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Pediatric Pain Management Karen Hewson, R. N. , M. N

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1 Pediatric Pain Management Karen Hewson, R. N. , M. N
Pediatric Pain Management Karen Hewson, R.N., M.N. College of Nursing, University of Saskatchewan

2 Outline Problem of Pediatric Pain
Myths/Misconceptions: Fact or Fallacy? Pain In Children’s Lives Assessment of Pain Pain Management Principles Procedural Pain Special Challenges: Neonates, Chronic Pain, End of Life Leadership and Advocacy

3 Pain in Children’s Lives (Kuttner, 2010)
Pain part of growing up Pain part of exploring the world Preschoolers during play experience an average on one “owie” every 3 hours Children frequently fall in playgrounds, riding bikes Children often experience pain as a result of dental care Some children and adolescents struggle for years with painful diseases and hospital treatments

4 The Problem of Pediatic Pain
Perpetuation of myths Lack of knowledge –pre professional, professional, Lack of interprofessional collaboration Knowledge transfer challenges Challenge of pain assessment in children Institutional barriers Everyone’s Problem Yet Nobody’s Problem

5 Fact or Fallacy? Infants and young children do not experience pain like adults Infants and young children will not have memory of painful experiences Neonates do not feel pain like older children and adults due to immature nervous systems Self report is always accurate in pediatric pain assessment Narcotics (opioids) should be avoided in infants and children due to risk factors such as respiratory depression and addictions

6 Fact or Fallacy(con’t)
Opioids should be avoided in adolescents due to the problem in society with substance abuse The harmful effects of analgesics are more serious than the harmful effects of unrelieved pain PRN (as needed) analgesics are more effective than scheduled analgesics Parental presence usually results in a lack of cooperation by the child Topical anesthetics such as EMLA or Ametopp make it more difficult to draw blood and perform procedures, such as IV insertion

7 Misguided Beliefs About Pain in Infants
Infants do not have the capacity to experience or remember pain Infants are neurologically immature and therefore cannot conduct pain impulses. Infants do not remember pain, because of cortical immaturity. Sleeping infants are not experiencing pain (Kuttner,2010; Twycross, A., Dowden, S., & Bruce, E. 2009)

8 Infants and Children do not express pain the same way as adults
Self report is gold standard in pain assessment “Pain is what the experiencing person says it is, when and where it is…” Challenges with non-verbal individuals * rely on physiological and behavioural measures (and the belief there is a reason for the pain!) A number of validated and reliable non-verbal pain scales based on these measures: PIPP, NIPP, FLACC (Kuttner, 2010; Twycross, A., Dowden, S., & Bruce, E. 2009)

9 Long term effects Unrelieved pain in infants can result in long term developmental problems Unrelieved pain in infants can permanently change their nervous system and may “prime” them for having chronic pain (Kuttner,2010; Twycross, A., Dowden, S., & Bruce, E. 2009)

10 Infant Memory of Pain Infants undergoing circumcision without pain relief compared to those who had pain relief had increased pain responses at subsequent routine vaccinations (Taddio et al., 1997)

11 Infants feel pain equally and perhaps more severely than older children and adults
The anatomical, physiological and biochemical prerequisites for pain perception are present in early part of intrauterine life Infants have larger receptive fields and possibly a higher concentration of substance P receptors (neurotransmitter related to sensation of pain) Nonmyelinated transmission: lack of inhibitory neurotransmitters (Mathew & Mathew, 2003)

12 Harmful Effects of Untreated Pain in Children
Respiratory (lungs)compromise Cardiovascular (heart) compromise Increased stress hormones Increased glucose secretion Slowing of gastrointestinal/genitourinary systems Poor nutritional state Muscle tension, spasm and fatigue Behavioural and psychological disturbances, PTSD Long term neurological effects Chronic pain syndromes (Kuttner,2010; Twycross, A., Dowden, S., & Bruce, E. 2009)

13 Pain Related Concerns in infancy Childhood and Adolescence
Acute illness Chronic Illness Unintentional injuries ex trauma Child abuse *These children experience pain d/t disease, injury, treatments and procedures

