PAIN

MANAGEMENT
IN CHILDREN
 OBJECTIVES:
• After mastering the contents of this chapter, you should be able to:
• 1. Describe the major methods and techniques of pain management for children.
• 2. Identify National Health Goals related to pain management in children that nurses can help the nation
achieve.
• 3. Use critical thinking to analyze ways nursing care for a child in pain could be more family centered.
• 4. Assess a child regarding whether pain management is needed or adequate.
• 5. Formulate nursing diagnoses for a child in pain.
• 6. Identify expected outcomes for a child in pain.
• 7. Plan nursing care for a child in pain.
• 8. Implement nursing care related to a child in pain such as suggesting an alternative therapy.
• 9. Evaluate outcomes for achievement and effectiveness of care of a child in pain.
• 10. Identify areas related to care of children in pain that could benefit from additional nursing research or
application of evidence-based practice.
• 11. Integrate knowledge of pain in children with nursing process to achieve quality maternal and child
health nursing care.
A. PHYSIOLOGY OF PAIN

• 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.”
A. PHYSIOLOGY OF PAIN
• As in adults, 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.
• 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)
A. PHYSIOLOGY OF PAIN
• Pain impulses join central nervous system (CNS) fibers in the dorsal horn of the spinal cord. Here the impulses
are projected upward to the brain, where they will be perceived as pain.
• • Acute pain is sharp pain. It generally occurs abruptly after an injury. Paper cuts are examples of lacerations
that cause acute pain.
• • Chronic pain is pain that lasts for a prolonged period (often defined as 6 months). Acute pain usually causes
extreme distress and anxiety; chronic pain can lead to depression and less ability to achieve (Eccleston et al.,
2009).
• • Cutaneous pain is pain that arises from superficial structures such as the skin and mucous membrane. A paper
cut is an example.
• • 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.
• • Visceral pain involves sensations that arise from internal organs such as the intestines. The pain of
appendicitis is visceral 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.
A.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. 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.
• When pain is felt the pituitary and hypothalamus glands attempt to modify pain by
releasing endorphins or polypeptide compounds that simulate opiates in their ability
to produce analgesia and a sense of well-being.
• Children also modify pain by physical actions such as shifting position or rubbing the
body part.
• Several theories have been proposed to explain the transmission of pain and how
pain can best be managed. Of these, the gate control theory is the best known.
B.GATE CONTROL THEORY OF PAIN

• The gate control theory of pain (Melzack & Wall, 1965) attempts to explain how pain impulses travel
from a site of injury to the brain, where the impulse is actually registered as pain.
• This theory envisions gating mechanisms in the substantia gelatinosa of the dorsal horn of the spinal
cord that, when activated, can halt an impulse at that level of the cord. This prevents the pain impulse
from being received at the brain level and interpreted as pain. Gating mechanisms can be stimulated
by three techniques: cutaneous stimulation, distraction, and anxiety reduction.
B.GATE CONTROL THEORY OF PAIN
• Gating mechanisms can be stimulated by three techniques: cutaneous stimulation, distraction, and
anxiety reduction.
• Cutaneous stimulation has an effect because when the peripheral nerves next to an injury site are
stimulated, the ability of the A-delta or C-fiber nerves at the injury site to transmit pain impulses
appears to decrease. Rubbing an injured part such as a stubbed toe and applying heat or cold to the
site are effective maneuvers to suppress pain because they activate these nearby fibers. This
technique is especially effective with children because the rubbing is not only comforting from a
physical standpoint but also conveys psychological warmth.
• Distraction allows the cells of the brainstem that register an impulse as pain to be preoccupied with
other stimuli so a pain impulse cannot register. Having a child focus on an action or a thought is a
common form of distraction. Telling a child to say “ouch” while an injection is administered is the
simplest use of this technique.
• Pain impulses are perceived more quickly by the brain if anxiety is also present. Therefore, attempts
to reduce a child’s anxiety as much as possible can help reduce the feeling of pain. Teaching a school-
age child about what to expect with a procedure is the kind of technique that does this.
 C.ASSESSING TYPE AND DEGREE OF PAIN

