Pain Management in Children
Content
PAIN MANAGEMENT IN CHILDREN
y Important aspect of medical management y Neonate and children y All pediatricean should familiar with y Failure to assess-critical factor leading to undertreatment
Pediatric pain response
y Pain perception in infants,children,adult-similar y Some difference exist-due to neurophysiological , cognitive
immaturity
y Peripheral nervous,central nervous structures present &
function early in gestation
y Newborn infants possess well developedhypothalamopitutory
adrenal axes
physiological,metabolic,behavior y Negative response.
y Tachycardia,tachypnoea,elevated blood pressure y Increased release of catecholamine,corticosteroid,glucagon y High metabolic rate,less nutritional reserve-catabolic state
induced by acute pain ²more damaging to children than adult
PAIN PERCEPTION
y Cerebrum,thalamus-control centres-process ®ister the y y y y y
experience of pain Trauma-release of bradykinin,subs P,histamine Facilitate the transmission of pain Small C fibres,large A delta fibres-pickup messageTransmit the signal to spinalcord Neurotransmitters-glutamate,subst P,adenosine triphosphate allow pain to ascend to brainstem thr spinothalamictract & enter higher centres of brain
HIGHER CENTRE PROCESS
y Location,intensity,fear of situation,past,present experience y Considered before the brains blocking response y By blocking further pain impulses from reaching higher
centres or by producing endorphin-saturate pain receptor sites along spinalcord,in brain
Nociceptive,neuropathic pain
y Altered excitability of central or peripheral nervous system-
dysfunction or injury-longer period of time,burn,shoot,stab,neurologic examint,hyperalgesia,allodynia,no skin pathology
PAIN ASSESSMENT/TOOLS
y Challenge to health care profes-to quantify pain intensity in
nonverbal infants,pre verbal & verbal children
y QUEST approach-comprehensive,use multiple sources y Question the child y Use pain rating scale y Evaluate behaviour y Secure parents involvement y Take pain in to account y Take action
Question the child
y Most reliable indicator
y Self report-most critical component
y Involve the parents
Pain rating scale
y Provide subjective ,quantitative measures of pain intensity
y Selected that is suitable to childs age,cognitive
development,cultural development
y Infants,Toddlers &prescool children,school age
children&adolescent
Pain scale
description
Age range
consideration
NIPS-neonatal infant pain scale
Facial expression,cry,breathi ng pattern,movement of arms,legs,state of arousal Incorporates categories of pain behavior 6 Cartoon faces-very happy smiling to a tearful face depicting worst hurt
Preterm,term neonate Quick,easybut less specific-use only behavioural indices,fewer rgadation per category >2 months Simple frame work to quantify pain Reflect mood vs pain.may be inaccurate for chronic pain Requires childs ability to count,some concept of no&their values in rlation to other no Reliable,valid-adults ,children.conquired concept of
FLACCface,leg,activity,cry,co nsolability, FACES PAIN SCALE
3-8 yrs
Numerical rating scale Rate their current pain 5-13yrs using numbers with 0 representing the least amount of pain VAS-visual analogue scale Variety of VAS scale>8yrs some with no,word description,some with
Cognitive impairment
y Inability to express pain,failure of caretakers to recognise
pain signals
y There r behavioural scales to measure y Evaluate behaviour y Irritable,angry,sad,depressed,withdrawn,aggressive
behaviour,deny pain/prolonging hospital stay,increased HR,RR,BP,decrease in 02 saturation,dilation of pupil,flushing or pallor-subside in chronic pain
Secure parents involvement
y Primary sourse of information
y Feel more comfortable expressing pain when parents r
present
y 99persent of children state that having their parent present
provideed the most comfort when in pain
TAKE THE CAUSE
y Pathology of pain ²clues to the expected intensity,type of
pain
y Scc-severe,sore throat-mild
y Pain perception ²subjective-knowing path is important
Take action
y Relieve or minimize pain by using analgesic ,adjuvant drugs
& non pharmacological agents
y Regardless of the treatment given it is essential to
