an efficient analgesic in an IV dose of 0.25–0.5 mg/kg for acute postoperative pain in children.[31] The recommended oral/rectal dose is 1 mg/kg thrice a day. Rectal diclofenac has a peak action in 30–60 min Diclofenac has been found to be twice as effective as acetaminophen for postsurgical pain.[32] Adverse effects, though rare in children, include reports of anaphylactoid reactions.
Local anesthetic drugs
Neonates and infants <3 months of age are at much higher risk of local anesthetic toxicity.[33] Elimination half-lives of local anesthetic drugs are prolonged 2–3 times and their metabolism by hepatic microsomal enzymes is significantly impaired. Using these agents in limited doses well below, their toxic dose for peripheral or central blocks can form an effective component of multimodal analgesia.[23] Topical agents like eutectic mixture of local anesthetic (EMLA cream and 4% liposomal lidocaine) have a role in postoperative analgesia for superficial procedures like circumcision, alone or in combination with penile nerve blocks.[23],[24]
Peripheral nerve blocks or regional anesthesia techniques are an important component of multimodal analgesia for postoperative pain management of majority of the surgical procedures in children.[23],[33],[34] Adjuvants such as clonidine, fentanyl, and morphine are generally avoided in infants <6 months of age because of possible side effects which should be balanced with its action of prolonging analgesia. Continuous regional analgesic techniques are beneficial when the analgesic requirement is expected to exceed the duration of effect of a single injection. Ultrasound-guided blocks are preferred whenever the equipment, skills, and expertise are available to reduce complications and local anesthetic dose. Epidural or spinal (opioids with or without LA) anesthesia should be routinely considered for postoperative pain management in children undergoing major thoracoabdominal or lower extremity surgeries, particularly for patients at risk of cardiopulmonary complications or prolonged ileus. The caudal route is generally preferred for access to epidural space in infants. Catheters can be threaded up to thoracic levels for cardiac, mediastinal, and pulmonary procedures, preferably under ultrasound guidance. Safe LA doses are lower for young infants and should be carefully maintained well within the recommended doses for single injection or continuous infusions. Duration of infusions should be limited to <36 h for neonates.[33] Vigilant monitoring is strongly recommended for all the children receiving neuraxial analgesic modalities for perioperative analgesia.
Opioids
The most effective treatment for moderate to severe pain relief in newborns is with opioids. They provide analgesia as well as sedation, have a relatively broad therapeutic window, and effectively diminish the physiologic stress response. Morphine and fentanyl are the most used opioids for neonates in India, though more potent and shorter-acting drugs such as sufentanil, alfentanil, and remifentanil can be used depending on availability. Prescriptions of mixed opioids (viz., codeine and tramadol) are gradually declining from pediatric practice after reports on pharmacogenetic changes associated with their use were published.[5],[13]
Morphine is used as a continuous infusion or as intermittent IV boluses (0.05–0.1 mg/kg/dose) in infants during major surgery. Observational studies and trials suggest that both intermittent boluses and continuous morphine administration are safe and effective in reducing postoperative pain in infants.[35]
Fentanyl is used for postoperative analgesia following major surgeries like cardiac surgery, or children with pulmonary hypertension or congenital heart disease. Recommended bolus dose is 0.5–1 μg/kg IV. Slow administration over 3–5 min minimizes the incidence of the chest wall or skeletal muscle rigidity. The advantage of fentanyl lies in its ability to provide rapid pain relief with minimal blood pressure fluctuations and reduced gastrointestinal motility and urinary retention compared to morphine. However, continuous infusions of fentanyl are not advocated in preterm neonates as per the American Association of Pediatrics and Canadian Paediatric Society guidelines because of lack of evidence for significant benefit over morphine and potential for adverse effects.[18],[27] Bradycardia and chest wall rigidity remain the chief side effects. Naloxone should always be available to reverse respiratory depression associated with the use of opioids. Alternate routes of dispensation like transmucosal and inhalational have also been found to be equally effective.[35]
Remifentanil, an ultrashort-acting opioid, is a good alternative for short procedures and surgeries because it is not eliminated by liver metabolism.[35] There are limited data available on its use in small children.[13],[18]
Worrisome side effects of opioids are respiratory depression, hypotension, delayed feeding, and urinary retention. Hence, doses need to be cautiously tailored. Parent- or nurse-controlled analgesia is a useful modality to reduce consumption of opioids compared to continuous drug infusions, especially in smaller children.[13],[36]
Alternative or adjuvant medications
Methadone, ketamine, and dexmedetomidine have been used for pain management in infants and young children, but limited due to lack of evidence of effectiveness and concerns about adverse effects and potential for neurotoxicity.[35],[37],[38] Ketamine is a dissociative anesthetic widely used for procedural, operative, or postoperative analgesia and sedation in children. It provides good analgesia, amnesia, and sedation, while maintaining the respiratory drive and preserving hemodynamic status in lower doses (intramuscular or IV 0.5–2 mg/kg/dose). Ketamine can be an effective analgesic option for hemodynamically unstable children where opioids would not be suitable.
Dexmedetomidine
It has been used in preterm and term infants and demonstrated effective analgesic effect with no respiratory depressant in usual doses.[35] It is increasingly being used for sedation in mechanically ventilated infants and children in the intensive care unit setting and for short-term sedation in the nonoperating room setting.[38] However, because of the limited data on its safety and efficacy, the routine use of this drug is not recommended in neonates until larger randomized trials demonstrate that it is both advantageous and safe in newborns. Case reports of seizures or bradycardia in neonates have raised further concern on the use of dexmedetomidine in this population.[39]
| Summary and Recommendations | | |
Pain management in preverbal children is often inadequate and neglected due to challenges in its assessment and management. Untreated pain in young children has been correlated with adverse long-term behavioral, neurodevelopmental, and cognitive effects. Age-appropriate PATs should be used and sound understanding of the mechanisms of action and roles of various nonopioid and opioid therapies can help optimize pain management. The IAPA recommendations for managing perioperative or peri-procedural pain in small children are listed in [Table 5].
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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