• Pain assessment is difficult with children, not only because children have
difficulty describing pain but also because some children will suffer with pain
rather than report it, unaware that someone could make it go away. Other
children may distract themselves by methods such as concentrating on play.
Some children may sleep, not from comfort but from the exhaustion caused by
pain. Cultural differences also influence how pain is expressed (Box 39.2).
• All of these things can make using 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. Keep in mind a child’s developmental level as well as
chronological age when assessing for pain.
D.PAIN ASSESSMENT
• The techniques to assess pain must vary
depending on the age of the child and the
type and extent of pain. A variety of pain
rating scales have been devised for use
with children.
• Pain Experience Inventory
• The Pain Experience Inventory is a tool
consisting of eight questions for children
and eight questions for the child’s parents.
 D. PAIN ASSESSMENT
• CRIES Neonatal Postoperative Pain Measurement Scale
• The CRIES inventory is a 10-point scale on which five physiologic and behavioral variables frequently associated
with neonatal pain can be assessed and rated (Krechel & Bildner, 1995):
• • Amount and type of crying
• • Need for oxygen administration
• • Increased vital signs
• • Facial expression
• • Sleeplessness
• Each area is scored from 0 to 2, and then a total score is obtained (Table 39.2). On the scale, infants with a score
of 4 or more are most likely to be in pain and need interventions to reduce discomfort. The scale cannot be used
with infants who are intubated or paralyzed for ventilatory assistance because they would have no score for cry,
and because their faces are obscured, it is difficult to rate them for facial expression.
D. PAIN ASSESSMENT
• The COMFORT Behavior Scale
• The COMFORT behavior scale is a pain rating scale devised by nurses to
rate pain in very young infants (van Dijk et al., 2005).
• 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).
• In addition to rating physical parameters, the infant is then observed for
2 minutes and the evaluation of the baby’s pain is documented on an
analogue (1-to-10) visual scale.
 D. PAIN ASSESSMENT
• FLACC Pain Assessment Tool
• The FLACC Pain Assessment Tool (Merkel et al., 1997) is a scale by which health care providers can rate
a child’s pain when a child cannot give input, such as during circumcision (Brady-Fryer, Wiebe, &
Lander, 2009).
• It incorporates five types of behaviors that can be used to rate pain:
 facial expression,
 leg movement,
 activity,
 cry, and
 consolability.
 Data indicate the scale is reliable and valid. Because a child does not provide active input, an older
child may experience a loss of the self-control that can come from active participation by using this
scale.
 D. PAIN ASSESSMENT
• Poker Chip Tool
• The Poker Chip Tool (Hester & Barcus,
1986) 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.
• FACES Pain Rating Scale
• This scale consists of six cartoon-like
faces ranging from smiling to tearful (Fig.
39.2).
D. PAIN ASSESSMENT
• Oucher Pain Rating Scale
• The Oucher (Beyer, Denyes, & Villarruel, 1992) 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 numbered scale portion, point to each section of the scale and explain
 0 means “no hurt”;
 1 to 29 means “a little hurt”;
 30 to 69 means “middle hurt”;
 70 to 99 means “big hurt”; and
 100 means “the biggest hurt you could ever have.”
D. PAIN ASSESSMENT
• Numerical or Visual Analog Scale
• A numerical or visual analog scale (Fig. 39.3) 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.”
 D. PAIN ASSESSMENT
• Adolescent Pediatric Pain Tool
• The Adolescent Pediatric Pain Tool (APPT) combines a visual
activity and a numerical scale (Savedra et al., 1992). On one half
of the form (Fig. 39.4) 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.” For a thirdactivity, tell children to point to or circle
as many words as possible on the form that describe their pain
(words such as horrible, pounding, cutting, and stinging).
• The scale is suggested for use in children 8 through 17 years. As
many children below this level need so much help reading and
interpreting the multitude of words that describe pain it makes
the form impractical below this age.
• This is a useful tool for involving parents to talk with their child
about pain. Reading the words together helps children examine
the type, location, and level of pain they are experiencing. It
also helps parents to better understand what their child is
experiencing.
 D.PAIN ASSESSMENT

• Logs and Diaries

• Having children keep logs or diaries in which they note when
• pain occurs and then rate the pain each time it occurs is useful
• for assessing children with chronic but intermittent pain.
• Examining such a diary can not only reveal when pain occurs
• but also provide direction for pain management.
E.PAIN MANAGEMENT
• PAIN MANAGEMENT
• Pain management techniques, like assessment techniques, 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.
F. PHARMACOLOGICAL PAIN RELIEF
• Pharmacologic pain relief refers to the administration of a wide variety of analgesic
medications (D’Arcy, 2007). 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.
 As a rule, intramuscularly administered analgesia should be avoided in children because
children dislike injections. Be certain children understand it is acceptable to ask for
medication for pain; they may not know they can unless this is stressed by health care
providers.
 F. PHARMACOLOGICAL PAIN RELIEF
• 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
(Subramanian et al., 2008).
• The cream is applied to the skin, and the site is then covered
with an occlusive dressing or plastic wrap. To be most effective,
it must be applied at least 1 hour before an expected
procedure (Box 39.8). Parents can apply anesthetic cream at
home before bringing a child to a clinic visit for a procedure
such as bone marrow aspiration (Fig. 39.6). Caution them not
to allow their child to remove the dressing and eat the cream
(it could anesthetize the gag reflex). It also is potentially
dangerous if rubbed into the eyes.
 F. PHARMACOLOGICAL PAIN RELIEF

