Pain management in children

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Pain management in children
Children's pain scale.JPG
Pain scale used in children
Specialty Pediatrics, anesthesia, palliative medicine

Pain management in children is the assessment and treatment of pain in infants and children. [1]

Contents

Types

Acute

Usually, acute pain has an obvious cause and is expected to last for a few days or weeks. It is usually managed with medication and non-pharmacological treatment to provide comfort. [2] Acute pain is an indication for needed assessment, treatment and prevention. While a child is experiencing pain, physiological consequences can jeopardize healing and recovery. Unrelieved pain can cause alkalosis and hypoxemia that result from rapid, shallow breathing. This shallow breathing can lead to the accumulation of fluid in the lungs, taking away the ability to cough. Pain can cause an increase in blood pressure and heart rate, putting stress on the heart. Pain also increases the release of anti-inflammatory steroids that reduce the ability to fight infection, increase the metabolic rate and affect healing. Another harmful outcome of acute pain is an increase in sympathetic effects such as the inability to urinate. Pain can also slow the gastrointestinal system.[ citation needed ]

Inadequate pain management in children can lead to psycho-social consequences, including lack of interest in food, apathy, sleep problems, anxiety, avoidance of discussions about health, fear, hopelessness and powerlessness. Other consequences include extended hospital stays, high re-admission rates and longer recovery. [3]

Examples of harmful consequences of unrelieved pain include: [4]

Neuropathic

Neuropathic pain is associated with nerve injuries or abnormal sensitivities to touch or contact. Though neuropathic pain is relatively uncommon in children compared to adults, greater awareness of these conditions is on the rise. [6] Some causes may include past surgeries and amputations, [7] "autoimmune and degenerative neuropathies", [6] and injury to the spinal cord. [6]

Symptoms may include a tingling, shooting, prickling or burning sensation. The pain can be intermittent or continual and is often exacerbates in the evenings. [7] [8]

Neuropathic pain can be peripheral or central. Peripheral neuropathic pain refers to disturbance in the function of peripheral nerves while central neuropathic pain refers to nerves in the central nervous system.

Though not FDA-approved to address pain in children, anticonvulsants such as gabapentin and pregabalin have been used in severe neuropathic impairment (SNI). [8] Other options are serotonin-norepinephrine reuptake inhibitors (SNRIs). Despite limited studies in children (limited to those with depression), SNRIs such as Venlafaxine have been shown to be effective. [8]

Cancer pain

Cancer pain in children may be caused by the cancer itself or the side effects of treatment. Tumors can cause pain in two different ways, either by the physical pressure it places on organs or by occluding normal bodily functions. Treatment such as surgery and injections can also lead to significant pain for the patient. [9] If untreated, the pain can suppress the immune, interfere with sleep, and increase the chance of depression. Many different health care professionals will manage the child's pain and are referred to as the patient's palliative care team, these include oncologists, anesthesiologists, neurologists, surgeons, psychiatrists, and pharmacists. Hospitals may also hire individuals who specialize in music or art therapy, these therapies include acupuncture, biofeedback, massage therapy, and hypnosis. [10]

Treatment of the cancer pain is tailored to the child based on age, treatment, and side effects. The goal is to achieve sufficient background control of pain and minimize any acute exacerbation of severe pain. Oftentimes medications such as non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, or opiates are used to manage the pain. Additionally, non-pharmacological can also be used to manage the child's pain, this includes distracting the child, massages, acupuncture, heat/cold therapy, exercise, and quality sleep. [10] [11]

Chronic

Chronic pain in children is unresolved pain that affects activities of daily living and may result in a significant amount of missed school days. Chronic pain is present for long periods of time and is characterized as mild to severe. Chronic pain has also been described as the pain experienced when the child reports a headache, abdominal pain, back pain, generalized pain or combination of these. Chronic pain can develop from disease or injury and can occur simultaneously with acute pain. Children who experience chronic pain can have psychological effects. Caring for a child in pain may cause distress to the caregiver, may cause costs due to healthcare or lost wages from time off work, and may stop caregivers from leaving the house.[ citation needed ]

Diagnosis

Example pain assessment chart based on the Wong-Baker Faces Pain Rating Scale Wong-Baker scale with emoji.png
Example pain assessment chart based on the Wong–Baker Faces Pain Rating Scale

Assessment of pain in children depends on the cooperation and developmental stage of the child. Some children cannot assist in their assessment because they have not matured enough cognitively, emotionally, or physically. [12] The following sections list signs of distress and possible pain in children by age group:

Younger infants

Older infants

Toddlers

Toddlers show signs of distress and possible pain by:

School-age children

School-age children show signs of distress and possible pain by:

Adolescent

Adolescents show signs of distress and possible pain:

Quantitative pain assessment

Although pain is subjective and can occur in a continuous spectrum of intensities, there are assessment tools that compare pain levels over time. This kind of assessment incorporates pain scales and requires a high enough developmental level for the child to respond to questions. [12] A verbal response is not always necessary to quantify pain.

