Providing quality pediatric pain management during end of life care

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Author: Danielle Cassidy, PharmD, BCPS
Audience: continuing education for hospice nurses
Background: describes common developmentally appropriate tools for assessing pain in children, general principles of pediatric pharmacology, common pharmacological interventions, side effects commonly associated with opioid medications & side effect management strategies.

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  • (Reference 2, 4, 6, 13)Analgesia often is insufficient because physicians are insecure with opioid dose administration & fail to adjust the opioid dose fast enough to match changing requirements.-At present, only about 5000 children dying each year receive hospice indicating that the vast majority of children might benefit from palliativecare & hospice services.- However, 2006 when the World Health Organization, the American Academy of Pediatrics, & the Institute of Medicine called attention to the unmet needs of dying children, forward progress in pediatric palliative care has gained momentum.
  • (References 1,5)-In 2001 APP & APS issue a joint statement regarding the pediatric pain
  • (Reference 2, 4)Currently no official established criteria for determining if a child is eligible for palliative care. A general guide was published by the Royal College of Peds & Child Health in 1997 in which they outlined medical conditions appropriate for pallative care services.-Palliative care is appropriate for children with a wide range of conditions, even when cure remains a distinct goal.-AAP has supported concepts of palliative care, stating that “the components of palliative care are offered at diagnosis & continued throughout the course of illness, whether the outcome ends in cure or death.” -Palliative care should be accessible in any setting, including home, hospital, & school.
  • (Reference 1-3)(Raeanna’s suggestion: Make sure to define nociception vs. neuropathic for this audience-verbal definition adequate)Similar to adults pain in kids can be nociceptive or neuropathic Neuropathic pain= complex chronic pain resulting from injury to the peripheral or CNS.Nociception= refers to the ability to feel pain and usually caused by stimulation of the nocipector.Nociceptive includes visceral (spleen, liver, gallbladder, ascites, intestinal cramps) & somatic pain (mucous membranes, bone, muscle, skin).pain is a subjective experience & ideally, the assessment of pain relies heavily on self-report.
  • Reference 2, Pediatric pain assessment differs from adult in that it must take into consideration the developmental stage of the child. Validated assessment tools to assess physical pain based on age & cognitive ability. Behavioral scales may under represent the intensity of persistent pain, as compared with self-reports.Usually at 7 years of age, children understand the proportionality of numbers & colors and can generally use the same scales as adults (i.e., Visual Analog Scale, Numeric Rating Scale). It is important to incorporate the primary caregivers input into ur overall assessment for 2 reasons: they generally know their children best, & they may have concerns & observations that may have been subtle during clinical examination.Also similar to adults, children with chronic pain adapt to their pain & often do not exhibit changes in vital signs, or common behavioral changes associated with pain such as withdrawing from the environment or crying. -Cognitive, behavioral, emotional, & psychosocial factors (e.g., family learning, culture), & other factors (e.g., gender) play a role in a child’s pain experiences, with children & adolescents responding to noxious experiences differently at different developmental stages.
  • References: 2,7-10-When assessing pain at different points—as in assessing the effectiveness of a dose of medication—the same assessment method should be used for eachassessment.
  • Results in a total score of 0-10.
  • References: 2, 7, FLACC also has be used in cognitively impaired.
  • References: 1, 2, 7Both preschool & school-age children may attribute their pain to being punished for something they did, & it is important to address this proactively to reassure themthat this is not the cause of their pain.
  • References, 11, 12
  • References 1, 3
  • There are age-related differences in body composition. Body weight is based on a higher percentage of water in neonates as compared with older children & adults.
  • -
  • Most analgesics (including opioids & local anesthetics) are conjugated in the liver Neonates: P-450 subtype 2D6, which converts codeine to morphineExample: In young children sustained release morphine is often used TID vs. bid in adults.enzyme systems involved in drug conjugation (sulfation, glucuronidation, oxidation),
  • Renal blood flow, glomerular filtration, & tubularsecretion increase in the first weeks of life, approaching adult values by 8-12 months.Example decreased clearancemeperidine & morphine active metabolites.
