Pain Management in Peds

Pain Management
Aola H. Al Duhaim RN, BScN
Pain Management CNC
AolaH.Duhaim@kfsh.med.sa
Pediatrics

The IASP defines Pain as:
“An unpleasant sensory and emotional experience
associated with actual or potential tissue damage, or
described in terms of such damage“
King Fahad Specialist Hospital
Dammam
‫الـتخـصـصي‬ ‫فـهـد‬ ‫الـمـلـك‬ ‫مــسـتــشـفى‬
‫الــدمـام‬

The IASP defines Pain as:
"Pain is whatever the experiencing person says it is and
exists whenever he says it does."
Margo McCaffery
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PAIN
▫ Motivates us to withdraw from damaging or
potentially damaging situations.
▫ Protect the damaged body part while it heals, and
avoid those situations in the future.
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Pain Pathway:

Children are at Risk of Inadequate Pain
Management
▫ Age-Related Factors
 Neurobiological
 Physiological
 Psychological
▫ Misconceptions
Inadequate analgesia
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Developmental Neurobiology
• Sensory fibers are abundant by 20 weeks
• Functional spinal reflex is present by 19 weeks
• Connection to the thalamus are present by 20 weeks
Lee SJ, Ralston H, Drey EA, Partridge J, Rosen MA. Fetal Pain: A Systematic
Multidisciplinary Review of the Evidence.
JAMA. 2005;294(8):947-954
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Developmental Neurobiology
• Connection to the subplate neurons are present by 17
weeks e` intensive differentiation by 25 weeks
• Mature thalamocortical projections not present till
29-30 weeks
Lee SJ, Ralston H, Drey EA, Partridge J, Rosen MA. Fetal Pain: A Systematic
Multidisciplinary Review of the Evidence.
JAMA. 2005;294(8):947-954
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NOW well accepted by Neuroscientists and Pain Specialists that..
 The nervous system is sufficiently developed before birth.
 Children experience pain from birth onward
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NOW well accepted by Neuroscientists and Pain Specialists that..
 Infants and young children may experience a greater
neural response  more pain sensation and pain-related
distress
 The impact of painful experience on the young
 long-term effects can occur
 i.e. lowered pain tolerance
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Physiological Changes
• CNS (BBB)
• Liver ( Hepatic blood flow Vs.
Immaturity)
• Protein Bindings (Albumin Vs.
AAG)
• Kidney (Protein load ,
Excretion Capability)
• Volume of distribution (water
Vs. Fat compartments)
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Physiological Changes
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Cognitive Factors
• Understanding the pain source
• Ability to understand what happen
• Expectation regarding the quality or strength of pain
• Previous experience
• Knowledge of pain control strategies
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Behavioral Factors
• Distress responses (child and family)
▫ May initiate, maintain or exacerbate a child’s
pain.
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Emotional Factors
• Vary widely & include:
▫ Neutral acceptance
▫ Anxiety
▫ Fear
▫ Anger
▫ Frustration
▫ sadness
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Developmental Stages
 Neonate
up to 1 mth
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Misconceptions
• The myth that infants and children do not feel pain, or
suffer less from it than adults.
• Lack of routine pain assessment in children.
• Lack of knowledge regarding newer modalities and
proper dosing strategies for the use of analgesics in
children.
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The American Academy of Pediatrics and
the American Pain Society

• Fears of respiratory depression or other adverse effects
of analgesic medications.
• The belief that preventing pain in children takes too
much time and effort.
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The American Academy of Pediatrics and
the American Pain Society
Misconceptions

Classification of Pain
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Sharp & well localized.
Reproduce by touching &
moving the affected area
Somatic1-Nociceptive
Noxious stimulation of
specific pain receptors
Thermal, Mechanical or
Chemical
Deep or Superficial
Stretch, Inflammation &
Ischemia
Poorly localized, cramping,
colicky in nature & may feel like
vague deep ache

2-Non-Nociceptive
within PNS / CNS
Nerve cell dysfunction.
No specific receptors for pain
Neuropathic
AKA: Pinched/ Trapped Nerve
Degeneration, Pressure,
Inflammation ..
it becomes electrically unstable,
firing off signals randomly
Sympathatic
Over-Activity of Sympathetic
Nervous System, and CNS/ PNS
More Commonly After Fractures or
Soft Tissue Injuries
may lead to Complex Regional
Pain Syndrome (CRPS).
Partially Sensitive to:
Paracetamol
NSAIDs
Opioids.
More Sensitive to:
•Anti-Depressants
•Anti-Convulsants
•Anti-Arrhythmics
•NMDAAntagonists
•Topical Capsaicin may be helpful

