The presentation is about magnitude of pain burden in children, assessment of pain, challenges in management and management strategies.

1. PAIN MANAGEMENT IN
CHILDREN
Dr. Ashok Jadon,
MD, DNB, MNAMS, FIPM, FIPP, FAMS, FIAPM

2. PAIN IN CHILDREN IS
DIFFERENT FROM ADULTS?
• The concept of pain goes far beyond the
sensory experience
• Fear of separation from their parents produce
suffering (Fear & Anxiety) which increase the
perception of pain in children
• An important goal is to eliminate the suffering
associated with pain.

3. WHAT ARE THE CHALLENGES?
• Individuality of verbal and nonverbal
Expression of pain.
• They do not have verbal skills to report pain,
• Pain may be overlooked
• Children may fear reporting pain
• Results in an injection
• How do we use the pain assessment
information?
• Discrepancies between surrogate & actual
pain intensity
What is the
right method?

4. BARRIERS & DETERRENTS:
• Lack of education about pain
• Medication Dosing
• Treatment of side effects
• Our own (poor) understanding that a child does
not “look like” in pain
• Misunderstanding of risks of use of opioids
• Fear of addiction
• Fear of respiratory depression

5. TODAY…..THE REALITY IS OUR
PATIENTS’ PAIN IS OFTEN….
Untreated Under-treated
Inappropriately Treated

6. ADVOCACY IN MANAGEMENT
• Patient is the authority on his pain
• Accept the report
• Recognize that pain thresholds and levels of
thresholds are variable
• Take appropriate action
• Avoid “expected responses” for interventions

7. PAIN ASSESSMENT TOOLS

8. SELF-REPORT OF PAIN
• The single most reliable indicator
• However, consider whether the child is
competent to provide such information
• Select an age-appropriate scale
• Ask in trusting environment
• Assumption is that the number the child reports
will be believed by the health care provider

9. WONG & BAKER
FACES PAIN RATING SCALE
• Useful for children age 5-12 years
• Some children 3-5 years of age can use it
Donna Wong and Connie Baker in 1983

11. NUMERICAL PAIN SCALE (NRS)
• Usually > age 12 years
• Ask the patient to rate their pain from 0
to 10
• Requires the understanding that,
increasing ordinal numbers mean pain at
a higher intensity

12. PAIN BEHAVIORS ASSESSMENT
• Under age 5 years or the patient cannot self report:
• We need a behavioral scale
Merkel et al. 1997

13. CAUTION ABOUT BEHAVIORAL PAIN
ASSESSMENT METHODS
• No way we can accurately know how
persons are feeling if they can not speak or
report their pain level themselves
• But also must include
• Critical thinking (“Does what I see make sense
for this patient?”)
• Input of family members
• Rational decision making (“trial of analgesic to
see if behaviors of child improve”

14. MULTIMODAL -MULTIDISCIPLINARY
PAIN MANAGEMENT

15. NON-PHARMACOLOGIC PAIN
MANAGEMENT
• Physical
• Massage
• Heat and cold
• Acupuncture
• Behavioral
• Relaxation
• Art and play therapy
• Biofeedback
• Cognitive
• Distraction
• Imagery and Hypnosis

16. PAIN MEDICATIONS
• Paracetamol (Acetaminophen)
• PO: 10-15 mg/kg every 4-6 hours
• PR: Loading dose 35-50 mg/kg;
• Maintenance dose 20 mg/kg every 6 hours
• Ibuprofen
• PO: 5-10 mg/kg every 6-8 hours
• MAX 40 mg/kg/day
• Contraindicated in active GI bleeding,
hypersensitivity to NSAIDs
• Caution in severe asthmatics
Mixing the two increase the efficacy?

17. PAIN MEDICATIONS..
• Ketorolac
• NSAID
• Available PO, IV, IM
• IV dose is 0.5mg/kg, every 6 hours
• IV infusion of 0.17 mg/kg/h.
• Ketorolac is not recommended for use in
infants aged < 1 year

18. PAIN MEDICATIONS: OPIOIDS
• Weak opiate (Codeine/ Tramadol/Butradol:)
• [4-20-2017] FDA has restricted the use of codeine and
tramadol medicines in children.
• Tramadol and Phenergan (50mg+25mg)
• Butrum (+ Phenergan)
• Strong opioid: Meperidine (Pethidine): 1 mg/kg IV, 1.8
mg/kg, IM, subcutaneously (SC) every 3 to 4 hours as
needed.
• Caution for OPIOIDS: 4–6 months of age.

