World Health Organization · 1st edition, 2020 (published 2021) · 40 pages
WHO recommendations on physical, psychological and pharmacological interventions for chronic pain in children 0–19 years.
- Issuer
- World Health Organization
- Edition
- 1st edition, 2020 (published 2021)
- Audience
- Policy-makers, programme managers, healthcare providers, professional societies, researchers, families and caregivers
- Evidence
- GRADE-rated recommendations based on systematic reviews; best practice statements based on clinical practice principles
- Reviewed
- 23 Oct 2026 · GMJ
What this guideline says
GMJ summary
This WHO guideline addresses a significant global public health problem: chronic pain affects approximately one-quarter to one-third of children worldwide, causing substantial emotional, physical and social disability. Chronic pain is defined as pain persisting or recurring for longer than three months and includes both primary pain (with significant emotional distress or functional disability) and secondary pain due to underlying conditions such as cancer, sickle-cell disease or surgery.
The guideline presents four conditional recommendations based on systematic reviews of evidence. Physical therapies may be used alone or in combination with other treatments (very low certainty evidence). Psychological management through cognitive behavioural therapy and related interventions (acceptance and commitment therapy, behavioural therapy, relaxation therapy) may be delivered face-to-face or remotely (moderate certainty evidence). Appropriate pharmacological management tailored to specific indications may be used (low certainty evidence), and morphine may be used under principles of opioid stewardship for end-of-life care and in children with life-limiting conditions (very low certainty evidence).
The guideline emphasises a biopsychosocial approach requiring multimodal, interdisciplinary care. It balances ensuring access to appropriate pain relief with preventing medication misuse, particularly opioids. Best practice statements stress child- and family-centred care, comprehensive biopsychosocial assessment, shared decision-making, and attention to the child’s developmental stage, cognitive abilities and social context. The guideline identifies substantial research gaps, particularly in low- and middle-income countries, in children under 10 years, and in real-world effectiveness studies.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Physical therapies (exercise, aerobics, yoga, stretching, strengthening, hydrotherapy) may be used alone or combined with other treatments for chronic pain management.
- Cognitive behavioural therapy, acceptance and commitment therapy, behavioural therapy and relaxation therapy are recommended psychological interventions, deliverable face-to-face or remotely.
- Pharmacological management should be tailored to specific indications and conditions; limited evidence exists for anticonvulsants, antidepressants and NSAIDs in children with chronic pain.
- Morphine may be used under opioid stewardship principles for end-of-life care and in children with life-limiting conditions; requires appropriately trained healthcare providers and continuous monitoring.
- Opioid stewardship essentials: use only for appropriate indications by trained providers, continuous monitoring of pain impact and adverse effects, clear plan for continuation/tapering/discontinuation, and attention to procurement, storage and disposal.
- Comprehensive biopsychosocial assessment is essential before treatment, using age-, context- and culturally appropriate pain assessment tools.
- Care must be child- and family-centred, addressing cognitive, emotional and physical health as well as educational, cultural and social needs.
- An interdisciplinary, multimodal approach should be adopted, tailored to individual needs, family desires and available resources.
From the guideline
Verbatim
“Access to pain management is a fundamental human right.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As a WHO consultant and public health leader in Georgia, I view this guideline as critically important for the South Caucasus, where paediatric pain services remain underdeveloped despite our progress in universal health coverage. The recommendation I would stress to Georgian clinicians is the imperative of comprehensive biopsychosocial assessment before initiating any treatment—our medical culture still tends toward purely biomedical approaches, yet the evidence shows that addressing psychological and social dimensions is essential for effective pain management in children. The realistic implementation challenge we face is capacity: we lack trained providers in CBT and physical therapy for paediatric pain, and our essential medicines lists include morphine but prescribing practices remain constrained by regulatory barriers and opiophobia. Georgia's experience with hepatitis C elimination and our national immunisation programme demonstrates that we can implement evidence-based protocols when we invest in provider training and health system strengthening; we must apply the same systematic approach to paediatric pain services, starting with integration into primary care and the medical school curriculum.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 23 Oct 2026
Applicability
Georgia and the South Caucasus
For Georgia and the South Caucasus, implementation of these guidelines requires strengthening capacity in paediatric pain services, which are often under-resourced in the region. Georgia’s universal health coverage programme (since 2013) provides a framework for including comprehensive pain services, but national essential service packages must incorporate physical and psychological therapies alongside pharmacological interventions to avoid over-reliance on medications. The guideline’s emphasis on opioid stewardship is particularly relevant given global concerns about both inadequate access to pain relief and risks of misuse. Healthcare providers will need training in biopsychosocial assessment and multimodal pain management. For remote or rural areas in Georgia, Armenia and Azerbaijan, the evidence supporting remote delivery of psychological therapies (internet-based, telephone) offers a practical implementation pathway. National policies will need to ensure that morphine and other essential analgesics are available for appropriate paediatric use, including palliative care, while establishing regulatory frameworks for safe prescribing, monitoring and disposal.