14 Premature Infant Pain Average painful procedures per day and in some infants up to 300/week 40-90% receive no effective treatment (Stevens et al., 2003) * Stevens et al *greater than 300 procedures in a week 2003 Preterm infant survival has risen steadily because of advancements in the knowledge and technology used to care for neonates (Martin et al., 2009). As a result, an increasing number of preterm infants are undergoing a neonatal intensive care unit (NICU) experience. During their NICU stay, preterm infants are subjected to an average of painfully invasive procedures per day, with repeated heel sticks (HSs) accounting for 55%-86% of these procedures ( [Carbajal et al., 2008], [Evans et al., 2005] and [Lago et al., 2005]). Unrelieved pain caused by HSs, associated with detrimental physiologic outcomes in all major organ systems, can be life threatening ( [Anand, 1998], [Holsti et al., 2004], [Mainous and Looney, 2007] and [Taddio et al., 2002]), and can have long-term cumulative behavioral sequelae, such as altered pain sensitivity ( [Abdulkader et al., 2008] and [Hermann et al., 2006]) and altered development and stress responsivity ( [Grunau et al., 2005] and [Grunau et al., 2004]). Exposure to these procedures without pain-reduction interventions has serious and lasting implications for adverse biobehavioral outcomes. Although recent advances in neurobiology and clinical studies have demonstrated that preterm infants do experience and respond to pain ( [Anand and Hall, 2008] and [Fitzgerald and Walker, 2009]; Slater et al., 2010), 40%-90% of infants do not receive any preventive and/or effective treatment to reduce procedural pain ( [Carbajal et al., 2008], [Lago et al., 2005], [Porter and Anand, 1998], [Sabrine and Sinha, 2000] and [Stevens et al., 2003]).

15 Chronic Pain in Children and Adolescents
Affects % of children and adolescents Reported as young as 3 years of age, however most prevalent in early teens Can be part of a chronic medical condition, develop following surgery, illness or injury or have no obvious cause Despite the significant physical, psychological, social and economic impact on children and families, chronic pain is often under-recognized and undertreated Physical and psychological impact of chronic pain in school age children can impact overall health and persist throughout adolescents and adulthood Children and teens with chronic pain have an increased incidence of anxiety and depression (Stinson & Bruce, 2009; Kuttner, 2010) Affects 15 – 20 % chidlren and adolescents Lasts longer than 3 months Children and teens with phsyical diability from disease or trauma often have chronic pain which affects all aspects of their lives

16 Chronic Pain in Children
“Chronic pain in children is the result of a dynamic integration of biological processes, psychological factors and socio-cultural context, considered within a developmental trajectory” (American Pain society Position Statement on Chronic Pain in Children, 2006) Has no apparent protective purpose and often the consequence of damaged, abnormally functioning nerves Despite the significant physical, psychological, social and economic impact on children and families, chronic pain is often under-recognized and undertreated (Stinson, 2009).

17 Fundamental Principles of Pain Management in Children
A child’s pain is to be believed and acknowledged Pain is real, and children and adolescents are the true authorities on their pain Treating children in pain requires a thorough understanding of the interaction of biological, psychological and social systems impacting the pain experience (Kuttner, 2010)

18 Guidelines in Pediatric Pain Management
“First do no harm” Understand developmental influences Be honest! Give choices when possible Involve parents and caregivers Take a pain history

19 Guidelines (con’t) Respect “safe places”ex. child’s bed, playroom
Choose the most appropriate analgesic, route and schedule Observe and prevent side effects of analgesics Use non-pharmacological methods Use a team approach

20 Self report of Pain in Children and Adolescents
Studies show that children can give a reliable self report of pain as early as age 3 (Twycross, 2009; Kuttner, 2010) Self report of pain is most reliable if the child is not overly distressed (Ibid.) Self report of pain is more reliable when parental support is present (Ibid.) A number of reliable and valid self report tools have been tested in children based on their developmental age and stages (Stinson, 2009; Kuttner, 2010)

