Pain Management in Infants and Children

1
Pain Management in Infants and Children

• Lynette Thacker
• Clinical Nurse Specialist
• Paediatric Palliative Care

Disclaimer Whilst every effort has been made to
ensure that the information in this presentation
is accurate and referenced the author does not
accept any responsibility for the use by any
third parties.
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Operational Definition of Pain

• Pain is whatever the experiencing person says it
  is, existing whenever he says it does.
• BELIEVE THE PATIENT!
• Ref McCaffery and Pasero Pain Clinical
  Manual, 1999).

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Myths About Pain in Children

• Infants are neurologically immature and therefore
  cannot conduct pain impulses.
• Infants do not remember pain, because of cortical
  immaturity.
• Children do not report pain while playing or
  sleeping so they must get over it quickly or not
  be experiencing it.

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The Golden Rule

• What is painful to an adult is painful to an
  infant and child unless proven otherwise.

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Types of Pain

• Nociceptive
• Somatic
• Well-localized
• Pain receptors in soft tissue, skin, skeletal
  muscle, bone
• Visceral
• Vague
• Visceral organs
• Neuropathic
• Damaged sensory nerves

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Classification of pain

• Many different systems
• e.g. based on
• Duration acute/chronic/persistent
• Intensity mild/moderate/severe
• Location
• Presumed pathophysiology visceral, somatic,
  sympathetic
• Sensitivity to opioids sensitive/insensitive/par
  tially insensitive
• Pragmatic

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Pragmatic classification of pain

• Neuropathic
• Disordered sensation
• Responds to anticonvulsants and antidepressants
• Bone
• Intense and focal
• Responds to NSAIDs and bisphosphonates
• Muscle spasm
• Responds to muscle relaxants and antispasmodics
• Cerebral irritation
• Caused by brain injury
• Signs of anxiety
• Responds to benzodiazepines

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Concept of Total Pain Management

• Four aspects must be addressed
• Physical
• Psychological
• Social
• Spiritual
• Last 3 can be met only after pain
• and related symptoms (e.g., N/V,
• anxiety) are controlled.

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QUESTT

• Question the patient/parent/carer
• Use pain rating scale
• Evaluate behavior physiologic signs
• Secure familys involvement
• Take cause of pain into account
• Take action and assess effectiveness

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Pain Assessment

• What is the policy for pain assessment and
  documentation in your area?
• Methods of assessment vary according to age and
  cognitive level of child
• Patient report
• Numerical scale 1 to 10
• FACES can be used at all ages
• FLACC used on infants

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Physiological Indications of Acute Pain

• Dilated pupils
• Increased perspiration
• Increased rate/ force of heart rate
• Increased rate/depth of respirations
• Increased blood pressure
• Decreased urine output
• Decreased peristalsis of GI tract
• Increased basal metabolic rate

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Infant Response to Pain

• Forcefully closed eyes
• Lowered brows
• Deepened furrow between nose and outer corner of
  lip.
• Square mouth
• Cupped tongue

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Toddler and Pre-school

• Limited in their cognitive abilities in
  localizing and expressing pain intensity, and
  understanding reasons for pain.
• Find out word they use to express pain
• Point to pain
• Faces is a good tool for them.

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School-age

• Increased ability to communicate pain in more
  abstract terms.
• They can describe pain squeezing, stabbing or
  burning
• Respond well to direct questioning.
• Tools body outline, faces scale, visual analog.

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Acute Illness

• Middle ear infection, pharyngitis, meningitis,
  abdominal pain, fractures
• Treatment determined by severity of pain
• Paracetamol
• Non-steroidal
• Opioids
• Locally applied medications
• Relaxation and distraction

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Pre-procedural Pain

• Key to managing procedural related pain is
  anticipation
• Anticipated intensity and duration
• Child / parent receive appropriate information to
  minimize distress

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Operative Pain

• Morbidity and mortality can be reduced by good
  pain treatment
• Plans for postoperative pain should be discussed
  before surgery
• Goal is to control the pain as rapidly as
  possible

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Post-Operative Pain

• Oral administration is preferred for mild to
  moderate pain.
• IV is indicated for immediate pain relief.
• Persistent moderate to severe pain continuous
  around the clock dosing at fixed intervals is
  recommended.
• PCA patient-controlled analgesia used only
  when patient can use pump on their own.

