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Pain management in children

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Pain management in children

Pain management in children is the assessment and treatment of pain in infants and children. Pain has many different definitions. It is a sensation of anxiety, discomfort and distress.[1] Physiologically, pain can be described in terms of nerve stimulation and conduction of nerve impulses to the brain. Such stimulation can mild, localized, chronic, acute or agonizing. Even in children, pain is tied to emotional and psychological components.[2] The consequences of untreated pain can increase the incidence of complications and even death.[3][4] Children can have significant pain related to Epidermolysis Bullosa, Osteogenesis Imperfecta, cancer, metabolic/neurologic diseases, palliative care, and sickle cell disease.[5] One clinician has described the use of evidence-based approaches to managing pain in children: "Pain management practices should be based on scientific facts or agreed best practices, not on personal beliefs or opinion. The burden of proof lies with the healthcare professional, NOT the patient."[6] The pain of many children is undertreated.[4]

Indications

The indications for the treatment of pain in children are not always clear due to misconceptions that still exist.

Misconceptions of pain in children
Incorrect Valid References
Infants cannot sense pain like adults nerve pathways exist at birth, though immature
newborns experience physiological changes and surge in hormones that indicate stress		 [7][4]
Infants cannot feel pain because of
unmyelinitated nerve fibers		 complete myelinitation is not necessary for the transmission
of pain impulses to the brain		 [7]
Young children cannot indicate where
pain originates		 Young children can use a body chart to indicate where their pain originates [7]
If a child is able to sleep then they
are not in pain		 Sleep occurs because of exhaustion [8]
"Pain builds character" [4]

The indications for the treatment of pain can vary among health care providers and are subject to the provider's personalities, culture, and acceptance of pain in children. The characteristics of pain will help determine assessment, diagnosis and treatment. Pain can be acute, recurrent, chronic or a combination of these. The pain of children has been characterized as having "plasticity and complexity" and in need of timely and continuous assessment. A best practice is to ask for descriptions of the pain before querying the child about location, intensity, quality, and tolerance. Personal viewpoints and assumptions by providers regarding the meaning of a behavior need evaluation. There is "a relatively pervasive and systematic tendency for proxy judgments to underestimate the pain experience of others".[4]

Minor invasive, and painful procedures often don't include a treatment plan for anticipated pain. During circumcision, infant boys do not consistently receive appropriate pain control. Newborn circumcisions are quite painful and associated with irritability and feeding disturbances for days after the procedure.[4]

Acute pain

Acute pain has an obvious cause and is expected only to last for a few days or weeks. It is usually managed with medication and then with non-pharmacological treatments to provide comfort.[9][1]

Acute pain is an indication for assessment, treatment and prevention. While in pain, physiological changes occur that can further jeopardize healing and recovery. Unrelieved pain can cause alkalosis and hypoxemia that results from rapid, shallow breathing. The shallow breathing then leads to the accumulation of fluid in the lungs and the inability to cough can prevent the secretions from being expelled. The pain can cause an increase in blood pressure, heart rate creating great stress on the heart. Pain will increase the release anti-inflammatory steroids that will reduce the ability to fight infection. These same steroids that are released increase the metabolic rate and impact healing. Children experiencing pain have an increase in sympathetic effects such as the inability to urinate. The pain can also slow down the gastrointestinal system. This can result in the child receiving inadequate nutrition. Muscle cramps, stiffness, and stress prevents moving around, an essential activity in recovery.[10]

Inadequate pain management in children can have psycho-social consequences. These can be a disinterest in food, apathy, sleep problems, anxiety, avoidance of subsequent discussions about health, fear, hopelessness and powerlessness. Other consequences can be longer hospital stays, high readmission rates and a longer recovery.[10] On the other hand, the American Association of Pediatrics describes pain with immunizations as "The pain associated with the majority of immunizations is minor.".[11]

Besides the obvious relief of suffering, managing pain in children will reduce the risk of later consequences due to unrelieved pain:[12]

  • infants with a higher than average heel sticks can have poorer cognitive and motor function
  • distress caused by needle-sticks make later medical treatment more difficult
  • children who have experienced invasive procedures later develop post-traumatic stress (PST)
  • children who have severe burns and receive relatively higher doses of morphine have fewer PST symptoms[13]
  • boys circumcised without anesthesia were found to have greater distress when given immunizations than uncircumcised boys.[14]
  • severe pain as a child is associated with higher reports of pain in adults[15]

