Pediatric Pain Management

“Pain is such an uncomfortable feeling that even a tiny amount of it is enough to ruin every enjoyment.”

Will Rogers

Infants and children who are in pain are especially difficult to diagnose and treat. Babies and young child may not be able to indicate where their pain is located, or how severe it is. Even a child who is lying still and silent may be suffering great pain and simply not know how to communicate this distress. Children may experience nausea when they are in pain causing caretakers to treat the nausea without being aware that it is occurring because the child is in pain.

When a child is known to suffer from chronic pain, caretakers may overreact to normal crying by thinking the child is crying out with pain when s/he may simply need to be changed, burped or fed. Misreading the signals a child is sending out may result in over or under-medication either from thinking that the child is not suffering when s/he actually is, or thinking s/he is suffering when they are not.

Children tend to regress when pain inhabits their body. This may manifest as bed-wetting, thumb sucking, temperamental outbursts, or refusal to engage in normal activities. This may incur discipline rather than empathy from caretakers who simply don’t understand that the child is not being defiant, but has a genuine concern that needs to be addressed.

It is important to include the child’s family in assessing and treating pain. The family’s insights into the child will provide a valuable resource for healthcare providers to use in deciding how to treat the wee one. The family can also help professionals in communicating with the child at the child’s level of understanding.

The Myths and Facts of Pediatric Pain Management

MYTH: Young Infants do not feel pain. Children’s nervous systems are immature and are unable to perceive and experience pain the way adults do. (Texas Cancer Council, 1999)

FACT: The Central nervous system of a 26 week old fetus possess the anatomical and neurochemical capabilities of experiencing nociception (Anand, 1998)

MYTH: Children easily become addicted to narcotics.

FACT: Less than 1% of children treated with opioids (Narcotics) develop addiction. (Foley, 1996)

MYTH: Children tolerate pain better than adults.

FACT: Younger children experience higher levels of pain during procedures than older children. Children’s tolerance for pain increases with age. (Bromme, Rehwalt and Fogg, 1998; Broome and others 1990)

MYTH: Children are unable to tell you where they hurt.

FACT: Children may not be able to express their pain in the same manner as adults. Children are able to point to the body area where they are experiencing pain or draw a picture illustrating their perception of pain.

MYTH: Children become accustomed to pain or painful procedures.

FACT: Children exposed to repeated painful procedures often experience increasing anxiety and perception of pain with repeated procedures (Zeltzer, 1990).

MYTH: Children will tell you when they are experiencing pain.

FACT: Children may not report pain due to fear of administration of a painful analgesic (injection) or fear of returning to the hospital. Children who have experienced chronic pain may not be aware that they are experiencing pain. Young children may not have adequate communication skills or others may not think it is necessary to tell health professionals about the pain (Favaloro and Touzel, 1990).

MYTH: Children’s behaviors reflect their pain intensity.

FACT: Children are unique in their ways of coping. Children’s behavior is not a specific indication of their pain level (Beyer, McGrath and Berde, 1990).[1]

Barriers to Pain Management in Children

There are many barriers to adequate pain management in children including a bias on the part of health care systems and institutions that refuse to admit that children experience severe pain, poor assessment techniques, and unfounded fears of addiction, tolerance, and adverse effects both on the part of healthcare providers and on the part of the patients themselves. Many studies have shown that failure to assess pain adequately, and differences between the clinician’s and patient’s perceptions of pain, are major causes of unrelieved pain in children.

The patients themselves can be a barrier to providing adequate pain relief because children often have negative attitudes about taking medicines, a fear of injections, and a concern about becoming addicted to narcotics. Often, patients do not like to be labeled as “complainers” and so they refuse to reveal their pain. Sometimes a child simply wants to go home from the hospital soon and fears that s/he will have to stay longer if they admit that they are still in pain.

While an adult’s pain is often reflected in their vital signs (elevated pulse, respirations and blood pressure), this is not always the case for children. Children may look comfortable and have normal vital signs—they may even be able to sleep peacefully—and still be in pain. Children tend to be more easily and fully distracted from their pain than adults, thereby fooling the healthcare provider into thinking that because they are playing or watching TV without evidence of pain that it has diminished. [2]

Despite the ability of the child to disguise their suffering, healthcare providers should consider the child an authority on his/her own pain, and believe the child’s assessment of his/her own pain when asked to measure it on a pain scale. The child has the right to expect a rapid and effective response to a complaint of pain. Healthcare providers must treat the pain, reassess frequently, and continue to treat the pain until the patient is comfortable or side effects of pain medication prevent further treatment. A balanced approach to pain management in children combines both physical therapies and medication, frequently utilizing a combination of analgesics that work by different mechanisms.

Using Pediatric Pain Scales for Assessment & Documentation

A health care professional needs to assess for the presence of pain in each and every pediatric patient they encounter. If pain is present, its intensity is scored, typically using a standardized 0 to 10 scale. Pain scores are documented in writing, just like vital signs, making them readily available to all members of the health care team. The American Pain Society actually suggests that pain should be thought of as the 5th vital sign. Assessment on a pain scale should be accompanied by a complete physical and history to determine the cause of the pain.

