Pain Management in Infants and Children Lynette Thacker Clinical Nurse Specialist Paediatric Palliative Care Explain that the presentation will cover acute, chronic and pain experienced in 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.

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). Definition of pain that exists for all ages, but needs to be considered in the context of the child’s cognitive, emotional, social and cultural aspects.

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. Explain that there is research demonstrating that neonates experience pain and actually there is evidence that repeated exposure to painful procedures results in sensitising neural pathway development. This results in a lowering of pain thresholds not an increase. Accept that children can distract the experience of pain through play and this does not mean that they are not in pain. Sleeping is another mechanism that the body adopts to distract from pain and often it is not restful sleep when a child is in pain.

The Golden Rule What is painful to an adult is painful to an infant and child unless proven otherwise. Difficult when caring for the children and young people with impaired cognition. We have to take a pragmatic approach sometimes and this means to consider the physical nature of pain, if we think this may cause pain then we should treat as if there is pain. Example given is a child with neurological impairment having an extended abdomen from obstruction being given Paracetamol, when an adult may be given an opioid.

Types of Pain Nociceptive Somatic Well-localized Pain receptors in soft tissue, skin, skeletal muscle, bone Visceral Vague Visceral organs Neuropathic Damaged sensory nerves There are several types of pain. -Nociceptive pain is caused by activation of pain receptors in the body. It can be divided into somatic pain and visceral pain. *Somatic pain is usually characterized as sharp and well-localized and related to pain in skin, soft tissue, muscle or bone. *Visceral pain is generally more vague and related to activation of pain receptors in the visceral organs like the kidney or liver. -Neuropathic pain is often characterized as burning, shooting, tingling or electric. It is related to abnormal functioning of sensory nerves (i.e. by transection, compression, etc.)

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/partially insensitive Pragmatic In palliative medicine – classification tends to be pragmatic – based on recognisable clusters of pain symptoms and their response to different interventions

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 Neuropathic can be disorder of sensation like firery/icy sensation even sensation of trickling water. Often there will be skin changes in colour, temperature and appearance “goose pimple” for example. Gabapentin is an example of an anticonvulsant used to treat neuropayhic pain, amitryptiline and example of an antidepressent which will also aid sleep and lift the patients mood. Bone Can be intense and focal like a fracture but can also be disperse, many children with impaired mobility may experience bone pain from abnormal micro structure of the bone and micro fractures. This type of pain can respond to bisphosphonates such as Pamidronate Muscle spasms occur in acute fractures, in organs such as the bowel or in neuro-impairment from muscle groups of the limbs. During the muscle spasm acute pain is experienced but any sustained muscle spasm will result in pain. Cerebral irritation is seen with many of the infectious diseases if the infection has crossed the brain-blood barrier but is often seen in children who experience frequent seizures.

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. When manageing any pain the following concepts are adopted to ensure an holistic approach. Physical – Cause of pain, experience of pain, how is pain being communicated etc Psychological – How does it make the child/young person feel to be in pain. What do they know about the pain. What is the meaning of pain to them (worsening of symptoms). Are there any burdens or benefits to be gained from the pain. Social – How the wider family view the pain, what impact is the child/young person being in pain have on the family, does the family experience any burdens/benefits from the child/young persons pain. Spiritual – Are there religious needs associated with the pain but spiritual is more than religion. It is also concern’s the meaning of pain in relation to sickness/health or life/death, ability/disability.

QUESTT Question the patient/parent/carer Use pain rating scale Evaluate behavior & physiologic signs Secure family’s involvement Take cause of pain into account Take action and assess effectiveness Another approach to ensure that any type of pain experienced whether acute/chronic/palliative is approached in an holistic manner.

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

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

Infant Response to Pain Forcefully closed eyes Lowered brows Deepened furrow between nose and outer corner of lip. Square mouth Cupped tongue

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.

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.

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 Difference treatment will be offered dependant on severity, some risks with opioids because the patients are often opioid naïve and more likely to experience side effects such as drowsiness, nausea and vomiting, respiratory depression Play and distraction is still a very important method of pain relief.

Pre-procedural Pain Key to managing procedural –related pain is anticipation Anticipated intensity and duration Child / parent receive appropriate information to minimize distress Play therapy will reduce procedure anticipated pain but the parents play a huge role in what they convey to children as a trusted adult.

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 Medication will be based on the operation that is carried out but it is important that children/young people understand how to use Patient Controlled Analagesia before the operation.

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.

Non-pharmacologic Pain Management Physical Massage Heat and cold Acupuncture Behavioral Relaxation Art and play therapy Biofeedback Cognitive Distraction Imagery and Hypnosis Non-pharmacologic interventions may be helpful in managing pediatric pain and decreasing medical use. However, many of these services are not available in the middle of the night. These strategies would be important to recommend to the day-time team and parents would need support to help the child/ young person use them. The Royal Bath Hospital website is useful to explore Biofeedback as a management for chronic/palliative care pain.

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. Split the group into two and ask them to consider the case studies which are acute pain issues in children with palliative care needs. Case Study 1 – You want them to be able to identify that this child’s pain relief may need to be set higher initially to accommodate that opioids are already being used but then the child’s home regime may need to be changed post operatively as some of the pain may have been relieved by surgery. How are they going to assess pain. Other things to consider is how positioning this child will have an effect on pain management and how will they deal with muscle/dystonic spasms once in a cast. This child could also experience agitation from noisy unfamiliar environments and lack of familiar handling. The parents may be concerned regards anaesthetics and how the child will cope with these.

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. Bobby’s 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 Bobby’s pain in the post-operative period. Case study two – This is an acute injury but careful consideration needs to be given in relation to the use of opioids as this child is opioid naïve and as renal failure. We would use ½ the dose of opioids. NSAID are also contraindicated in renal failure. The syndrome will confuse most people but the key would be to ask parents about the syndrome and find out how it is affecting the child. Also need to undertake a full assessment of understanding and communication abilities. How are they going to prepare child and parents for theatre. How are they going to assess pain. There may be some associated problems with being hospital and having surgery because of deceased siblings , Would hope this comes out in discussion,.

WHO analgaesic ladder 1 – paracetamol, aspirin 2 – codeine, tramadol, low dose bup patch 3 – morphine, diamorphine, fentanyl, high dose bup patch, methadone, oxycodone, hydroxymorphone 1 – paracetamol, ibuprofen 2 – codeine, not all children metabolize codeine tramadol, low dose buprenorphine patch 3 – morphine, diamorphine, fentanyl, high dose buprenorphine patch, methadone, oxycodone, hydroxymorphone

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

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…..

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 Explain that there breakthrough does not alter the regular timings of the background analgesia ie if dose given at 9am and regular is due at 10am it is still given.

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

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

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

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

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

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

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.