Analgesics and sedatives (peds)


  • Requires a more careful approach than typically needed in the adult population.
  • Children may require sedation for procedures that are done with topical anesthetic in the adult population and evaluation of pain in infants and young children can be challenging.


  • There are a number of well established frameworks for evaluating pain that are helpful in the pediatric ED; which framework works best is dependent on the age of the patient and provider preference[1].


CRIES Scale (used to establish baseline and assess discomfort over time):

0 1 2
Crying None High-pitched Inconsolable
Requires O2 None <30% FiO2 needed >30% FiO2 needed
Increased Vital Signs Normal HR and BP Increased HR and BP <20% Increased HR and BP >20%
Expression Normal Grimace Grimace and Grunt
Sleeplessness None Wakes frequently Awake constantly


  • <1yo: Neonatal Infant Pain (NIPS) Scale (score of >5 generally should be treated pharmacologically)
0 1 2
Facial Expression Relaxed Grimace
Cry None Whimper Vigorous Cry
Breathing Pattern Relaxed Variable Breathing
Arms Relaxed Restrained
Legs Relaxed Restrained
State of Arousal Not fussy Fussy

  • >1yo: FLACC Scale
0 1 2
Face No expression or smile Grimace, frown, or withdrawn Quivering chin, clenched jaw
Legs Relaxed Restless, tense Kicking, drawn up
Activity Lying quietly or easy movement Squirming, tense Arched, rigid, or jerking
Cry None Moaning, whimpering, complaining Steady crying or screaming
Consolability Relaxed Distractable Difficult to console or comfort

Verbal Children >3yo

For pain assessment in the verbal child who is >3yo, consider using a visual pain scale such as the Wong-Baker scale (shown below).


Escalation of Care

Escalation of care generally depends on the source and severity of pain that the patient is experiencing. Consider starting with non-pharmacologic interventions and escalating to topical, oral, or IV as appropriate.

Non-pharmacologic methods

First line of care for an uncomfortable infant or child in the ED should include non-pharmacologic methods such as heat or icing. Distraction can also be a useful technique for consolation, including:

  • Pacifiers
  • Multimedia displays/videos
  • Engagement with Child Life Specialist

Topical Anesthetics

While not as frequently used in the adult context, topical anesthetics play a major role in pain management in pediatrics. The most frequent uses for topical anesthetics are enable PIV placement and to "pre-treat" open wounds prior to bedside evaluation and repair. Common options include:

Topical Anesthetics
Name Principal Indication Onset/Duration
LET Use on open wound for laceration repair 30-45 minutes/variable
EMLA Use on intact skin. Can assist with PIV placement, LP, or abscesses 45-60 minutes/~120 minutes
LMX Use on intact skin. Can assist with PIV placement, LP, or abscesses 20-30 minutes/~60 minutes

Intranasal and IV analgesia

If the above are not adequate or appropriate for the patient at hand, providers can consider inhaled analgesics or, if IV access is available, IV analgesia. As with adult patients, it is recommended to avoid opioids when possible. See below for common dose ranges for analgesics in the pediatric population.

Considerations for Sedation

In general, the indications for pediatric sedation are to relieve pain, reduce anxiety, and ensure cooperation/patient safety during a procedure. Once it is determined that a pediatric patient will need sedation, the evaluation of said patient is essentially the same as for adults. Collect a medication list and determine allergies before conducting an airway evaluation. Consent the parent(s) prior to sedation. The following are a set of commonly used sedatives along with their indications, courtesy of Dr. Michael Mojica's PEM Guides.

Class Imidazole sedative hypnotic
Pharmacology Onset: 1 minute, Duration: 3-12 minutes
Benefits Cardiovascular stability, decreases intracranial pressure
Adverse Effects Transient cortisol depression, myoclonic activity
Indications Non-painful radiologic procedures (e.g. head CT)
Contraindications Adrenal insufficiency, chronic steroid use
Dose 0.2-0.4 mg/kg
Comments Notify parents and CT technicians before administration that myoclonic jerks may occur, that they do not represent seizure activity and that they are typically is very brief in duration
Class Sedative-hypnotic
Pharmacology Onset 1-2 minutes, Duration 3-5 minutes
Benefits Titratable, decreases ICP, Antiemetic, Anticonvulsant
Adverse Effects Respiratory depression

Apnea (usually resolves with jaw thrust) Cardiovascular depression: Hypotension No analgesic properties, painful administration

Indications Long duration nonpainful, radiologic procedures (e.g. MRI), post rapid sequence intubation for head trauma
Contraindications Hypotension: Maximize volume status prior to use. < 6 months associated with high rate of complications, Egg/Soy allergies are no longer considered a contraindication
Dose Initial dose: 1.5–2.0 mg/kg

Subsequent dose: 0.5-1.0 mg/kg Q1-3 minutes to effect Infusion: 250 µg/kg/minute (0.25 mg/kg/min)

