Pain in

Children
Ikeu Nurhidayah

Pain Assessment
and Management
 Acute Pain- the History !
• Before 1970 - no formal research looking at pain
management in children

• Swafford and Allen,1968: “pediatric patients

seldom need medication for pain relief”

• 1974 – 13/25 children received no analgesia after

surgery such as nephrectomies, palate repairs
and traumatic amputations
 Do children feel pain?
• Pain fibers present at end of 2nd
trimester
• Increased heel sensitivity post heel
sticks
• Crying increases for days post
circumcision
• 6 month olds-anticipate and avoid
pain
 What is Pain?
• “Pain is whatever the experiencing
person says it is, existing whenever
they say it does”

(McCaffery and Pasero, 1999)

 What is pain?
• " Pain is an unpleasant sensory and
emotional experience associated with actual
or potential tissue damage, or described in
terms of such damage. It may be acute or
chronic.
• Pain is always subjective. Enormous
individual differences in response to painful
stimuli exist.
• (from The Classification of Child and Adolescent Mental
Diagnoses in Primary Care: Diagnostic and Statistical
Manual for Primary Care (DSMPC)
• Child and Adolescent Version, American Academy of
Pediatrics,1996.)
 What is Pain?
• The pain stimulus is interpreted
based on the context or meaning
of the pain to the individual, as
well as the individual's
psychological state, culture,
previous experience, and a host
of other psychosocial variables.
 What is Pain?
• As a result, the same noxious
stimulus may cause different
amounts of pain in different
individuals based on personal
characteristics."
– (from DSM-PC) Child and Adolescent
Version, American Academy of
Pediatrics, 1996.)
 Let’s review what is Pain
• Pain is a signal,
– nothing more,
– nothing less
• ALL PAIN IS REAL
• PAIN is PAIN,
• Suffering is
Optional!
 Pathophysiology of Pain
• Acute vs Chronic
Pain
– What is Acute Pain?
• brief duration:
usually less than 3
months
• Identifiable cause /
injury / surgery or
disease
• predictable end
• subsides with
healing
 Pathophysiology of Pain
• Acute vs Chronic
– What is chronic
pain?
• Persistent pain
lasting longer
than 6 months
that is generally
associated with a
prolonged
disease process
 Pathophysiology of Pain
• Nociceptors
– Free nerve endings at site of tissue damage
– Purpose of nociceptors are to transmit pain
impulses along specialized nerve fibers,
• the A-delta and C-fibers, to the dorsal horn of the
spinal cord
• Substantial gelatinosa, aka “gate-keeper”
– Regulates transmission of pain and other nerve
impulses to the CNS
– Located in the dorsal horn of spinal cord
 Pathophysiology of Pain

© 2006 by Pearson Education, Inc.

Jane W. Ball and Ruth C. Bindler
Upper Saddle River, New Jersey 07458
Child Health Nursing: Partnering with Children & Families All rights reserved.
 Pathophysiology of Pain
• Brain
– Once sensation reaches the brain other
factors may influence pain intensity…like
what?
– Pain signal transmitted through spinal
pathways where perception occurs.
– Descending tracts can alter perception
through the release of inhibitory
neurotransmitters
 Pathophysiology of Pain
• Autonomic Nervous System
– Activated in response to pain
• Tachycardia
• Peripheral vasoconstriction
• Diaphoresis
• Pupil dilation
• Increased secretion of catecholamines and
adrenocorticoid hormones
 Pathophysiology of Pain
• Gate Control Theory
– Since pain and non-pain impulses are
sent along the same pathways, non-
pain impulses can compete with pain
impulses for transmission
 Types of Pain
• Nociceptive: stimuli from somatic
and visceral structures
– somatic: sharp/stinging; superficial -
dermal or epidermal layers; deep-
bones or deeper structures
– visceral: abdominal organs, peritoneum
and pleura
• Neuropathic: stimuli abnormally
processed by the nervous system
– damage to a nerve - infiltration,
compression or infection
 Types of Pain
• Somatic
– Sharp, hot, stinging
– Generally well localized
– Associated with local and surrounding
tenderness
 Types of Pain
• Visceral
– Dull, cramping, colicky, often poorly
localized
– Tenderness locally or in the area of
referred pain
– Associated with symptoms such as
nausea, sweating and cardiovascular
changes
 Types of Pain
• Neuropathic
– Pain descriptors – burning, shooting and
stabbing
• Dysaesthesia (unpleasant abnormal
sensations)
– Hyperalgesia (increase response to a
normally painful stimulus)
– Allodynia (pain due to a stimulus that
does not normally evoke pain eg. light
touch)
 Physiological consequence
of Pain
• Affects multiple body systems
• (refer to table 18-1)