Pain can be caused by medical procedures. Acute pain can be expected in response to many if not most invasive procedures. Anticipation of pain and distress can guide the pre-treatment pain-prevention plan based upon past reports of pain associated with the procedure. Those with technical expertise and experience are most likely to minimize the pain as much as possible. Preparation before a procedure with information that can be understood by children and parents can minimize distress. Parents can benefit from advice regarding effective methods of comforting a child.[4]

The type of procedure will determine the use of deep sedation and anesthesia. In some cases, the best methods to preventing and relieving pain will be building self-esteem. Other non-pharmacological treatments can be effective. These can be cognitive behavioral strategies, imagery, relaxation, massage, heat compression, calm adults, a quiet environment, and clear, confident explanations by providers. Some children benefit from the opportunity for self-regulation. Distress can be addressed and controlled. Such treatment plans have resulted in reductions of reports of pain and the assessed levels of pain in children. Pain reduction during invasive procedures is closely linked to controlling distress. Treating distress even for minor or uncomplicated procedures, likes venipuncture can be implemented.[4]

Neuropathic pain

Neuropathic pain is associated with nerve injuries or abnormal sensitivities to touch or contact. other causes are, postsurgical, post-amputation.[5]

Cancer pain

Cancer pain can differ from the other types of pain. In addition, a child can have pain for other reasons not associated with cancer. Pain in children without cancer can present as headaches, muscles strains and "as being part of being a child."[1] Pain experienced by children is related to the stage or extent of the cancer. Children with cancer may have no pain. One child may have a different threshold for pain than another. Other sources of pain from cancer are:

  • a growing tumor pressing on a body organ or nerves
  • inadequate blood circulation because of blocked blood vessels
  • blockage of an organ or a 'tube' of the organ
  • the spread of the cancer to other places
  • infection
  • inflammation
  • side effects of chemotherapy, radiation or surgery
  • inactivity and stiffness
  • depression and anxiety[1]

Recurrent pain

Recurrent pain is pain that arises periodically and can result in absences from school. This type of pain may be the most common. It is described as:

  • periodic instead of persistent
  • consisting of tension and migraine headaches
  • abdominal pains
  • chest pain and limb pains[5]

Chronic pain

Chronic pain in children is unresolved pain that affects activities of daily living and may result in significant days lost at school. It is characterized as mild to severe and present for long periods of time.[1] Chronic pain can develop from disease or injury with acute pain. Girls are more likely to have chronic pain. Some have described chronic pain as the pain experienced when the child reports: headache, abdominal pain, back pain, generalized pain or combinations of these.[5] Children with chronic pain can have psychological effects. In addition, families may also suffer emotionally when the child experiences pain. Caring for a child in pain has social consequences related to the disability and limitations that acommpany the pain. Pain in children involves additional costs from healthcare and lost wages because time off from work is taken to care for the child.[16]

Causes

The causes of pain in infants and children are most likely to be the same as in adults. Pain be experienced in many ways and is dependent upon the child's:

  • prior painful episodes or treatments
  • age and developmental stage,
  • disease or type of trauma,
  • personality,
  • culture,
  • socioeconomic status,
  • presence of family members and family dynamics.[17]

Assessment

Further information: Infant crying
sample pain assessment chart

Ongoing and frequent assessment between all those involved in the treatment plan is documented in a readily accessible format - usually the patient record.[4] Assessment of the pain in children depends upon the cooperation and developmental stage of the child. Some children do not have the ability to assist in their assessment because they have not matured enough cognitively, emotionally, or physically.[17]

Young infant

Signs of distress and possible pain are exhibited by young infants by:

  • inability to distinguish the stimulus from the pain
  • ability to exhibit a reflexive response to pain
  • expressions of pain
    • tightly closed eyes[5]
    • open mouth resembling a square rather than an oval or circle
    • lowered eyebrows and tightly drawn together
  • rigid body
  • thrashing
  • loud cry[17]
  • increase in heart rate even while sleeping[citation needed]

Older infant

Signs of distress and pain are exhibited in older infants by:

  • deliberate withdrawal from pain and possible guarding
  • loud cry
  • facial expression of pain[17]

Toddler

A toddler can express distress and pain by:

