This document provides an overview of acute pain management in children. It discusses the difficulties in assessing and treating pain in children, as well as the physiological and behavioral effects of acute pain. General principles for managing acute pain in children include anticipating and preventing pain, adequately assessing pain using age-appropriate tools, using a multi-modal approach including pharmacological and non-pharmacological therapies, involving parents, and using non-noxious routes of medication administration when possible. Specific pharmacological therapies for acute pain in children such as acetaminophen, NSAIDs, opioids, and local anesthetics are also reviewed.

1. Acute Pain Management
in Children
Presenter : Ranjith Nelluri
( 2nd yr MD)
Moderator : Dr.Govardhani
(Asst.Professor)

2. • International Association for the Study of Pain
– An unpleasant sensory and emotional experience
arising from actual or potential tissue damage or
described in terms of such damage
– Sensory, emotional, cognitive, and behavioral
components that are interrelated with environmental,
developmental, socio-cultural, and contextual factors

3. DIFFICULTIES
• Belief that children, especially infants, do not feel pain the
way adults do
• Lack of routine pain assessment
• Lack of knowledge in pain treatment
• Fear of adverse effects of analgesics, especially respiratory
depression and addiction
• Belief that preventing pain in children takes too much time
and effort
• Parental understanding of pain
• Personal values and beliefs; i.e. pain builds character
• AAP 2001 Task Force on Pain in Infants, Children and Adolescents

4. • Historically children and infants received less post-
operative analgesia than adults
• Well documented that children are often undertreated for
pain
• Specifically in neonates:
– Recent studies show that neonates can experience pain by 26
weeks of gestation
• Mature afferent pain transmission
– Untreated pain in neonates lead to increased distress and altered
pain response in the future

5. Acute Pain in Children
• Acute illness
• Procedural pain
• Surgical pain
• Postoperative pain
• Exacerbation of chronic pain

6. Effects of Acute Pain
• Physiologic
• Metabolic
• Behavioral

7. Physiologic Response
• Increased heart rate
• Increased respiratory rate
• Increased blood pressure
• Decrease in oxygen saturation

8. Metabolic Response
• Increased secretion of catecholamine,
glucagon, and corticosteroids.
• Delayed wound healing
• Poor intake
• Impaired mobility
• Sleep disturbances
• Irritability

9. General Principles of
Pain Management
• Anticipate & prevent pain
• Adequately assess pain
• Use multi-modal approach
• Involve parents
• Use non-noxious routes

10. Anticipate & Prevent Pain
• Prepare patient and parent on what to expect
• Guide them on ways to minimize pain and anxiety
• Utilize quiet environment
• Distraction , parental presence
• Treat pain prophylactically when anticipated
– E.g. Following surgery or local anesthetic for lumbar puncture
– Takes more medication to treat pain than to prevent its
occurrence

11. Pain Assessment
• Obtain a detailed assessment of pain
– description of pain, experience with pain medications, use of non-
pharmacologic techniques, parent experience with pain
– Quality, location, duration, intensity, radiation, relieving & exacerbating
factors, & associated symptoms
• Use age appropriate tool
– Scales for neonate, infant, children ages 3-8, >8 years, and children with
cognitive impairments
• Directly ask child when possible
• Pain can be multi-dimensional and therefore, tools can be limited

12. PQRSTU mnemonic
• Provocative/Palliative factors (For example, "What makes your pain better or
worse?")
• Quality (For example, use open-ended questions such as "Tell me what your
pain feels like," or "Tell me about your 'boo-boo'.")
• Region/Radiation (For example, "Show me where your pain is," or "Show me
where your teddy hurts.")
• Severity: Ask child to rate pain, using a pain intensity scale that is appropriate
for child's age, developmental level, and comprehension. Consistently use the
same pain intensity tool with the same child.
• Timing: Using developmentally appropriate vocabulary, ask child (and family) if
pain is constant, intermittent, continuous, or a combination. Also ask if pain
increases during specific times of the day, with particular activities, or in specific
locations.
• How is the pain affecting you (U) in regard to activities of daily living (ADLs),
play, school, relationships, and enjoyment of life?