19. OPIOID CONT..
• Morphine: PO: 0.2-0.5 mg/kg every 4-6 hours
• IV: 0.05-0.2 mg/kg every 2-4 hours
• PCA: 0.015 mg/kg/hr basal with 0.015 mg/kg PCA dose
q10 min lockout
• Fentanyl: IV 0.5 to 3 mcg/kg/dose over at least 5
minutes; may repeat every 2 to 4 hours as needed;
• Intranasal: Children >1 year: 1.5 micrograms/kg
• IV PCA can also be used
• Fentanyl (12.5mc/hr)and Buprenorphine(5mc/hr)
Patches

20. ALGORITHM FOR NEONATAL ANALGESIA
• (33% Oral Sucrose)
• Preterm infant ( 0.2–0.5 mL)
per procedure maximum 2.5
mL in 24 hours.
• 1day – 1 month, (0.5–1 mL)
maximum 5 mL in 24 hours.
• 1–18 months (1–2 mL)
maximum 5 mL in 24 hours if
aged <3 months, or 10 mL in
24 hours if >3 months.

21. ALGORITHM FOR PAIN IN CHILDREN
• Diclofenac sodium 12.5 mg and 25 mg preparations are
approved for use in children aged over one year.
• NSAIDs & risk of acute kidney injury in children,
• NSAIDs should be second-line to paracetamol in most cases
and should be prescribed with caution in children who are
dehydrated.
3.Ketorolac 4.Meperidine
PCA,
Ketamine, RA

22. ROLE OF PCA
>5YRS. OF AGE
• IV-PCA is one of the most effective methods.
• Morphine is the most commonly used opioid.
• Fentanyl/ Hydromorphone/ Meperidine
• Background infusion: NO or YES
• Small-dose naloxone infusion (0.25 μg/kg/hour)
• Ketorolac+ Morphine= Better analgesia, less side
effects
• Ketamine or Tramadol with Morphine

23. NURSE OR PARENT
CONTROLLED ANALGESIA IN
CHILDREN
• Parent controlled analgesia in children
• Risk of Overdose
• Good Option
• Nurse controlled analgesia in children
• Better when used with Basal infusion
Prerequisite for PCA: Teaching Training of user
Before use

24. ROLE OF REGIONAL ANESTHESIA
IN PAIN MANAGEMENT

25. CAUDAL EPIDURAL
• Single-shot caudal analgesia.
• The volume 0.5 mL/kg =T-10 level, 1 mL/kg=
lower thoracic 1.25 mL/kg=mid thoracic levels
• High caudal block (T4)
• 1.5 mL/kg, (high volume/low concentration
0.15% Ropivacaine) is better
Duration of analgesia is short
60-90 min

26. TO PROLONG CAUDAL ANALGESIA
• LA+ Adjuvants
• Dexmedetomidine, Clonidine, s(+)-ketamine
• Morphine used but ……needs special
attention (may be in elderly children)
• Caudal catheter
• To prolong duration, decrease dose of LA
• Easy to insert up to thoracic levels
• Maintenance/ contamination is an issue
• Caudal PCA…
Test is to confirm the effectiveness
of the caudal block, test the tone of
anal sphincter

27. ROLE OF RA
• Epidurals (Thoracic & Lumbar)
• All regional blocks
• Single Shot (with adjuvants) or Catheter
Technique
They all provide effective postoperative
analgesia and
should be used whenever feasible.

28. ROLE OF PREEMPTIVE ANALGESIA
IN CHILDREN
• Initiated treatment before the surgical procedure in
order to reduce this sensitization.
• NSAIDs, Opioid, Ketamine, Caudal blocks,
Dexamethasone, Epidurals, Local blocks
• Overall, no analgesic benefit when compared with pre
& Post incision.
• Scope: Persistent post surgical pain, Gabapentinoids

29. ROLE OF INTERFASCIAL PLANE BLOCKS
(IFPB)
• TAP, PECS 1& 2, SAP RSB, QLB, ESPB,
IL/IH
• The recent literature supports the use of IFPB
as a component of MMA
• Better pain relief, less opioid use and
reduced opioid side effects
• Always use USG
• Incidence of LA toxicity may be higher than
in adults.

30. SUMMARY
• Pain in children is more difficult to assess and treat relatively to
adults.
• Multiple validated scoring systems do exist to assess pain in
pediatrics. However, there is no standardized or universal
approach for pain management.
• Availability of newer drugs, technique and technology helps in
better pain relief in children.
• We should always use multimodal and multidisciplinary approach
to mange the pain in children.

31. Thank You