  • References: 2, 7, 13, 14In an effort to improve pain control in children with life-threatening conditions or persistent pain, the WHO developed a simple, effective pain-management strategy based on the four principles.By the clock-when meds are given on a prn basis for moderate to severe pain, children may fear their pain may become frighten & anxious.
  • Nonopioid Analgesic (– Adjuvant Drug) ‘analgesic ladder’ should be used, recognizing that starting at level 2 or 3 instead of at level 1 may be appropriate.
  • IM-if used recommend that a numb medication like Emla be applied prior to administration.Patient-controlled analgesia (PCA) is now widely used in ped as a convenient way to prevent delays in relieving episodic pain. Activation of the button by parents (“parent-controlled analgesia”) is widely accepted in palliative Patient controlled can be used in children as young as 5 yrs old.
  • Fruit juice-not recommended due to osmotic properties The only long-acting oral liquid opioid available in the United States is methadone. Fentanyl patch is contraindicated in opioid navie patients. On rare occasions a nasogastric tube is necessary to assist with medication delivery, particularly if the medication is vital to the child’s care & it is viewed as the least noxious method of obtaining the medication from the point of view of the child. Some children, especially when ill with mucositis ornausea, refuse or cannot tolerate oral medication. In these instances, transdermal orintravenous routes need to be considered. In general, rectal, subcutaneous, & intramuscularroutes of administration of pain medication are avoided in children whenpossible. Often, & especially if children need intravascular access for other reasons,a percutaneous intravenous catheter or central venous catheter is placed for continuousopioid administration
  • Aspirin carries a risk of provoking Reye’s syndrome in infants & children. If other analgesics are available, aspirin use should be restricted to indications where anti-platelet or anti-inflammatory effect is required, rather than as a routine analgesic or antipyretic in neonates, infants, or children.
  • Meperidine is generally not recommended when other opioids are available because of the potential for seizures and other toxicities due to its metabolite, normeperidine.
  • Advantages: as per adult studiesAnalgesic effect is mediated via the opioid m-receptor and an antagonism at the NMDA receptor
  • Types of metabolic conditions not defined
  • These episodes may be alleviated by increasing the daily regular morphine dose by 25–30% if more than three daily rescue doses are needed. The breakthrough painopioid dose should be adjusted regularly to an increasing basal opioid need.
  • These episodes may be alleviated by increasing the daily regular morphine dose by 25–30% if more than three daily rescue doses are needed. The breakthrough painopioid dose should be adjusted regularly to an increasing basal opioid need.
  • References: 2,7, 13, 14All opioids cause decreased intestinal motility that lead to constipation.
  • Some may experience this side effect.Ondansetron preferred as well tolerated and non-sedating, most study 5hts antagonist in kids.Lorazepam- only when other treatment fail or are contraindicated (0.02-0.05 mg/kg/dose (max2 mg) every 6 hours PRN).meltoclopramide- risk of EPS is low in kids, but the exact incidence has not been defined.
  • True respiratory depression is characterized by sleepiness, decreased consciousness, decreased respiratory rate, & central apnea.opioid dose reduction by 50% (titrated to achieve pain control without respiratory depression.The greater the tolerance to opioids the greater the sensitivity to the administration of naloxone, thus Naloxone should be titrated in very small amounts to avoid precipitation of withdrawal.
  • References: 14
  • Three steps: initiation of the therapy, dose titration, & maintenance.The opioid dose often has to be escalated in the last week of lifealthough occasionally a dose reduction might be necessary.
  • Providing quality pediatric pain management during end of life care

    1. 1. Providing Quality Pediatric PainManagement During End of Life Care Danielle Cassidy, Pharm.D. May 2012
    2. 2. Learning Objectives Describe common developmentally appropriate tools for assessing pain in children. List some general principles of pediatric pharmacology. List common pharmacological interventions for treatment of pediatric pain. List side effects commonly associated with opioid medications & management strategies.