Comments An IV fluid bolus should be readily available for hypotension
Class Opioid
Pharmacology Onset 2-3 minutes, Duration 20-60 minutes
Benefits Analgesic, Hemodynamic stability (Less histamine release), Reversible with Naloxone
Adverse Effects Respiratory depression

Chest wall rigidity with high doses or rapid administration

Indications Painful conditions and procedures
Contraindications Pt with poor respiratory drive
Dose IV: 1 mcg/kg, maximum dose 100 mcg

IN: 1-2 mcg/kg, maximum dose 100 mcg

Comments Chest wall rigidity may require Naloxone or a paralytic
Class Opiate
Pharmacology Onset 5-10 minutes, Duration 2-4 hours
Benefits Analgesic, Reversible with Naloxone
Adverse Effects Respiratory depression, Hypotension (histamine release)
Indications Painful conditions and procedures
Contraindications Pt with poor respiratory drive
Dose 0.1 mg/kg
Class Benzodiazapine
Pharmacology IV: Onset 1-2 min, Duration 30-60 min
Benefits Amnestic, anxiolysis, anticonvulsant, Reversible with Flumazenil
Adverse Effects Respiratory depression

Paradoxical agitation in children

Indications Anxiolysis

Use in conjunction with an opioid for painful procedures

Contraindications Pt with poor respiratory drive
Dose IV: 0.1 mg/kg

IN: 0.3-0.5 mg/kg, maximum dose 10 mg

Class Alpha 2 agonist
Pharmacology Sedative, anxiolytic and mild analgesic properties

Lipid soluble: Readily cross the blood brain barrier

Benefits Minimal effects on respiratory function
Adverse Effects Cardiovascular effects: Hypotension, bradycardia

Use with caution in patients with liver and renal disease

Indications Non-invasive imaging
Dose Loading: 1-3 mcg/kg over 10 minutes, may be repeated

Infusion: 0.5-2 mcg/kg/hour Can be given orally and intranasally as well

Comments Compared to Propofol:

Similar cardiovascular adverse events without respiratory depression Analgesic Longer induction, recovery and discharge times An IV fluid bolus should be readily available for hypotension


Pediatric patients are generally safe to be discharged home if their pain is well-controlled, they can walk unsupported (if appropriate for age), and can tolerate fluids. If pain is uncontrolled after escalation of care in the emergency department (particularly if a clear source of pain has not been identified), consider admission for further workup and management.

Pediatric doses for Common Analgesics



  • PO/PR: 10-15mg/kg/dose q4-6hrs
  • Children’s Tylenol is 160mg/5ml
  • Max: 75mg/kg/day or 4000mg/day


  • PO: 4-10mg/kg/dose q6-8hrs
  • Children’s Motrin is 100mg/5ml
  • Max: 40mg/kg/day


  • IM/IV: 0.5mg/kg/dose q6hrs


  • PO: 1-2mg/kg/dose q4-6hrs


Naloxone (opioid overdose reversal)

  • IV/IM: 0.001-0.02mg/kg/dose


  • IM/IV: 0.05-0.2mg/kg/dose q2-4hrs


  • IV: 0.015mg/kg/dose q4-6hrs
  • PO: 0.03-0.08mg/kg/dose q3-4hrs


  • IV: 1-2 mcg/kg/dose q1-2hrs
  • IN: 1-2 mcg/kg/dose via atomizer


  • PO: 0.05-0.15mg/kg/dose q4-6hrs


  • PO: 0.5=1mg/kg/dose q4-6hrs


  • IV/PO: 0.05-0.1mg/kg/dose q6hrs

Combination Medication

Acetaminophen with Codeine

  • PO: 0.5-1mg/kg/dose of codeine q4-6hrs

Acetaminophen with Hydrocodone

  • PO: 0.15mg/kg/dose of hydrocodone q4-6hrs

Acetaminophen with Oxycodone

  • PO: 0.05-0.15mg/kg/dose of oxycodone 14-6hrs

Pediatric doses for Common Sedatives


  • IM: 0.05-0.15mg/kg; max 10mg
  • IV:
    • 6mo-5yr: 0.05-0.1mg/kg initially with up to 0.6mg/kg needed; max 6mg
    • 6yr-12yr: 0.025-0.05mg/kg initially with up to 0.4mg/kg needed; max 10mg
    • 12yr-16yr:1-2mg initially with up to 2.4-5mg needed; max 10mg
  • PO: 0.25-0.5mg/kg; max 20mg


  • IV/PO: 0.05-0.1mg/kg q4-8hrs


  • IV: 0.5-2mg/kg
  • IM: 3-7mg/kg

Chloral hydrate

  • PO: 25-50mg/kg


  • IV: 1-2mg/kg over 30 seconds


  • IV: 0.3mg/kg

See Also


  1. “Pediatric Pain.” n.d. Accessed October 14, 2022.