Pain Management

in Children
Helping Children With Pain
 Learning Objectives

Definition of Pain

Potential Consequences of Untreated

Pain

Age Specific Physiology and

Pharmacology

Treatment Guidelines
 Pain Receptors -
Nociceptors
Receptors are present all over the body that are
sensitive to noxious stimuli

skin = polymodal receptors: touch/pressure,

heat and chemicals

cornea, dentine, periosteum = unimodal

receptors: pain only

All sensory nerves will produce pain sensation if

stimulated sufficiently
 Source of Pediatric Pain

Acute Pain Pain associated with

Procedural Pain chronic disease
Surgical Pain Sickle cell disease
Post-traumatic pain
Burn pain
Juvenile
Chronic (Persistent) Pain Fibromyalgia
Abdominal Pain Juvenile Rheumatoid
Limb Pain Arthritis
Headache Pain
Cancer
Chest pain
Neuropathic Pain
 Responses to pain
Respiratory Changes:
Rapid shallow breathing
Inadequate lung expansion
Inadequate cough
Neurological Changes:
Sympathetic activity ↑
Metabolic Changes:
Metabolic rate↑
Immune system changes:
Depression of immune response
Gastrointestinal Changes:
Intestinal secretions and smooth
muscle tone ↑
Potential Physiologic
consequences
Alkalosis
SaO2↓ , atelectasis
Retention of secretions
Tachycardia, change in sleep pattern,
increase blood glucose and cortisol
Fluid and electrolyte losses↑
Increase risk of infection
Impaired gastrointestinal
functioning, ileus
 The Vicious Cycle of Pain

Social
Isolation Poor
Inactivity
Mood

Psychological
and social factors
can perpetuate Fatigue
Stress
pain, especially PAIN
in chronic pain
disorders
Poor Poor Self
Sleep Efficacy
Anxiety

Kelly KK, et al. PediatrClinic North Amer. 2005; 52:611-6393

How children differ from adults with
respect to pain management

The cognitive immaturity and developmental status

of the child can increase their lack of cooperation
and make any treatments or procedures more
difficult.
Small children have a high oxygen consumption
and low alveolar volume. Therefore, they will
desaturate more rapidly with periods of apnea in
comparison with adults
The absorption and metabolism of some drugs
changes as neonates mature to infants and toddlers.
Oral IM Submukosa Lokal/Infiltrasi Topikal Inhalasi IV

Dissolution Absorbsi

Protein Cairan
Organ target
Plasma Plasma

Distribusi Metabolisme
Jaringan

Ekskresi Metabolit Ekskresi Obat

Drugs
Routes Empedu Ginjal Ginjal
 Perubahan Prematur Bayi Anak
Fisiologi
Waktu Pengosongan Tidak teratur Meningkat Meningkat
Lambung
pH Lambung >5 4-2 2-3 ( normal)
Motilitas usus berkurang meningkat meningkat
Luas permukaan berkurang Mendekati Sama dengan
usus dewasa dewasa
Fungsi Bilier Belum matang Mendekati Sama dengan
dewasa dewasa
Permeabilitas Kulit Meningkat Meningkat Dewasa
Absorpsi Oral Erratic - berkurang meningkat Sama dengan
dewasa
Absorpsi rektal Sangat efisien efisien Sama dengan
dewasa
Absorpsi Sangat efisien efisien Sama dengan
dewasa
 Facts About Children and Pain

Neural Mechanism that allow sensation and

transmission of pain are present at 20 weeks
gestation
Infants demonstrate behavioral, physiological,
and hormonal indicators of pain
Children’s pain tolerance actually increases with
ages
By 4 years of age, children can accurately point
to the body area or mark the painful site on a
drawing
Children as young as years can use pain scales
 PAIN ASSESSMENT
The gold standards of pain assessment in children is the self-
report
No universally accepted standard pediatric pain assessment
tool
Selection of the appropriate tool should be based on:
Child’s age
Cognitive development
Medical condition
Ethnic background and gender
The ability of children to report and to describe pain emerges
with increasing age and experience and typically follows a
developmental progression,