    3. 3. Background
    4. 4. Background Pediatric pain is a commonly undertreated symptom & many children experience pain at end of life. One study reported more than 60% of parents felt their child received inadequate pain relief at the end of life13. An inpatient hospital study noted that 53% of children dying from cancer reported well controlled pain after initiating a pediatric palliative care program2. Estimated 50,000 infants, children, & adolescents die each year in the United States.  ~16,000 are attributable to complex chronic conditions.  ~5,000 receive hospice or palliative care services. Overall progress of pediatric palliative/hospice care has lagged significantly behind the strides made in hospice/palliative care services for adults with terminal illness.
    5. 5. Background: Common Misconceptions The American Academy of Pediatrics (AAP) & The American Pain Society (APS) recommend pediatric pain be recognized & treated more aggressively. Myths/Barriers  Infants & children do not feel pain, or suffer less from it than adults.  Misunderstanding of how to quantify a subjective experience.  Lack of routine pain assessment.  Lack of knowledge regarding analgesic dosing strategies.  Fears of analgesic adverse effects, including respiratory depression & addiction.  Belief that preventing pain takes too much time & effort.
    6. 6. Background: Medical ConditionsAppropriate for Pediatric Palliative Care Conditions for which curative treatment is possible, but may fail (e.g. advanced cancer, complex congenital heart disease or airway anomalies). Conditions requiring intensive long-term treatment aimed at maintaining the quality of life (e.g. HIV, cystic fibrosis, epidermolysis bullosa, severe GI disorders) . Progressive conditions where treatment is purely palliative after diagnosis (severe metabolic disorders, certain chromosomal abnormalities). Conditions involving severe, nonprogressive disability, causing extreme vulnerability to health complications (severe cerebral palsy, extreme prematurity). Himelstein BP, Hilden JM, et al. Pediatric Palliative Care. N Engl J Med 2004;350:1752-1762
    7. 7. Background: Overview of Pediatric Pain Pain can be nociceptive or neuropathic. Nervous system is fully developed to process nociception by 26 weeks of gestation. Infants & young children experience a greater neuronal response following noxious stimuli than adults due to:  More robust inflammatory response.  Immature inhibitory pathways. Painful experiences can lead to long-term effects such as lowered pain tolerance for months after the event & behavioral issues.
    8. 8. Pediatric Pain Assessment
    9. 9. Pain Assessment Pediatric pain scales  Observational (neonates & infants)  Allows assessment of those unable to verbalize their pain.  Simple self-report (preschool & school age children)  Uses facial expressions or small objects to describe pain intensity.  Adult numerical pain scale, visual analog scale, verbal report reserved for children 7 years & older. Caregiver input should be included in overall assessment. Gold standard is self-report for any child able to verbalize their pain. Children with chronic pain rapidly adapt & may not exhibit some of the features used in these tools.
    10. 10. Acute Pain Assessment: NeonatesScale Scale Indicators Degree of Crying, Required oxygen, Increased vitalCRIES signs (heart rate &/or blood pressure), Expression (e.g. grimace), & Sleeplessness.Premature Infant Pain Gestational age (greater than or less than 36 weeksProfile (PIPP) gestational age), behavioral state before painful stimulus, change in heart, change in oxygen saturation, brow bulge, eye squeeze, nasolabial furrow.Neonatal Infant Pain Facial expression, breathing patterns, extremity muscleScale (NIPS) tone , & state of arousal.Neonatal Pain, Scores can be adjusted for gestational age.Agitation & Sedation Crying/Irritability, Behavior state (e.g. arousal,Scale (N-PASS) movement), facial expression, muscle tone of extremities, & vital signs.
    11. 11. Example of CRIES Scale Krechel, SW and Bildner, J. CRIES: a new neonatal postoperative pain measurement score– initial testing of validity and reliability. Paediatric Anaesthesia 1995;5 53-61.
