Hesperian Health Guides
Medicines for pain
HealthWiki > Helping Children Live with HIV > Chapter 13: Helping children with pain > Medicines for pain
To best treat a child’s pain at home with medicine:
- Give medicine by mouth, not by injection.
- Give regular doses as prescribed and dose routinely. Do not wait until the pain gets worse.
- Start with ibuprofen or paracetamol (acetaminophen).
Ibuprofen and paracetamol are good, low-cost medicines that treat pain in children and are easy to find. They can be given 3 to 5 times a day, and paracetamol can be taken for long periods of time. If these do not control the pain, use stronger medicines.
Morphine and other narcotic (opioid) medicines are strong medicines used to relieve pain. Usually, a small amount is given at first and gradually increased as needed until the dose is enough to ease the child’s pain. Sometimes other medicines are also given to the child, to prevent nausea or constipation caused by morphine.
Morphine is very safe to use with a child in pain. Many people, including some health workers, worry that morphine is dangerous for a child. They fear the child will become addicted, or that giving too much will kill the child. But morphine is not addictive to a person in pain. The right dose will stop the child’s pain and will not endanger him.
Children need smaller amounts of pain medicine than adults. For babies, pain medicine often comes as a liquid that must be measured carefully. See doses and other information on how to use these medicines. It may be best to get help from a health worker to find out what dose of morphine your child needs. Once you know, you can safely give the medicine each day.
Give medicine before a child is in pain. Do not wait until pain is very strong. Pain is easier to control this way and requires less medicine.
Contents
Paracetamol (acetaminophen)
Paracetamol treats both pain and fever and is very safe for children.
But do not give your child more than the recommended amount. Too much can be poisonous. Read the label or talk to your health worker or pharmacist to know for sure how much paracetamol is in your medicine, so you can give the correct dose. Some cold and cough medicines include paracetamol along with other medicines. So also read the labels for any other medicines your child takes, and if they contain paracetamol, give less additional paracetamol to account for what the child takes in those medicines. Keep paracetamol where children cannot reach it, especially if it is in a sweet syrup.
Dose by weight: Give 10 to 15 mg for each kg the child weighs, up to 4 doses a day, and no more than 60 total mg per kg in a day (sunrise to sunrise). Wait 4 hours between doses.
Dose by age if you cannot weigh the child. Babies must be at least 4 months old.
| Age | Dose | Using liquid-120 mg in 5 ml OR Using 500 mg tablet | |
| A child under 1 year old | 60 mg | 2.5 ml | |
| A child 1 to 2 years old | 125 mg | 5 ml OR ¼ tablet |  |
| A child 3 to 7 years old | 250 mg | 10 ml OR ½ tablet |  |
| A child 8 to 10 years old | 375 mg | ¾ tablet |  |
Ibuprofen
Ibuprofen treats muscle pain, joint pain, headache, and fever.
Dose by weight: Give 5 to 10 mg for each kg the child weighs, every 6 to 8 hours, up to 3 or 4 doses a day, and no more than 40 total mg per kg a day (sunrise to sunrise). Do not give for more than 10 days in a row without talking to a health worker. Give with or after food to prevent belly pain.
Dose by age if you cannot weigh the child. Babies must be at least 4 months old.
| Age | Dose | Using liquid-120 mg in 5 ml OR Using 500 mg tablet | |
| A child 4 to 12 months | 40 to 50 mg | 1 ml OR ¼ tablet | |
| A child 1 to 2 years old | 80 to 100 mg | 2 ml OR ½ tablet | |
| A child 3 to 5 years old | 120 to 150 mg | 3 to 4 ml OR ¾ tablet | |
| A child 6 to 10 years old | 200 mg | 1 tablet |  |
Use paracetamol and ibuprofen together for strong pain
If you have both of these medicines, and one alone does not control pain in your child, you can try giving both, either together or at different times. These medicines work in different ways, so doing this means your child gets more pain relief, but not a harmful amount of either medicine. You must plan the doses to be the right number of hours apart, and take care not to mix up the medicines. It is best to write down the time when you give each dose, to help you keep track.
An example: Your child is 3 years old and weighs 18 kg. Using only one medicine, she still has pain. Her paracetamol dose is 250 mg, every 4 to 6 hours. Her ibuprofen dose is 100 mg, every 6 to 8 hours. Both can be given up to 4 times a day.
Here are 2 different ways to use paracetamol and ibuprofen together for pain:
Morphine
Morphine relieves moderate or strong pain very well, and must be prescribed by a health worker. You can learn to give morphine to a child by mouth at home. In a hospital, morphine is often given in the vein (IV). It is safe to give children morphine and it makes them feel much better.
Ask a health worker how much to give. They often start with a small dose and give a little more every hour until the child’s pain stops. Then they add up how much they gave all together to relieve the child’s pain, and give that amount every 4 hours. The goal is to find a strong enough dose to control the pain, without giving so much that the child becomes sleepy or has too many uncomfortable side effects. Different children need different amounts of morphine for the same pain. As long as side effects are few and manageable, you can continue to raise the dose slowly until it works. For severe pain, you can also use ibuprofen and paracetamol with morphine, and you will need less morphine. This means there will be fewer side effects from morphine.