  • expressing pain verbally
  • thrashing extremities
  • crying loudly
  • screaming
  • being uncooperative
  • pushing away perceived source of pain (palpation)
  • anticipating a pain-inducing procedure or event
  • requesting to be comforted
  • clinging to a significant person, possibly the one perceived as being protective[17]

School-aged child

School-aged children express pain in similar ways as toddlers but also by:

  • anticipating the pain but less intensively, understands concepts of time, i.e., imminent vs future pain
  • stalling, trying to talk out of the situation where pain is anticipated
  • having muscular rigidity[17]

Adolescent

Cultural expectations begin to influence expressions of pain.[citation needed] Adolescents express pain:

  • with muscle tension, but with control
  • with verbal expressions and descriptions[17]

Quantitative pain assessment

Though pain is subjective and can be considered to exist as a spectrum rather than an exact determination, different assessment tools exist to compare pain levels over time. This kind of assessment incorporates pain scales and requires a high enough developmental level so that the child can respond to the question(s).[17] A verbal response is not always necessary to quantify the pain.

Pain scales

A pain scale measures a patient's pain intensity or other features. Pain scales are based on self-report, observational (behavioral), or physiological data. Self-report is considered primary and should be obtained if possible. Pain measurements help determine the severity, type, and duration of the pain, and are used to make an accurate diagnosis, determine a treatment plan, and evaluate the effectiveness of treatment. Pain scales are available for neonates, infants, children, adolescents, adults, seniors, and persons whose communication is impaired. Pain assessments are often regarded as "the 5th Vital Sign".[18]

Examples of pain scales
Self-report Observational Physiological
Infant — Premature Infant Pain Profile; Neonatal/Infant Pain Scale —
Child Wong-Baker Faces Pain Rating Scale – Revised;[19] Wong-Baker FACES Pain Rating Scale; Coloured Analogue Scale[20] FLACC (Face Legs Arms Cry Consolability Scale); CHEOPS (Children's Hospital of Eastern Ontario Pain Scale)[21] Comfort
Adolescent Visual Analog Scale (VAS); Verbal Numerical Rating Scale (VNRS); Verbal Descriptor Scale (VDS); Brief Pain Inventory — —

During treatment

A physical therapist uses play as part of the child's treatment plan

Clinicians responsible for the child monitor the child frequently in tertiary care centers (hospitals). Pharmacological and non-pharmacological or both treatment modalities are used to manage the pain. Parents or caregivers are also requested to provide their own pain assessments. At the beginning of pharmacological treatment, clinicians monitor the child for adverse reactions to the medications. The levels of some medications are monitored to ensure that the child is not over medicated or receives toxic levels of the drug. The levels will also provide the results that will indicate that the levels in the blood are high enough to be effective in managing the pain. Medications are metabolized differently between even children of the same age. The factors that influence the levels of medications that control pain are the height, weight, and body surface of the child in addition to any other illnesses that a child might have.[17] Some medications may have a paradoxical effect in children, that is, an effect that is the opposite of the expected effect. Clinicians monitor for this and any other reactions to the medication.[22][23]

Because children process information differently than adults, a-traumatic measures are used to reduce anxiety and stress. Treatment centers for children often employ these procedures. Examples are:

  • allowing the parent or caregiver to be present for painful procdures
  • using a treatment room for painful procedures to ensure that the child's room is a place where little pain can be expected
  • establish other 'pain-free zones' where no medical procedures are allowed such as a playroom
  • offering choices to the child to give them some control over the procedures
  • modelling procedures with dolls and toys
  • using age-appropriate vocabulary and anatomical terms the child can understand.[17]

Non-pharmacological pain management

Pain relieving, non pharmacological management of pain during immunizations can be sugar on a pacifier, comforting during and after the injections, visualization of 'blowing away the pain' (like bubbles), chest to chest hugging, and giving the child choices about injection sites.[11] Other non-pharmacological treaments that have been found to be effective:

  • careful explainations of the procedure with pictures or other visual aids
  • allow the child to ask questions of medical staff
  • tour the place where the procedures will occur
  • older children may benefit from watching a video that explains the procedure
  • small children can play with dolls or other toys with a clinician to explain the procedure
  • hypnosis and imagery with a psychologist or medical doctor can help with techniques that narrow the focus of the child
  • distraction with songs, stories, toys, color, videos, TV or music
  • relaxation such as deep breathing or massage[1]