CAN J ANESTH 2001 / 48: 6

 Classified as
Self Report Measures
Gold Standard
Most valid approach
Require sufficient cognitive and language
development to understand the task and
generate accurate response
Exist in verbal and non verbal formats
Verbal : structured interviews, questionnaires,
self-rating scales, pain adjective descriptors
Non verbal : facial expression scales, visual
analog scales, drawings
 * 
As bad as it
could be

0 1 2 3 4 5 6 7 8 9 10

No Pain
Observer based behavioural scales
FLACC and CHEOPS for acute procedural
and postoperative pain;
COMFORT scale for children in intensive
care
Parents Postoperative Pain Measure (PPPM)
for postoperative pain managed by parents
at home
 Goals of Pain management in
Children

Eliminate or reduce pain to tolerable levels

The child is pain-free when at rest.
The child can move about or be handled without
discomfort.
The child should sleep undisturbed by pain.

Prevent or minimize side effects from pain medications

Restore function and maintain joint mobility

Educated patient and/or family

General Treatment Guideline

Anticipate predictable painful experiences and

intervene accordingly. Prevention is better than
treatment.

Involve that family in the child’s care, as family insights

are very helpful.

Use multimodal approaches to pain management,

incorporating pharmacologic and non-pharmacologic
interventions when possible.
Early effective treatment is safer and more efficacious
than delayed treatment and

Early treatment results in improved patient comfort and

may be associated with decreased clinical
complications and decreased mortality
 The 3P’s of Pain Prevention and
Intervention
Pharmacological
Give analgesics regularly
use least invasive route

Pharmacological follow WHO step treatment

Psychological Physical
Heat and / or cold
massage
pressuse
Physical Ambulate
Psychological
explanation to child and parent
Distraction
child life or behavioural health
 Practice Guide
Assess Pain

When :
On admission, once a shift, before/during/after
painful procedures or surgical interventions
How :
Use Developmentally Appropriate Test

Is Pain Present? Yes

No Management and Interventions

3 P’s
 Acute Pain Management

Pharmacology
NSAID-s and Acetaminophen
Other Drugs
Opioid
Regional / Local Anesthesia
Neuraxial Block
Peripheral Block
Topical Anesthetic
Non Pharmacology
 Acetaminophen

Most widely used analgesic for mild to

moderate pain
Inexpensive
Useful in patients with aspirin sensitivity
Used alone and in combination with opioids
Most commonly used oral regimen: 10-15
mg/kg/dose q4-6 hours
Produces therapeutic plasma concentrations
(10-20 mcg/mg)
 Ketoprofen
ketoprofen administered i.v. during the operation
produced analgesia and reduced opioid consumption
and the incidence of vomiting in children 1-12 yo after
strabismus surgery.

KOKKI H., HOMAN E. Acta Anaesthesiol Scand 1999; 43: 13–18

Ketorolac
Ketorolac was used safely in neonates and infants who
have had cardiac surgery at our institution. Ketorolac was
not associated with any adverse hematologic or renal
effects. Prospective investigation is warranted to further
assess the safety and effectiveness of ketorolac in this
patient population.
 Ketamine

Ketamine 1 mg/kg) i.v. provides satisfactory serum

concentrations for children undergoing sedation for painful
procedures of <5-min duration and produces concentrations
associated with analgesic effect for more than 10 min.

Clearance increases with decreasing age in children.

Ketamin : Topical , Neuraxial

DAVID HERD AND BRIAN J. ANDERSON,

Pediatric Anesthesia 2007 17: 622–629
 Tramadol

Centrally acting analgesic

Mechanism of action
weak μreceptor agonist
monoaminergic activity at spinal level to block
serotonin and norepinephrinereuptake
produces active metabolite
Less potential for dependence?
Used for mild to moderate acute pain in children
Dose : 1.5 – 2 mg/kg i.v.

