effect. medication further information: analgesic adjuvant acute pain, chronic pain, neuropathic pain and recurrent pain in children is most often managed with medication. most of these medications are analgesics. these include acetaminophen, nsaids, local anesthetics, opioids, and medications for neuropathic pain. regional anesthesia is also effective and recommended whenever possible. it is important to use caution when administering opioids to neonates and young infants. there is a higher risk for apnea and hypoventilation in this population, due to their decreased breathing response. the effectiveness and adverse effects associated with the use of the injectable nsaid ketorolac postoperatively or following or during surgery is not clear due to insufficient quantity and quality of evidence. it is not clear from clinical trials if it is more effective to provide pain control around the clock or provide pain relief as needed for children recovering from surgery. chronic pain treatment chronic pain is treated with a variety of medications and non-pharmacological interventions. the world health organization recommends using a two step treatment approach based on the level of pain in children. the first step explains mild pain treatment, while the second step considers moderate to severe pain. opioids, such as morphine, is an example of a drug of choice for moderate-severe pain in children with medical illnesses. some side effects of opioid use can include cognition deficits, dependence, altered mood, and disturbances of endocrine development. non-pharmacological treatment for children to help relieve periodic pain includes counseling and behavior modification therapy. the american association of pediatrics states that psychological interventions, such as relaxation and cognitive strategies, have strong evidence for pain management. acute pain treatment the approach to acute pain should take into account the severity of the pain. non-opioid analgesics, such as paracetamol (acetaminophen) and nsaids, can be used alone to treat mild pain. for moderate to severe pain, it is optimal to use a combination of multiple agents, including opioid and non-opioid agents. postoperative pain a panel, including the american pain society and american society of regional anesthesia and pain medicine, recommends multimodal analgesia, which they define as a combination of pharmacological agents and non-pharmacological techniques to treat postoperative pain. a significant benefit of this technique is that non-opioid analgesics used in combination with opioids can decrease the amount of opioids required and reduce the risk of opioid-related side effects. medications can be delivered as needed or around-the-clock depending on the patient's needs. for children, intravenous patient-controlled analgesia (iv-pca) can be used when parenteral administration is preferred. iv-pca allows for consistent opioid levels, which can be a better alternative to scheduled intramuscular injections. in addition, studies have shown that children as young as 6 years old can use the iv-pca correctly. dental pain for projected moderate to severe pain, analgesics can be used on a regular schedule for the first 36 to 48 hours after a dental procedure. nsaids are preferred over other analgesics to treat acute mild to moderate postoperative pain, due to the inflammatory component of dental pain. alternating between the nsaids and acetaminophen in combination is another option. in addition, these two agents are considered equivalent or better than opioids for managing musculoskeletal pain, which includes dental pain. cancer pain cancer pain is managed differently in children. typically, medical history, physical examinations, age and overall health of the child are evaluated. the type of cancer may influence decisions about pain management. the extent of the cancer, and the tolerance of the child to specific medications, procedures or therapies are also taken into account, as well as the preferences of the parent or caregiver. medications used to treat cancer pain include non-steroidal anti-inflammatory drugs (nsaids) and opioids. non-steroidal anti-inflammatory drugs (nsaids) non-steroidal anti-inflammatory drugs (nsaids): used as treatment for pain and as an anti-inflammatory. can be administered as oral tablet or liquid. it is recommended to use the lowest dose and shortest duration possible to control pain. nsaids are not approved for infants under 3 months old. general adverse effects for nsaids: renal impairment hepatic impairment gastrointestinal issues (nausea, diarrhea, constipation, flatulence) dyspepsia rash dizziness abdominal pain contraindicated for: hypersensitivity reactions cardiac impairment reye's syndrome coagulation defects ibuprofen 5–10 mg/kg every 6–8 hours (max dose 1200 mg/day) opioids opioids: doses are based on the child's body weight. they can be administered as oral, parenteral, buccal, transdermal, nasal or rectal formulations. it is recommended to start at a low dose and titrate up to effect. general adverse effects for opioids: constipation hives nausea vomiting pruritus respiratory depression the frequency of prescribing for these pain medications has more than doubled from 1990 to 2010 with 20-50% of adolescents who complain of headache, back pain, or joint pain receiving a prescribed opioid. before an adolescent or young adult is prescribed opioids, they should be screened for risk factors for opioid drug abuse. prescription drug monitoring programs (pdms) are now available in 37 states and 11 states have programs in development. the use of opioids can result in a number of complications in children, including respiratory depression and risk for unintended overdose and opioid misuse later in life. these risks can be reduced by the use of nsaids (e.g. ibuprofen) and paracetamol. using nsaids and paracetamol can be opioid-sparing, leading to less opioid use in situations such as peri-operative pain management. the efficacy and safety of opioids in children have not been established. a 2014 cochrane review for nalbuphine for postoperative pain treatment in children, reported insufficient evidence of the efficacy and adverse events of nalbuphine in this population; further research is needed in this area. other side effects of opioids are constipation, fatigue, and disorientation. children can develop opioid tolerance, where larger doses are needed to have the same effect. tolerance occurs earlier in children than in adults, especially with prolonged use. when tolerance to opioids develop, it takes a larger dose of the opioid to achieve the same analgesic effect. non-pharmacological treatments have few side effects. treatment for children and adolescents with conditions that are life limiting for children with lifelimiting conditions including cancer, the evidence supporting or refuting specific treatment approaches is very weak. society and culture the indications that treatment is needed are not always clear for children because of poor assessments and the tendency to undertreat pain. misconceptions about pain in children incorrectvalid