Pharmacotherapy

Further information: Analgesic adjuvant

The use of medications to treat acute, chronic, recurrent and neuropathic pain is most common. Most instances of pain in children are treated with analgesics. These include acetaminophen, NSAIDs, local anesthetics, opioids, and medications for neuropathic pain.[5] The most effective approach to pain management in children is to provide round the clock instead of providing pain relief as needed. Regional anesthesia is effective and recommended whenever possible. Opioids are effective but depress breathing in infants.[5]

Chronic pain treatment

Chronic pain is treated with a variety of medications and non-pharmacological interventions. Opioid tolerance and withdrawal can be seen in the NICU and PICU. Other side effects with opioid use can be: cognition deficets, altered mood, and disturbances of endocrine development. Opioid misuse can occur in adolescents and is associated with the use of alcohol, cigarettes and marijuana.[5]

Non-pharmacological treatment for children in helping to relieve periodic pain episodes and severity includes counselling and behavior modification therapy.[5] The American Association of Pediatrics have suggested that parents be educated on providing round the clock medication administration after their children receive surgery.[24]

Acute pain treatment

For acute pain, multiple medications given at the same time is the most effective. This results in lower pain scores, provides greater relief, allows lower dosing (and side effects), targets different nerve pathways, and can be tailored to the child.[25][5]

Cancer pain treatment

Cancer pain in children is managed differently in children. Clinicians treating the pain can come from a variety of disciplines or specialities. The medical history, physical examinations, age and overall health of the child is evaluated. The type of cancer may influence decisions about pain management. The extent of the cancer, the tolerance of the child to specific medications, procedure or therapies is also taken into account. The preferences of the parent or caregiver is also part of determining the best way to treat cancer pain in the child.[1] For cancer pain, opioids are effective. The side effects can be: constipation, fatigue, and disorientation. Some opioids can be given orally. Others are given IV, subcutaneous, or transdermal. Switching medications may be necessary. Dosing for children has been based upon studies with adults or short-term studies. Children can develop opioid tolerance where larger doses are needed to have the same effect. When resistance to opioids develop, the pain responsiveness is reset and everything hurts more. Tolerance is more likely to develop in younger children.[5]

History

In the recent past it was believed that the experssions of pain in babies was reflexive and due to the immaturity of the infant brain, the pain could not really be perceived.[26] Attempting to relieve pain in infants was considered futile since it was thought to be impossible to measure the child's pain.[27]

These beliefs along with cultural concerns of opiate addiction contributed to the clinicians of the time withholding pain relief.[28]

In 1994, responding to the need for a more useful system for describing chronic pain, the International Association for the Study of Pain (IASP) classified pain by the:

  1. region of the body involved (e.g. abdomen, lower limbs),
  2. system whose dysfunction may be causing the pain (e.g., nervous, gastrointestinal),
  3. duration and pattern of occurrence,
  4. intensity and time since onset, and
  5. cause[29] This system was criticized by Clifford J. Woolf and others as inadequate for guiding treatment.[30]

Woolf suggested three categories of pain:

  1. nociceptive pain,
  2. inflammatory pain which is associated with tissue damage and the infiltration of immune cells, and
  3. pathological pain which is a disease state caused by damage to the nervous system or by its abnormal function (e.g. fibromyalgia, peripheral neuropathy, tension type headache, etc.).[31]