• Respiratory Changes
– Respiratory Alkalosis
– Decreased O2 sats
– Retention of secretions
Physiologic Consequences of
Pain
• Neurological
– Increase in HR, blood sugar, cortisol levels,
and intracranial pressure (risk for IVH)
• Metabolic effects
– Increase in fluid and electrolyte losses
• Immune System
– Increased risk of infection
• Gastrointestinal
– Impaired functioning
 Behavioral Indicators of
Pain
• Restlessness and agitated or hyper-alert
state
• Short attention span
• Irritability
• Facial grimacing, posturing, guarding
• Anorexia
• Lethargy
• Sleep disturbance
• Aggression
 Assessing Pain in Children
• Behavioral • Children’s
Responses and Understanding of
Verbal Descriptions Pain by
of Pain by Children Developmental
of Different Stage
Developmental
Stages
 Myths and Misconceptions
around Pain
• Active children cannot be in pain
• Generally there is a “usual” amount of pain
associated with any given procedure
• If children are asleep then they are pain free
• Giving narcotics to children is addictive and
dangerous
• Narcotics always depress respiration in children
• Infants don’t feel pain
• The less analgesia administered to children the
better it is for them
 Why is Pain Assessment
Important?
• Provides an avenue for more effective
management of pain
• Promotes communication between the
child, parents and health professionals
• Supports evidence based practice
• Provides continuity through the hospital
• Allows children to indicate the intensity of
their pain
 Challenges with Assessing
Children !
• Lower levels of verbal fluency / non-
verbal children
• May not verbally communicate
presence of pain unless specifically
asked
• Pain highly individualized
• Parents often called upon to provide
pain ratings - can be different to
patients perspective
 Criteria For Selecting A
Pain Tool
• Established as valid and reliable
• Developmentally appropriate
• Easily and quickly understood
• Liked by patients, families and
clinicians
• Inexpensive
• Appropriate for different languages
and culture
 The Questt Tool
• Question the child
• Use pain rating tools
• Evaluate behavior and physiological
changes
• Secure parents involvement
• Take the cause of pain into account
• Take action and evaluate the results
 Pain Assessment Tools
• Newborn/ Infant:
– CRIES
• Developed for use in preterm and ft infants in ICU
• Measures crying, O2 sat, HR, BP, expression and
sleeplessness
– Neonatal Infant Pain Scale (NIPS)
• Evaluates facial expression, cry, breathing, arms,
legs and state of arousal
– Premature Infant Pain Profile (PIPP)
• Gestational age, behavioral state, HR, O2 sat, brow
bulge, eye squeeze, and nasolabial furrow; often
used for procedural and post-op pain
 CRIES neonatal
postoperative Pain Scale
• Refer to table 18-5
 NIPS Scale
• Refer to table 18-6
• Recommended for children under 1
year old.
• A score of 3 or more= pain
 Pain Assessment Tools
• Toddler
– FLACC
– Oucher
– Faces pain-rating scale

• Preschooler
– Oucher
– Faces Pain-rating Scale (usually 3 and over)
– FLACC
• Acronym for face, legs, cry and consolability
– Body Outline (3 and over)
 Oucher Pain Scale

A B C

© 2006 by Pearson Education, Inc.