Key subjects to ask patients about during a pain assessment include the following characteristics of their pain:

• Intensity

• Location

• Onset

• Duration

• Variation

• Quality

In the hospital setting, the patient’s pain is assessed at least as often as vital signs are taken, because ongoing assessment is necessary to evaluate changes in pain and the effectiveness of its treatment. Pain should be assessed at intervals appropriate to the severity of pain and the patient’s situation. For many patients, this will mean assessment of pain every 4 hours, but the time between assessments must be individualized to the patient’s need. In the ambulatory care setting, pain assessment should be completed with every new episode of care.

Pediatric Pain assessment should be appropriate to the developmental level of the child being assessed. Pain in children can be communicated by words, expressions, and behavior (crying, guarding a body part, grimacing).

Using the QUEST Principles of pain assessment (Baker and Wong, 1987) may be helpful in assessing pediatric pain.

Question the child.

Use pain rating scales.

Evaluate behavior and physiological changes.

Secure parent’s involvement.

Take cause of pain into account.

Take action and evaluate results.

Neonates

Situations that are painful for older children and adults can be expected to be painful for babies. Neonates that are ill may not be able to cry.

Signs Of Acute Pain                                             Signs of Chronic Pain

Crying and moaning                                               Apathy

Muscle rigidity                                                       Irritability

Flexion or flailing of the extremities    Changes in sleeping and eating patterns

Diaphoresis (sweating)                      A lack of interest in their surroundings

Irritability                                                              Guarding

Changes in vital signs, and pupillary dilatation

Older Children

Children less than 3 years old or unable to communicate, clinicians should use the FLACC scale.

FLACC Scale: This is a behavior scale that has been tested with children age 3 months to 7 years. Each of the five categories (Faces, Legs, Activity, Cry, Consolability) is scored from 0-2 and the scores are added to get a total from 0-10. Behavioral pain scores need to be considered within the context of the child's psychological status, anxiety and other environment factors.

The FLACC is a behavior pain assessment scale
University of Michigan Health System (can be reproduced for clinical or research use)

Children over 3 may use the Faces scale.

Wong-Baker FACES Pain Rating Scale

From Wong DL, Hockenberry-Eaton M, Wilson D, Winkelstein ML, Ahmann E, DiVito-Thomas PA: Whaley and Wong’s Nursing Care of Infants and Children, ed. 6, St. Louis, 1999, Mosby, p. 1153.

This scale can be used with young children (sometimes as young as 3 years of age). It also works well for many older children and adults as well as for those who speak a different language. Explain that each face represents a person who may have no pain, some pain, or as much pain as imaginable. Point to the appropriate face and say:

(0) "This face is happy and does not hurt at all."

(2) "This face hurts just a little bit."

(4) "This face hurts a little more."

(6) "This face hurts even more."

(8) "This face hurts a whole lot."

(10) "This face hurts as much as you can imagine, but you don’t have to be crying to feel this bad."

Ask the patient to choose the face that best matches how she or he feels or how much they hurt.

Word Graphic Scale

Children over 5 may be able to use deblockedor words (stinging, burning).

This scale can be used with patient as young as 5 years of age. It uses a line with words to describe pain intensity from "no pain" to "worst possible pain". Show and explain the scale to the patient and then ask him or her to point (or mark) anywhere along the line that shows how much pain they have. To find a number for documentation count the black dots, starting with zero at the far left, to the area where the patient points, up to ten at the far right.

Children over 6, who understand the concepts of rank and order, can use numerical scale, color scale (as shown in Chapter One of this course), and the word scale.

Factors Influencing Pain Ratings

Because each child may regress when they are in pain, it is important to use whatever tool that they are able to understand. Children often deny pain because they fear consequences (e.g., physical exam or injection) if they admit to having pain. Young children may not understand the relationship between pain assessment, treatment and the relief of pain. Observation of a child's behavior is helpful in the evaluation of pain. Including the patient's family or guardian may help in the assessment of pain. Observation of a child's behavior is the only way to assess a non-communicative child.

Documentation

The documentation of a child’s pain is similar to the documentation protocols shown in Chapter One of this course for adults. It is important to track and record how responsive a pediatric patient’s pain is to various types of treatments and triggers. A 24-hour flow sheet that includes hourly notations as to the patient’s pain scale score, along with comments as to what the patient was doing, and treatments received during the hour previous to the notation can help the doctor determine both the cause of the pain, and when and how to treat it.

Progress notes can also be used to summarize the type and severity of the pain that a pediatric patient is experiencing. These notes should indicate the intensity and characteristics of the patient's pain, along with current treatment and a future pain management plan.

If Patient Controlled Analgesic (PCA) or an epidural drip is used to control pediatric pain, an Analgesia flow sheet should be used to document pain scores and the administration of the analgesia.

Pharmacologic Pain Management Principles

Oral or intravenous administration of pain medication is the preferred method with which to medicate children against pain. Most children would rather have pain than an intramuscular (IM) injection, so it is wise to avoid IM injections.

