1. Prepared by Office of Kids and Families March 2016 Infants and Children: Management of Acute and Procedural Pain in Emergency Departments

2. Session Outline Background & aim of the guideline Pain Pathway Pain Assessment Tools Pharmacological & non-pharmacological pain management Reassessment & escalation Summary 1

3. Background Children’s acute pain is often inadequately managed Ongoing assessment and reassessment is essential –Is the child in pain? –How severe is the pain? –Has analgesia been effective? This reduces morbidity and mortality Use of a validated pain assessment tool supports –effective pain management –consistency –objectivity 2

4. PAEDIATRIC ACUTE PAIN ASSESSMENT AND MANAGEMENT ALGORITHM 3

5. Developmental Responses to Pain 4 Infantsirritability, crying, withdrawal, restless, poor sleeping and feeding ToddlersUnusually quiet, crying, regressive behaviour, pointing, using pain words Pre-schoolersquiet, avoid having parts of their body examined School agedWithdrawal, may deny pain to avoid further pain, anxiety AdolescentsAffect their mood, refuse or over-request medication, increased muscular tension

6. Pain Assessment Tools 5 ScaleTarget Group Neonatal Infant Pain Scale (NIPS) less than 2 months (Appendix 3) 26 Face, Legs, Activity, Cry, Consolability (FLACC) between 2 months to 7 years (Appendix 4) 27 Faces Pain Scale (FPS-R)over 4 years (Appendix 5) 28 Linear Scale (visual analogue scale) over 7 years (Appendix 6) 29 Revised FLACC (r-FLACC)children with cognitive impairment (Appendix 7) 30

7. Neonatal/Infant Pain Scale (NIPS) under 3 months AssessmentScore = 0Score = 1Score = 2 Facial expression Relaxed muscles (Restful face, neutral expression) Grimace (Tight facial muscles; furrowed brow, chin, jaw) Cry No cry (Quiet, not crying) Whimper (Mild moaning, Intermittent) Vigorous cry (Loud scream; rising, shrill, continuous) Breathing patterns Relaxed (usual pattern for this infant) Change in breathing (In-drawing, irregular, faster than usual; gagging; breath holding) Arms Relaxed/restrained (No muscular rigidity; occasional random movements of arms) Flexed/extended (Tense, straight legs; rigid and/or rapid extension, flexion) Legs Relaxed/restrained (No muscular rigidity; occasional random leg movement) Flexed/extended (Tense, straight legs; rigid and/or rapid extension, flexion) Arousal Sleeping/awake (Quiet peaceful sleeping or alert random leg movement) Fussy (Alert, restless, and thrashing) NIPS interpretation – add the scores from each of the 6 assessments for a score of 0 – 7 0 = No pain, 1-2 = Mild pain, 3-4 = Moderate pain, 5-7 = Severe pain

8. FLACC (3 months to 4 years) Score 0Score 1Score 2 F ace No particular expression or smile Occasional grimace or frownFrequent to constant frown, clenched jaw, quivering chin L egs Normal position or relaxedUneasy, restless, tenseKicking, legs drawn up A ctivity Lying quietly, normal position, moves easily Squirming Shifting back / forth / tense Arched, rigid or jerking C ry No cry (awake or asleep) Moans or whimpers, occasional complaints Crying steadily, screams or sobs, frequent complaints C onsolability Content, relaxedReassured by occasional touching, hugging or talking to distractible Difficult to console or comfort FLACC interpretation – add the scores from each of the five assessments for a score of 0-10 7

9. r-FLACC (cognitive impairment) Score 0Score 1Score 2 F ace No particular expression or smile Occasional grimace or frown withdrawn, disinterested Appears sad or worried Frequent to constant frown, clenched jaw, quivering chin Distressed looking face, expression of fright or panic L egs Normal position or relaxed Usual tone and motion or limbs Uneasy, restless, tense Occasional tremors Kicking, legs drawn up Marked increase in spasticity, constant tremors or jerking A ctivity Lying quietly, normal position, moves easily Regular, rhythmic respirations Squirming Shifting back / forth / tense or guarded movements, mildly agitated (e.g. head movement back and forth, aggression), shallow splinting respirations, intermittent sighs Arched, rigid or jerking Severe agitation, head banging, shivering (not rigors) breath-holding, gasping or sharp intake of breaths, severe splinting C ry No cry /verbalisation (awake or asleep) Moans or whimpers, occasional complaints. Occasional verbal outburst or grunt Crying steadily, screams or sobs, frequent complaints. Repeated outbursts, constant grunting C onsolability Content, relaxedReassured by occasional touching, hugging or talking to distractible Difficult to console or comfort. Pushing away caregiver, resisting care or comfort measures Individual Child Behaviours in response should also be noted and included in the assessment r-FLACC interpretation – add the scores from each of the five assessments for a score of 0-10