21 Pain Perception in Children Bio-Psycho-Social Model (Twycross, A
Pain Perception in Children Bio-Psycho-Social Model (Twycross, A., Dowden, S., & Bruce, E. 2009) Child’s Pain Experience Biological factors Age Cognitive development Gender Genes Temperament Psychological Factors Fear Previous Pain Experiences Social Factors Family Learning Culture

22 Pain Assessment : Have we missed the mark?
Pain as the “5th Vital Sign” Pain scores: the concept of interpretability Clinical meaning must also be assessed: mild, mod or severe -treatment threshold, satisfaction with analgesia (Stinson et al., 2006)

23 Pain Scales Practice in advance Use same tool for same child
Evaluate at rest and with activity Document , including response to interventions

24 Standard Pain Scales Numerical Rating Scale (NRS) 0-10
Faces Pain Scale – Revised (FPS-R) 0 -10 FLACC behavioural scale

25 Reprinted with permission

26 *reprinted with permission

27 Factors in the Denial of Pain in Children
Developmental stage Believe the pain is punishment Influence of parent/health care professional (HCP) Adolescent sense of “imaginary audience” Longer hospital stay Fears of unknown, worsening pathology, death, addictions, ‘drugs are bad’ Challenge of chronic pain – not identified by child (Kuttner,2010; Twycross, A., Dowden, S., & Bruce, E. 2009)

28 Behavioural Responses
Variable Facial expression, body posture, vocalization Child may sleep in presence of pain Children use distraction well Judgments can lead to poor pain control

29 Observational Scales Face Legs Arms Cry Consolability (FLACC) 0-10
Neonatal/Infant Pain Scale (NIPS) Premature Infant Pain Scale (PIPP) Non-Communication Children’s Pain Checklist (NCCPC) Parent’s Post-operative Pain Measure Pediatric Pain Profile

30 FLACC Behavioural Scale
Lack of researach on very low BW and very premature neonate response to pain ex may be flaccid or limp in reponse to noxious stimuli Infant motor skill developementTypically cepaholocaudal and proximodistal progress One exception: studies show infants reaching for objects with feet first, before reaching with arms

31 Facial Expression of Physical Distress
NASO- LABIAL FOLD deepened

32 Behavioral Response Facial expression of pain.
Observed in the 25 weeker though youner gestational age associ with less reactivity and demonstrated increasing behaviours as they matured 9longitudinal study) Facial expression of pain.

33 Infant Crying in Pain Cry of infant in pain is higher pitched, less melodious and more harsh Only relevant in infants that vocalize cry Neonates and infants with ‘silent crying’ are not taken into consideration (Wong et al, 2009)

34 Pain Assessment Special circumstances
When children are Limited English proficient (LEP), pain assessments must be conducted in the language the child is most familiar (Boyd, Bee & Johnson, 2009; Dowden, S., & Bruce, E Twycross, 2010). Children with developmental or communication disabilities are often under assessed and under treated for pain (Kuttner, 2010).

35 Measurement of Pain Severity in Children with Developmental or Communication Disabilities
Children with neurological disorders such as cerebral palsy or autism may have difficulty expressing their pain in a way that others understand In addition to communication barriers, these children often have multiple medical problems and often undergo multiple medical procedures (Stinson, 2009)

36 Assessment of Pain Severity in Children with Developmental or Communication Disabilities
Behavioural cues: facial expression, moaning, screaming, sweating or flushing, changes in posture and movement, changes in sleep and eating, changes in mood and sociability (Stinson, 2009)

37 Keep in mind… Children in pain may regress to an earlier stage of development A child’s experience of illness and hospitalization may change their perception of and ability to cope with pain (Kuttner, 2010)

38 A High Index of Suspicion
In summary, assessment of a child’s pain can be very challenging. Even with a multidimensional approach, there may be uncertainty about the presence and severity of pain, particularly in infants and young children. When a child cannot or will not report pain, a high index of suspicion may be the most helpful assessment and a trial of analgesics is usually helpful for diagnosis (McCaffery, 1996)