• Oral Analgesia
• Oral analgesia is advantageous because it is cost-effective and relatively easy to administer. Many
analgesics can be prepared as elixirs or suppositories for children unable to swallow pills. Analgesia can be
adequately achieved if dosing is correct.
• Over-the-counter analgesics, such as acetaminophen (Tylenol), are flavored to make them taste good. Caution
parents that even though such drugs taste sweet, they should never refer to medicine as “candy.”
• Toxicity from too-frequent or overly large doses of acetaminophen can lead to severe liver damage in children
(Karch, 2009).
• Nonsteroidal anti-inflammatory drugs (NSAIDs) are excellent for reducing the pain that accompanies
inflammation in injuries such as sprained ankles or rheumatic conditions. Examples of NSAIDs include 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.
 F. PHARMACOLOGICAL PAIN RELIEF
• 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
• 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.
• Acknowledge their concern but reassure them the risk for addiction during short-
term use is remote. Reinforce that the main concern is supplying adequate pain
relief for their child.
 F. PHARMACOLOGICAL PAIN RELIEF

• 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.
 F. PHARMACOLOGICAL PAIN RELIEF
• Intravenous Administration
• IV administration of analgesia, 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.
• If a child’s pain is frequent or constant, continuous IV administration may be
necessary to reduce the level of pain. As the child becomes able to take
medications by mouth, oral forms of analgesics are then administered.
• When switching from IV to oral medications, it is important to use
equianalgesic doses. As-needed (PRN) dosing should be avoided because it
leads to inconsistent administration.
F. PHARMACOLOGICAL PAIN RELIEF
• Patient-Controlled Analgesia
• Patient-controlled analgesia (PCA) 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.
• Parents or a nurse can administer a new dose to children younger than this. Morphine is a
common analgesic used for PCA administration (Cho, Ha, & Rhee, 2007). 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.
• If pain is constant, a continuous infusion should be used so that pain relief continues even
while the child sleeps. The pump can still be programmed for bolus dosing to cover
episodes of increased pain.
 F. PHARMACOLOGICAL PAIN RELIEF
• Conscious Sedation
• Conscious sedation refers to a state of depressed consciousness usually
obtained through IV analgesia therapy (Hertzog & Havidish, 2007). The
technique allows a child to be both pain-free and sedated for a procedure.
Unlike with the use of general anesthesia, 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
(Fig. 39.7).
• 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.
F. PHARMACOLOGICAL PAIN RELIEF

• Intranasal Administration
• Intranasal administration is becoming an attractive way to dispense medicine for
children. Influenza vaccine, for example, is now available in an intranasal form
(Carpenter et al., 2007).
• Midazolam (Versed) is a short-acting adjuvant sedative that can be administered
intranasally by nasal drops or nasal spray before surgery or procedures such as
nuclear medicine scanning (Karch, 2009). Because it has a very short duration of
action, it may require repeat administration. Because midazolam has no analgesic
action, analgesia, such as with morphine, should also be used if the procedure will
be painful.
F. PHARMACOLOGICAL PAIN RELIEF

• Local Anesthesia Injection

• Local anesthetics 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.
• For many children, the sight of the anesthetic needle is so frightening that they
cannot listen to the assurance that the momentary needlestick will actually prevent
further pain.
• The use of an anesthetic cream before the injection relieves the needlestick pain
and allows the anesthetic to numb the deeper tissues.
F. PHARMACOLOGICAL PAIN RELIEF
• Epidural Analgesia
• 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.
• Epidural anesthesia is commonly used for childbirth.
• Children who have orthopedic or chest surgery, for example, may have an epidural
catheter inserted in the operating room and continue to receive analgesia by this
method to relieve postsurgical pain (Schoen, 2007). This is a very effective route of
analgesia in the postoperative child in the first few days.
• Some parents may be reluctant to allow this type of analgesia because they equate
it with spinal anesthesia, which can be followed by severe headaches. You can
assure them that an epidural needle does not enter the cerebrospinal fluid, so
spinal headaches are rare.
G. NON-PHARMACOLOGICAL PAIN MANAGEMENT
FOR CHILDREN
• Distraction • Acupuncture
• Substitution of Meaning or Imagery • Crystal or Gemstone Therapy
• Thought Stopping • Herbal Therapies
• Hypnosis • Biofeedback
• Aromatherapy and Essential Oils • Therapeutic Touch and Massage
• Magnet Therapy • Transcutaneous Electrical Nerve
• Music Therapy Stimulation
• Yoga and Meditation • Heat or Cold Application