10. Faces Pain Scale Revised > 4 years Instructions: In the following instructions, use the terms "hurt" or "pain," whichever seems right for a particular child: "These faces show how much something can hurt. This face [point to left-most face] shows no pain. The faces show more and more pain [point to each from left to right] up to this one [point to right-most face] - it shows very much pain. Point to the face that shows how much you hurt [right now]." 9

11. Linear Pain Scale > 7yrs 0 2 4 68 10 TIPS: Ask the child to point along the line saying the “0” end is “No Pain” and the “10” end is “Worst Pain”. Don’t ask them “what is their score out of 10” because children want to get 10 out of 10, so just ask them to point at the line. 10

12. Mild, Moderate and Severe Pain Scores Pain ToolMild PainModerate PainSevere Pain Neonatal NIPS 1-2 / 73-4 / 75-7 / 7 Paediatric FLACC/r-FLACC Faces – Revised Linear 1-3 / 104-6 / 107-10 / 10 11

13. 3 Ps of pain management ‘P’Description Play Psychological management:  Involve parents  Cuddles  Child-friendly environment  Age appropriate explanation with reassurance Distraction management:  Toys  Blowing bubbles  Reading or story-telling with visual imagery  Using superhero or magical images Physical  Limb immobilisation  Dressings for burns  Cold packs  Positioning  Quiet, darkened room  Deep breathing Pharmacological Analgesia via a variety of administration routes (i.e. topical, oral, intranasal, intravenous, intraosseous) Local or regional anaesthesia (e.g. femoral or regional blocks)

14. Distraction Techniques by age There are also various apps on Smart Phones and tablets are useful for all age groups AgeDistractionPreparationAfter Infant Relaxation Music Touch and Massage Parents calm voice Bubbles Rattles and Shakers Books Singing Brief description moments before the procedure Cuddles Singing Toys Soft voice Books Toddler Relaxation Music/Singing Light & Sound Toys Pop-up Toys Books Bubbles Counting Brief description 5 minutes before the procedure with visual cues if possible Stickers Toys TV/Movie Stories Singing Pre-Schoolers Favourite music Bubbles Books Focused Breathing Magnet Books Brief verbal explanation with visual cues or materials 10-15 minutes prior if possible Stickers Craft activity Drawing Colouring TV/Movie Stories School Aged Favourite music DVD Focused Breathing and/or Guided Imagery Stress Ball Talking about Favourite Things ‘I Spy’ Style Books Verbal explanation with visual cues and materials 10-30 minutes prior Sticker Craft Activity TV/ DVD Stories Adolescent Favourite Music Jokes Focused Breathing and/or Guided Imagery Search and Find Books Stress Ball Relaxation Jokes Verbal explanation with visual cues and material 10-30 minutes prior Verbal reward Ask if they have any questions regarding what just happened

15. Paediatric Quick Pain Guide 14

16. Neonatal Quick Pain Guide 15

17. Paracetamol (Panadol) Useful in the management of acute pain –First line treatment - effective for mild pain –Effective addition to other analgesics for moderate/ severe pain Use age >1 month Non-steroidal anti-inflammatory drugs Analgesic and anti-inflammatory properties Review to see if analgesia is adequate 16

18. Ibuprofen (Nurofen) Non-steroidal anti-inflammatory drugs Analgesic and anti-inflammatory properties Useful in the management of acute pain Use age >6 months Combined with paracetamol is effective in management of moderate acute pain Useful in musculoskeletal pain and headache Avoids opioid related side effects 17

19. Don’t forget the Sugar! -Sucrose solution -25% solution or single use 24% vials -Effective up until approximately 6 months of age -Mediates an increase in endogenous opioid release -Reduces procedural pain and minimises crying 18

20. Intranasal Fentanyl Quick & easy Rapidly absorbed – therapeutic levels in 2 minutes Easily administered for severe pain Doesn’t require a needle to administer Decreases time to analgesia Well tolerated Equivalent pain relief to IV morphine 19

21. ALA – topical analgesia Adrenaline, lignocaine and amethocaine mixture Applied in the wound for 30 mins Provides effective local anaesthesia Allows wound management with minimal discomfort 20

22. Reassessment Must, must, must reassess –Before and after analgesia Use the same pain assessment tool for consistency Escalation of care required if: –ongoing pain –increased pain –uncontrolled pain 21

23. Summary Use the right tool for the right patient –Choose pain assessment tool to suit developmental age of child Pharmacological interventions –Paediatric & Neonatal Quick Pain Guides Non-pharmacological interventions –Distraction Techniques, play, physical Importance of reassessment for effective pain management Consider escalation criteria 22