39 Parental Presence and Pain
“The presences of a known and trusted adult makes the experience bearable for both children and adolescents in a myriad of obvious and subtle ways, and enables them to cope” (Kuttner, 2010, p. 75). Both children and adolescents have reported that what has counted the most when having pain is having parents with them (Kuttner, 2010) Teens may say they can handle it on their own but it is important to offer support until they are coping (Kuttner, 2010)

40 Pharmacological Principles
Prn (as need) versus scheduled analgesia Pre-emptive analgesia (in advance of painful procedure) Choice of analgesic, dose range and frequency Route of choice: considerations Proper dosing Prevention and management of side effects

41 Analgesics Acetaminophen –dosing, alternating, adjunctive
NSAIDS: Ibuprofen, Naprosyn, Ketorolac Codeine concern Meperidine (Demerol) not recommended Morphine “gold standard” Hydromorphone Other: ketamine, methadone, fentanyl Twycross, A., Dowden, S., & Bruce, E. 2009

42 The Codeine Concern No longer recommended in children
Weak opioid with ceiling effect Metabolized and converted to Morphine in the body Ineffective in approximately 30% (poor metabolizers) Approximately 5% ultra rapid metabolizers –deaths have been reported Consider NSAID, low dose Morphine Twycross, A., Dowden, S., & Bruce, E. 2009

43 The Dark Side of Demerol
Metobolite nor-meperidine accumulates in CNS and can cause neurotoxic effects (tremor, seizures, confusion, nervousness) Can cause seizures in children after single dose Rapidly accumulates Subsequent doses less effective Higher rates of side effects Twycross, A., Dowden, S., & Bruce, E. 2009

44 Morphine Well known, well studied
Mimics body’s endogenous opioids “endorphins” Most frequently used opioid in moderate to severe pain in pediatrics, but still underutilized Standard by which other opioids are compared Twycross, A., Dowden, S., & Bruce, E. 2009 Unwarraned Fear of morphine still hinders adequate pain relief for children in many countries

45 Ketamine Anesthetic agent with analgesic effects
Uses: anesthesia, procedural sedation, analgesia In creased use as low dose infusion increasing use in pediatric complex acute and cancer pain Opioid sparing; useful with kidney/liver dysfunction Can be used solely or as co-analgesia Adverse effects: dysphoria , increased salivation and agitation at higher doses (Twycross, A., Dowden, S., & Bruce, E. 2009) -analgeia even at very low anaesthetic doses -can reduce opioid consumption up to 30% -blocks pain wind up and hyperalgeia-therefore prob most efficacious for escalating pain or as rescue analgesic drug responive to opoiod analgesics -single dose less effective than infusion in combo with opiod infusion/PCA or alone –short half life -useful with renal or hepatic dysfunction metabolized in liver with min drug remaining for excretioin Adverse effects –main s effect dysphoria esp vivid dreams and hallucin about 10 % pts (may be similar to opoid rates) -resp and cv changes minimal -when used higher doses for procedural sedation, increase salivation, agitaiton and emergence reactions have been report –more concerns with ariway – need trained clinician with advanced airway skilss -when used for pain min adverse effects apart from dysphoria and often well tolteratve if pts know what to expect ad that effects limited to duraiton of infusion Routes: IV, po, IT, epi and sc – po, IV bolus procedural – IV inf pain

