1. Pain Assessment in Infants and Children
Donna L. Wong,
PhD, RN, PNP, CPN, FAAN
Web site:
D. Wong 2002
; Copyright.

2. Facts about Pain in Infants and Children
Infants, regardless of age, feel pain.
The youngest premature infant has the anatomic and physiologic components to perceive pain or “nociception” and demonstrates a severe stress response to painful stimuli.

3. Pain Mechanisms in Newborns
Complete myelination of nerve pathways not required for pain transmission
C-fibers are unmyelinated and A-delta fibers are thinly myelinated
Incomplete myelination results in slower conduction velocity but offset by shorter distances

4. Pain Mechanisms in Newborns, cont.
Complete myelination of pain pathways to brainstem and thalamus by 30 weeks gestation; thalamus to cortex by 37 weeks
Nociceptive nerve endings in cutaneous and mucous surfaces by 20 weeks of gestation

5. Pain Mechanisms in Newborns, cont.
Threshold for responding to cutaneous stimulation is lowest in youngest neonates
Inhibitory pathways do not develop until after birth

6. Stress Responses to Postoperative Pain in Neonate
Biochemical Changes:
 stress hormones
corticosterone
adrenaline, noradrenaline
glucagon
aldosterone
 metabolites
glucose
lactate
pyruvate

7. Facts about Pain in Infants and Children
Unrelieved pain in infants can permanently change their nervous system and may “prime” them for having chronic pain.

8. Changes in Peripheral Nervous System
Sensitization --  sensitivity of receptor (nociceptor)
 frequency of firing of receptor
Neuronal sprouting --  receptor field, eg, neuromas
When sensitized, receptors respond to new forms of stimulation, eg, hyperalgesia, allodynia

9. Changes in Central Nervous System
Central sensitization – formation of spontaneous impulses
Wind-up --  in magnitude of response to C fiber activity by dorsal horn neurons
Long-term potentiation – cellular “memory” for pain may lead to  responses to nociceptor stimuli
Facilitation –  impulse threshold and  intensity of response
Neuronal sprouting --  nerve endings into adjacent laminae (I and II may spread to III)

10. Children Do Not Tolerate Pain Better Than Adults
Children’s tolerance to pain actually INCREASES with age.

11. Children Can Tell You Where They Hurt
Children beyond infancy can accurately point to the body area or mark the painful site on a drawing; children as young as three years can use pain scales.

12. Children Do Not Always Tell The Truth About Pain
Children may not admit having pain to avoid an injection, because of constant pain, or because they believe others know how they are feeling.

13. Children Do Not Become Accustomed To Pain or Painful Procedures
Children often demonstrate INCREASED behavioral signs of discomfort with repeated painful procedures.

14. Consequences of inadequate analgesia during painful procedures in children
N = 21 children, BMA or/and LP, RCT placebo vs transmucosal fentanyl (TF)
Placebo group rated pain higher than TF group
Placebo group then received TF
Children <8yrs. (n=5) still rated pain higher than TF group
Ref: Weisman SJ, Bernstein B, Schechter NL: Arch Pediatr Adolesc Med 152(2): , Feb 1998.

15. Behavioral Manifestations of Pain May Not Reflect Pain Intensity
Children’s developmental level, coping abilities, and temperament, such as activity level and intensity of reaction to pain, influence pain behavior.

16. Coping Behaviors vs Pain/Fear Ratings
N=17 children, ages 3-15 yrs, during LP
Active Behaviors =  Pain Rating
Resists, denies, attacks
Passive Behaviors =  Pain Rating
Avoids, cooperates, ignores
Mean Pain Rating = 4.9/6 (SD = 1.5)
Fear Rating: low not related to behaviors
Ref: Broom M, et al: ONS, 17(3): , 1990.

17. Parents Want to be Involved in Their Child’s Pain Control
Parents need information about assessing pain and using interventions to relieve pain.
Parental presence during painful procedures is generally desirable for the child and parent.

18. 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.

19. Risk of respiratory depression from opioids to treat pain
3 of 3,263 patients developed respiratory depression from parenteral meperidine (Demerol) during hospitalization (0.09%)
No patient developed respiratory depression from oral meperidine
Ref: Miller, RR & Jick, H; J. of Clin. Pharm. 18: ,1978.