    12. 12. Acute Pain Assessment: ObservationalScales for Nonverbal Young ChildrenScale MeasurementFLACC For ages 2 months to 7 years. Measures physiologic changes of the Face (degree of grimace), Legs (degree of restlessness/tension), Activity (degree of agitation), Cry (degree of crying); & Consolability (amount of physical consoling needed to comfort child).Cognitively R-FLACC, The Non-Communicating Children’s PainImpaired Checklist-Revised (NCCPC-R), & The Paediatric Pain Profile (PPP).
    13. 13. Acute Pain Assessment: Simple Self ReportScales for Verbal Young ChildrenScale MeasurementFACES Ages 3 years & up. Uses 6 faces starting with a happy face & progressing to a crying face. Explain to the child the 1st face has no pain, the 2nd face has a little pain, the 3rd face has a little more pain, the 4th has more pain still, the 5th face has a lot of pain, & the 6th face is the worst pain ever, but the child does not need to be crying to experience the worst pain ever. Then the child is asked which face best describes how they feel.Oucher Ages 3 years & up. Similar to FACES, but uses a picture scale for young children & a numeric scale for older children. Available in different ethnic & gender versions. (www.oucher.org)Hester’s Ages 5 years & up. Given 4 chips & told that one chip representsPoker Chip a small amount of pain, 2 chips mean more pain, 3 chips meanScale even more pain, & 4 chips mean the worst pain ever. The children are then asked to put the number of chips in the interviewer’s hand & that best describes their pain.
    14. 14. Examples of the OUCHER Scale Accessed February 24, 2012 at http://www.oucher.org/order.html
    15. 15. Chronic Pain AssessmentScale MeasurementThe Varni-Thompson Pediatric Pain Ages 4-16 years. Provides aQuestionnaire comprehensive assessment of the pain experience in children with chronic pain.Douleur Enfant Gustav-Roussy For ages 2 to 6 years. Measures chronic pain by incorporating several items that deal with pain, anxiety, & psychomotor behaviors.
    16. 16. Developmental Pharmacology: An Overview
    17. 17. Pharmacology: Body Compartments Age: neonates Trend: decreased fat, decreased muscle, & increased water. Clinical implications: Some water soluble drugs have  Increased drug distribution in extracellular fluids.  Increased duration of action.  Increased dosing interval. How does body composition differ in aging adults?  Increasing fat & decreasing water.  Result- increased drug distribution & accumulation of lipid soluble drugs.
    18. 18. Pharmacology: Plasma Age: Neonates Trend: Decreased concentrations of drug binding proteins (albumin & α-1 glycoprotein) Clinical Implications:  Higher concentrations of active (unbound) drug for highly protein-bound medications.  Increased potential for overdose or toxicity. How does plasma differ in aging adults?  Decreasing/unchanged albumin & increasing α-1 glycoprotein.  Result- decreased distribution of water soluble drugs.
    19. 19. Pharmacology: Hepatic Age: neonates, infants, & children 2-6 years. Trend:  Neonates & infants: enzymes involved in drug metabolism mature at varying rates over 1-6 months of life.  Children 2-6 years: increased hepatic mass. Clinical Implications:  Neonates & infants: decreased metabolic clearance; decreased infusion rates or increased dosing intervals.  Children 2-6 years: increased metabolic clearance; increased infusion rates or decreased dosing intervals. How does hepatic function differ in aging adults?  Decreased liver mass, decreased liver blood flow, & decreased/unchanged function of enzymes.  Decreased metabolism & increased duration of action.
    20. 20. Pharmacology: Renal Filtration Age: neonates & infants. Trend:  Decreased glomerular filtration rate.  Sufficiently mature to clear medications by 2 weeks of age & normalizes by 8-12 months. Clinical Implications:  Accumulation of renally excreted drugs or their active metabolites.  Decreased infusion rates or increased dosing intervals. How does renal function differ in aging adults?  Decreased filtration, decreased renal mass, & decreased renal blood flow.  Decreased elimination & increased duration of action.