46 Adjuvant Analgesic Drugs
Antidepressants ex TCAs Anticonvulsants: ex. gabapentin, Clonidine, Dexmedetomidine Topicals ex lidocaine, NSAID (Twycross, A., Dowden, S., & Bruce, E. 2009) -work to assist anlgeis – co-analgesics ex muscle relaxant, used to counter effects of analgeis rex n and vor analgesic int heri own right ex keamin, gaba, amitripltye Anticonvulsant – reduce neuronal excitabilty -the physiology of pain and epilepsy are simiar therefroe anticonv work at analgesis -tx of chronic neuropathic pain and may work in acute neurpathic -used in chronic pain in kids, not yet licences -gabapentin first choics less adverse effects ?–can reduce post op pain and anxiety in adults -topiramiate –migrain prophylaxis in adults -start low and slow to avoid s effects –can still see :dizzy, sedation, hyperactivity, aggressiveness, edema TCAs- rapid onset of anlgesic effects in addiont to their other antidepressant effects-their additional effects of improved sleep and mooed elevations may also improve pain –effetive from neuropathic pain -Kuttner – chemo induced neuropathy, complex regoinal pain syndrome, infiltrative tumour pain, phantom pain post amp, burn pain, functional abd pain – neg: ECG chagens and antichol/antihistamin effects ex dry mouth, constpiation, blurred vision, sedation SSRI – no evidence that better than placebo –more research? –take 4-6 weeks for effect SRNI ex effexor –effective in neuropathic pain but less effective than TCAs Alpha 2 ex clonidine-produce sedation and analgesia without impairing respiration – can be used an anxiolytic and analgesice – usefyul to control sx of opioid and benzo withdrawal -improves post-op anlagesic – sedation and hypotension at higher oses IV, po epidural -dexmedatomide –reduced opoid use by 50% when used as sedative in ICU settings –used as alternative to benzodiazepines for sedation in the peds ICU Baclofen –effedtive antispasmodic, acts on GABA rececptros at spinal cord level – po or IT for tx of severe spasticity and dsytonia ex CP Benzos – skeletal muscle spasm thus reducing pain exp following ortho surgery Can be used as adjuncts to systmeic or regoinal anaesthics Biophosphanates – bone pain metastatic cancer -also Botox

47 Definitions Addiction –psychological dependence on drugs with drug seeking and drug using behaviour Physical dependence –physiological response to dose reduction or abrupt discontinuation of a drug leading to withdrawal symptoms Tolerance –decreased effectiveness of a drug over time Pseudoaddiction-drug seeking behaviour due to untreated pain Twycross, A., Dowden, S., & Bruce, E. 2009

48 Guidelines for Opioid Tolerant Patients
Do not withhold opioids Maintain patient opioid regime as baseline Opioid requirements are higher for acute pain Often have less opioid side effects Adjuvant medications may help Assess and manage signs of withdrawal (Twycross & Dowden, 2009) Terms pseudoacction Children may develop physical depedncance quicker Those with or without addiction – need guideines to ensure abstinence syndrome is miniized or avaoided Who: hx ofillicit drug use, either using opioids or on a treatment program, chronic pain/chronic cancer pain treated with opioids Pts with acute opioid tolerance due to recent high requirements ex ICU admisssion, major trauma s/s iwthdrwaysl: sweating, n and v, agitation,k diarheea, yawning, dilated pupiles, anxiety, resltess, insomnia, tachy, hyerperten, abd pain Adjuvant ex tramadol, ketamine, NSAIDS, regoinal analgeisa

49 Placebos (Twycross, A., Dowden, S., & Bruce, E. 2009)
Placebos administered without patient consent are considered unethical 30 % population has placebo response “Physical “pain and “psychological “ pain cannot be separated (Twycross, A., Dowden, S., & Bruce, E. 2009)

50 Non Pharmacologic Strategies
Parental Presence Distraction Relaxation Guided imagery TENS Biofeedback Heat/Cold Self-hypnosis (Kuttner, 2010) Kuttner P 13 natural endorphins-opiod morphine like -suppresses pain-found throughou baody-value of nonpharma- reason why opiods work well P12 quoute -girl candyland 12 year old -heightend sense Non pharma 54 how well self hypnosis works in kids Nonpharmacologic treatment of pain Stress and anxiety play important roles In the pain experience. Many of tbe nonpharmacologic treatments can reduce the associated stress and atixiety. Staff must be familiar with concepts of cliild development in order to implement the appropriate nonpharmacologic treatment (Table 1). One key element is the preparation and education of both tbe child and the family tar the procedures and the plan for pain management. Tlic- use of the nonpbarniacologic strategies should be used as an adjimct in tbe treatment of pain. There has been some controversy regarding parents" role. Some clinicians feel that parents can increase a child's anxiety or that the child only mentions pain when the parent is present. Scbool-age and younger children want ER If tbe parent chooses to remain during tbe procedure, it is helpful to teach them or demonstrate for them some nonpharmacologic strategies they can use to reduce their child's level of atixiety/distress. If tbe parent chooses tiot to remain during the procedure due to his or her own level of distress, it is important to support that parent's decision.