Acute Pain:
• More common
• Begins suddenly
• Sharp in quality
• Serves as a warning of disease/threat
• Caused by ..
▫ Procedures
▫ Surgery
▫ Broken bones
▫ Dental work
▫ Burns or cuts
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Chronic Pain:
• Longer than 3-6 months
• Despite the fact that an injury has healed
• Pain signals remain active in the nervous system for
weeks, months, or years.
Such as:
• Cancer pain
• Arthritis pain
• Neurogenic pain (pain resulting from damage to nerves)
• Psychogenic pain (pain not due to past disease or injury or any visible sign
of damage inside)
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Breakthrough pain:
A sudden Flare-up of pain that “break through” the
around the clock medication used for persistent pain.
Up to 86% of the patients
3 – 30 min & require different Tx.
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Overtreatment
Increased around the clock
medication
Increased side Effects
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BTP Medications may not act
quickly enough
Patient suffer pain up to 30 min
or more
Undertreatment
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Quick onset BTP medication
Last as long as the BTP (30min)
Easily used
Has manageable Side Effects
PreferredTreatment
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Why Should we Treat Pain?
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Pain Assessment:
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When ..?
• On admission
• After any known pain- producing event
• With each new report of pain
• Routinely at regular intervals
• After intervention
▫ at appropriate time (e.g. 15-30 min P` IV , 1 hr P` PO);
Follow-up assessment is crucial
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• To assess pain adequately we must consider..
▫ The developmental stage
▫ Age
▫ Experience
▫ Family Culture/Belief
▫ Language
▫ Severity of Illness
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Neonates and Infants
▫ They communicate distress by crying
▫ Should involve the parents
 Notice changes in the infant not obvious to the health care
provider
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Neonates and Infants
Observational pain scales (unable to verbalize)
These scales, though essential, also respond to distress
from causes other than pain, such as hunger, fear or
anxiety
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Preschool and School Age Children
Simple self-report scales using facial expressions or
small objects
To allow more accurately description of their pain
intensity.
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Pain Scales:
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Observational Pain Scales
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NIPS 0 – 1 Y

CRIES
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0 – 1 Y

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FLACC 2M – 3 Y

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2- Poker Chip Scale “pieces of hurt,”
1- Oucher Scale (ethnic versions) well accepted in children over 6 years of age

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3- Wong-Baker
Faces Scale (free to
use)
(available in 30 languages)4-
5- VAS , NRS
8 years and older
without difficulty

