Pain in

Pediatric
Nur Surya Wirawan

Pain Response
Premature infants show metabolic
stress responses postoperatively that
can be blocked by intravenous
opioids.
The increasing crying and
behavioural changes occur for days
after circumcision can be blocked
with the use of regional anesthesia.

 Incidence of postoperative pain :

Mather & Mackie : only 25% of children were
pain free.
Beyer : adults received twice the number of
opioid doses.
(Mather I , Mackie J. The Incidence of Postoperative Pain in
Children. Pain 1983)

Pain management in newborn :

Newborns undergo surgery with minimal
anesthesia.
Procedural pain without consideration of
discomfort.
(Schecter NL , Allen DA. Physicians Attitude Towards Pain in
Children. J Dev Behav Pediatr . 1986)

Inadequate Pediatric Pain Management

Unfamiliarity with doses.

Fear of complcation.
Inadequate training of medical professional.
Limited clinical information.
Limited available research.

Why treat pain ?

Treatment & alleviation of pain
are a basic human right !

regardless

of age

Fishman SM. Recognizing Pain Management as a Human Right: A First Step

Anesthesia Analgesia 2007.

Pediatric Pain Assessment

Pain management begins with an assessment of
the child with pain .
Not only the explicit pain features but also the
situational factors that modulate pain-measurement of
infant pain is just one aspect of comprehensive pain
assessment.
Pain in infants can only be accessed & measured by
indirect method.
Gaffney A et al. Measuring Pain in Children: Developmental & Instrument Issues.
Pain in Infants,Children and Adolescents 2 nd Ed 2003.

Pediatric Pain Assessment

Self-Reporting measures
Behavioural parameters
Physiological parameters
Unidimensional tool
Multidimensional tool
Anand KJS.Pain and Pain Management during Infancy.
Research and Clinical Forum 1998

Behavioural parameters

Crying characteristics.
Facial expressions.
More specific and
consistent than
Simple motor responses. physiological
measurements.
Complex behavioural
responses.

Physiological Parameters

Heart rate.
Respiratory rate.
Blood pressure.
Objective,
Precise , but
Palmar sweating.
not specific for pain
Vagal tone.
Oxygen saturation.
Transcutaneous O2/CO2.
Intracranial pressure.

Biochemical Parameters

Catecholamines : Epinephrine, Norepinephrine.

Cortisol : blood, saliva, or urine.
-Endorphin
Growth hormone, glucose, glucagon, renin,
aldosterone, and lactate have also been
noted to increase with pain.
Insulin secretion (usually suppressed).

PAIN ASSESSMENT TOOL

Reliability
Validity
Specificity/Sensitivity
Clinical utility/Feasibility

Self-Report Measures

Wong Baker Faces Pain Scale

Faces Pain Scale-Revised
Visual Analog Scale (VAS)
Pieces of Hurt Tool
MSPCT

Section 3. Pain Assessment

Pediatric Anesthesia 2008, 18 (Suppl. 1), 14-18.

Self Report

Behavioural Measures
PIPP (Premature Infant Pain Profile)
CRIES (Crying Requires Oxygen Saturation
Increased Vital Sign Expression Sleeplessness)
COMFORT Scale
Neonatal Facial Coding Scale.
FLACC (Face,Legs,Arms,Cry,Consolability)
CHEOPS (Childrens Hospital of Eastern Ontario
Pain Scale)
Objective Pain Scale
Section 3. Pain Assessment
Pediatric Anesthesia 2008, 18 (Suppl. 1), 14-18.

Facial Expression of Physical

Distress

NASOLABIAL FOLD
deepened

Cry Spectrography
Crying hunger,anger,discomfort
,pain ?
ABC Pain Analyzer :
* Is the first cry acute ?
* Are burst rhythmic ?
* Is crying constant in time ?
Bellieni CV,Buonocore G, Pain Assessment and Spectral Analysis of
Neonatal Crying. Neonatal Pain Springer 2007.

Pharmacologic Intervention
Nonsteroidal antiinflammatory drugs.
Intermittent/continuous opioids.
Peripheral nerve block & Regional
anesthetic techniques.

American Academy of Pediatric,Canadian Paediatric Society,Committee on

Drugs,Committee on Fetus and Newborn and Section on Anesthesiology
Prevention and Management of Pain and Stress in the Neonate
Pediatrics 2000

Pharmacological
Consideration
Neonates have delayed maturation of liver enzyme
systems which involved in drug metabolism.
Children have a higher percentage of body weight
as water and less as fat. Dosages of water soluble
drugs vs fat soluble drugs should be adjusted.
Children have reduced plasma albumin. This result
in a greater availability of active drugs and
increased medication passages into the brain.
Neonates have diminished ventilatory responses to
decreased oxygen contents in the blood.

NSAIDs
Effective for mild or moderate pain.
Anti-inflammatory & antipyretic
effects.
Opioid sparing effect.
NSAIDs + paracetamol better
analgesia. Analgesia Review. Pediatric Anesthesia 2008.

NSAID Doses in Children

DRUG

Ketoprofe
n
Ibuprofen
Naproxen
Diclofena
c
Ketorolac

LOADING
DOSE
(mg/kg)

MAINTENANC
E
DOSE
(mg/kg)

INTERVAL
(hours)

DAILY MAX
DOSE
(mg/kg)

2
10
10
2
0.5

1
10
5
1
0.25

6-8
6-8
8-12
6-8
6-8

5
40
15
3
2

Kokki H. Use.Abuse and Misuse of NSAIDS in Children

European Journal of Anesthesiology 2005

Opioids
Morphine or Fentanyl most often used.
Avoid Demerol (Meperidine)
Requires frequent and thorough
assessment of adequacy of pain relief
and possible side effects
< 6 months continuous respiratory
monitoring:
* < 1 month : 9 hours
After the last
* 1-6 months : 4 hours
administraton

Estimated Values for Vd t1/2

CL of Morphine
Vd
(L/kg)

t1/2
(h)

CL
(ml/min/kg
)

Preterm

2.8 + 2.6

9.0 + 3.4

2.2 + 0.7

Term

2.8 + 2.6

6.5 + 2.8

8.1 + 3.2

Infants &
children

2.8 + 2.6

2.0 + 1.8

23.6 + 8.5

Kart T, Lona L. Recommended Use of Morphine in Neonates,Infants and Children Based on Literature
Review : Part 1 Pharmacokinetics.
Pediatric Anesthesia 1997.

Caudal epidural analgesia

Most popular central block
Easiest & safest approach
Excellent analgesia-painfree
awakening
Applicable to children of all ages

Nonpharmacological
Strategies

Behavioural interventions.
Cognitive interventions.
Distraction.
Hypnosis.
Sucrose solutions.

Thanks for Listening

Because of
you

Objective Pain Scale

Observation
Blood Pressure

Crying

Movement

Agitation

Verbalizes pain

Criteria

Points

+ 10% preop value

>20% preop value
>30% preop value
Not crying
Crying responds to
t.l.c.
Crying respons to
t.l.c.
None
Restless
Trashing
Asleep or calm
Mild
Hysterical
Asleep/no
verbalization
Cannot localize pain

0
1
2
0
1
2
0
1
2
0
1
2
0
1
2

Childrens Hospital of Eastern Ontario

Pain Scale
(CHEOPS)
Score
Cry
Facial
Verbal
Torso
Legs

smile
+
neutral
neutral

+
composed

shifting/tense
kick/squirm

scream
grimace
pain complaint
restraint
restraint