The initial choice of analgesic is based on the severity and type of pain:

IV opioids such as Morphine can be safely titrated to effect in the pediatric setting. Doses should be titrated up or down in slight doses and should not be discontinued with first gradually lowering the dose.

PCA is an acceptable methods of administering pain medications. Patients and families should be educated on PCA delivered medication. Parents should be instructed never to push the PCA button when the child is asleep.

The proper dosage of pain medication in children is calculated by factoring the child’s weight, age, and the severity of the pain to find the dose that will control pain without depressing the child’s breathing. In some cases children require more pain medication than adults (in milligrams/ kilogram) do to achieve pain control. Repeat patients usually need more medication to attain the same degree of pain relief. The child’s respiratory status should be carefully monitored when the child is given narcotics. It is important not to under-medicate a child out of fear of over-medicating him/her.

Most pain medications have side effects. Effective pain relief is often accompanied by at least some of these side effects. Be prepared to treat the side effects of opioids if they occur. These drug side effects become more common as doses of opioids are increased to treat severe pain. These side effects include nausea and vomiting, constipation, pruritus (itching), mental confusion, sedation, respiratory depression, and hypersensitivity reactions. Proper use of opioids includes management of these side effects, rather than discontinuation of opioids in a patient with severe pain.

Addiction, Physical Dependence and Tolerance

Addiction to narcotics is rare (less than 1% of patients) and usually occurs in patients with a prior history of substance abuse, which is seldom the case with young and elementary school children. Addiction is defined as the continued use of a specific psychoactive substance (such as a narcotic pain killer) despite physical, psychological or social harm.

Physical dependence differs from addiction. Pediatric patients taking opioids on a chronic basis develop a physical dependence, and experience withdrawal symptoms during sudden abstinence from the drug. Addiction is primarily a psychological problem; dependence is a physical response to continued use of narcotics.

Tolerance is the need for higher opioid doses to maintain a constant effect. While this is a poorly understood phenomenon, most patients on chronic opioids do not experience tolerance. Alternative explanations, such as a new source of pain or progression of an existing disease (especially a neoplasm), should be considered when tolerance occurs.

Addiction is a maladaptive behavior pattern, where the need to take a drug interferes with other life activities. The individual is preoccupied with a continuing drug supply, despite deterioration of family, school, and other social relationships. Addiction should be suspected if the following factors are involved:

These are difficult patients to deal with and often psychiatry or chronic pain consultation is helpful.

Use of opioids inpatients with a history of substance abuse is occasionally necessary. In these cases, a treatment contract should be utilized. This typically sets out basic terms, such as the single physician who will prescribe medication, the medication schedule that the patient is expected to adhere to, and the conditions which will lead to discontinuation of narcotic therapy.

Pseudo-addiction must be differentiated from true addiction. Pediatric patients experiencing continued pain will exhibit anxiety and drug-seeking behavior. These behaviors typically disappear once the pain is relieved. This pseudo-addictive behavior is extinguished by adequate pain relief, unlike the continued drug-seeking behavior of true addiction.

Non-Pharmacologic Approaches to Pain in Children

Although analgesics are the mainstay of pediatric pain relief, most pain is best treated with a combination of drug (analgesic) and non-drug approaches.

Non-drug approaches to pain management can enhance comfort, promote sleep, and enhance the quality of life.

Non-pharmacologic interventions should routinely be used. Although these strategies alone are frequently insufficient for moderate to severe pain, they are usually helpful in conjunction with drug therapy. Such strategies may include:

Cognitive-behavioral

• Education
• Relaxation, imagery
• Psychotherapy, counseling
• Hypnosis
• Biofeedback
• Music, literature, art, play
• Prayer, meditation

Physical

• Massage
• Acupuncture, acupressure
• Application of heat or cold
• TENS
• Immobilization
• Therapeutic exercise

Children benefit from the same therapies as do adults, but the activities must be age appropriate, and made to be a fun as possible for the child. Yale University has recently created a “Pain Coloring Book” where the characters explore ways to manage their pain. Keeping in mind that children are more easily distracted from pain than adults, reading, music, art and play activities tend to be highly effective means of focusing children away from their pain.

Empathy

Whether you are involved in helping an adult or a child with managing their pain, the most important aspect of their care is letting them know that you care. Sometimes the touch or hug of another makes the pain go away, if for only a moment. Empathetic utterances such as “I am so sorry that you hurt,” allow the patient to relax and let a competent other take charge of the situation. When patients know that they can express their reaction to their pain in a supportive, non-judgmental environment it serves to reduce their stress. Be the patient’s “soft place to land” and you will discover that all pain diminishes a bit when human kindness is put in play.

THE END

Study Questions

Answering the following questions is an optional activity. These questions are provided as a study aid to help you prepare to take the post test.

1. Name at least four barriers to effective pain management in children.
   
2. Name the six characteristics of pain that you should ask a child about to assess the nature of his/her pain?
   
3. When assessing a five year old child for pain, which pain scale would you chose and why?
   
4. What are the benefits and risks involved in giving children narcotic pain medications?
   
5. Why do Cognitive Behavioral and physical therapies work well with children?