i. Any correctable environmental and physical factors causing discomfort should be addressed alongside the introduction of pharmacological agents

ii. A normal pattern of sleep should be encouraged. Attention should be paid to lighting, environmental noise and temporal orientation of patients

i. All critically ill children have the right to adequate relief of their pain. Local and regional anaesthetic techniques should be considered. A patient controlled analgesia (PCA) device may be useful in older children

ii. Pain assessment should be performed regularly by using a scale appropriate to the age of the patient and routinely documented. The level of pain reported by the patient must be considered the current standard of analgesia. Patients who cannot communicate should be assessed for the presence of pain-related behaviours and physiological indicators of pain. A therapeutic plan for analgesia should be established for each patient and regularly reviewed

iii. Recommended pharmacological agents for analgesia include opioids (eg, morphine, fentanyl) for the relief of severe pain, non-steroidal anti-inflammatory drugs (NSAIDs) for moderately severe pain, and paracetamol for mild to moderate pain

i. Adequate analgesia should be provided to all critically ill children regardless of the need for sedation. The use of clinical guidelines for sedation is recommended

ii. The level of sedation should be regularly assessed and documented using a validated and age-appropriate sedation assessment scale. The desired level of sedation should be identified for each patient and regularly reassessed. Doses of sedative agents should be titrated to produce the desired level of sedation

iii. Recommended pharmacological agents for sedation include midazolam or clonidine. Early use of enteral sedative agents (eg, chloral hydrate, promethazine) is recommended. Propofol should not be used to provide continuous sedation in critically ill children

i. The potential for opioid and benzodiazepine withdrawal syndrome should be considered after 7 days of continuous therapy

ii. When subsequently discontinued, the doses of these agents may need to be routinely tapered