Pain relief for babies and children

Owen is teething.

This is causing moderate discomfort to all concerned.

It also prompts me to vent about pain relief for kids, and babies in particular.

Your child is entitled to effective pain relief

The World Health Organisation (WHO) and the International Association for the Study of Pain are pushing for analgesia to be recognised as a fundamental human right. It isn’t (yet), but most people would hopefully agree that allowing someone you are responsible for to suffer pain when you have access to a simple remedy is a pretty grim thing to do.

As a parent or guardian in Scotland you are required to “safeguard and promote [your] child’s health, development and welfare” (from the Children (Scotland) Act 1995).

As a parent or guardian in Scotland you can get free medicine for your child from your local pharmacy (see the NHS minor ailment service if this is news to you.)

It would appear that some folk regard withholding basic medicines (paracetamol, ibruprofen, etc) from their child for months on end as some kind of achievement.

Before I join those last three statements with a straight line and a big question mark, let’s talk about:

What is pain relief?

Not just drugs.

Pain relief is distraction. Reassurance. Massage. Hot things. Cold things. Positioning. Compression. Pain relief can come from the belief that something will help—placebos can have measurable effects.

The first response to pain in any child should not be to reach for the Calpol. Cuddle them. Rub it better. Get the magic sponge. Sing (Owen is particularly fond of Flanders and Swann’s The Hippopotamus, and I can accidentally modulate through at least four different keys during the chorus).

You’ll be delighted to know that breast milk (or at least, the action of being breast fed) has mild painkilling properties (see WHO study here). Even sugar might have a very mild positive effect (although a Lancet study in 2010 suggested maybe not.)

If none of this works, though, up steps our modern world of safe and effective painkillers. You’ve got three classes of pain relievers (analgesics) to pick from:

  • Paracetamol, or acetaminophen for any Americans wandering by. It’s in a class of its own, and no one is quite certain why it works (but work it does). Tackles mild to moderate pain, has some anti-swelling properties, and is reasonably good at knocking down a fever.
  • Non-steroidal anti-inflammatory drugs (NSAIDs) like ibruprofen. Similar effects to paracetamol, but better at taking down swelling (so your go-to drug for soft tissue injuries like twisted ankles). More side-effects than paracetamol. Aspirin is an NSAID, and should never be given to under 16s unless under doctor’s orders (see the next section on analgesic options for why).
  • Chunkier painkillers called opiates based around the chemistry of the opium poppy, like codeine and morphine. Hit pain hard, but bring with them a bunch of side effects (including addiction). There’s nothing over-the-counter for children here.

Brief diversion: if you haven’t completely blocked out childbirth, mums will hopefully remember being offered gas and air (properly known as Entonox, Nitronox, or nitrous oxide). Whilst cracking for dealing with pain, this is actually an anaesthesia thing (removing sensation) and not an analgesic (which leave sensation, but kill the feeling of pain itself). Sticking temporarily with childbirth; diamorphine is an opioid analgesic, and epidurals are anaesthetics applied to the spinal nerves.

If any of that comes up in a pub quiz, let me know. So I can avoid the pub.

Before we go any further, don’t rely on a blog for information on administering drugs to your child! Read the packet, or ask a pharmacist or other healthcare professional.

What analgesic options do I have?

For babies over two months’ old, paracetamol. Over three months and 5 kilograms; paracetamol or ibruprofen. Unlike adults, the NHS currently advises that children (and babies) don’t take both paracetamol and ibruprofen together.

Some handy links from the NHS:

Never give anyone under 16 years’ old aspirin. It has been proven that young people who take aspirin have a markedly higher chance of developing Reye’s Syndrome, which causes a variety of unpleasant symptoms including blindness and death. (The difference between Bonjela and Bonjela Teething is that the latter doesn’t have any of the aspirin content of the former.)

Aren’t there side effects? I read paracetamol causes asthma?

Yup, and you’ll have read it in the Daily Mail, which is a good indication of the current scientific opinion of the study responsible.

The chief criticism everyone else made is that the researchers failed to separate cause from effect. Kids with asthma are more likely to catch colds, coughs and flu than those without asthma. So they’re also more likely to take paracetamol to help (chiefly to lower a raised temperature). The study didn’t check whether those who reported wheezing many years after taking paracetamol also had wheezing before taking paracetamol for the first time. The NHS comment on this is here and the European Medicines Agency’s is here. Conclusion: paracetamol does not cause asthma.

If you stick to the permitted doses and reasons to administer, paracetamol has almost no instances of adverse side effects.

