Pain Management in

Children
CN-109_b Lecture
 Pain
• is a difficult concept to define because it is experienced uniquely.
It is important to remember that it is subjective (experienced by
the person), not objective (able to be determined by
observation).
• McCaffery’s classic description of pain (Pasero & McCaffery,
2004) is the one most useful with children:
• “The sensation of pain is whatever the person experiencing it
says it is, and it exists whenever the person says it does

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 Pain
• For children, pain is not only a hurting sensation, but it can also
be a confusing one because a child did not anticipate the pain,
does not have words to explain how it feels, and cannot always
understand its cause
• Because pain is an individualized sensation, it may be
experienced and expressed differently by different children

• children’s perception of the situation influences their response to

the situation, independent of the intensity of the pain.

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 PHYSIOLOGY OF PAIN
• pain in children occurs for one of four reasons:
• reduced oxygen in tissues from impaired circulation,
• Pressure on tissue,
• external injury,
• or overstretching of body cavities with fluid or air.
• The stimuli causing pain are not always visible or measurable. In
addition, anxiety can lead to increased pain regardless of the
physical stimuli

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 PHYSIOLOGY OF PAIN
Pain conduction consists of four major steps:
• transduction (sensing the pain sensation),
• transmission (routing the pain sensation to the spinal cord),
• perception (the brain interprets the sensation as pain),
• and modulation (steps taken to relive pain).

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 Pain conduction consists of four
major steps:
• Transduction (sensing the pain sensation),
• transmission (routing the pain
• sensation to the spinal cord), perception (the brain interprets
the sensation as pain),
• and modulation (steps taken to relive pain)

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 PHYSIOLOGY OF PAIN
• Transduction begins in the peripheral nerves when a mechanical,
thermal, or chemical stimulus activates nociceptors, a specialized
group of sensory receptors

• (To play an online video about pain transduction)-already part of

the assignment

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 Types of Pain
• Acute pain is sharp pain. It
generally occurs abruptly after an
injury.
• Paper cuts are examples of
lacerations that cause acute pain.

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 Types of Pain
• Chronic pain is pain that lasts for
a prolonged period (often defined
as 6 months).

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 Types of Pain
• Acute pain usually causes extreme distress and anxiety; chronic
pain can lead to depression and less ability to achieve (Eccleston
et al., 2009)

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 Types of Pain
• Cutaneous pain is pain that arises
from superficial structures such as
the skin and mucous membrane.
• A paper cut is an example

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 Types of Pain
• Somatic pain is pain that originates
from deep body structures such
as muscles or blood vessels.
• The pain of a sprained ankle is
somatic pain

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 Types of Pain
• Visceral pain involves sensations
that arise from internal organs
such as the intestines.
• The pain of appendicitis is visceral
pain

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 Types of Pain
• Referred pain is pain that is
perceived at a site distant from its
point of origin.
• Right lower lobe pneumonia, for
example, is often first thought to
be abdominal pain because the
pain of this is referred to the
abdomen

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 PHYSIOLOGY OF PAIN
• A child’s pain threshold refers to
the point at which the
• child first feels pain.
• This varies greatly from person to
person and is probably most
influenced by heredity.
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• All people also have a point above
which they are not willing to bear
any additional pain. This is a
person’s pain tolerance.
• Pain tolerance levels are probably
most affected by cultural
influences
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 • Gate Control Theory of Pain- already part of the assignment

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Assessing
Types and
Degree of
Pain
 Assessing Types and Degree of
Pain
• Pain assessment is difficult with
children, not only because children
have difficulty describing pain but • All of these things can make using
also because some children will
suffer with pain rather than
report it, unaware that someone
could make it go away
• Cultural differences also influence
how pain is expressed
only subjective measures, such as
observation, to assess pain
misleading
• Pain assessment in children is also
difficult because techniques vary
widely from assessment of a
nonverbal infant to
• an older adolescent

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 Assessing Types and Degree of Pain
• The Infant
it was believed that infants do not feel pain because of incomplete
myelinization of peripheral nerves.
• This is no longer believed to be true, because myelinization is
not necessary for pain perception
• A second argument against needing to provide pain relief
to infants was that they have no memory

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 The Infant

• observing for cues such as diffuse

body movement; tears; a high-
pitched, sharp, harsh cry; stiff
posture; lack of play; and fisting
are all cues to reveal discomfort
• the chief mark of pain in infants is
that when pain is present, they
cannot be comforted completely

