PAIN IN CHILDREN

1. Pediatric Pain

2.  An unpleasant sensory or emotional experience
associated with actual or potential tissue damage,
or described in terms of such damage (International
Association for the study of Pain: IASP,1979)
 Does the human neonate capable of perceiving pain ????
Definition of pain

3. Babies do experience pain!
Myth 1: “Babies don’t feel pain...”

4. Babies do remember pain!
Myth 2: “They don’t remember...”

5. Pain is not character building,
it has a negative influence on children !
Myth 3: “Pain is character building…”

6.  Significant fluctuations in HR, BP, ICP, Oxygen level, and
stress hormones level
 Sleep disturbances, agitation, crying
Short term effects of inadequate pain management
Long term effects of inadequate pain management
 Inadequate surgical pain management has more
clinical complications, prolonged hospitalization time
and higher mortality rates
 Behavioral and Psychological sequaela

7. Pediatric pain assessment

8. Neonatal pain assessment
Facial expression
Eyes squeeze
Brow bulge
Nasolabial furrow
Vocal expression

9. FACES pain rating scale (3-7 years)
The Wong Baker Scale

10. OUCHER scale (3-7 years)
Available in versions for males and females and in
multicultural forms. The child is asked to point to
the picture that best shows how he or she feels
Categorical

11. Verbal Report Scale (>7 years)
“On a scale of 0 to 10, with 0 being ‘no pain’ and
10 being ‘the worst pain ever’, how would you
rate your pain?”
Categorical

12. Visual Analog Scale (>7 years)
A straight line. The left end of the line representing
no pain and the right end of the line representing
the worst pain. Patients are asked to mark on the
line where they think their pain is
Non categorical

13. Pediatric procedural analgesia

14.  A medically controlled state of depressed consciousness that:
1. Allows protective reflexes to be maintained.
2. Retains the patient ability to maintain a patient airway
independently and continuously
3. Permits appropriate response by the patient to physical
stimulation or verbal command, e.g., “open your eyes”.
Conscious Sedation, AAP, 1992

15.  A medically controlled state of depressed consciousness or
unconsciousness from which the patient is not easily aroused.
It may be accompanied by a partial or complete loss of
protective reflexes, and includes the inability to maintain a
patent airway independently and respond purposefully to
physical stimulation or verbal command.
Deep Sedation, AAP, 1992

16.  A medically controlled state of depressed consciousness
accompanied by a loss of reflexes including the inability to
maintain a patent airway independently and respond
purposefully to physical stimulation or verbal command
General Anesthesia, AAP, 1992

17.  A Technique of administering sedatives or dissociative agents
with or without analgesics to induce a state that allows the
patient to tolerate unpleasant procedures while maintaining
cardiorespiratory function. Procedural sedation and analgesia is
intended to result in a depressed level of consciousness but one
that allows the patient to maintain airway control independently
and continuously. Specifically, the drugs, doses, and techniques
used are not likely to produce a loss of protective airway reflexes.
 Significant improvement over the traditional AAP terminology
Procedural Sedation and Analgesia (PSA),
ACEP, 1998

18.  Naloxon
Introduced in 1960, proven to be safe in children.
Opioid antagonist of choice for PSA
 Flumazenil
Introduced in 1987, proven to be safe in children
 Nalmefen
New Opioid antagonist, Introduced in 1995, proven to be useful in
adults. Long acting (3.5h).
 Only one study in children (Nov 2001, Ann Em Med): Patients who
had PSA with Fentanyl/Midazolam received Nalmefen after the
procedure. Sedation reversal parameters were improved, no side
effects, no cardiorespiratory changes, no resedation phenomena.
Nalmefen seems to be effective in children. (small sample)
Antagonists

19. Narcotic analgesia in the pediatric
acute abdomen

20.  The Ethical dilemma of withholding analgesia while
awaiting surgical evaluation
 4 prospective randomized controlled double blind studies
in adults, no studies in children
 All 4 studies use Morphine sulfate or Morphine derivatives
Narcotic analgesia in acute abdomen

21.  In all studies, opiates didn’t change management and were
not found to be associated with increased morbidity or
mortality. None of the trials was able to identify even one
patient in which analgesia led to a poor outcome
 In adults the use of narcotic analgesia doesn’t mask
symptoms or change the physical exam findings
 In children there is no data
Narcotic analgesia in acute abdomen

22. Neonatal analgesia

23.  Acetaminophen?
 Not effective in controlling neonatal procedural pain
 Ibuprofen?
 Its safety under 6 months of age hasn’t been established
 Codeine?
 Codeine requires the conversion to its active component,
Morphine. This enzymatic conversion activity is <10% of
that seen in adults
Analgesia for minor invasive procedures in neonates
(Neonates usually suffer more than one poke……)

24. ACUTE PAIN SERVICE

25. The assessment and management of Acute
pain in Infants, Children, and Adolescent
 The AAP and APS jointly issued this general statement to
emphasize the responsibility and the obligation of Physicians to
treat acute Pain in children
 Discusses myths about pain in children, the importance of pain
assessment, procedure related pain and recommends using
guidelines for PSA
Policy Statement, 09/2001
American Academy of Pediatrics
American Pain Society

26. The assessment and management of Acute
pain in Infants, Children, and Adolescent
 “Because of the diversity and complexity of the
clinical issues present; pain treatment, including
choice of drug, dosage, and route, must be
tailored to the individual patient, and analgesic
given in the overall context of
what is best for the patient”
Policy Statement,
American Academy of Pediatrics
American Pain Society