y Moniter & evaluate the effectiveness of the interventions
Integrative pain management
y State of art pain management in 21st century demands y Pharmacological mnagement,supportive,non
pharmocological management y Pharmacological mnagement
y 4 concepts-by the ladder y
y y
-by the clock
-by the mouth -by the child
By the ladder
y WHO analgesic stepladder approach-multistep approach to y treat pain ,is a guide for initiating analgesic drugs and y dosages correspond to patients reported level of pain
By the clock
y Common cause of under treatment-PRN-pro re nata or as
needed dosing schedule
y Analgesia applied in a random fashion y Brief period of pain relief followed by potentially long period
of pain with increasing side effect
y Appropriate if used to provide extra dose of a regularly
scheduled analgesia to treat breakthrough pain
By mouth
y Route of administration y Oral/subligual-able to swallow ²should be the first choice-
parenteral to ora calculate the dose to maintain equal analgesic strength y Rectal-absorbtion inconsistent-contraindicated in neutropenic,thrombocytopenic because of risk of infection o rbleeding y Trans dermal/topical-cannot take oral,no IV access acceptible alternative,excellent pain control-EMLA-PRIOR TO insert SUBCUT needle,cannula
Route of administration
y Intramuscular-shouid be avoided-Fear-wont report the pain
y IV-for children with analgesic dose requirement that exceed
reasonable oral dosing or whom oral not tolerated
y Epidural/caudal/intrathecal-high dose of opioids ineffective
inrelieving pain,cause intolerable side effects
By the child
y Need of the individual child must be taken in to account
y No standard dose that will work for all children
y Goal-keeping the child pain free
Analgesic drugs
y Oral dextrose in neonate y Non opioid y Opioid y Patient controlled analgesia y Non pharmacological analgesia
Oral dextrose in neonate
y Mediated by the release of endogeniously released opioid
y Non pharmacological ²safe-effective-useful,
feasible,inexpensive
y To painful procedure-venepuncture
nonopioids
y Ferquently used-acetaminophen,ibuprofen y Acetaminophen-analgesic,antipyretic, y doesnot provide antiinflammatory effect,affect platelet
function,irritate stomach y Hepatotoxic
y NSAIDS-analgesic,antipyretic, antiinflammatory effect,affect
platelet function,irritate stomach,potential renal COX1,COX 2(toxicity less ²limited pedidtric data-)
opioids
y Bind with certain receptors y Mu-in CNS-central analgesia-development of respiratory
depression,physical dependence,withdrawl symptoms
y Kappa-greatest concentration in cerebral cortex,substansia
gelatinosa of the dorsal hornanlgesia at the level of spinalcord,brain-less role-physical dependence,withdrawl symptoms
y Delta-substansia gelatinosa of the dorsal horn-primary effect
on spinal &supraspinal analgesia
Mu agonist r commonly used
y R morphine,fentanyl,codein y Analgesic effect has no ceiling and dosing is limited only by
the presence of side effect
y Morphine-standard opioid-to which others r compared y Remain a valuable drug for the treatment of acute severepain y Paek effect 15mnts after iv bolus,duration of action 2-3hrs y Liver metabolishes to M6G ²also potent opioid-eliminate d
by kidney
administration
y Dilute in 5percent glucose or o.9saline y Reduce or stop infusion eachday,restart when first sign of
discomfort occurs y Otherwise-overdose,difficulty in weaning from ventilator
y Meperidone-pethidine-mu agonist-out of favour-short
duration of action-accumulation of toxic metabolite normeperidine-seizure a low dose
y
Depend on opioid route of administration vary
y Adverse effect-most common-
nausea,vomiting,constipation,pruritis,respiratory depresssion y -awaken child,give 02,decrease dose 25percent y American pain society-naloxoneo.5microgram/kg iv every 2mnts until repiration improves with compriming apin management
All opioids ² tolerence,dependency,addiction
y tolerence-progressive decline in analgesic potency ²need to
increase dose,adding appropriate adjuvant,switch to another opioid
y cross tolerence between opioid-doseof new opioid reduced
up to 50percent of equianalgesic dose.