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 The Infant
• Preterm neonates may have a
particularly difficult time
organizing a distress response to
cue a health care provider to the
presence of pain

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 The Toddler and Preschooler
• Determining when and how much
pain is present continues to be
difficult with toddlers and
preschoolers because they may
not have a word in their limited
vocabularies to describe the
sensation they fee

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 The Toddler and Preschooler
• ” They may have difficulty
comparing the pain they feel now
to past pain (is it better or
• worse?) because they have had
little experience with past
• pain.
• Words such as “sharp,” “nagging,”
or “aching” have no meaning in
relation to pain until a child has
experienced each type
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• To assess such a child’s pain
accurately, use the child’s term or
teach the child that “pain” is the
same as “boo-boo.”
• For some toddlers, pain is such a
strange sensation that, aside from
crying in response to it, they may
react aggressively (pounding and
rocking) as if to fight it off. They
also may avoid being touched or
held.
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 The Toddler and Preschooler
• Preschool children can describe • Consider it as punishment
they have pain but continue to
have difficulty describing its • Pain is something to be expected
intensity. for, or thinking that adult already
know that they are in pain—
• They begin to use comforting
mechanisms, such as gritting teeth, egocentricity behavior
pressing a hand against a forehead, • Helpful is to observe for their
pulling on their ear, holding their behavior
throat, rubbing an arm, or
grimacing, to control or express
pain

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 The School-Age Child and Adolescent

• can have difficulty envisioning that • school age will regress with pain
a word like “sharp” applies both such as baby-talk or lying in a fetal
to knives and to the feeling in position.
their abdomen. • Children this age can understand
• Because of this, they continue to that if pain will last only an instant,
have difficulty describing pain. such as with an injection, it can be
They may also assume that you, as controlled through
an authority figure, already know nonpharmacologic activities such
they have pain as distraction techniques

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 The School-Age Child and Adolescent
• Doing some preassessment work
with them, such as giving them 10
different-sized triangles and asking
them to arrange them from
smallest to largest, is a good way
to evaluate if they understand
incremental measurements
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• Adolescents commonly use adult
mechanisms for controlling pain.
Some are even more stoic in the
face of pain than adults, trying to
avoid stereotypes of “crybaby” or
“chicken.”
• This tendency makes assessment for
body motions that could indicate
pain, such as clenched hands,
clenched teeth, rapid breathing, and
guarding of body parts, not as helpful
as it may be in adults.
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PAIN
ASSESSMENT
 PAIN ASSESSMENT
• The techniques to assess pain • (self-reporting on a pain rating
must vary depending on the age scale) is the most accurate
of the child and the type and method for assessment.
extent of pain
• Although monitoring for
physiologic findings such as a
change in pulse or blood pressure
may give some indication that a
child is under stress, these are not
the most dependable indicators of
pain.

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 PAIN ASSESSMENT
• Pain Experience Inventory
• is a tool consisting of eight
questions for children and eight
questions for the child’s parents. It
is designed to elicit the terms a
child uses to denote pain and
what actions a child thinks will
best alleviate the pain
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• CRIES Neonatal Postoperative
Pain Measurement Scale
• is a 10-point scale on which five
physiologic and behavioral
variables frequently associated
with neonatal pain can be
assessed and rated
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 CRIES Neonatal Postoperative Pain
Measurement Scale

• Amount and type of crying

• Need for oxygen administration
• Increased vital signs
• Facial expression
• Sleeplessness

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 The COMFORT Behavior Scale

• behavior scale is a pain rating

scale devised by nurses to rate
pain in very young infants
• On the first part of the scale, six
different categories (alertness,
calmness/agitation, crying, physical
movement, muscle tone, and facial
expression) are rated from 1 to 5.
• Six is the lowest score (no pain),
and 30 is the highest (a great deal
of pain).

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 FLACC Pain Assessment Tool
• is a scale by which health care
providers can rate a child’s pain
when a child cannot give input,
such as during circumcision
• It incorporates five types of
behaviors that can be used to rate
pain: facial expression, leg
movement, activity, cry, and
consolability.
• Dataindicate the scale is reliable
and valid

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 Poker Chip Tool
• uses four red poker chips placed
in a horizontal line in front of the
child.
• The technique can be used with
children as young as 4 years of
age, provided the child can count
or has some concept of numbers.
To use the tool, tell the child,
“These are pieces of hurt.”