Pain scales

A pain scale measures a patient's pain intensity and other features. Pain scales can be based on observational (behavioral) or physiological data, as well as self-report. Self-report is considered primary and should be obtained if possible. Pain measurements help determine the severity, type, and duration of pain. They are also used in diagnosis, to determine a treatment plan, and to evaluate the effectiveness of treatment. Pain scales are available for neonates, infants, children, adolescents, adults, seniors, and persons with impaired communication. Pain assessments are often regarded as "the 5th vital sign". [13]

Examples of pain scales
Self-reportObservationalPhysiological
Infant—Premature Infant Pain Profile; Neonatal/Infant Pain Scale—
Child Wong-Baker Faces Pain Rating Scale – Revised; [14] Coloured Analogue Scale [15] FLACC (Face Legs Arms Cry Consolability Scale); CHEOPS (Children's Hospital of Eastern Ontario Pain Scale) [16] Comfort
Adolescent Visual analogue scale (VAS); Verbal Numerical Rating Scale (VNRS); Verbal Descriptor Scale (VDS); Brief Pain Inventory ——

Causes

The causes of pain in children are similar to the causes in adults.

Pain can be experienced in many ways and depends on the following factors in each child:

During treatment

A physical therapist uses play as part of a child's treatment plan. US Navy 060822-N-2832L-128 Navy Lt. Rachel Oden, of Casa Grande, Ariz., a physical therapist plays with a young girl during her first day of physical therapy for her neuromuscular control deficits.jpg
A physical therapist uses play as part of a child's treatment plan.

Clinicians responsible for a child monitor the child frequently in tertiary care centers (hospitals). Pharmacological and non-pharmacological treatments are used to manage the pain. Parents or caregivers are also requested to provide their own pain assessments. At the beginning of pharmacological treatment, clinicians monitor the child for adverse reactions to the medications. The levels of some medications are monitored to ensure that the child is not overmedicated and does not receive toxic levels of any drug. The levels also indicate whether there would be enough drug in the blood to be effective in managing the pain. Medications are metabolized differently between children of the same age. Factors that influence the levels of medications controlling pain include the height, weight, and body surface of the child, as well as any other illnesses. [12] Some medications may have a paradoxical effect in children, which is an effect that is the opposite of the expected effect. Clinicians monitor for this and any other reactions to medication. [17] [18]

After treatment

Post-procedural treatment in children is primarily prescription opioids. Morphine is effective and relatively safe, and is often used with moderate to severe pain. [19] Codeine and tramadol should be avoided especially in children younger than 12 years old since metabolism varies due to genetic differences between individuals, [20] and, in the case of tramadol, this medication has not been well studied in children. [21] However, other interventions include medications classified as non-opioid analgesics, which are useful in post surgical treatment. [22] For example, acetaminophen or ibuprofen can be used as a non-opioid analgesics. Unlike acetaminophen, ibuprofen has anti-inflammatory property which can be useful for pain in inflammatory conditions. Aspirin is not used in pediatric population due to its association with Reye's syndrome.

Management

Atraumatic measures

Because children process information differently from adults, treatment centers for children often use atraumatic measures to reduce anxiety and stress. Examples include:

Non-pharmacological

Depending on the source of pain, there are many non-pharmacological options to be considered. Also, depending on the age of the child, different approaches may be more suitable.

Non-pharmacological methods to manage discomfort during immunizations or painful procedures in young babies (up to 12 months of age):

Non-pharmacological treatments for older children include:

Non-pharmacological treatment for pain associated with venipuncture in children includes hypnosis and distraction. These treatments reduced self-reported pain and when combined with cognitive-behavioural therapy (CBT) the reduction of pain was even greater. Other interventions have not been found to be effective and these are suggestion, blowing out air, and distraction with parent coaching did not differ from control for pain and distress. [30]

For children and adolescents who experience chronic pain- behavioral treatment, relaxation training, cognitive behavioral therapy (CBT) and acupuncture have been proven to be effective for some patients. [31] For recurrent abdominal pain a 2017 Cochrane review found some evidence that CBT and hypnotherapy were effective in reducing pain for the short term. [32]

For children over one year of age, there is no strong evidence to suggest that eating or sucking on a sweet tasting solution has an analgesic effect. [33]