13. Goal of Pain Rating Scale
Identify characteristics of pain
Establish a baseline assessment
Evaluate pain status
Effects of intervention

14. Assessment in Neonates & Infants
• Challenging
• Combines physiologic and behavioral parameters
• Many scales available
– NIPS (Neonatal Infant Pain Scale)
– FLACC scale (Face, Legs, Activity, Cry ,Consolability)

15. CRIES scale

16. FLACC scale

17. Neonatal Infant Pain Scale (NIPS)

18. Children between 3-8 years
• Usually have a word for pain
• Can articulate more detail about the
presence and location of pain; less able to
comment on quality or intensity
• Examples:
– Color scales
– Faces scales

19. Children older than 8 years
• Use the standard visual analog scale
• Same used in adults

20. Children with Cognitive Impairment
• Often unable to describe pain
• Altered nervous system and experience pain
differently
• Use behavioral observation scales
– e.g. FLACC
• Can apply to intubated patients

21. 4: Patient & Parental Involvement
• Parent
– Excellent sources of information on child
– Learn techniques to help coach through pain
– Reduces anxiety
• Patient
– Age & developmentally appropriate
– Gives them control in their pain experience
– Learn techniques to help with pain control
– Reduces anxiety

22. Multi-modal Approach
• Pharmacological therapy
• Interventional therapy
• Non pharmacological therapy

23. Non-pharmacologic Therapy
• Physical
– Massage
– Heat and cold
– Acupuncture
• Behavioral
– Relaxation
– Art and play therapy
– Biofeedback
• Cognitive
– Distraction
– Imagery and Hypnosis

26. World Health Organization (WHO)
Principles of
Pediatric Acute Pain Management
• By the clock
• With the child
• By the appropriate route
• WHO Ladder of Pain Management

27. By the Clock
• Regular scheduling ensures a steady blood level
• Reduces the peaks and troughs of PRN dosing
• PRN = as little as possible???

28. With the Child
Analgesic treatment should be
individualized according to:
• The child’s pain
• Response to treatment
• Frequent reassessment
• Modification of plan as required

29. Correct Route
Oral
Nebulized
Buccal
Transdermal
Sublingual
Intranasal
IM
IV / SC
Rectal

31. Pharmacological intervention

33. Non-opioid Analgesics
• Mild to moderate pain
• No effects of respiratory depression
• Highly effective when combined with opioids
• Acetaminophen
• NSAIDs
• COX-2 inhibitors
• Aspirin
– No longer used in pediatrics

34. Acetaminophen
• Antipyretic
• Mild analgesic
• Administer PO or PR
• Pediatric Oral dose 10-15 mg/kg/dose every 4 hr
– Infant dose is 10-15 mg/kg/dose every 6-8 hr
• Onset 30 minutes

35. Acetaminophen
• Per rectum dose
• 35-50mg/kg once followed by 20 mg/kg/dose
every 6 hours
– Uptake is delayed and variable
– Peak absorption is 60-120 minutes
– Unreliable to cut suppositories
• Maximum daily dosing
– <2yrs : 60-75 mg/kg/day
– >2yrs kg : 90-100 mg/kg/day

36. Side Effects of Acetaminophen
• Generally a good safety profile
– Do not use in hepatic failure
• Causes hepatic failure in overdose
– Infant drops are MORE concentrated than the
children’s suspension
• Infant’s Acetaminophen 80 mg/0.8 mL
• Children’s Acetaminophen 160 mg/5 mL

37. NSAIDs
• Antipyretic
• Analgesic for mild to moderate pain
• Anti-inflammatory
– COX inhibitor  Prostaglandin inhibitor
• Platelet aggregation inhibitor