20. Incidence of anaphylaxis in penicillin administration
Anaphylaxis 4 of 1000 – 4 of 100 (0.004 – 0.04%)
At least 300 deaths/year
Ref: Hardman J, Limbird L, Gilman A: Goodman & Gilman’s the pharmacological basis of therapeutics, ed. 10, 2002, p

21. Protective benefits of opioids
As tolerance to analgesic effect of opioids occurs, tolerance to respiratory depressant effect also occurs.
Pain =  opioids =  respiratory
depression

22. Risk of Addiction in Children
Adolescent/198 with SCD admitted for 423 hospitalizations for pain (Morrison, 1991)
Children/610 with SCD (Brozovic & others, 1986)
Children/135 with Cancer (Rogers, 1990)
Children/144 postoperative intravenous opioids (Dilworth & Mackellar, 1987)

23. Definitions confused with addiction
Involuntary and physiologic responses:
Drug tolerance: need for larger dose of opioid to maintain original effect.
Physical dependence: withdrawal symptoms when chronic use of opioid is discontinued or opioid antagonist (Narcan) is given.

24. Narcotic Addiction Behavioral and voluntary pattern
characterized by compulsive drug-seeking behavior
leading to overwhelming involvement with procurement, and
use of opioid NOT for medical reasons, such as pain relief.

25. 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).

26. Children’s Pain Continues To Be Poorly Controlled
Pain during procedures and surgery, postoperative pain, and disease-related pain are inadequately controlled.

27. End of Life: Pediatric Cancer
Survey of 103 parents whose child died of cancer (1990 – 1997)
Interviews conducted average 3.1 years after death
 Focused on quality of life during last month of life
Ref: Wolfe J & others: NEJM 342(5): , 2000.

28. End of Life: Pediatric Cancer, cont.
89% of children suffered from 1 of 4 problems; 50% suffered from 3 or more:
Fatigue
Poor appetite
Pain -- treated in 76%, successful in 27%
Dyspnea -- treated in 65%, successful in 16%

29. Multidimensional Model of Pain Assessment

30. 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.

31. QUESTT Question the patient Use pain rating scale
Evaluate behavior and physiologic signs
Secure family’s involvement
Take cause of pain into account
Take action and assess effectiveness

32. Question the Child Verbal Indications of Pain
Much less common than in adults
May not understand term, such as “pain”
May speak globally, such as “I don’t feel good”
May deny pain for fear of injection
Cries, screams, groans, moans

33. Question the Child, cont.
Use a variety of words to describe pain, such as owie, boo-boo, ouch, hurt, ow ow
Know words in other languages
Spanish: Ay ay, duele, lele, dolor

34. Have Child Locate Pain by:
Marking body parts on a human figure drawing
Point to area with one finger on self, doll, stuffed animal
Point to “where mommy or daddy would put a bandage”

35. Use diagram to have child locate pain

36. Burn patient’s drawing

37. Use Pain Rating Scale
In 2001 Joint Commission on Accreditation of Healthcare Organizations (JCAHO) published Pain Standards
One of the standards is to make pain rating the 5th vital sign.

38. Use Pain Rating Scale, cont.
Select a scale that is suitable for the child’s age, abilities, and preferences
Teach child to use scale before pain is expected, such as preoperatively
Use same scale with child each time pain is assessed
Ask child about acceptable or functional pain level

39. Types of Pain Rating Scales
Numbers
Visual analogue
Words
Colors
Faces
Behavior/physiologic
signs

40. Samples of Pain Rating Scales From JCAHO Pain Standards
0-10 Numeric Scale
Simple Descriptive Scale
Visual Analog Scale (VAS)
Wong-Baker FACES Pain Rating Scale

