What Compounding Pharmacists Need to Teach Parents About Children’s Pain Relief Guidelines

What Compounding Pharmacists Need to Teach Parents About Children’s Pain Relief Guidelines

i-pillParents share a common concern about the difficulty in determining how to best address their children’s pain. It’s not just their worry about what’s causing the pain and natural empathy when a child hurts—they become baffled about which product to choose when confronted with multiple shelves of OTC products and they’re unsure about when pain is serious enough to call the pediatrician. Guidance from a community pharmacist is likely appreciated, but many parents may hesitate to reach out. Compounding pharmacists need to intervene to answer questions and educate parents about children’s pain relief guidelines.

Assessing Pain in Children

Headaches account for 20 percent of all pain in children, but the incidence of pediatric migraine is on the rise. This is followed by abdominal pain, which affects 10 to 18 percent of children and is most prevalent between the ages of 8 to 10 years.1 The thing to remember about parents whose kids are suffering from pain is that their perceptions are diverse. Some may not recognize when pain is cause for concern, while others elevate mild pain into a major event. Pharmacists need to find the middle ground, help assess the pain based on its location, duration and intensity, and offer recommendations. These symptoms indicate it’s time to see a pediatrician:

Abdominal pain:

  • Pain in the groin area may be testicular torsion—this is a medical emergency
  • Pain lasts longer than 24 hours
  • Vomiting lasts longer than 24 hours or it appears green, yellow or bloody
  • Pain accompanied by sweating, lethargy or fever
  • Pain in lower right abdomen indicative of appendicitis
  • Pain associated with urinary frequency
  • Pain associated with a rash


  • Headache combined with fever, stiff neck or vomiting needs immediate attention to rule out serious infection like meningitis
  • Not relieved by OTC treatment and lasts several hours
  • Intense pain affects normal activities like eating
  • Interfere with sleep
  • Increase in frequency or severity
  • Very painful, sudden headache
  • Headache with weakness, numbness, vision problems, balance problems, confusion or behavior changes
  • Headache following a head injury

Pharmaceutical Management of Pediatric Pain

Studies show that children don’t receive adequate pain treatment when compared to adult protocols.2 Untreated pediatric pain has long-term consequences in the form of chronically sensitized pain pathways and a higher risk of anxiety disorders, so it’s important to ensure they get appropriate treatment. Pediatric dosage guidelines exist for acetaminophen and ibuprofen; otherwise, pharmacists must extrapolate from guidelines for adult pain relief. U.S. Pharmacist offers these tips:3

  • Double-check patient weights prior to dispensing or recommending OTC analgesics.
  • Verify dosing calculations. Pediatric medications come with two instructions that are easy to misread—mg/kg/day and mg/kg/dose. To avoid errors, the Pediatric Pharmacy Advocacy Group recommends that prescribers include both the mg/kg and the full calculated dose when writing prescriptions.
  • Dispense medication in unit-dose, ready-to-administer form.
  • Use doses rounded to the nearest teaspoon or half-teaspoon whenever possible to make dosing easier for parents and caregivers.

The World Health Organization recommends categorizing pediatric pain as mild versus moderate to severe. Mild pain should be treated with paracetamol in children under 3 months old, while older children can use paracetamol or ibuprofen. WHO suggests opioids for moderate-to-severe pain. Here’s more specific information on pediatric analgesic choices:

  • Acetaminophen vs. NSAIDs – The two most common analgesics used for children are acetaminophen and ibuprofen. Six trials found that ibuprofen achieved significantly better pain relief than acetaminophen, while 11 other trials found no difference in efficacy or safety between the two.
  • NSAIDs vs. Opioids – When morphine was compared with ibuprofen following tonsillectomy, their efficacy and adverse events were similar. Several systemic reviews suggest that NSAIDs alone do not increase the risk of hemorrhage in post-tonsillectomy patients, although caution is still advised.
  • Codeine – The 2012 black box warning about severe respiratory depression and potential death from using codeine after tonsillectomy and/or adenoidectomy was followed by an FDA warning in 2015 against the use of codeine in cough and cold medications for patients younger than 18.
  • Tramadol – This opioid is currently under FDA review for its potential to depress respiratory function. The FDA recommends careful monitoring or avoiding codeine and tramadol in pediatric patients.
  • Opioid-sparing effect – Studies suggest that the opioid-sparing effect of acetaminophen versus ketoprofen was similar, but combining the two drugs was more effective and may help limit the use of opioids.

Parent and Caregiver Education Improves Safety

It’s worth repeating an obvious piece of advice: parent education prevents the risk of toxicity. Simple rules about dosing instructions need to be reinforced because parents may be tempted to give a little extra medication when children’s pain persists. Unfortunately, they may figure they do the same when in pain, so there’s no harm for children. Another concern is this: more than 40 percent of parents give cough and cold medications to children younger than age 4, in spite of black box warnings against pediatric consumption.4 Keep this advice in mind when counseling parents:

  • Medication review – Make sure parents aren’t giving their kids multiple OTC products containing duplicate agents, such as acetaminophen or ibuprofen. Remind them not to use aspirin in children younger 17 years old. Analgesics don’t generally interact with food, but check food-related instructions for other meds the child may take.5
  • Dosage warnings – Make sure parents receive an appropriate dosing cup or measuring tool rather than kitchen spoons.
  • Don’t mix medications with foods – Parents may mix medication with food, but this reduces effectiveness if all the food isn’t eaten.
  • Medication refusal – Compounding pharmacists can talk about flavorings or other options such as transdermal forms that make it easier for kids to take meds. Another trick is to let the child suck on a popsicle before giving meds to help numb the taste.
  • Opioids – When you fill prescriptions for opioids, don’t simply staple the manufacturer’s patient information sheet to the package. Tell parents and caregivers to seek emergency medical help if they notice slow breathing, difficulty breathing, noisy breathing or confusion.

Pharmacist Support for Parents Makes the Difference

Sometimes parents need guidance about OTC medication choices, other times they simply need reassurance about treating children’s pain. Remind them that pain should never be ignored and it’s always better to ask questions than to let a potential underlying condition progress. In the process, you have the opportunity to promote children’s health and improve family life.

Pharmaceutica North America provides a selection of NSAIDs, high-quality bulk active pharmaceutical ingredients, OTC supplements and compounding kits that meet the varied needs of your pediatric patients. Contact us today so we can answer questions and develop a plan to support your compounding pharmacy.

Show 5 footnotes

  1. “Pain in Children,” May 2015, http://www.practicalpainmanagement.com/pain/pain-children?page=0,1
  2. “Pediatric Pain Management,” 2016, http://www.medscape.com/viewarticle/860648_1
  3. “Safe Use of Analgesics in Acute Pediatric Pain,” May 2016, https://www.uspharmacist.com/ce/safe-use-of-analgesics
  4. “Forty Percent of Parents Give Young Kids Cough/Cold Medicine That They Shouldn’t,” April 2014, https://www.sciencedaily.com/releases/2013/04/130422102032.htm
  5. “Food and Medication Interactions,” November 2015, https://www.healthychildren.org/English/safety-prevention/at-home/medication-safety/Pages/Food-and-Medication-Interactions.aspx

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