38. NSAIDs: Ibuprofen
• Dose 5-10 mg/kg/dose every 6 hours
– Adult dose 400-600 mg/dose every 6 hours
• Onset 30-45 minutes
• Maximum daily dosing
– <60 kg: 40 mg/kg
– >60 kg: 2400 mg
• May use higher doses in rheumatologic disease

39. NSAIDs: Ketorolac
• Intravenous NSAID (also available P.O.)
• Dose every 6 hours
• < 2 years: 0.25 mg/kg i.v.
• > 2 years: 0.5 mg/kg i.v., max. 30mg, max of 5 days)
• Onset 10 minutes
• Maximum I.V. dose 30 mg every 6 hours
• Monitor renal function
• Do not use more than 5 days
– Significant increase in side effects after 5 days

40. Side Effects of NSAIDs
• Gastritis
– Prolonged use increases risk of GI bleed
– Still rare in pediatric patients compared to adults
– NSAID use contraindicated in ulcer disease
• Nephropathy (ATN)
• Bleeding from platelet anti-aggregation
– Increased risk versus benefit post-tonsillectomy
– NSAID use contraindicated in active bleeding
• Delayed bone healing?

41. COX-2 inhibitors
• Selectively inhibits Cyclooxygenase-2 which reduces
risk of gastric irritation and bleeding
• Same risk for nephropathy as non-selective COX
inhibitors
• Shown to have increased cardiovascular events in
adults
• More studies needed in pediatric patients
– COX-2 inhibitors used in rheumatologic diseases

42. Opioids
• Codeine
• Oxycodone
• Morphine
• Fentanyl
• Hydromorphone
• Methadone

43. Opioids Analgesics
• Moderate to severe pain
• Various routes of administration
• Different pharmacokinetics for different age
groups
– Infants younger than 3 months have increased risk of
hypoventilation and respiratory depression
• Low risk of addiction among children

44. Codeine
• Oral analgesic (also anti-tussive)
• Weak opioid
– Used often in conjunction with acetaminophen to
increase analgesic effect
• Metabolized in the liver and demethylated to
morphine
– Some patients ineffectively convert codeine to
morphine so no analgesia is achieved
• Dose 0.5-1 mg/kg every 4-6 hours

45. Oxycodone
• Oral analgesic
• Mild to moderate pain
• Hepatic metabolism to noroxycodone and
oxymorphone
• Can be given alone or in combination with
acetaminophen
• Dose 0.05-0.15 mg/kg every 4-6 hours
• Maximum 5-10 mg every 4-6 hours

46. Morphine
• Available orally, sublingually, subcutaneously, intravenous, rectally,
intrathecally
• Moderate to severe pain
• Hepatic conversion with renally excreted metabolites
– Use in caution with renal failure
• Duration of I.V. analgesia 2-4 hours
– Oral form comes in an immediate and sustained release
• Dose dependent on formulation
• I.V. Dose 0.05-0.2 mg/kg/dose every 2-4 hours
• Onset 5-10 minutes
• Side effect of significant histamine release

47. Fentanyl
• Available intravenous, buccal tab, lozenge and transdermal
patch
• Severe pain
• Rapid onset, brief duration of action
– With continuous infusion, longer duration of action
• I.V. Dose 1 mcg/kg/dose every 30-60 minutes
• Side effect of rapid administration may produce glottic and
chest wall rigidity
• Careful observation, CRM and immediate availability of airway
equipment

50. Ketamine
Analgesic dose : 0.1-0.5mg/kg
infusion - 4µg/kg/min

51. Patient/Parent Controlled Analgesia (PCA)
• Programmable pump that allows patient control of
intravenous analgesia
• Patient can choose when to deliver a dose of opioid and
achieve relief quickly
• Inherent safety in the PCA: patient will fall asleep when
over sedated and is unlikely to administer too much
drug
• Teaching is integral and essential

52. PCA
• Useful for sickle cell vaso-occlusive episodes,
postoperative pain, cancer pain, palliative care
• Take patient’s age, maturity, and medical condition into
the decision