Questions this guideline answers
Quick answers
What defines chronic pain in children?
Chronic pain is pain that persists or recurs for longer than 3 months. It can be primary (characterized by significant emotional distress or functional disability, independent of biological or psychological contributors) or secondary (with clear underlying etiology such as cancer, sickle-cell disease, surgery, or other diseases). Chronic pain affects approximately 25–33% of children globally, with about 1 in 20 experiencing moderate to high pain-related disability.
Which psychological therapies are recommended and how should they be delivered?
Cognitive behavioural therapy (CBT), acceptance and commitment therapy (ACT), behavioural therapy and relaxation therapy are recommended. These can be delivered either face-to-face or remotely (internet, smartphone, CD-ROM, manuals) with similar effectiveness. The evidence shows small benefits for reducing pain intensity, 50% pain reduction, and functional disability post-treatment, with moderate certainty evidence for disability reduction at follow-up. Group formats can be supportive but require skilled facilitation.
When can morphine be used in children with chronic pain?
Morphine may be used for end-of-life care and in specific situations for children with life-limiting conditions (illnesses with no cure where early death is expected), always under opioid stewardship principles. It must be prescribed by appropriately trained healthcare providers who monitor the child regularly, assess benefits and risks individually, have a clear plan for continuation/tapering/discontinuation, and ensure safe storage and disposal. Morphine is never a stand-alone treatment and must be part of biopsychosocial care. No comparative studies exist for opioids in children with chronic pain.
What are the essential components of opioid stewardship in children?
Opioid stewardship requires: (1) use only for appropriate indications, prescribed by trained providers with careful benefit-risk assessment; (2) continuous monitoring and evaluation of pain impact and adverse effects by trained providers; (3) a clear plan for continuation, tapering or discontinuation according to the child's condition, with the child and family informed of the plan and rationale; and (4) attention to procurement, storage and disposal of unused opioids to prevent diversion and accidental exposure.
Related on GMJ
Interconnected resources
Dictionary of Public Health
Drugs A–Z
GMJ News coverage
ASF accreditation standards
Other guidelines on this topic
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- Quality health services and palliative care: practical approaches and resources to support policy, strategy and practice
- Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022
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- Issuer
- World Health Organization
- Type
- Guideline
- Edition
- 1st edition, 2020 (published 2021)
- Status
- Current
- Published
- 2021-01-07
- Languages
- English
- Scope
- Physical, psychological and pharmacological interventions for management of primary and secondary chronic pain in children 0–19 years
- Audience
- Policy-makers, programme managers, healthcare providers, professional societies, researchers, families and caregivers
- Pages
- 40
- Licence
- CC BY-NC-SA 3.0 IGO
- ISBN
- 9789240017870
- Evidence
- GRADE-rated recommendations based on systematic reviews; best practice statements based on clinical practice principles
- Next review
- Not specified
- Record history
- Created 23 Oct 2026 · updated 23 Oct 2026 · next check Apr 2027
World Health Organization. Guidelines on the management of chronic pain in children. Geneva: World Health Organization; 2020. Licence: CC BY-NC-SA 3.0 IGO.GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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