    21. 21. Aging & Renal Function: Example Infants to 19 years of age: >120 mL/min 20 to 49 years of age: 99-116 mL/min 50+ years of age: <99 mL/min
    22. 22. Pharmacology: Respiratory Age: neonates. Trend: diminished ventilatory responses to hypoxemia & hypercarbia. Clinical Implications  Respiratory pauses or apnea lead more rapidly to hypoxemia.  Further impairment can be seen with central nervous system depressant drugs such as opioids & benzodiazepines (these medications are still appropriate for symptomatic relief & comfort when needed).
    23. 23. Pain Management
    24. 24. Pain Management: NonpharmacologicTherapies World Health Organization (WHO) recommends considering to augment pain & anxiety. Examples include:  Improved sleep hygiene.  Cognitive behavior techniques, such as hypnosis, guided imagery, biofeedback, & mindfulness based stress reduction.  Child life specialists to help distract the child with games, toys, & play therapy.  Yoga.  Massage.  Acupuncture or Accupressure  Art or music therapy.  Transcutaneous electrical nerve stimulation.  Aromatherapy
    25. 25. Pain Management: General TreatmentPrinciples Dosing is based on mg/kg. Infants younger than 6 months or less than 10 kg, opioid doses are usually reduced by 25-30% of the nominal starting dose. Adolescents heavier than 50 kg can be dosed using typical adult dosing. As in adults, renal & liver function must also be considered & adjusted for according to the degree of organ dysfunction.
    26. 26. Pain Management: WHO AnalgesicTreatment Principles By the ladder: analgesics should be started & escalated in a stepwise approach based on the severity of symptoms. By the clock:  Analgesics should be given on a scheduled basis to provide stable blood levels of the medication.  Rescue doses should be available for breakthrough pain. By the mouth: analgesics should be given by the simplest, most effective, & least painful route available that allows for effective pain control. By the child: analgesics dose/frequency should be based on the individual child’s circumstances & their response to therapy.
    27. 27. Pain Management: WHO Analgesic Ladder Step 1: Mild pain (pain scores 1-4 out 10) Acetaminophen, non-steroidal anti- Non-Opioid Analgesics inflammatory drugs Step 2: Moderate pain (pain scores 5-7) Weak Opioids Codeine, hydrocodone, tramadol Step 3: Severe pain (pain scores 8-10) Morphine, oxycodone, Strong Opioids hydromorphone, fentanyl, methadone
    28. 28. Pain Management: Routes of AdministrationPros & ConsZernikow B, Michel E, et al. Pediatric Palliative Care: Use of Opioids for the Management of Pain. Pediatr Drugs2009;11(2):129-151.
    29. 29. Pain Management: Oral DrugConsiderations Many children less than 6 years cannot swallowpills/capsules. Alternative opioid formulations  Liquid: methadone, morphine immediate release, hydrocodone/APAP, oxycodone, codeine.  Transmucosal: fentanyl lollipop (Actiq®)  Transdermal: fentanyl patch Crushable pills are an alternative when the drug is not available in liquid formulation. Masking aversive-tasting medications: stir into small quantities (~5 mL) of chocolate/strawberry syrup, pudding, ice cream, applesauce, or 100% fruit juice (not recommended for less than 6 months of age) .