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Non-pharmacologic Pain Management

• Physical
• Massage
• Heat and cold
• Acupuncture
• Behavioral
• Relaxation
• Art and play therapy
• Biofeedback
• Cognitive
• Distraction
• Imagery and Hypnosis

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Case Study 1

• Alex is a 6 year old, admitted for osteotomy as
  treatment for bilateral dislocated hips from
  quadriplegic dystonic cerebral palsy. He is
  non-verbal, gastrostomy fed and as epilepsy.
• Present analgesia consists of Buprenorphine patch
  15micrograms and Oromorphine 3.5milligrams as
  required for pain.
• Using the holistic approach of physical/
• psychological/social/spiritual aspects how would
  you manage Alex pain in the post-operative
  period.

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Case Study 2

• Bobby is a 14 year old, admitted with a fractured
  radius and ulna. He is has a Lawrence Moon Biedal
  Barr Syndrome. He has chronic renal failure,
  visual impairment, mild learning disability and
  is verbal.
• Present analgesia consists of Paracetamol
  500milligrams as required for pain.
• Bobbys younger brother died 3 years ago from a
  more severe form of Lawrence Moon Biedal Barr
  Syndrome.
• Using the holistic approach of physical/
• psychological/social/spiritual aspects how would
  you manage Bobbys pain in the post-operative
  period.

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WHO analgaesic ladder
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Golden Rules
Oral meds if possible NB adjuvants at all
stages Do not rotate within a step, move
up Major opioids should always be regular
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Adjuvant Analgesics

• Adjuvant not primarily analgesic but can
  improve pain in certain circumstances
• Neuropathic - anticonvulsants (carbamazepine,
  gabapentin), antidepressants (amitriptyline),
  NMDA receptor antagonists (methadone, ketamine)
• Bone - NSAIDs, bisphosphonates, RTx, chemo
• Muscle spasm - Benzodiazepines, baclofen,
  tizanidine, botox
• Cerebral irritation- Benzodiazepines,
  phenobarbitone
• Inflammatory/Oedema Steroids
• Non-pharmacological - Physio, Psychology..

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• Initiating strong opioid therapy
• What drug?
• Morphine - short acting formulation (Oramorph,
  Sevredol)
• By mouth if possible
• What dose?
• 1mg/kg/day total daily dose 30mg
• 30mg 6 4 hourly dose 5mg
• And for breakthrough pain?
• Give the 4 hourly dose (5mg) as required

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• Titration phase
• Aim to match the amount of analgesia given with
  the degree of pain experienced
• Add up all doses taken in 24 hours so if 6 doses
  x 5mg
• 30mg 30mg 60mg
• 60mg 6 10mg
• Prescribe 10mg 4hrly and 10mg prn for
  breakthrough pain

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• Maintenance phase
• More convenient opioid preparations
• MST
• Total daily Oramorph requirement 60mg
• Appropriate MST dose 30mg bd
• Diamorphine SCI
• Total Oramorph requirement 60mg
• Appropriate Diamorphine dose 20mg/24hrs
• 60mg/3 as Diamorphine 1/3rd stronger than Oral
  morphine
• Prescribe breakthrough analgesia

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Side Effects

• Nausea, vomiting and puritus are common side
  effects
• Drowsiness
• Respiratory Depression
• Constipation with prolonged use of opioids

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Monitoring

• What monitoring is required per hospital policy?
• A cardiac / respiratory monitor is used for
  infants less than 7 months
• Oximetry monitors for other patients during use
  of IV opioids
• Unstable respiratory status
• History of difficult airway management
• Neurologically impaired

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Documentation

• The assessment and measure of pain intensity and
  quality, appropriate to the patients age, are
  recorded in a way that facilitates regular
  re-assessment and follow-up according to criteria
  developed by the organization.

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Take Home Points

• Assess pain using an age appropriate tool.
• Consider starting an around the clock regimen.
• Continually assess pain and modify medication
  regimen appropriately.
• When to call for medical assistance
• Patient has persistent or worsening pain despite
  appropriate analgesic regimen.
• When to transfer to a higher level of care
• Patient develops respiratory depression with
  opiates
• Control airway and ventilation
• Order opioid antagonist (Naloxene)while calling
  for help

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Narcotics Are No More Dangerous for Children
Than Adults

• Addiction from narcotics (opioids) used to treat
  pain is extremely rare in adults no reports
  substantiate this fear in children reports of
  respiratory depression in children are rare.