Home' Australian Pharmacist : Australian Pharmacist November 2014 Contents Australian Pharmacist November 2014 I ©Pharmaceutical Society of Australia Ltd. 43
CONTINUING PROFESSIONAL DEVELOPMENT
in self-reporting however a child of
seven will have increased reliability of
Although numerous scales exist, the
following three scales may assist across
• Infant/neonate: Observational scale
using the Face, Legs, Arms, Cry,
Consolability (FLACC) scale is the most
common observational scale and is
well-validated scale for acute pain.3
• Age four to 12 years: Faces pain scale
-- revised (see Figure 1).4
• Age eight years through to adult:
Verbal Numerical Scale (VNS) as self
reporting is more reliable in this
What should I try for Blake's pain
before using medicine?
Non-pharmacological care is useful for
many types of pain, including teething,
and should be provided whenever
appropriate. It can be divided into
• environmental interventions such
as providing a warm crib or room,
a calm and quiet atmosphere and
• physical interventions including
swaddling, hugging, stroking or a
• distraction techniques such as a
dummy/pacifier, breastfeeding, music,
singing or drawing.
For teething, a useful physical
intervention is recommended by
the Australian Dentists Association.
Wash your hands, and then gently rub
the baby's gum with a clean finger.
Alternatively, the baby can be given a
dummy, teething ring, sugar-free rusk or
wet washcloth to bite.
What pain relief can you o er for
Blake's teething pain?
Paracetamol is the first-line analgesic
for children as it has a high oral
bioavailability and the onset of
analgesic effects occurs within
30 minutes.2 The community pharmacy
is well equipped with different oral
formulations of paracetamol and the
COUNSELLING IN PRACTICE
parent or guardian has the option
to choose either drops or an oral
suspension for an eight month old such
as Blake.6 If a trial of paracetamol alone
is not effective, adding a non-steroidal
anti-inflammatory drug (NSAID) such
as ibuprofen has been found to be
effective for mild to moderate pain,
and can be considered for children over
three months of age.6
What about topical agents to help
with the teething pain?
Various topical agents are available
are available over-the-counter to help
alleviate the pain associated with
teething. These products contain
local anaesthetics (lignocaine-based
preparations) and/or analgesics
(choline salicylate-based preparations).8
However, caution is advised when
recommending these products.
Preparations containing choline
salicylate should be used with caution
due to the potential toxicity at doses
similar to those recommended in
over-the-counter teething gels.9
Lignocaine-based products are also not
recommended as infants can be harmed
if they accidentally swallow too much
of the medication.10 Pharmacists should
be aware of these cautions, as well as
the little evidence supporting the use
of these gels, in order to appropriately
advise on the use of these products.
If any topical agent is used,
the pharmacist should advise parents
or guardians to wash their hands
thoroughly before applying topical
agents directly to the painful area of the
gums. When breastfeeding, topical gels
should be avoided just prior to a feed
as this can affect the infant's ability to
Can I use paracetamol and
ibuprofen at the same time?
If required, paracetamol can be used
with appropriate doses of an NSAID
such as ibuprofen for greater analgesia.6
A pharmacist should ensure parents
and guardians understand the correct
dosing regimen for each medication.
Paracetamol can be given every 4--6
hours while ibuprofen can be given
every 6--8 hours.
An ongoing review of the child's pain
is important to ensure that all agents
are used at the lowest effective dose for
the shortest possible time. For example,
advise Leigh that when Blake seems
settled she should cease one of the
analgesics and continue to review the
need for the other.
It is important to note, that when
treating fever only, there is no clinically
significant benefit in combining or
alternating paracetamol with ibuprofen.8
Figure 1. Faces pain scale -- revised4
In the following instructions, say 'hurt' or 'pain', whichever seems right for a
These faces show how much something can hurt. This face [point to left-most face]
shows no pain. The faces show more and more pain [point to each from left to
right] up to this one [point to right-most face] - it shows very much pain. Point to
the face that shows how much you hurt [right now].
Score the chosen face 0, 2, 4, 6, 8, or 10, counting left to right, so '0' = 'no pain' and
'10' = 'very much pain.' Do not use words like 'happy' and 'sad.' This scale is intended
to measure how children feel inside, not how their face looks.
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