Morphine comes in a prepared solution to give by mouth with 2 mg in each ml of liquid, or as tablets of 10 mg. The least costly way is to have a pharmacy mix morphine powder into water for drinking. You can make a 5 mg, 50 mg, or 100 mg in 5 ml solution this way.
Give morphine regularly every 4 hours for pain. If the child becomes sleepy with this dose during the day, lower each dose a little but watch for signs of pain.
Dose:
A child 1 month to 12 months old: 0.1 to 0.2 mg for each kg the child weighs
A child 1 to 2 years old: 0.2 to 0.4 mg for each kg the child weighs
A child 2 to 5 years old: 0.4 to 1 mg for each kg the child weighs
A simple way to start a child of any age on morphine, especially if you cannot weigh him, is to start with 1 to 2.5 mg of morphine. Give this every 4 hours for 1 day. If the child still feels pain, add more morphine to the dose — half of the previous day’s dose. You can increase the dose every day until you reach a dose that stops the pain between regular 4-hour doses.
Watch for signs of too much morphine — very slow breathing, difficulty breathing, or being very sleepy. These are signs the dose should be smaller.
To help a child sleep through the night
You may also give more morphine at bedtime so the child will not wake up in pain in the night. First try the regular dose plus half the dose (if the child’s regular dose is 2 mg, give 3 mg at bedtime). If the child still wakes during the night with pain, double the regular dose before you put your child to bed for the night.
How to give an extra dose if pain returns between regular doses
If the child’s pain comes back between regular doses, you can give an extra dose of morphine. It is best to give more medicine quickly instead of waiting for the next dose when the pain has become stronger and might need even more to be effective.
Side effects of morphine
Most side effects happen at the start of treatment or when the dose is increased. If they do not stop after a few days, the morphine dose should be reduced.
Many children have constipation (hard stool) from taking morphine. To prevent and help with this, have the child drink plenty of water (or breastfeed often) and, if the child is older than 6 months, give foods high in fiber such as bran, cassava, carrots, turnips, pumpkin or sunflower seeds, and fruits. You can also give dried and crushed paw paw (papaya) seeds. If stool will not come out, giving the child a small spoonful of oil in the morning may help it move later in the day.
A child may feel ill or vomit during the first few days of taking morphine. A health worker may prescribe another medicine to help with this. Some children keep feeling ill on morphine and need to change to another pain medicine.
Sometimes children get headaches, or have a dry mouth, or become dizzy or lightheaded, or have changes in their mood while taking morphine.
Morphine’s most dangerous side effect is slow breathing. To check breathing, count breaths for a minute. Healthy breathing for children of different ages is:
- 20 or more breaths a minute in a baby from birth to 6 months old.
- 16 or more breaths a minute in a child from 6 months to 2 years old.
- 14 or more breaths a minute in a child from 2 to 5 years old.
Too-slow breathing is a sign the dose should be reduced. Try reducing by half.
Warnings: Some cough medicines contain codeine, which is related to morphine. Do not give a child any medicine with codeine in it while also giving morphine.
Do not stop morphine suddenly. Lower the dose slowly and give it less often, over a few days if treatment was less than 2 weeks. If longer, stop over 5 to 10 weeks.
Morphine sometimes comes in a prolonged release (slow release) form, which is given less often, usually every 8 to 12 hours. This form is more costly and not widely available. If you want to use it, ask a health worker how much to give and how often. Do not give this slow-release form every 4 hours.
Helping children who worry about illness and pain
Children in pain, especially older children, are often worried and afraid, which can make their pain worse. Talk with them about their illness to learn what kind of support they need, and to gently correct any wrong ideas they have. Ask your child how she feels and listen with care to her answers. Help her understand that feeling distress is normal when you are ill or hurting. Reassure her that you will do all you can to ease her pain. But be honest. Do not promise you will completely stop her pain unless you are sure you can.
Children also need healthy ways to express their feelings. For example, ask them to tell a story or draw a picture that shows how they feel. For more ways to help children express feelings about illness, see Chapter 4.
Children may ask questions about their pain or illness. To help:
- Give your child your full attention and show you are listening. Be patient and listen to everything your child says.
- Try to answer difficult questions in simple, reassuring ways. Think about what your child can understand. Ask questions to find out more about what the child knows, wants to know, and fears.
 Why did Rani run away?
She used to play with me!
I don’t know. What do you think? |
 Her mama made a face at me. Did I do something wrong?
Hmmm. You were a little upset when your mouth hurt so much. Maybe Rani thought you were being mean.
I will speak to Rani’s mother, and ask what is wrong, OK? |
It is difficult for most caregivers to have a child feeling pain and to be unsure how to help. Take care of yourself, so you can be calm and patient, which helps both your child and yourself as you try different things. Ask for support, especially if you are tired, upset, or also in pain yourself. See Care for children, families, and caregivers for more about ways caregivers can support themselves and each other.