Patient controlled analgesia
y Permits patient to self administer small dose of opioid iv/sub
cut at frequent interval
y Is a portable computerised syringe system connected to pts
iv line that allows self administration of medication
y Age .>6yrs-with moderate to severe pain ²post
operative,scc,cancer,burn
y Allows child to push a hand held button that attaches to and
activates machine
drug
Parenter aequianal gesidose 10mg
Starting dose-iv
Iv;oral
onset
duration
Max dose
commen ts
morphine
B-501:3 100micgm 2-4hrl cn1030/kg/da 1:1iv to id
1-2hrs
4-6hrs
60mg/dos Oral-rapid e onset,mini mal res dep dis3micg/kg /dose Adv disadv
fentanyl
100B-1250micgm 3micg/kg cn-12micg/kg /hr 1.5mg B-1520micg/k g 4hrl cn5micg/kg /hr
1-2mnts
20-30
hydromor phone
1:5
Almost 2-4hrs immediate ly
5mg/dose
tramadol
100mg
1mg/kg 3- 1:1 4hrl cn0.25mg/k
4-6hrl
Non pharmacological approach
Cognitive-behavioral
y Education y Relaxation y Imagery y Psychotherapy-councelling y Hypnosis-biofeedback y Music,literature,art,play y Prayer,meditation
physical
y Massage y Acupuncture y Applic of heat/cold y TENS y Immobilisation,graded
mobilisation y Therapeutic exercise
Newer analgesic agent
y Dexmeditomedine-an imidazole component-
specific,selective alpha adreno receptor agonist
y Presynaptic activation-inhibits release of norepinephrine-
terminae the propaagtion of pain signal y Postsynaptic-in CNS-INHIBITS SYMPATHETIC ACTIVITYcan decrease BP,HR
y Combined-analgesia,sedation,anxiolysis-avoid
multiagenttherapy
y Important aspect of medical management y Neonate and children y All pediatricean should familiar with y Failure to assess-critical factor leading to undertreatment
Pediatric pain response
y Pain perception in infants,children,adult-similar y Some difference exist-due to neurophysiological , cognitive
immaturity
y Peripheral nervous,central nervous structures present &
function early in gestation
y Newborn infants possess well developedhypothalamopitutory
adrenal axes
physiological,metabolic,behavior y Negative response.
y Tachycardia,tachypnoea,elevated blood pressure y Increased release of catecholamine,corticosteroid,glucagon y High metabolic rate,less nutritional reserve-catabolic state
induced by acute pain ²more damaging to children than adult
PAIN PERCEPTION
y Cerebrum,thalamus-control centres-process ®ister the y y y y y
experience of pain Trauma-release of bradykinin,subs P,histamine Facilitate the transmission of pain Small C fibres,large A delta fibres-pickup messageTransmit the signal to spinalcord Neurotransmitters-glutamate,subst P,adenosine triphosphate allow pain to ascend to brainstem thr spinothalamictract & enter higher centres of brain
HIGHER CENTRE PROCESS
y Location,intensity,fear of situation,past,present experience y Considered before the brains blocking response y By blocking further pain impulses from reaching higher
centres or by producing endorphin-saturate pain receptor sites along spinalcord,in brain
Nociceptive,neuropathic pain
y Altered excitability of central or peripheral nervous system-
dysfunction or injury-longer period of time,burn,shoot,stab,neurologic examint,hyperalgesia,allodynia,no skin pathology
PAIN ASSESSMENT/TOOLS
y Challenge to health care profes-to quantify pain intensity in
nonverbal infants,pre verbal & verbal children
y QUEST approach-comprehensive,use multiple sources y Question the child y Use pain rating scale y Evaluate behaviour y Secure parents involvement y Take pain in to account y Take action
Question the child
y Most reliable indicator
y Self report-most critical component
y Involve the parents
Pain rating scale
y Provide subjective ,quantitative measures of pain intensity
y Selected that is suitable to childs age,cognitive
development,cultural development