Pain Assessment in Pediatrics
Adult Pediatrics
Pain
Fear
Pain receptors are the same in the pediatric patient compared to the adult.
But Children do have increased fear and anxiety.
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Pain control must be based on scientific fact, not on
personal beliefs or opinions
Optimal pain management is the right of all patients
and the responsibility of all health professionals
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Treatment should include
▫ Pharmacological - Appropriate Multi-Modal
▫ Non-Pharmacological
▫ Sympathetic Nerve Blocks – as needed
▫ Intensive Rehabilitation
 Occupational and Physiotherapy.
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Pharmacologic Pain Management
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• Special Considerations in Treating Infants and
Children.
• Although most of the major organ systems in infants
are well developed at birth, their functional maturity
is often delayed.
• In the first months:
▫ These systems rapidly mature  similar to adults before 3
months of age.
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Multi-Modal Medications
• Inhibition of peripheral inflammatory response
to tissue injury (NSAIDs)
• Blocking the pain receptors (Opioids)
• Neural blockade of transmission of pain
impulses (Regional Tech./Neuraxial blocks)
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Multi-Modal Medications
• Prevention of “Central Sensitization” before
tissue injury (Preemptive analgesia)
• Prevention & treatment of anxiety accompanying
acute pain.
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Preemptive analgesia
• Treatment that ..
▫ Starts before surgery
▫ Prevent the establishment of Central Sensitization
caused by Injury/Inflammatory responses.
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Drugs used for pain management
• Non-Steroidal Anti-Inflammatory Drugs (NSAIDS)
• Acetaminophen
• Opioids
• Adjuvant
• Others
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Analgesics (Opioids/L.A)
Most are conjugated in the liver.
Newborns, and especially premature infants, have
delayed maturation of the enzyme systems involved
in drug conjugation
▫ Several of these hepatic enzyme systems mature at varying
rates over the first 6 months of life.
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Glomerular filtration rates :
▫ Diminished in the first week of life, especially in premature
infants
▫ but sufficiently mature to clear medications and metabolites
by 2 weeks of age.
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Newborns
have a higher percentage of body weight as water and
less as fat
 Water soluble drugs often have larger volumes of
distribution.
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Newborns
• Have reduced plasma concentrations of both albumin
and alpha-1 acid glycoprotein
 may lead to higher concentrations of unbound drug (active), and
thereby greater drug effect or drug toxicity.
• Have diminished ventilatory responses to hypoxemia
and hypercarbia - especially premature infants
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Acetaminophen
• Excellent safe profile and lack of significant side
effects
• commonly used
• mild to moderate pain,
• often combined with opioid (for more severe pain)
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Acetaminophen
• Can results in Hepatotoxicity
• Infants and children produce high levels of GSH as a
part of hepatic growth  may provide some
protection
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Acetaminophen
• Still acetaminophen toxicity are highest in pediatric
patients.
▫ Analysis of Poison Control Center data, FDA adverse
event reports, and clinical trial reports indicate that
therapeutic doses of <75 mg/kg daily are safe with
respect to hepatotoxicity.
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NSAIDs
• Pharmacodynamics and pharmacokinetics are not
much different than in adults.
• Potential for GI, renal and other toxicities exist
but less than in adults.
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NSAIDs
• Ibuprofen
▫ frequently chosen
▫ mild to moderate pain
▫ liquid form easy administration
▫ fever reduction
▫ pain relief
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Patient Controlled Analgesia
• Widely used for postoperative pain relief
• Appropriate preoperative teaching and
encouragement
• As young as 6 to 7 years of age can independently
use the PCA
• 4 and 6, however, require encouragement from their
parents and nurses
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Local Anesthetics and Regional Anesthesia
• Topical Anesthetics (EMLA)
• provide pain relief prior to needle-stick
procedures
• requires 30 to 60 minutes to become fully
effective after application.
• must be applied in a thick layer
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EMLA
• Clinical trials have shown effectiveness of EMLA in
reducing the pain or distress of a number of common
pediatric procedures including:
▫ venous cannulation
▫ Venipuncture
▫ lumbar puncture,
▫ Circumcision
▫ urethral meatotomy
▫ Immunizations
▫ dermatologic procedures … etc.
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Nonpharmacologic Pain Management
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Comfort Methods:
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Repositioning
Singing
or soft music
Gentle stroking
Rocking with the child
in a rocking chair

Swaddling
Comfort Methods:
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Watching a movie
Reading a book
Other methods used at home
to comfort the child

Psychological strategies:
For children undergoing repeated painful procedures,
cognitive-behavioral therapy
▫ decrease anxiety and distress
▫ help children master a distressing situation.
▫ take time to learn and master
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Psychological strategies:
• Distraction techniques
▫ divert attention away from painful stimuli
• positive incentive techniques
▫ provide a small reward (e.g., stickers or prizes)
Decrease anxiety but not adequate as the sole means of
pain relief.
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Persistent Pain in Children
• Children with chronic medical disease can
experience:
▫ a significant amount of pain associated with both their
underlying disease and the procedures that are performed to
treat it.
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Persistent Pain in Children
• Children with chronic medical disease can
experience:
▫ They deserve not only access to adequate pain medication,
but also psychological support to help them continue to
learn and grow as they should.
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SUMMARY
• The pediatric nervous system is fully developed and
able to respond to Nociceptive stimuli even in pre-
term neonates
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SUMMARY
• Pain can have lasting physiological and
developmental consequences if not appropriately
managed
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SUMMARY
• Regular pain assessment is fundamental to good pain
management but is often poorly performed
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SUMMARY
• A variety of pain assessment tools are available and
should be utilized according to a patient’s age and
developmental stage
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SUMMARY
• Multi-modal therapy is appropriate for managing all
forms of pediatric pain and should utilize
combinations of local anesthetic, paracetamol,
NSAIDs and opioids as appropriate
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SUMMARY
• Adequate monitoring, safety equipment and
resuscitation skills are needed to safely manage
patients requiring combinations of sedation and
analgesia for painful procedures
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SUMMARY
• The pharmacokinetic and pharmacodynamic profile
of commonly used analgesics can be variable
depending on the age and development
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THANK YOU
Aola H. Al Duhaim RN, BScN
Pain Management CNC
AolaH.Duhaim@kfsh.med.sa
Dammam

Pain Management in Peds

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