Pediatric Anesthesia 2006 16: 54–58

Codeine is contraindicated to treat pain or cough, and tramadol
is contraindicated for treating pain in children under 12.
Tramadol is contraindicated for treating pain after surgery to
remove tonsils and/or adenoids for children under 18. Use of
codeine for this purpose was placed under the same restriction
in 2013.
Codeine and tramadol are not recommended for use in
adolescents ages 12-18 who are obese or have conditions
such as obstructive sleep apnea or severe lung disease.
Mothers should not breastfeed when taking codeine or tramadol.
 OPIOID ANALGESIA

Oral

• morphine/MS Contin

• oxycodoneIR/oxycontinSR

Intravenous • morphine

• fentanyl

• hydromorphone
 Neonatal Opioid
Metabolism

Elimination twice as long as older patients

Glomerular Filtration slows elimination of active

metabolite

P450 function slows morphine clearance

 Morphin

“Gold Standard”

Side effects

Neonates especially sensitive to adverse effects

altered μ1 to μ2 receptor ratio
developmental differences in morphine
metabolism
Dosing Recommendations for Opioid
Analgesics in Neonates
Opioid-Related Side Effects

Changes in mood, sedation, confusion

Respiratory depression
Decreased gastrointestinal motility,
constipation
Nausea, vomiting
Orthostatic hypotension
Tolerance, physical dependence
Withdrawal Syndrome
 Topical Anesthetics
n  EMLA (a eutectic mixture of the local
anesthetics lidocaine and prilocaine) was
one of the first topical anesthetics
commercially available for use on intact
skin and has been the most extensively
used and studied.
n  Vapocoolant sprays (primarily ethyl
chloride) have been used for the
treatment of myalgic pain since the 1950s.
 Nonpharmacologic interventions to
reduce pain and distress with procedures
Technique Description
Distraction Infant: pacifier, bubbles, toys
Toddler: bubbles, songs, pop-up books, party blower,
kaleidoscope, toys
School-age: videos, video games, search for objects in
pictures, stories, jokes, counting, nonprocedural conversation
Adolescent: music by headphones, video games,
nonprocedural conversation, focusing on objects
Deep breathing
Have the child breathe rhythmically with slow deep breaths.
Blowing
Have the child blow out imaginary candles or take a deep
breath and blow away the pain. Party blowers have been
used successfully
Superhero imagery Have the child imagine that he or she is a superhero and the
procedure is a special mission
Guided imagery Help the child imagine a favorite place or activity,
concentrating on all the associated sensations
Thought-stopping Teach the child to think or say Stop! when feeling pain
and positive self- and then to think or say, I can handle this, or similar
statements positive self-statements
 Take home messages

Expand knowledge about pediatric pain and pediatric

pain management principles and techniques.

Provide a calm environment for procedures that reduces

distress-producing stimulation.

Use appropriate pain assessment tools and techniques.

Anticipate predictable painful experiences, intervene,

and monitor accordingly.
Use a multimodal (pharmacologic, cognitive
behavioral, and physical) approach to pain
management and use a multidisciplinary
approach when possible.
Involve families and tailor interventions to the
individual child.
Advocate for child-specific research in pain
management and Food and Drug Administration
evaluation of analgesics for children
Advocate for the effective use of pain medication
for children to ensure compassionate and
competent management of their pain.
 Take home messages
(Don’t)
Don’t under estimate pain in children, children do suffer
from pain

Don’t forget to assess pain in children

Knowledge barrier will lead to mismanage pain in children

Fears of respiratory depression or other adverse effects of

analgesic medications will end in under treatment of pain

The belief that preventing pain in children takes too much

time and effort
“Pain can be endured and defeated
only if it is embraced.
Denied or feared, it grows”

–Dean Koontz