Pain Pain Management in Management in

Infants and Infants and ChildrenChildren

Lynette ThackerLynette Thacker

Clinical Nurse Specialist Clinical Nurse Specialist

Paediatric Palliative CarePaediatric Palliative CareDisclaimer: Whilst every effort has been made to ensure that the information in this presentation is accurate and referenced the author does not accept any responsibility for the use by any third parties.

Operational Definition of Operational Definition of PainPain

“Pain is whatever the experiencing person says it is, existing whenever he says it does.”

BELIEVE THE PATIENT! Ref: McCaffery and Pasero: Pain: Clinical

Manual, 1999).

Myths About Pain in ChildrenMyths About Pain in Children• Infants are neurologically immature and

therefore cannot conduct pain impulses.• Infants do not remember pain, because of

cortical immaturity.• Children do not report pain while playing or

sleeping so they must get over it quickly or not be experiencing it.

The Golden RuleThe Golden Rule

What is painful to an adult is painful to an infant and

child unless proven otherwise.

Types of PainTypes of Pain• Nociceptive

– Somatic• Well-localized• Pain receptors in soft tissue, skin, skeletal muscle, bone

– Visceral• Vague• Visceral organs

• Neuropathic• Damaged sensory nerves

Classification of pain• Many different systems

– e.g. based on:• Duration – acute/chronic/persistent• Intensity – mild/moderate/severe• Location• Presumed pathophysiology – visceral, somatic,

sympathetic• Sensitivity to opioids – sensitive/insensitive/partially

insensitive• Pragmatic

Pragmatic classification of pain• Neuropathic

– Disordered sensation– Responds to anticonvulsants and antidepressants

• Bone– Intense and focal– Responds to NSAIDs and bisphosphonates

• Muscle spasm– Responds to muscle relaxants and antispasmodics

• Cerebral irritation– Caused by brain injury– Signs of anxiety– Responds to benzodiazepines

QUESTTQUESTT

• Question the patient/parent/carer• Use pain rating scale• Evaluate behavior & physiologic

signs• Secure family’s involvement• Take cause of pain into account• Take action and assess

effectiveness

Pain AssessmentPain Assessment• What is the policy for pain assessment and

documentation in your area?• Methods of assessment vary according to age and

cognitive level of child– Patient report– Numerical scale – 1 to 10– FACES – can be used at all ages– FLACC used on infants

Physiological Indications Physiological Indications of of

Acute PainAcute Pain

• Dilated pupils• Increased perspiration• Increased rate/ force of heart rate• Increased rate/depth of respirations• Increased blood pressure• Decreased urine output• Decreased peristalsis of GI tract• Increased basal metabolic rate

Infant Response to PainInfant Response to Pain• Forcefully closed eyes• Lowered brows• Deepened furrow between nose and outer

corner of lip.• Square mouth• Cupped tongue

Toddler and Pre-schoolToddler and Pre-school• Limited in their cognitive abilities in localizing

and expressing pain intensity, and understanding reasons for pain.

• Find out word they use to express pain• Point to pain• Faces is a good tool for them.

School-ageSchool-age• Increased ability to communicate pain in more

abstract terms.• They can describe pain: squeezing, stabbing or

burning• Respond well to direct questioning.• Tools: body outline, faces scale, visual analog.

Acute IllnessAcute Illness• Middle ear infection, pharyngitis, meningitis,

abdominal pain, fractures• Treatment determined by severity of pain

– Paracetamol– Non-steroidal – Opioids– Locally applied medications– Relaxation and distraction

Pre-procedural PainPre-procedural Pain• Key to managing procedural –related pain is

anticipation• Anticipated intensity and duration• Child / parent receive appropriate information

to minimize distress

Operative PainOperative Pain• Morbidity and mortality can be reduced by

good pain treatment• Plans for postoperative pain should be

discussed before surgery• Goal is to control the pain as rapidly as

possible

Post-Operative PainPost-Operative Pain• Oral administration is preferred for mild to moderate

pain.• IV is indicated for immediate pain relief. • Persistent moderate to severe pain – continuous

around the clock dosing at fixed intervals is recommended.

• PCA – patient-controlled analgesia – used only when patient can use pump on their own.