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 FACES Pain Rating Scale
• This scale consists of six cartoon-
like faces ranging from smiling to
tearful
• Explain to the child that each face
from left to right corresponds to
a person who has no hurt up to a
lot of hurt

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 Oucher Pain Rating Scale
• consists of six photographs of
children’s faces representing “no
hurt” to “biggest hurt you could ever
have.”
• Also included is a vertical scale with
numbers from 0 to 100.
• To use the photograph portion,
point to each photograph and
explain what each photo represents.
• Ask the child to point to the photo
that best represents the child’s
degree of hurt

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 Numerical or Visual Analog Scale

• uses a line with

• end points marked “0 no pain” on the
left and “10 worst pain” on the right.
• Divisions along the line are marked in
units from 1 to 9.
• Explain to children that the left end of
the line (the 0) means a person feels no
pain.
• At the other end is a 10, which means a
person feels the worst pain possible.
• The numbers 1 to 9 in the middle are
for “a little pain” to “a lot of pain.”

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 Adolescent Pediatric Pain Tool

• combines a visual activity and a

numerical scale
• On one half of the form is an
outline figure showing the anterior
and posterior view of a child.
• To use the tool, tell a child to color
in the figure drawing where pain is
felt.
• In addition, on the right side of the
form, tell the child to rate present
pain in reference to “no pain,” “little
pain,” “medium pain,” “large pain,”
and “worst possible pain.”

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Pain
Management
 Pain Management
• vary greatly depending on the age of a child and the degree and
type of pain a child is experiencing.
• Children with chronic pain or pain not relieved with standard
approaches may benefit from a referral to a pain management
specialist or team
• It is important that pain be assessed in an organized and
consistent manner so relief and interventions do not vary based
on the health care provider

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 Pain Management

• not prescribed potent analgesics because of the fear that the

drugs commonly used, such as morphine, would decrease their
respiratory rate to an unsafe level
• Today, it is recognized that if the dosage of an opiate such as
morphine is based on the child’s size, there is no more danger of
respiratory depression in children than in adult
• checking that the correct dosage has been prescribed, opiates
can be given with confidence to decrease
pain without untoward effects.

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Non-
pharmacologic
Pain managment
 Non- pharmacologic Pain managment
• Nonpharmacologic pain relief
measures can be used
independently or as complements
to pharmacologic pain relief.
• They fit under the umbrella of
alternative and complementary
therapies.
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• Distraction
• aim at shifting a child’s focus from
pain to another activity or interest
• Blowing soap bubbles, for
example, could be used during an
injection to
accomplish this.
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 Distraction

• If oral glucose is offered to infants

during painful procedures, the
pain they experience appears to
be significantly less
• It is hypothesized that drinking
glucose not only serves as a
distraction technique but also
activates endorphins and produces
a central analgesic effect

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 Substitution of Meaning or Imagery
• or guided imagery is a distraction
technique to help a child place
another meaning (a nonpainful one)
on a painful procedure (Russell &
Smart, 2007)
• Success with this technique requires
practice, so it has limited application
in an acute care setting.
• This technique works well with
quick, simple procedures such as
venipunctures or chronic pain
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• Be certain a child thinks of a
specific image.
• Help the child elaborate on the
image to make it more concrete
each time it is used so the child’s
mind stays on the image (what
color is the rocket ship? Are there
stripes on the sides? What does
the pilot look like?)
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 Thought stopping
• is a technique in which children
are taught to stop anxious
thoughts by substituting a positive
or relaxing thought.
• As with imagery, this technique
requires a great deal of practice
before it is used in a painful
situation
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• Anticipatory anxiety is a negative
force because it increases the pain
experience during a procedure
and makes the time before it full
of anxiety as well.
• For this technique, help children
to think of a set of positive things
about the approaching feared
procedure
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 Non- pharmacologic Pain managment
• Hypnosis-not a common pain
management technique with
• children but can be very effective
when a child is properly trained in
the technique (Robertson, 2007).
• For best results, a child needs to
train with a therapist before
anticipated pain,
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• Aromatherapy and Essential Oils
• is based on the principle that the
sense of smell plays a significant
role in overall health.
• When an essential oil is inhaled, its
molecules are transported via the
olfactory system to the limbic
system in the brain.
• The brain responds to particular
aromas with emotional responses
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 Non- pharmacologic Pain managment