    30. 30. Pain Management: Nonopioid DrugsDrug Dose <50kg (max dose) Dose ≥50kg (max dose)Acetaminophen PO/IV: 10-15 mg/kg every 4-6 PO/IV: 650-1000 mg every 4-6 hours (90 mg/kg/day or 4g/day) hours (4g/day) Rectal: One time 40mg/kg Rectal: 1000mg every 4-6 loading dose followed by, hours (4g/day) 20mg/kg rectally every 4-6 hours (120 mg/kg/day or 4g/day)Ibuprofen 5-10 mg/kg PO every 6-8 hours 400-600 mg PO every 6-8 (40mg/kg or 2.4 g/day) hours (2.4 g/day)Naproxen 5 mg/kg PO every 8-12 hours 250-375 mg every 8-12 hours (24mg/kg or 1 g/day)× (1 g/day)Ketrolac 0.25-0.5 mg/kg IV every 6 15-30 mg IV every 6 hours hours (2 mg/kg or 120mg/day) x (120mg/day) x 5 days 5 days × Higher doses can be used for children with rheumatologic disease. Berde CB & Sethna NF. Analgesics for the Treatment of Pain in Children. N Engl J Med 2002;347(14)1094-1103.
    31. 31. Pain Management: Initial Opioid Dosing InOpioid Naïve ChildrenBerde CB & Sethna NF. Analgesics for the Treatment of Pain in Children. N Engl J Med 2002;347(14)1094-1103.
    32. 32. Pain Management: Methadone Only long acting opioid available as an oral liquid. No published studies evaluating its use in pediatric palliative/hospice care. Advantages:  May still exhibit analgesia even if morphine, fentanyl, or hydromorphone have failed.  May be beneficial for patients with neuropathic pain. Disadvantages:  Extremely long half-life (children: 4-62 hrs, adults: 9-87 hrs)  Biphasic elimination- can result in slow accumulation & toxicity 2-5 days after initiation or dose changes (monitor for side effects).
    33. 33. Pain Management: WHO Recommendationfor Methadone  Use only after failing morphine & hydromorphone.  Oral route is preferred.  To prevent toxicity:  Initiation: Administer on as needed basis for the first 2-3 days. When frequency requirements are well established, round the clock dosing can be initiated.  Maintenance: increase dose as needed every 2-5 days as needed to achieve pain control.  Avoid in kids with rapidly changing clinical conditions or metabolic conditions that could interfere with drug clearance.
    34. 34. Case Study: Initial IV morphine titration A 2 year old (weight= 12 kg) has severe pain & is unable to hold down any oral liquids at this time. Initial IV morphine titration:  Starting dose of morphine 0.1 mg/kg x 12 kg = 1.2 mg.  Reassess the child in 30 minutes  If still in pain & not sedated provide a repeat dose of 1.2 mg.  If still in pain, but somewhat sedated provide a repeat dose at 25-50% of the starting dose (0.3-0.6 mg).  The child is now comfortable. Adapted from: WHO. Cancer pain relief & palliative care in children. Geneva: World Health Organization, 1998.
    35. 35. Case Study: Initial IV morphine titrationcontinued… Continuous infusion of morphine:  Starting infusion rate 0.03 mg/kg/hour x 12 kg = 0.36 mg/hour.  Provide hourly rescue doses for PRN breakthrough pain at 50-200% of the hourly infusion rate (0.18-0.72 mg).  Assess the child in one hour. Child is still comfortable.  Reassess the child in 4 hours. Child has moderate pain, is withdrawn, & cries when not held.
    36. 36. Case Study: Initial IV morphine titrationcontinued… Titration:  Administer a rescue bolus dose 0.1 mg/kg x 12 kg= 1.2mg.  If repeated breakthrough pain occurs increase the infusion rate by 25% (0.25 x 0.36 mg/hour) + 0.36 mg/hour = 0.45 mg/hour. Continue to provide rescue doses PRN .  Alternatively, continue rescue doses for 24 hours then increase the infusion rate by the amount of rescue doses administered over that 24 hour period.  For example if six rescue doses of 0.5 mg were given then increase the infusion rate by [(0.5mg x 6 doses) ÷ 24 hours] + 0.36mg/hour = 0.48mg/hour.
