Pain in children is a public health concern of major significance in most
parts of the world. Although the means and knowledge to relieve pain exists, children’s pain is often not
recognized, is ignored or even denied. These guidelines address the pharmacological management of
persisting pain in children with medical illnesses. As such, they replace the previous guidelines, Cancer
pain relief and palliative care in children, which exclusively covered cancer pain. They include several
clinical recommendations, including a new two-step approach of pharmacological treatment. The guidelines
also point to the necessary policy changes required and highlight future priority areas of
The overall objective of these guidelines is to provide evidence-based
recommendations on pain treatment, including opioid analgesics, non-opioid analgesics and adjuvant
medicines to improve the management of pain in children, that is, neonates, infants and children aged
0-10 years experiencing persisting pain related to medical diseases. They can also be applied to
adolescents as the majority of the evidence retrieved and appraised refers to studies in populations comprising
patients from 0 to 18 years. The guidelines deal specifically with the pharmacological management of
persisting pain in children with medical illnesses, where “persisting pain” refers to any
long-term pain and “medical illnesses” refers to specific situations of ongoing tissue damage where
there is a clear role for pharmacological treatment.
Types of pain included are nociceptive pain due to inflammation or tissue
injury, as well as neuropathic pain from nerve compression or disruption, resulting from disease. Conditions
considered include but are not restricted to persisting pain from cancer, cancer treatment, major
infection (e.g. HIV/AIDS), arthritis and other rheumatological diseases, sickle cell disease (SCD), trauma,
burns, persisting neuropathic pain following amputation, etc.
These guidelines exclude acute traumas, perioperative and procedural pain.
Also, chronic complex pain where there is no evidence of ongoing tissue disruption such as fibromyalgia,
headache, or recurrent abdominal pain is not addressed, as treatment of these conditions requires a
multimodal approach with extensive use of non-pharmacological techniques as well as pharmacological
therapy. Non-pharmacological interventions such as cognitive-behavioural therapy, other psychological
techniques and physical interventions are important, often effective and are elements of an integrated pain management
plan. However, review and recommendations regarding these techniques are also beyond the scope of
these guidelines. Furthermore, disease-specific therapies, such as anti-cancer and sickle cell
disease therapies, are an essential component of care, but fall outside the scope of these guidelines.
The targeted audience for these guidelines are health-care providers in the
widest meaning: from medical practitioners, clinical officers, nurses and pharmacists, to personnel
caring for children. They are also intended for policy-makers and public-health and programme managers,
who may not be directly involved in providing care for children, but nevertheless play a
crucial role in making rapid, effective and safe pain management available at various levels of the health
system. Policy-makers and regulatory authorities are crucial in facilitating legal access to – and
ensuring proper use of – opioid analgesics for pain management.
These guidelines will also provide the basis for a number of other WHO
publications related to the management of moderate to severe pain in children for specific audiences. They
may be intended specifically for palliative-care workers, for pharmacists, or for policy-makers
and hospital directors. They may also include agenda cards with dosing tables and wall charts for addressing
the patients and their caregivers. Furthermore, the recommendations in these guidelines will be used to
update other WHO documents pertinent to child health guidance...