• Magnet Therapy-is based on the • Copper also

belief that magnets can control or • is believed to have pain-relieving
shift body energy lines to restore ability and is often incorporated
health or relieve pain into rings and bracelets for this
• Although many people find relief reason.
from magnet therapy, the relief
may be more of a placebo effect
than an actual change in pain level

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 Non- pharmacologic Pain managment

• Music Therapy
• is the use of music for calming or
improving well-being and can be
effective even for premature infants.
• It can help to relieve pain both
because it can be relaxing and is a
distraction Children may“blast” music
not because they enjoy hearing it
that loud but because they are
feeling great pain and need that level
of distraction to feel free of pain.

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 Non- pharmacologic Pain managment

• Yoga and Meditation- a term derived • Yoga may be helpful in reducing

from the Sanskrit word for union, pain through its ability to relax the
involves a series of exercises that
were originally designed to bring body and possibly through the
people who practice it closer to release of endorphins
God.
• It offers a significant variety of
proven health benefits, such as
increasing the efficiency of the heart,
slowing the respiratory rate,
improving fitness, lowering blood
pressure, promoting relaxation,
reducing stress, and allaying anxiety
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 Non- pharmacologic Pain managment

• Acupuncture-involves the
insertion of needles into critical
positions ) in the body to achieve
pain relief
• Although acupuncture is almost
painless, children can be very
afraid of it at first because of the
sight of the needles.
• This level of stress can make it an
unattractive option for pain
management for children

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 Non- pharmacologic Pain managment
• Crystal or Gemstone Therapy-
believe that gemstones or crystals
have healing powers, which are
magnified when they are
positioned around the body.
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• Herbal Therapies
that specific herbs are helpful in
relieving pain for their child and in
general improving their child’s
health.
Some examples include chamomile tea
(inflammationreduction), garlic (anti-
inflammatory, anticancer), ginger
(nausea or vomiting reduction),
goldenrod (urinary tract inflammation
reduction), or peppermint (abdominal
pain relief )
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 Non- pharmacologic Pain managment

• Biofeedback-is based on the belief • Therapeutic Touch and Massage

that people can regulate internal
events such as heart rate and pain • is the use of touch to provide
response comfort and relieve pain
• A biofeedback apparatus is used to
measure muscle
• tone or the child’s ability to relax.
Biofeedback can be effective with
adolescents but is less effective with
school-age and younger children
because they tend to resist the
biofeedback information or cannot
concentrate for long enough for
training to be effective

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 Non- pharmacologic Pain managment
• Transcutaneous Electrical Nerve
Stimulation-involves applying small
electrodes to the dermatomes
that supply the body portion
where pain is experienced
• The principle underlying this
technique is the same as rubbing
an injured part: the current
interferes with the transmission of
the pain impulse across small
nerve fibers.
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• Heat or Cold Application
• Cold reduces pain by constricting
capillaries and therefore reducing
vessel permeability and edema
and pressure at an injured site.
After the first 24 hours of an
injury, applying heat may be more
helpful because this dilates
capillaries, increases blood flow to
the area, and again helps reduce
edema
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Pharmacologic
management
 Pharmacologic management
• Pharmacologic pain relief refers to
the administration of a wide variety
of analgesic medications
• Many children need analgesic agents
in addition to nonpharmacologic
techniques for pain relief, especially
for acute pain.
• Medications can be applied topically
or given orally, intramuscularly,
intravenously, or by epidural injection

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 Pharmacologic management
• Topical Anesthetic Cream
To reduce the pain of procedures
such as venipuncture, lumbar
puncture, and bone marrow
aspiration, a local anesthetic
cream or a solution of lidocaine
and epinephrine can be used

• EMLA(Eutectic Mixture of Local

Anesthetics)-

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 Oral Analgesia
• Oral analgesia is advantageous
because it is cost-effective and
relatively easy to administer
• Acetaminophen (Tylenol)
Toxicity from too-frequent or
overly
• large doses of acetaminophen can
lead to severe liver damage in
children
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• Nonsteroidal anti-inflammatory
drugs (NSAIDs) are excellent for
reducing the pain that accompanies
inflammation in injuries such as
sprained ankles or rheumatic
condition
• ibuprofen and naproxen
• Long-term administration of any
NSAID can lead to severe
• gastric irritation and may be
associated with heart attacks, so it
should not be used longer than
prescribed
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 Oral Analgesia
• Children should not receive acetylsalicylic acid (aspirin) for
routine pain relief, especially in the presence of flulike symptoms,
because there is an association between aspirin administration
and the development of Reye syndrome