    37. 37. Managing Opioid Side Effects
    38. 38. Opioid Side Effects: Constipation Constipation is an anticipated chronic side effect that is uncomfortable & sometimes painful. ~50% of terminally ill children experience prolonged constipation & should be treated preventively when on opioid therapy. Prophylactic treatment:  Combination therapy is generally indicated with a stimulant laxative (senna) plus either a stool softener (docusate) or osmotic agent (magnesium, lactulose, polyethylene glycol).  Adding more fiber to the diet may be helpful only if liquids are also increased.
    39. 39. Opioid Side Effects: Nausea & Vomiting Quickly develop tolerance to the emetic effect of opioids & usually resolves within one week of initiation. Potential treatments therapies:  Ondansetron (preferred), granisetron metoclopramide, prochlorperazine (PO/PR), chlorpromazine.  Alternatives: lorazepam, low-dose olanzapine, droperidol, haloperidol. Severe nausea/vomiting: consider rotating to different opioid or initiate low-dose naloxone infusion.
    40. 40. Opioid Side Effects: Pruritus Common side effect (~25%). Usually resolves after several days. Treatment:  If the pain situation is stable attempt a opioid dose reduction, or initiate scheduled antihistamine (diphenhydramine, hydroxyzine) therapy, or initiate low- dose naloxone infusion.  If pain is unstable or above measures are unsuccessful, opioid rotation is indicated.
    41. 41. Opioid Side Effects: Somnolence Often improves within a few days after initiation or titration of the opioid. Management:  If persistent or intolerable, the most effective therapy is rotating the opioid.  Alternately may try a trial of psychostimulant (e.g. methylphenidate).
    42. 42. Opioid Side Effects: Delirium & Myoclonus Delirium (rare)  Commonly occurs when receiving multiple medications or patient is critically ill.  Management: if clearly opioid related initiate a trial of haloperidol or rotate to a different opioid. Myoclonus  May be provoked in patients on high dose opioids (i.e. morphine or hydromorphone).  Management:  Considered benign if occurs during sleep.  If present during waking hours or severe a benzodiazepine can be scheduled or the opioid rotated.
    43. 43. Opioid Side Effects: Respiratory depression True respiratory depression is rare when opioids are dosed appropriately. Usually seen during rapid IV opioid administration for painful procedures or when co-administered with a centrally active medication such as benzodiazepines. Management (determined by treatment goals of the child & family):  Mild to moderate: stimulating the child, holding opioid dose, opioid dose reduction by 50%.  Severe: Respiratory support & if necessary naloxone (should be administered with extreme caution, as sudden opioid antagonism can lead to life-threatening withdrawal).
    44. 44. Conclusions Common tools to assess pain in children include observational scales (FLACC, CRIES) & simple-self report scales (OCHER, FACES). Neonates, infants, & young children often have pharmacological differences such as altered renal or hepatic function as compared to adults. The type of pharmacological intervention is dependent upon the level of pain observed and/or reported by the child. Common opioid side effects include constipation, nausea/vomiting, pruritus, & somnolence.
    45. 45. Aging & Renal Function: Example Infants to 19 years of age: >120 mL/min 20 to 49 years of age: 99-116 mL/min 50+ years of age: <99 mL/min
    46. 46. References1) American Medical Association Pediatric Pain Management (module 6). AMA release September 2007.2) Moody K, Siegel L, et al. Pediatric Palliative Care. Prim Care Clin Office Pract 2001;38:327-361.3) Berde CB & Sethna NF. Analgesics for the Treatment of Pain in Children. N Engl J Med 2002;347(14):1094-1103.4) Himelstein BP, Hilden JM, et al. Pediatric Palliative Care. N Engl J Med 2004;350:1752-1762.5) Committee on Psychosocial Aspects of Child & Family Health, American Academy of Pediatrics; Task Force on Pain in Infants, Children, & Adolescents, American Pain Society. The assessment & management of acute pain in infants, children, & adolescents. Pediatrics 2001;108(3):793- 797.6) Mathews TJ, et al. Annual summary of vital statistics: 2008. Pediatrics 2011:127(1):146-157.7) Klick JC & Hauer J. Pediatric Palliative Care. Curr Probl Pediatr Adolesc Health Care 2010;40:120-151.8) Lawrence J, Alcock D, McGrath P, et al. The development of a tool to assess neonatal pain. Neonatal Netw 1993;12(6):59–66.