References

  1. ^ a b c d e f g "Pain Management and Children". Stanford University School of Medicine, Stanford Children's Health. 2017. Retrieved 20 August 2017.
  2. ^ "Medical Definition of Pain". Retrieved 15 August 2017.
  3. ^ Verghese, Susan T; Hannallah, Raafat S (15 July 2010). "Acute pain management in children". Journal of pain research. 3: 105–123. PMC 3004641. PMID 21197314.
  4. ^ a b c d e f g h i Health, Committee on Psychosocial Aspects of Child and Family; Task Force on Pain in Infants, Children (1 September 2001). "The Assessment and Management of Acute Pain in Infants, Children, and Adolescents". Pediatrics. 108 (3): 793–797. doi:10.1542/peds.108.3.793. PMID 11533354 – via pediatrics.aappublications.org.
  5. ^ a b c d e f g h i j k Berde, Charles. "Pharmacotherapy of Pain in Infants and Children" (PDF). Food and Drug Administration. Retrieved 18 August 2017.
  6. ^ Twycross, p. 13.
  7. ^ a b c Twycross, p. 7.
  8. ^ Twycross & page 7.
  9. ^ Twycross, p. 140.
  10. ^ a b Twycross, p. 3.
  11. ^ a b "Managing Your Child's Pain While Getting a Shot". HealthyChildren.org. Retrieved 20 August 2017.
  12. ^ Twycross, p. 1.
  13. ^ Twycross, p. 4.
  14. ^ twycross, p. 3.
  15. ^ Twycross, p. 2.
  16. ^ http://americanpainsociety.org/uploads/get-involved/pediatric-chronic-pain-statement.pdf
  17. ^ a b c d e f g h i j Henry, p. 43.
  18. ^ "Pain: current understanding of assessment, management and treatments" (PDF). Joint Commission on Accreditation of Healthcare Organizations andnthe National Pharmaceutical Council, Inc. December 2001. Retrieved January 2013. {{cite web}}: Check date values in: |accessdate= (help)
  19. ^ "The Faces Pain Scale – Revised". Pediatric Pain Sourcebook of Protocols, Policies and Pamphlets. 7 August 2007.
  20. ^ Stinson, JN; Kavanagh, T; Yamada, J; Gill, N; Stevens, B (November 2006). "Systematic review of the psychometric properties, interpretability and feasibility of self-report pain intensity measures for use in clinical trials in children and adolescents". Pain. 125 (1–2): 143–57. doi:10.1016/j.pain.2006.05.006. PMID 16777328.
  21. ^ von Baeyer, C.L.; Spagrud, L.J. (2007). "Systematic review of observational (behavioral) measures of pain for children and adolescents aged 3 to 18 years". Pain. 127 (1–2): 140–150. doi:10.1016/j.pain.2006.08.014. PMID 16996689.
  22. ^ Moon, Young Eun (2013). "Paradoxical reaction to midazolam in children". Korean Journal of Anesthesiology. 65 (1): 2. doi:10.4097/kjae.2013.65.1.2. ISSN 2005-6419.
  23. ^ Mancuso, Carissa E.; Tanzi, Maria G.; Gabay, Michael (2004). "Paradoxical Reactions to Benzodiazepines: Literature Review and Treatment Options". Pharmacotherapy. 24 (9): 1177–1185. doi:10.1592/phco.24.13.1177.38089. ISSN 0277-0008.
  24. ^ Fortier, Michelle A.; MacLaren, Jill E.; Martin, Sarah R.; Perret-Karimi, Danielle; Kain, Zeev N. (1 October 2009). "Pediatric Pain After Ambulatory Surgery: Where's the Medication?". Pediatrics. 124 (4): e588–e595. doi:10.1542/peds.2008-3529. PMID 19736260. Retrieved 20 August 2017 – via pediatrics.aappublications.org.
  25. ^ Twycross, p. 147.
  26. ^ Chamberlain DB (1989). "Babies Remember Pain". Pre- and Peri-natal Psychology. 3 (4): 297–310.
  27. ^ Wagner AM (July 1998). "Pain control in the pediatric patient". Dermatol Clin. 16 (3): 609–17. doi:10.1016/s0733-8635(05)70256-4. PMID 9704215.
  28. ^ Mathew PJ, Mathew JL (2003). "Assessment and management of pain in infants". Postgraduate Medical Journal. 79 (934): 438–443. doi:10.1136/pmj.79.934.438. PMC 1742785. PMID 12954954.
  29. ^ Classification of Chronic Pain. 2 ed. Seattle: International Association for the Study of Pain; 1994. ISBN 0-931092-05-1. p. 3 & 4.
  30. ^ Towards a mechanism-based classification of pain?. Pain. 1998;77(3):227–9. doi:10.1016/S0304-3959(98)00099-2. PMID 9808347.
  31. ^ What is this thing called pain?. Journal of Clinical Investigation. 2010;120(11):3742–4. doi:10.1172/JCI45178. PMID 21041955.

Bibliography

  • Henry, Norma (2016). RN nursing care of children : review module. Stilwell, KS: Assessment Technologies Institute. ISBN 9781565335714.
  • Roberts, Michael (2017). Handbook of pediatric psychology. New York: The Guilford Press. ISBN 9781462529780.
  • Twycross, Alison (2014). Managing pain in children : a clinical guide for nurses and healthcare professionals. Hoboken: Wiley Blackwell. ISBN 9780470670545.
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