y Infants,Toddlers &prescool children,school age
children&adolescent
Pain scale
description
Age range
consideration
NIPS-neonatal infant pain scale
Facial expression,cry,breathi ng pattern,movement of arms,legs,state of arousal Incorporates categories of pain behavior 6 Cartoon faces-very happy smiling to a tearful face depicting worst hurt
Preterm,term neonate Quick,easybut less specific-use only behavioural indices,fewer rgadation per category >2 months Simple frame work to quantify pain Reflect mood vs pain.may be inaccurate for chronic pain Requires childs ability to count,some concept of no&their values in rlation to other no Reliable,valid-adults ,children.conquired concept of
FLACCface,leg,activity,cry,co nsolability, FACES PAIN SCALE
3-8 yrs
Numerical rating scale Rate their current pain 5-13yrs using numbers with 0 representing the least amount of pain VAS-visual analogue scale Variety of VAS scale>8yrs some with no,word description,some with
Cognitive impairment
y Inability to express pain,failure of caretakers to recognise
pain signals
y There r behavioural scales to measure y Evaluate behaviour y Irritable,angry,sad,depressed,withdrawn,aggressive
behaviour,deny pain/prolonging hospital stay,increased HR,RR,BP,decrease in 02 saturation,dilation of pupil,flushing or pallor-subside in chronic pain
Secure parents involvement
y Primary sourse of information
y Feel more comfortable expressing pain when parents r
present
y 99persent of children state that having their parent present
provideed the most comfort when in pain
TAKE THE CAUSE
y Pathology of pain ²clues to the expected intensity,type of
pain
y Scc-severe,sore throat-mild
y Pain perception ²subjective-knowing path is important
Take action
y Relieve or minimize pain by using analgesic ,adjuvant drugs
& non pharmacological agents
y Regardless of the treatment given it is essential to
y Moniter & evaluate the effectiveness of the interventions
Integrative pain management
y State of art pain management in 21st century demands y Pharmacological mnagement,supportive,non
pharmocological management y Pharmacological mnagement
y 4 concepts-by the ladder y
y y
-by the clock
-by the mouth -by the child
By the ladder
y WHO analgesic stepladder approach-multistep approach to y treat pain ,is a guide for initiating analgesic drugs and y dosages correspond to patients reported level of pain
By the clock
y Common cause of under treatment-PRN-pro re nata or as
needed dosing schedule
y Analgesia applied in a random fashion y Brief period of pain relief followed by potentially long period
of pain with increasing side effect
y Appropriate if used to provide extra dose of a regularly
scheduled analgesia to treat breakthrough pain
By mouth
y Route of administration y Oral/subligual-able to swallow ²should be the first choice-
parenteral to ora calculate the dose to maintain equal analgesic strength y Rectal-absorbtion inconsistent-contraindicated in neutropenic,thrombocytopenic because of risk of infection o rbleeding y Trans dermal/topical-cannot take oral,no IV access acceptible alternative,excellent pain control-EMLA-PRIOR TO insert SUBCUT needle,cannula
Route of administration
y Intramuscular-shouid be avoided-Fear-wont report the pain
y IV-for children with analgesic dose requirement that exceed
reasonable oral dosing or whom oral not tolerated
y Epidural/caudal/intrathecal-high dose of opioids ineffective
inrelieving pain,cause intolerable side effects
By the child
y Need of the individual child must be taken in to account
y No standard dose that will work for all children
y Goal-keeping the child pain free
Analgesic drugs
y Oral dextrose in neonate y Non opioid y Opioid y Patient controlled analgesia y Non pharmacological analgesia
Oral dextrose in neonate
