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Pediatric Pain Management

Assessment & Interventions

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Introduction

Definition of pain: an unpleasant sensory and emotional experience associated with actual or potential tissue damageAlways subjective and is learned through experiences R/T injury in early life Circumcision study

Can be assessed by verbal, behavioral and physiological indicators

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Need to differentiate

“PAIN” from “DISTRESS”

Pain related to fear and anxiety

Often exhibited by children

Highly correlated with the degree of pain in children

May reflect other emotional reactions

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Neonatal Pain Perception

Peripheral and central structures required for pain reception and function in 1st & 2nd trimesters EEG patterns/ cortical evoked potentials Cerebral glucose utilization

Newborn infants have well-developed H-P axis

Pain impulses in newborns conducted by unmyelinated C-type fibers

Newborns lack descending inhibitory neuro transmitters

RESULT: Infants cannot modulate their pain well.

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Developmental Reactions to Pain

Infants Rely on caregivers to notice pain Give behavioral signs that they are hurting

Change in activity—restlessness, clinging or whining, appetite

Physiologic indicators—tachycardia, tachypnea, BP

Developmental Reactions to Pain

Toddlers Have poor body boundaries Intrusive experiences, even if not painful, are

anxiety producing Often react intensely and physically resist

Biting, kicking, hitting, running away Help parents understand reactions and avoid

punishment Use play activities & distraction Use bandages but be aware of anxiety when

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Developmental Reactions to PainPreschoolers (3-6 yrs) Need reassurance that pain is not a punishment Magical thinking & egocentric

Exaggerated ideas about illness that are worse than reality Can lead to feelings of shame guilt, fear May view illness as punishment for something

Resist during painful procedures: fear of mutilation and bodily injury

Concrete thinkers; may misinterpret words Allow to express feelings – provide play opportunities Give simple explanations: short,simple, clear

Developmental Reactions to Pain

Preschoolers (3-6 yrs) cont’d

Praise for good behavior Cannot always indicate source or location of pain

Believe in the magical nature of pain—allows for effectiveness of some therapies e.g. kiss, bandaid. It works because they believe in it.

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Developmental Reactions to Pain

School Age (6-12 years) Able to locate pain in terms of body parts Main concern: body integrity; < concern for pain than

disability or death Feel that injury is r/t guilt (so they deserve pain) Want factual info & reasons for things

Adolescent (13-19 years) Afraid of looking like a baby Often hesitant to express feelings of pain Main concern: body image Fear death as well

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Pediatric Pain Scales

http://www.med.umich.edu/yourchild/topics/pain.htm Excellent link with LOTS of great information on

pediatric pain management from the University of Michigan.

Neonatal Infant Pain Scale

NIPS used at BroMenn for infants 1-10 scale Pain score of > 6 is considered reflective of

pain

Another resource that describes this scale from Cincinnati Children’s Hospital

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A, The FPS and FPS-R (Reprinted with permission from Hicks CL,

von Baeyer CL, Spafford PA, van Korlaar I, Goodenough B. The

Faces Pain Scale-Revised: toward a common metric in pediatric pain

measurement.

Deborah Tomlinson et al. Pediatrics 2010;126:e1168-e1198

©2010 by American Academy of Pediatrics

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Non-Pharmacological Pain Management

Infants Tactile: touching, stroking, patting,

swaddling Motion: rocking, bouncing Comfort: sucking/ pacifier, sucrose—

24% sucrose solution just before procedure

Environment: quiet, soft music, low lights

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Non-Pharmacological Pain Management

Toddlers & Preschoolers Preparation: simple, sensory, developmentally

appropriate Caregiver presence Distraction: bubbles, glitter wands, books, rain

stick Praise: offered freely, for trying (not for

succeeding) Simple choices “One voice”—allows distraction without over

stimulating

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Non-Pharmacological Pain Management

School Age Preparation/ rehearsal—have “practice kits”

with real equipment to feel and get familiar with procedure ahead of time.

Distraction Relaxation techniques

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Non-Pharmacological Pain Management

Adolescents Preparation—allow adequate time Distraction Relaxation techniques Often need lots of reassurance and clarification

of the procedure.

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EMLA/LMX-4 Cream

Dosage: 0-3months: 1 gram maximum, 10 sq.cm

surface area, 1 hour duration. 3-12 months, > 5 kg: 2 grams max, 20 sq. cm

surface area, 4 hour duration. 1-6 years, > 10 kg: 10 grams max., 100 sq.cm.

Surface area, 4 hour duration. 7-12 years, >20 kg: 20 grams max., 200 sq. cm.

Surface area, 4 hour duration.

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EMLA/LMX-4 Cream--techniques

Individuals with darker pigmented skin or who are dehydrated may require longer application time.Longer application required on thick skinRemoval of stratum corneum layer of skin may facilitate absorptionAlthough maximum analgesia occurs after 1 hour, shorter times partially effectiveApplication of warm compresses will lessen blanching and bring the veins back to visibility.

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Pediatric Doses for Acetominophen and Ibuprofen

Accepted doses for Acetominophen 10-10-mg/kg/dose is considered in neonates

1515-mg/kg/dose is WNL in older children If child weighs 12 lbs, how much would you

tell mom to give per dose?

Accepted doses for Ibuprofen 1010-mg/kg/dose is considered WNL. Some

pediatricians insist the child must be able to eat or drink to avoid irritation to the stomach.

If child weighs 22 lbs, how much would you tell mom to give per dose?

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How Acetaminophen is packaged

Infant Drops= 100mg/ml NO LONGER AVAILABLEElixir= 160mg/5ml most commonTylenol Chewables= 80mg/tabTylenol Junior Strength Chewable or Gelcap= 160mg/tabGive Acetaminophen every 3-4 hours prn.

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How Ibuprofen is packaged

Pediatric Drops= 100mg/2.5mlChildren’s Suspension= 100mg/5mlChildren’s Chewables= 100mg/tabletGive Ibuprofen every 6-8 hours, not to exceed 4 doses/dayAcetaminophen and Ibuprofen may be safely given alternately to enhance antipyretic effects of combined meds.

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A final thought

Use a balanced approach to pain management

Incorporate nonpharmacologic and pharmacologic therapy

Try multiple analgesics which work by different mechanisms.

Use developmentally appropriate communication & methods for providing comfort

Be aware of signs of pain at different ages