53. PCA
• Loading dose if patient is in pain so that there is a therapeutic serum level to start
• Basal infusion rate can deliver continuous background dose of opioid to maintain
therapeutic level
• Patient demand dose is the dose administered with each patient activation of the
pump (usually small)
• Lockout interval (5-10 min) prevents a second PCA dose before the previous bolus
has taken effect (important to prevent overdosing)
• Maximum hourly limit can be set based on the average hourly use of morphine
• Sedation and vital sign assessment is mandatory

54. Naloxone
• Opioid antagonist
• 1 ampule = 0.4 mg/mL
• Use when unresponsive to physical stimulation, shallow respirations
(<8 breaths/min), pinpoint pupils
• Stop Opioid
– For <40 kgs: Naloxone ¼ ampule with NS 9 mL = 10 mcg/mL
• Administer slowly and observe response
– 1-2 mcg/kg/min
• Discontinue naloxone as soon as patient responds
• Duration 30-45 minutes
– Monitor the patient; repeat doses may be needed

55. Local Anesthetics
• For IV cannulation, suturing, lumbar puncture, etc.
• Topical or infiltration
• Acts by blocking nerve conduction at Na-channels
• If administered in excessive doses, can cause systemic effects
– CNS effects of perioral numbness, dizziness, muscular twitching, seizures &
cardiac toxicity
– Aspirate back before injecting to avoid direct injection into blood vessels
– Calculate maximum mg/kg dose to avoid overdose

56. Anesthesia
• Regional
– Blocks afferent pathways to CNS
– Good for post-operative pain relief
– Epidural and caudal anesthesia
– Peripheral nerve blocks
• General

57. Caudal anaesthesia
 The armitage regime:
• O.5 ml/kg- all sacral dermatomes blocked
• 1 ml/kg- sacral and lumbar dermatomes blocked
• 1.25 ml/kg- upto midthoracic levels blocked
Bupivacaine in Concentration Dose Possible additives
Single dose
caudal
0.175%- 0.5% 0.75- 1.25
ml/kg (max. 3
ml/kg)
Epinephrine 2.5- 5 µg/kg
Clonidine 1- 2 µg/kg
Morphine 30- 70 µg/kg
Continuous
caudal
0.1%- 0.25% 0.4 ml/kg Fentanyl 2- 5 µg/kg

58. Epidural Block
• Epidural space more superficial in children than
adults
• Guideline for determining epidural depth:
– 1mm/kg of body weight
– Depth (cm) = 1 + 0.15 X age (years)
– Depth (cm) = 0.8 + 0.05 X weight (kg)
• Use shorter needles and extreme care

59. Epidural Block
• Dosing:
– Depends on upper level of analgesia required
– > 10 years of age:
• Volume to block one spinal segment
– V (in ml) = 1/10 X (age in years)
– < 10 years old:
• 0.04ml/kg/segment

60. Maximum dosage

61. Sucrose for Infants
• Sucrose 24% oral solution
• Can be used for procedures such as heel stick,
venipuncture, catheterization, etc.
• Effective analgesic in preterm and term infants
– Not effective beyond 3 months old
• Dip pacifier in sucrose solution or give 0.2 mL to buccal
area
– May repeat but be cautious with many doses to younger infants

62. • Anesthesiologists are like no other physicians: we are experts at controlling the
airway and at emergency resuscitation;
• we are real-time cardio pulmonologists achieving hemodynamic and
respiratory stability for the anesthetized patient;
• we are pharmacologists and physiologists, calculating appropriate doses
and desired responses;
• we are gurus of postoperative care and patient safety;
• we are internists performing perianesthetic medical evaluations;
• we are the pain experts across all medical disciplines and apply specialized
techniques in pain clinics and labor wards;
• we manage the severely sick and injured in critical care units;
• we are neurologists, selectively blocking sympathetic, sensory, or motor functions
with our regional techniques

63. THANK YOU