Jane W. Ball and Ruth C. Bindler
Upper Saddle River, New Jersey 07458
Child Health Nursing: Partnering with Children & Families All rights reserved.
Faces Pain Scale
 Pain Assessment Tools
• School Age
– Numeric Pain Scale (9 yrs- adult)
– Oucher
– Faces pain-relating scale
– Poker chip scale
– Work graphic
– Visual analogue
 Pain Assessment Tools
• Adolescent
– Numeric Pain Scale
– Oucher
– Faces Pain-relating scale
– Poker chip
– Work graphic
– Visual analogue
– Adolescent pediatric pain tool
 Numeric Pain Scale
• Numeric Rating Scale
– Let’s say 0 means no pain and 10
means the worst pain anyone could
have. How much pain do you have?
(score 0-10)
Assessing Readiness for Use
of Pain Scales
• Refer to Box 18-3
• Assess a chlid’s language, and
understanding of concepts
• Children 2-3 years-old
– Understand more or less
– No more than 3 choices on pain scale
• Only 26% of 5 year olds understand
numeric scale
– Which number is smaller 4 or 7?
 Children with Cognitive
Impairment
• Assessment of pain difficult
• Contribute to inadequate analgesia
• Merkel et al (1997)
– FLACC scale validated for cognitively
impaired children
 Intervention
• Pharmacologic and Non-
pharmacologic methods of pain
control
Pharmacologic Pain Control
• Pain Medications include:
– Opioids
– Nonsteroidal anti-inflammatory drugs
(NSAIDs)
– Non-narcotic analgesics
(acetaminophen)
Pharmacologic Pain Control
• Opioids
– Ex: morphine, codeine
– Often for severe pain
– Refer to p 575 for recommended drug
dosages and table 18-8, p 577 for S/Sx
of Opioid withdrawal
– Naloxone is the reversal agent used for
opioid adverse effects (hypotension,
respiratory depression)
Pharmacologic Pain Control
• NSAIDs and Non-opioid analgesics
– Ex of NSAIDS= aspirin, Ibuprofen, Naproxen
– Ex of Non-opioid analgesics= acetaminophen
• Most commonly used for bone,
inflammatory, and connective tissue
conditions
• NSAIDs and opioids can be used in combo
• Remember the differences b/t NSAIDs and
acetaminophen!
• Refer to p 576 for drug dosages
Nursing Considerations when
administering a Pain analgesic
• Always document pain level pre and
post medication administration
• Also document any other nursing
interventions and if they were useful
Patient Controlled Analgesia
(PCA)
• A method of administering IV or epidural
analgesic using a computerized pump that
is programmed by a healthcare
professional and controlled by the child
• Children 5 years and older
• Children should be able to push the button
and understand that this will give them
pain relief.
Non-pharmacologic Methods
of Pain Control
• Distraction
• Hypnosis
• Imagery
• Relaxation
• Comfort measures
– Quiet presence
– Music massage
– Heat/cold
– Baths
– vibrations
 Complimentary Therapies
for Pain Control
• Sucrose solution
• Muscle relaxation techniques
• Breathing techniques
• Electroanalgesia
• Biofeedback
• Acupucture
 Pediatric Considerations in
Disaster Preparedness
• Impact of disaster
– Psychological
• General effects
• Anxiety
• Stress
– fear
 Pediatric Considerations in
Disaster Preparedness
• Impact of Disaster
– Developmental considerations
• Toddler/ preschooler
• School age
• Adolescent
• Responses to Disasters by Children of
Different Age Groups
 Pediatric Considerations in
Disaster Preparedness
• Preparedness
– Pediatric drugs/ supplies
– Advanced planning
• Medically fragile in community
• Community disaster response systems
• Family
– Resource package
– Anticipatory Guidance
I hope this lecture wasn’t
too painful!!