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Year : 2013  |  Volume : 138  |  Issue : 4  |  Page : 570-571

WHO guidelines on the pharmacological treatment of persisting pain in children with medical illness

Department of Anaesthesiology & Intensive Care, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India

Date of Web Publication19-Nov-2013

Correspondence Address:
M K Arora
Department of Anaesthesiology & Intensive Care, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029
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Source of Support: None, Conflict of Interest: None

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How to cite this article:
Arora M K, Baidya D. WHO guidelines on the pharmacological treatment of persisting pain in children with medical illness. Indian J Med Res 2013;138:570-1

How to cite this URL:
Arora M K, Baidya D. WHO guidelines on the pharmacological treatment of persisting pain in children with medical illness. Indian J Med Res [serial online] 2013 [cited 2021 May 18];138:570-1. Available from:

(WHO Press, Geneva, Switzerland) 2012. 166 pages. Price: not mentioned.

ISBN 978-92-4-154812-0

The book consists of guidelines developed by a special WHO Guideline Development Group following a meeting hosted by Rockefeller Foundation in Italy in March 2010. This book specifically deals with the pharmacological management of 'persisting pain' in children suffering from medical illness. Persisting pain refers to long term pain related to various medical illnesses like cancer, infections (HIV), neuropathic pain and episodic pain (sickle cell crisis).

The book is divided into four chapters followed by seven annexes. It includes a brief executive summary including a reading guide in the beginning and a summary of principles and recommendations at the end.

Chapter 1 introduces and explains four classification systems of pain: (i) pathophysiological mechanism, (ii) etiology, (iii) anatomical location of pain, and (iv) duration of pain. It further describes the relevance of the classification system in clinical management of pain arising out of common medical illnesses. WHO recommends that a patient cannot be denied of pain relief irrespective of whether underlying cause has been identified.

Chapter 2 describes the importance of accurate pain assessment in optimal pain management. It recommends a comprehensive approach with inclusion of regular pain assessment into overall clinical care. The chapter includes a step-wise algorithm on evaluation of pain in paediatric population and mentions a summary of questions to be used by the healthcare providers during clinical evaluation. The chapter also mentions the behavioural indicators of acute and chronic pain in children with special account on preverbal and developmentally retarded children. The Table on pain intensity measuring scales mentioning four different scales will help healthcare providers in appropriate pain assessment.

Chapter 3 deals with the pharmacological treatment guidelines for healthcare professionals. This chapter describes the basic principles of drug therapy as introduced by the WHO which has been correct use of analgesic medication 'by the clock' (dosing at regular interval), 'by the mouth' (using appropriate route), 'by the individual' (adopting treatment to the individual child) along with adoption of new 'two-step strategy' in children over three step ladder pattern. The WHO recommends the use of paracetamol and ibuprofen for mild pain in the first step and morphine or any other strong opiod for moderate to severe pain in the second step. The chapter includes special note on opioid switching, opioid tolerance, dependence and withdrawal; and the role of adjuvant medications like steroids, local anaesthetics, biophosphonates, antidepressants, anticonvulsants and ketamine. The detailed dosage of individual analgesic drugs has been mentioned as well.

Chapter 4 focuses on ways to improves access to pain relief in health care system. It mentions the international regulations on opioid analgesics, national pain treatment policies and stresses on the need for training of health professionals, costs, availability of drugs and human resources.

The four chapters are followed by seven annexes. Annex 1 serves as the quick pharmacological guide for all the physicians involved in persisting pain treatment in children. It describes the pharmacological profile including dosage, adverse effects, drug interaction and equianalgesic dose of opioid and non-opioid analgesics recommended for this purpose. Annex 2 reports detailed considerations behind clinical treatment recommendations mentioned in chapter 3, and Annex 3 describes the detailed consideration behind the health care recommendations mentioned in chapter 4. Annex 4 provides detailed information on the studies retrieved and appraised before formulating the evidence behind the guidelines. The quality of evidence profile was produced applying the GRADE system. The guidelines development group identified several research gaps during the process and prescribed agenda for further research in Annex 5 to guide the scientific community. Annex 6 addresses policy makers, managers and health professionals and outlines the main aspects of procurement, supply and dispension of opioid medication and the requirements set by United Nations Convention on Narcotic Drugs, 1961. Annex 7 finally lists all the contributors to the development of the guidelines.

The special attributes of the book which will help the reader are (i) reading guide in the executive summary at the beginning of the book, (ii) a brief introduction at the beginning of each chapter mentioning the highlights of the chapter, and (iii) a summary of principles and both clinical and health care recommendations at the end of the book. However, this is the first edition of the book. Quality of evidence behind many of the recommendations being low, the latter may be modified with the availability of more research papers. The book should accordingly be updated at regular intervals. The target audience for this book as mentioned in the introduction is a wide range of healthcare providers: clinicians, nurses, pharmacists, policymakers and programme managers. With provision of clear description and specific recommendations in different chapters intended for different types of healthcare providers, the book serves its purpose. The book should encourage clinicians for better pain management and policymakers and managers for creating better environment where this persisting problem of 'persisting pain' in children suffering from chronic medical illness may be solved.


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