Non-pharmacologic Pain Non-pharmacologic Pain ManagementManagement

• Physical– Massage– Heat and cold– Acupuncture

• Behavioral– Relaxation– Art and play therapy– Biofeedback

• Cognitive– Distraction– Imagery and Hypnosis

Case Study 1Case Study 1Alex is a 6 year old, admitted for osteotomy as treatment for bilateral dislocated hips from quadriplegic dystonic cerebral palsy. He is non-verbal, gastrostomy fed and as epilepsy.

Present analgesia consists of Buprenorphine patch 15micrograms and Oromorphine 3.5milligrams as required for pain.

Using the holistic approach of physical/psychological/social/spiritual aspects how would you manage Alex pain in the post-operative period.

Case Study 2Case Study 2Bobby is a 14 year old, admitted with a fractured radius and ulna. He is has a Lawrence Moon Biedal Barr Syndrome. He has chronic renal failure, visual impairment, mild learning disability and is verbal. Present analgesia consists of Paracetamol 500milligrams as required for pain.Bobby’s younger brother died 3 years ago from a more severe form of Lawrence Moon Biedal Barr Syndrome.Using the holistic approach of physical/psychological/social/spiritual aspects how would you manage Bobby’s pain in the post-operative period.

WHO analgaesic ladder

Golden RulesOral meds if possible

NB – adjuvants at all stages

Do not rotate within a step, move up

Major opioids should always be regular

Adjuvant AnalgesicsAdjuvant’ = not primarily analgesic but can improve pain in certain

circumstances

• Neuropathic - anticonvulsants (carbamazepine, gabapentin), antidepressants (amitriptyline), NMDA receptor antagonists (methadone, ketamine)

• Bone - NSAIDs, bisphosphonates, RTx, chemo

• Muscle spasm - Benzodiazepines, baclofen, tizanidine, botox

• Cerebral irritation- Benzodiazepines, phenobarbitone

• Inflammatory/Oedema – Steroids

• Non-pharmacological - Physio, Psychology…..

Initiating strong opioid therapy

• What drug?Morphine - short acting formulation (Oramorph, Sevredol)By mouth if possible

• What dose?1mg/kg/day = total daily dose = 30mg30mg ÷ 6 = 4 hourly dose = 5mg

• And for breakthrough pain?

• Give the 4 hourly dose (5mg) as required

Titration phase

Aim – to match the amount of analgesia given with the degree of pain experienced

• Add up all doses taken in 24 hours so if 6 doses x 5mg30mg + 30mg = 60mg60mg ÷ 6 = 10mg

Prescribe 10mg 4hrly and 10mg prn for breakthrough pain

Maintenance phase

• More convenient opioid preparations– MST

• Total daily Oramorph requirement: 60mg• Appropriate MST dose: 30mg bd

– Diamorphine SCI• Total Oramorph requirement: 60mg• Appropriate Diamorphine dose: 20mg/24hrs= 60mg/3 as Diamorphine 1/3rd stronger than Oral morphine

• Prescribe breakthrough analgesia

Side EffectsSide Effects

• Nausea, vomiting and puritus are common side effects

• Drowsiness• Respiratory Depression• Constipation with prolonged use of opioids

MonitoringMonitoring• What monitoring is required per hospital

policy?• A cardiac / respiratory monitor is used for

infants less than 7 months • Oximetry monitors for other patients during use

of IV opioids – Unstable respiratory status– History of difficult airway management– Neurologically impaired

DocumentationDocumentation• The assessment and measure of pain intensity

and quality, appropriate to the patient’s age, are recorded in a way that facilitates regular re-assessment and follow-up according to criteria developed by the organization.

Take Home PointsTake Home Points• Assess pain using an age appropriate tool.• Consider starting an around the clock regimen.• Continually assess pain and modify medication regimen

appropriately.• When to call for medical assistance:

– Patient has persistent or worsening pain despite appropriate analgesic regimen.

• When to transfer to a higher level of care:– Patient develops respiratory depression with opiates

• Control airway and ventilation• Order opioid antagonist (Naloxene)while calling for

help

Narcotics Narcotics Are No More Dangerous Are No More Dangerous for Children Than Adultsfor Children Than Adults

• Addiction from narcotics (opioids) used to treat pain is extremely rare in adults; no reports substantiate this fear in children; reports of respiratory depression in children are rare.