Pharmacological treatment of moderate to severe pain in paediatric palliative care


Which analgesics and at what doses are most effective and safe to treat moderate to severe pain in paediatric palliative care?


  1. A comprehensive approach to pain management in PPC is proposed, with pharmacological and non-pharmacological measures, taking into account the aetiology of the pain, its pathophysiology (nociceptive, neuropathic or mixed pain), its intensity, and the particular characteristics of the patient and his or her family.
  2. The use of strong opioid analgesics is proposed for the relief of moderate to severe pain in PPC patients.
  3. Morphine is proposed as the strong opioid of first choice to treat moderate to severe persistent pain in PPC patients.
  4. Do not use minor opioids (tramadol, codeine) to treat moderate pain in PPC patients. In PPC patients with moderate pain, consider using major opioid analgesics at low doses.
  5. If treatment with an opioid does not provide adequate pain relief or if it causes intolerable adverse effects, it is proposed to change to another opioid.
  6. The dose of opioid analgesics should be adjusted (titrated) individually and progressively until the minimum effective dose is found. The response to treatment and the occurrence of adverse effects should be monitored.
  7. Treatment should be scheduled at regular intervals to provide baseline analgesia, with on-demand dosing for exacerbations (breakthrough pain), and oral/enteral dosing whenever possible.
  8. If neuropathic pain is suspected, consider treatment with gabapentinoids, low doses of tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs) or an anti-NMDA agent (ketamine).
  9. Inform the patient and family about the benefits and potential adverse effects of pain management. Develop the treatment plan taking into account the personal preferences and individual needs of each patient and family.



The CPG development group (CDG) has decided to formulate a series of general practical considerations because it believes that it is not possible to recommend specific interventions based on the scarce and very low-quality evidence found.

The CDG has taken into account the WHO guidelines on the pharmacological treatment of persistent pain in children with medical conditions, as well as its own clinical experience. The analgesic treatment of PPC patients follows a biphasic strategy based on the intensity and duration of pain.

The CDG recognizes that the management of pain in these patients is complex due to its diverse aetiology and the biological, cognitive, psychological, socio-cultural, and spiritual factors that influence the child’s perception of pain. Although they are not the focus of this question, the CDG considers it necessary to recall the importance of non-pharmacological measures such as ensuring a calm environment, postural changes, local heat or cold, physiotherapy, etc.

Complete clinical question

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