y Mediated by the release of endogeniously released opioid
y Non pharmacological ²safe-effective-useful,
feasible,inexpensive
y To painful procedure-venepuncture
nonopioids
y Ferquently used-acetaminophen,ibuprofen y Acetaminophen-analgesic,antipyretic, y doesnot provide antiinflammatory effect,affect platelet
function,irritate stomach y Hepatotoxic
y NSAIDS-analgesic,antipyretic, antiinflammatory effect,affect
platelet function,irritate stomach,potential renal COX1,COX 2(toxicity less ²limited pedidtric data-)
opioids
y Bind with certain receptors y Mu-in CNS-central analgesia-development of respiratory
depression,physical dependence,withdrawl symptoms
y Kappa-greatest concentration in cerebral cortex,substansia
gelatinosa of the dorsal hornanlgesia at the level of spinalcord,brain-less role-physical dependence,withdrawl symptoms
y Delta-substansia gelatinosa of the dorsal horn-primary effect
on spinal &supraspinal analgesia
Mu agonist r commonly used
y R morphine,fentanyl,codein y Analgesic effect has no ceiling and dosing is limited only by
the presence of side effect
y Morphine-standard opioid-to which others r compared y Remain a valuable drug for the treatment of acute severepain y Paek effect 15mnts after iv bolus,duration of action 2-3hrs y Liver metabolishes to M6G ²also potent opioid-eliminate d
by kidney
administration
y Dilute in 5percent glucose or o.9saline y Reduce or stop infusion eachday,restart when first sign of
discomfort occurs y Otherwise-overdose,difficulty in weaning from ventilator
y Meperidone-pethidine-mu agonist-out of favour-short
duration of action-accumulation of toxic metabolite normeperidine-seizure a low dose
y
Depend on opioid route of administration vary
y Adverse effect-most common-
nausea,vomiting,constipation,pruritis,respiratory depresssion y -awaken child,give 02,decrease dose 25percent y American pain society-naloxoneo.5microgram/kg iv every 2mnts until repiration improves with compriming apin management
All opioids ² tolerence,dependency,addiction
y tolerence-progressive decline in analgesic potency ²need to
increase dose,adding appropriate adjuvant,switch to another opioid
y cross tolerence between opioid-doseof new opioid reduced
up to 50percent of equianalgesic dose.
Patient controlled analgesia
y Permits patient to self administer small dose of opioid iv/sub
cut at frequent interval
y Is a portable computerised syringe system connected to pts
iv line that allows self administration of medication
y Age .>6yrs-with moderate to severe pain ²post
operative,scc,cancer,burn
y Allows child to push a hand held button that attaches to and
activates machine
drug
Parenter aequianal gesidose 10mg
Starting dose-iv
Iv;oral
onset
duration
Max dose
commen ts
morphine
B-501:3 100micgm 2-4hrl cn1030/kg/da 1:1iv to id
1-2hrs
4-6hrs
60mg/dos Oral-rapid e onset,mini mal res dep dis3micg/kg /dose Adv disadv
fentanyl
100B-1250micgm 3micg/kg cn-12micg/kg /hr 1.5mg B-1520micg/k g 4hrl cn5micg/kg /hr
1-2mnts
20-30
hydromor phone
1:5
Almost 2-4hrs immediate ly
5mg/dose
tramadol
100mg
1mg/kg 3- 1:1 4hrl cn0.25mg/k
4-6hrl
Non pharmacological approach
Cognitive-behavioral
y Education y Relaxation y Imagery y Psychotherapy-councelling y Hypnosis-biofeedback y Music,literature,art,play y Prayer,meditation
physical
y Massage y Acupuncture y Applic of heat/cold y TENS y Immobilisation,graded
mobilisation y Therapeutic exercise
Newer analgesic agent
y Dexmeditomedine-an imidazole component-
specific,selective alpha adreno receptor agonist
y Presynaptic activation-inhibits release of norepinephrine-
terminae the propaagtion of pain signal y Postsynaptic-in CNS-INHIBITS SYMPATHETIC ACTIVITYcan decrease BP,HR
y Combined-analgesia,sedation,anxiolysis-avoid
multiagenttherapy