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 Oral Analgesia
• For managing severe or acute pain, such as postoperative pain or
the pain of a sickle-cell crisis, opioids, such as morphine, codeine,
and hydromorphone (Dilaudid), are the usual drugs of choice.
Codeine may be given in combination with acetaminophen.
• Because this class of drugs is also referred to as narcotics,
parents may be reluctant to give their children these
medications, concerned their child will become addicted

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 Intramuscular Injection

• Opiates are available as intramuscular injections.

• Analgesia for children is rarely given by this route, however, as
injections are associated with pain on administration and also
produce great fear in children.
• It is also associated with several risks, including uneven
absorption, unpredictable onset of action, and nerve and tissue
damage.
• Other routes should be used whenever possible

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 Intramuscular Injection SITES

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 Intravenous Administration
• the most rapid-acting route, is the
method of choice in emergency
situations, in the child with acute
pain, and in a child requiring
frequent doses of analgesia but in
whom the gastrointestinal tract
cannot be used
• Common opioids given:
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• morphine, fentanyl, and
hydromorphone (Dilaudid).
• Hydromorphone is 8 to 10 times
stronger than morphine but very
similar to morphine in action.
Fentanyl has a shorter duration of
action than morphine. Side effects of
pruritus and vasodilatation are less.
• These features make it an ideal drug
to use for short, painful procedures,
such as debriding a burn or inserting
a chest tube to relieve a
pneumothorax
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 Intravenous Administration
• These analgesics can be given by
bolus injection or by continuous
infusion.
• If doses will be given periodically
by an IV line, advocate for the use
of an intermittent infusion device
to avoid repeated venipunctures
with each dose or the need for a
confining IV line to be in place

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 Intravenous Administration

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 Intravenous Administration
• All opioids have the potential to decrease respiratory rate,
although this is not a worry with accurate dosing.
• Other side effects include nausea, pruritus, vasodilatation, cough
suppression, and constipation.
• If toxicity with opioids should occur, naloxone (Narcan) can be
administered to counteract the effects

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 Patient-Controlled Analgesia
• is a form of IV administration that allows a child to self-
administer boluses of medication, usually opioids, with a
medication pump
• Children as young as 5 or 6 years may be able to assess when
they need a bolus of medicine and press the button on the
pump to deliver the new dose through an established IV line.
• Morphine is a common analgesic used for PCA administration

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 Patient-Controlled Analgesia
• The pump is set with a lock-out time so that after each dose the
pump will not release further medication even if the button is
pushed again; because of this, children cannot overmedicate
themselves.

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 Conscious Sedation
• refers to a state of depressed consciousness usually obtained through IV analgesia
therapy .
• The technique allows a child to be both pain-free and sedated for a procedure.
• protective reflexes are left intact and a child can respond to instructions during
the procedure.
• The technique is used for procedures such as extensive wound care; bone
marrow aspiration, which is potentially very painful; magnetic resonance imaging,
which may require a child to lie still for a long period of time; and endoscopy,
which is both potentially frightening and requires a child to lie still for a period of
time.
• In many health care settings, conscious sedation is administered and monitored by
nurses specially prepared in the technique

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 Conscious Sedation
• Drugs used for conscious sedation
can be something as common as
chloral hydrate or as involved as a
sedative-hypnotic-analgesic
combination that relieves both
anxiety and pain and depresses
the child’s memory of the event

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 Local Anesthesia Injection
• stop pain transmission by blocking nerve conduction of the
impulse at the site of pain.
• Children receive local anesthetic injections, such as lidocaine,
before procedures such as bone marrow aspiration and
peritoneal dialysis.

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 Epidural Analgesia
• injection of an analgesic agent into the epidural space just
outside the spinal canal, can be used to provide analgesia to the
lower body for 12 to 24 hours
• An opioid, often combined with a long-acting anesthetic, is
instilled continuously or administered intermittently.
• Opiate receptors in the spinal cord are affected directly,
providing analgesia

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thank you
mirjam nilsson
mirjam@contoso.com
www.contoso.com