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 2nd 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
• Simple motor responses. consistent than
physiological
• Complex behavioural measurements.
responses.
 Physiological Parameters
• Heart rate.
• Respiratory rate.
• Blood pressure. Objective,
• Palmar sweating. Precise , but
not specific for pain
• Vagal tone.
• Oxygen saturation.
• Transcutaneous O2/CO2.
• Intracranial pressure.
 Biochemical Parameters

• Catecholamines : Epinephrine, Norepinephrine.

• Cortisol : blood, saliva, or urine.
• b-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 (Children’s 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

NASO-
LABIAL 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 LOADING MAINTENANCE INTERVAL DAILY MAX

DOSE DOSE DOSE
(mg/kg) (mg/kg) (hours) (mg/kg)

Ketoprofen 2 1 6-8 5
Ibuprofen 10 10 6-8 40
Naproxen 10 5 8-12 15
Diclofenac 2 1 6-8 3
Ketorolac 0.5 0.25 6-8 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 t1/2 CL
(L/kg) (h) (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 & 2.8 + 2.6 2.0 + 1.8 23.6 + 8.5

children

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 Criteria Points

Blood Pressure + 10% preop value 0

>20% preop value 1
>30% preop value 2
Crying Not crying 0
Crying responds to t.l.c. 1
Crying respons to t.l.c. – 2
Movement None 0
Restless 1
Trashing 2
Agitation Asleep or calm 0
Mild 1
Hysterical 2
Verbalizes pain Asleep/no verbalization 0
Cannot localize pain 1
Localizes pain 2
 Children’s Hospital of Eastern Ontario Pain Scale
(CHEOPS)

Score 0 1 2
Cry – + scream
Facial smile composed grimace
Verbal + – pain complaint
Torso neutral shifting/tense restraint
Legs neutral kick/squirm restraint