However, it’s a particularly vicious drug on your liver if you overdose. You’ll notice that the pack will come with a big table of dosing information—read it carefully and stick to it. In 2011 the age brackets were narrowed considerably to minimise the range of child weights within each bracket and make accidental overdosing less likely. We found that an oral syringe made everything much more precise than a spoon (and also resulted in more of the medicine actually getting into Owen).

Oral syringe and bung
That’s an oral syringe (note there’s no needle!) plus a bung that goes in the top of the bottle with a syringe-size hole that makes it much easier to draw up the liquid.

Your pharmacist should be able to set you up with syringes if you ask nicely.

Seek immediate help for overdoses of all drugs, but particularly paracetamol. The effects of paracetamol overdoses generally don’t show until a few days later, when it’s too late for much to be done to fix the issue.

Apparently amber necklaces can also help with teething pain?

In 2002 the BBC reckoned 2,600 children choke on things every year. Just putting that out there.

People selling amber necklaces claim that they relieve teething pain when worn by babies. They overlook the fact that the beads can shatter fairly easily, and gloss over the idiocy of stringing anything around a babies neck.

The “active ingredient” they claim is in these million-year-old lumps of tree is butanedioic acid (generally called succinic acid by those trying to sell it, as that sounds less chemical-ly). This has no medical properties at all, but is used as an acidity regulator in the food industry (fun fact: bathing your child in beer would result in more succinic acid exposure than amber, particularly as there’s no way for the amber to release its acids, or for your baby’s skin to absorb it).

There’s a nice article by a paediatrician here that takes the time to work through the rest of the nonsense in a logical way.

If you’re still going to string pebbles around your baby’s neck, the NHS page on how to try and help a choking child is here. Act fast: permanent brain damage starts to occur after about three minutes (which is five minutes before your ambulance is likely to arrive).

OK, but surely there’s no harm in avoiding painkillers?

In 1985 an American baby had a major operation without the use of any drugs except a paralysing agent. This wasn’t unusual, as the prevailing opinion was that babies did not feel pain.

The baby’s mum (Jill Lawson) disagreed, started campaigning, and two years later the research started coming through in support.

Most studies now agree that babies do feel pain, and quite possibly more intensely than adults (called hyperalgesia, if you’re still taking notes for that pub quiz of horrors). They’re also more open to temporarily feeling pain from sensations that wouldn’t normally cause pain (allodynia). Finally, untreated pain and stress may go on to trigger psychological damage in later life. We discussed above many ways of relieving the immediate effects of pain, but only analgesics remove the pain itself.

Moving on from pain, what about raised temperatures? If your child is unfortunate enough to have a fever that can’t be controlled through cool fluids, clothing and surroundings, are you going to let them burn up all the way to convulsions? Or give them paracetamol?

And why is it paracetamol in particular that people celebrate avoiding? None of the other drugs on the WHO Essential Medicines list come in for such daftness—there are no Facebook statuses saying “they wanted to give my darling penicillin for meningitis, but we decided to stick with a compress of cow dung and honey.”

It’s just idiotic.

Have you finished yet?

I have gone on a bit, haven’t I?


In summary:

  • At some point, it is highly likely your child will be in pain. It’s one of those things.
  • Sometimes, you won’t be able to help them with cuddles, reassurance, and other tricks from the childcare toolbox.
  • Don’t then give up on them. Give them paracetamol.
  • Careful with your doses, always read the packs, and chat to your pharmacists and doctors.

I bet you can hardly wait until my next wandering rant on parents blocking their kids from immunisation, eh?


PS: Everyone feels pain differently, but more importantly pain is what the person feeling it experiences. Not what you decide they ought to be feeling. Treat what you see in front of you.

PPS: If your child hasn’t ever shown any signs of being in pain and therefore you’ve never needed painkillers; awesome. I’m sorry if it read like I was having a go at you.

PPPS: “Who is this DarkerSide chap to be telling me how to look after my child?” I hear you ask. Quite right. I’m just a jumped-up bike blogger—I’ve certainly got no professional medical training. I have been a front-line volunteer ambulance crew with both St John Ambulance and British Red Cross for the past five years (including plenty of NHS blue-light work), and I’ve done a reasonable amount of training for other people. I know nothing compared to any healthcare professional, and you should absolutely take their advice over anything you read online. All I aim to do is collate information from around the web, mix it in with a bit of personal experience, and present it in a (hopefully) entertaining way. Ok?

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Brilliant blog.
I am a doctor and could never BELIEVE that anyone could think babies dont feel pain. How idiotic.
As for pain relief , there is no reason why you shouldnt give analgesia to your baby.
I NEVER knew bonjela contains aspirin and that scares the hell out of me.
Homeopathy doesnt work for kids – give them proper pain relief.
As I say, brilliant article

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