51 Procedural Pain Management
Consider conscious sedation, general anesthetic Use topical anesthetics and/or sucrose Parental presence Positioning and restraint Respect safe places Pre and post therapeutic play –involve parents and child life specialists Advocate! Kuttner, 2010

52 Neonatal/Infant Procedural Pain Management
Kangaroo care, Swaddling Sucrose Studies on extubation, respiratory distress and pain Under 27 weeks gestation* work to be done (Kuttner, 2010; Twycross, A., Dowden, S., & Bruce, E. 2009

53 Leadership and Advocacy in Pain Management
Educate, dispel myths Evidence based practice/knowledge translation Pain as “5th Vital Sign” Ethics /legalities Institutional strategies Unit strategies Pediatric Pain Champions Interprofessional Team work (Twycross, A., Dowden, S., & Bruce, E. 2009 Releasing time to care Promoting change A number of strategies have been attempted to alter the practice behavior of healthcare professionals regarding pain control in children. These include educational initiatives, guideline development, and quality audits. Unfortunately, multiple studies have suggested that although these techniques have some impact on practice behavior, in general, disconnected initiatives (random lectures on pain, availability of guidelines, occasional quality audits) typically do not yield sustained Pediatric Pain Letter, December 2010, Vol. 12 No change in the quality of pain management at a given institution (Lomas et al., 1989; Lomas et al., 1991; Davis et al., 1995; Davis et al., 1999; Pisacane, 2008; Zernikow et al., 2008). It appears that unless concern about pain is perceived as a core institutional value and an essential element of care, initiatives by individuals, no matter how well meaning, will have only limited success. Interventions such as lectures and audits are more likely to impact on behavior if they fit into an institutional culture in which addressing pain is an expectation. In that way, appropriate pain management does not rely on the memory or good graces of any one practitioner but instead becomes part of the institutional fabric similar to issues of safety and confidentiality. For this to occur, first and foremost, providing comfort must be formally established by the administration as a priority. Inadequate pain management can then be viewed as out of context and should be seen as everyone’s responsibility to remedy. All of the measures previously mentioned (education, guidelines, audit) will be subsequently seen in a different light. A number of authors have written about Kuttner quote: Instead of minimizing misunderstanding or dismissin a child' pain, a skill prof can provide prompt pain relief and empower child to cope -p 7

54 Questions? Comments?

55 References Boyd, H., Bee, H. & Johnson, P. (2008). Lifespan Development. 3rd Canadian edition. Toronto: Pearson Education Dowden, S., McCarthy, M., & Chalkioadu, G. (2008). Achieving organizational change in Pediatric pain management. Pain Research Management 13 (4), Kuttner, l. (2010). A child in pain: What Health Professionals can do to help. Bethel: Crown House Publishing Stevens, B., Riahi, S., Cardoso, R., Ballantyne, M., Yamada, J., Beyere, J., Breau, L.Camfield, C., Finlay, G., Franck, L., Gibbons, S., Howlett, P., McKeever, P., O’Brien, K., & Ohlsson, A. The influence of context on pain practices in the NICU: Perceptions of health care professionals. Qualitative Health Research 21 (6), 757 – 770. Stinson, J. (2009). Pain Assessment. In Twycross, A., Dowden, S. and Bruce, E. (eds). Managing Pain in Children: A clinical guide. West Sussex: Blackwell publishing Ltd. Taddio, A., Goldbach, M., Ipp, M., Stevens, B. (1995). Effect of neonatal circumcision on pain response during vaccination in boys. Lancet 345 (8945), Twycross, A. ( 2009). Pain: a bio-psycho-social phenomenon. In Twycross, A., Dowden, S. and Bruce, E. (eds). Managing Pain in Children: A clinical guide. West Sussex: Blackwell publishing Ltd.


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