41. Numeric Scale 1 2 3 4 5 6 7 8 9 10
No Pain
Worst Pain

42. Simple Descriptive Scale
No Pain
Mild
Moderate
Severe
Very Severe
Worst

43. Visual-Analogue Scale*
No Pain
Worst Pain
Usually 0-10 cm long line.
Placed either vertical or horizontal.

44. VAS: Coloured Analogue Scale (Ref: McGrath, PA, et al: Pain, 1996.)

45. Wong-Baker FACES Pain Rating Scale

46. Sample of Child’s FACES Pain Rating Scale

47. Sample of Child’s FACES and Body Outline

48. Photographic/ Numeric Pain Scale
Oucher scale (Beyer)
White child, 3 year-old male

49. Photographic/ Numeric Pain Scale, cont.
Oucher scale (Beyer)
Black child, school age, male

50. Photographic/ Numeric Pain Scale, cont.
Oucher scale (Beyer)
Hispanic child, school age, male

51. Cultural Preference for Scales
100 African-American children with SCD rated preference of 3 scales:
FACES -- 56%
Black Oucher -- 26%
VAS -- 18%
Validity was strongest for FACES, then Oucher and VAS
Ref: Luffy R: Pediatric Nursing, Jan 2003.

52. Cultural Preference for Scales
Study of children in native country and preference of 0-5 vs FACES scales:
132 Chinese: FACES, 109 (82%)
167 Japanese: FACES, 120 (72%)
151 Thai: FACES, 115 (76%)
Ref: Wong D, DiVito-Thomas P: Multicultural study of the FACES scale, unpublished,

53. Evaluate behaviors and physiologic changes
Acute Pain vs Chronic Pain
Acute pain activates body’s fight or flight stress response.
When pain persists, body begins to adapt and there is a decrease in the sympathetic responses.
In chronic pain, stress response is absent or diminished.

54. 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

55. Possible Physiologic Signs of Pain in the Neonate
Physiological Variables
 HR, RR, PB
shallow respirations
 vagal nerve tone (shrill cry)
 pallor or flushing
diaphoresis, palmar sweating
 TcPO2 and  O2 saturation
EEG changes

56. Possible Signs of Pain in the Neonate: Behavioral Variables
Vocalizations:
Crying (often with apneic spells)
Whimpering, groaning, moaning
State changes:
Changes in sleep/wake cycles
Changes in activity level
Agitation or listlessness

57. Possible Signs of Pain in Neonate: Behavioral Variables, cont.
Bodily Movements:
Limb withdrawal, swiping, or thrashing
Rigidity
Flaccidity
Clenching of fists

58. Possible Signs of Pain in Neonate: Behavioral Variables, cont.
Facial expression (most reliable sign):
Eyes tightly closed or opened
Mouth opened, squarish
Furrowing or bulging of brow
Quivering of chin
Deepened nasolabial fold

59. Facial Expression of Physical Distress
NASO-
LABIAL FOLD
deepened

60. Observe for Specific Behaviors that Indicate Local Body Pain
Pulling ears
Rolling head from side to side
Lying on side with legs flexed on abdomen
Limping
Refusing to move a body part

61. Behavioral Pain Rating Scales
For infants and non-verbal children, use appropriate observational scales:
CRIES (32-60 weeks gestational age) (Kretchel & Bildner, 1995)
FLACC (full term neonate – 7 years) (Merkel & others, 1997) 
NPASS (Neonatal Pain, Agitation and Sedation Scale) (prematurity)
(Hummel & Puchalski, 2002)

62. FLACC

63. NPASS (Neonatal Pain, Agitation and Sedation Scale)

64. Pain Indicator for Communicatively Impaired Children (PICIC)
Most common cues identified by 67 parents:
Screwed up or distressed looking face
Crying with or without tears
Screaming, yelling, groaning, moaning
Stiff or tense body
Difficult to comfort or console
Flinches or moves away if touched
Ref: Stallard P, et al: Pain 98(1-2): , 2002.

65. Observe for Improvement in Behavior Following an Analgesic

66. Observe for Improvement in Behavior Following an Analgesic

67. Secure Family’s Involvement
Take pain history before pain is expected, such as on admission to hospital or preoperatively
Involve family in recording response to pain relief measures

68. Secure Parents’ Involvement, cont.

69. Take Cause of Pain into Account
Use common sense and logic.
Realize that for a an infant and small child, punctures are proportionally larger on their tiny bodies.

70. Take action and assess effectiveness
The only reason to assess pain is TO TAKE ACTION TO RELIEVE PAIN.
After intervention, assess child’s response to pain relief measures.
Determine timing of assessment based on expected onset and peak effect of intervention:
IV analgesic: assess after 5 minutes and 15 minutes

71. The Golden Rule
What is painful to an adult is painful to an infant and child unless proven otherwise.

72. Questions, Comments, Concerns