    47. 47. References Continued…9) Hummel P, Puchalski M, et al. Clinical reliability and validity of the N-PASS: neonatal pain, agitation and sedation scale with prolonged pain. J Perinatol 2008;28:55-60.10) Stevens B, Johnston C, et al. Premature Infant Pain Profile: Development & initial validation. Clin J Pain 1996;12:13-22.11) Gauvain-Piquard A, Rodary C, et al. Pain in children 2-6 years: A new observational rating scale elaborated in a pediatric oncology unit – preliminary report. Pain 1987;31:177-188.12) Varni JW, Thompson KL, et al. The Varni-Thompson pediatric pain questionnaire I. Chronic musculoskeletal pain in juvenile rheumatoid arthritis. Pain 1987;28:29-38.13) Zernikow B, Michel E, et al. Pediatric Palliative Care: Use of Opioids for the Management of Pain. Pediatr Drugs 2009;11(2):129-151.14) WHO. Cancer pain relief & palliative care in children. Geneva: World Health Organization, 1998.15) Krechel SW and Bildner J. CRIES: a new neonatal postoperative pain measurement score– initial testing of validity and reliability. Paediatr Anaesth 1995;53-61.16) National Kidney Foundation. Frequently asked questions about GFR estimates. National Kidney Foundation, Inc., 2010.
    48. 48. Pain Management: Routes of Administration Oral Transdermal Intravenous Intramuscular Rectal Generally not Rapid pain Generally not Painless Painless preferred by control recommended children Not indicated for Wide variability in Preferred by acute or Easiest to titrate Painful therapeutic drug children escalating pain & adjust rapidly levels management Useful for Used only when Wide variability in Can be used intermittent bolus pain has therapeutic drug when transient & continuous stabilized levels vomiting present infusions Appropriate for PCA use
    49. 49. Initiating Opioid Therapy for Severe Pain By the clock:  Initiate a strong opioid & administer the medication on a routine schedule basis.  Order a strong opioid for breakthrough pain. By the mouth:  Determine the appropriate route of administration that is the least invasive & most effective. By the child:  If taking oral opioids re-access the child at several days to determine if the treatment is adequate.  If using IV opioids re-access the child every 30 minutes.
    50. 50. Pain Management: WHO Recommendationfor Methadone  Use only after failing morphine & hydromorphone.  Oral route is preferred.  To prevent toxicity:  Initiation: Administer on as needed basis for the first 2-3 days. When frequency requirements are well established, round the clock dosing can be initiated.  Maintenance: increase dose as needed every 2-5 days as needed to achieve pain control.  Avoid in kids with rapidly changing clinical conditions or metabolic conditions that could interfere with drug clearance.
    51. 51. Pain Management: Methadone Only long acting opioid available as an oral liquid. No published studies evaluating its use in pediatric palliative/hospice care. Advantages:  May still exhibit analgesia even if morphine, fentanyl, or hydromorphone have failed.  May be beneficial for patients with neuropathic pain. Disadvantages:  Extremely long half-life (children: 4-62 hrs, adults: 9-87 hrs)  Biphasic elimination- can result in slow accumulation & toxicity 2-5 days after initiation or doses changes (monitor for side effects).
    52. 52. Pain Management: NonpharmacologicTherapies WHO recommends considering to augment pain & anxiety. Examples include:  Improved sleep hygiene.  Cognitive behavior techniques, such as hypnosis, guided imagery, biofeedback, & mindfulness based stress reduction.  Child life specialists to help distract the child with games, toys, and play therapy.  Yoga.  Massage.  Acupuncture or Accupressure  Art or music therapy.  Transcutaneous electrical nerve stimulation.  Aromatherapy

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