Medication

Acute pain, chronic pain, neuropathic pain and recurrent pain in children is most often managed with medication. Most of these medications are analgesics. These include acetaminophen, NSAIDs, local anesthetics, opioids, and medications for neuropathic pain. Regional anesthesia is also effective and recommended whenever possible. It is important to use caution when administering opioids to neonates and young infants. There is a higher risk for apnea and hypoventilation in this population, due to their decreased breathing response. [1] The effectiveness and adverse effects associated with the use of the injectable NSAID ketorolac postoperatively or following or during surgery is not clear due to insufficient quantity and quality of evidence. [34] It is not clear from clinical trials if it is more effective to provide pain control around the clock or provide pain relief as needed for children recovering from surgery. [35]

Chronic pain treatment

Chronic pain is treated with a variety of medications and non-pharmacological interventions. The World Health Organization recommends using a two step treatment approach based on the level of pain in children. The first step explains mild pain treatment, while the second step considers moderate to severe pain. Opioids, such as morphine, is an example of a drug of choice for moderate-severe pain in children with medical illnesses. [36] Some side effects of opioid use can include cognition deficits, dependence, altered mood, and disturbances of endocrine development.

Non-pharmacological treatment for children to help relieve periodic pain includes counseling and behavior modification therapy.[ medical citation needed ] The American Association of Pediatrics states that psychological interventions, such as relaxation and cognitive strategies, have strong evidence for pain management. [37]

Acute pain treatment

The approach to acute pain should take into account the severity of the pain. Non-opioid analgesics, such as paracetamol (acetaminophen) and NSAIDs, can be used alone to treat mild pain. [1] For moderate to severe pain, it is optimal to use a combination of multiple agents, including opioid and non-opioid agents. [1]

Postoperative pain

A panel, including the American Pain Society and American Society of Regional Anesthesia and Pain Medicine, recommends multimodal analgesia, which they define as a combination of pharmacological agents and non-pharmacological techniques to treat postoperative pain. [38] A significant benefit of this technique is that non-opioid analgesics used in combination with opioids can decrease the amount of opioids required and reduce the risk of opioid-related side effects. [1] Medications can be delivered as needed or around-the-clock depending on the patient's needs. For children, intravenous patient-controlled analgesia (IV-PCA) can be used when parenteral administration is preferred. [38] IV-PCA allows for consistent opioid levels, which can be a better alternative to scheduled intramuscular injections. [1] In addition, studies have shown that children as young as 6 years old can use the IV-PCA correctly. [38]

Dental pain

For projected moderate to severe pain, analgesics can be used on a regular schedule for the first 36 to 48 hours after a dental procedure. [39] NSAIDs are preferred over other analgesics to treat acute mild to moderate postoperative pain, due to the inflammatory component of dental pain. [39] [40] Alternating between the NSAIDs and acetaminophen in combination is another option. [39] In addition, these two agents are considered equivalent or better than opioids for managing musculoskeletal pain, which includes dental pain. [40]

Cancer pain

Cancer pain is managed differently in children. Typically, medical history, physical examinations, age and overall health of the child are evaluated. The type of cancer may influence decisions about pain management. The extent of the cancer, and the tolerance of the child to specific medications, procedures or therapies are also taken into account, as well as the preferences of the parent or caregiver.[ medical citation needed ] Medications used to treat cancer pain include non-steroidal anti-inflammatory drugs (NSAIDs) [41] and opioids. [42]

Non-steroidal anti-inflammatory drugs (NSAIDs)

Non-steroidal anti-inflammatory drugs (NSAIDs):

  • Used as treatment for pain and as an anti-inflammatory.
  • Can be administered as oral tablet or liquid.
  • It is recommended to use the lowest dose and shortest duration possible to control pain.
  • NSAIDs are not approved for infants under 3 months old.
  • General adverse effects for NSAIDs:
    • Renal impairment
    • Hepatic impairment
    • Gastrointestinal issues (nausea, diarrhea, constipation, flatulence)
    • Dyspepsia
    • Rash
    • Dizziness
    • Abdominal pain
  • Contraindicated for:
  • Ibuprofen 5–10 mg/kg every 6–8 hours (Max dose 1200 mg/day)

Opioids

Opioids:

The frequency of prescribing for these pain medications has more than doubled from 1990 to 2010 with 20-50% of adolescents who complain of headache, back pain, or joint pain receiving a prescribed opioid. [43] [44]

Before an adolescent or young adult is prescribed opioids, they should be screened for risk factors for opioid drug abuse. Prescription drug monitoring programs (PDMs) are now available in 37 states and 11 states have programs in development. [45]

The use of opioids can result in a number of complications in children, including respiratory depression and risk for unintended overdose and opioid misuse later in life. These risks can be reduced by the use of NSAIDs (e.g. ibuprofen) and paracetamol. Using NSAIDs and paracetamol can be opioid-sparing, leading to less opioid use in situations such as peri-operative pain management. [46] The efficacy and safety of opioids in children have not been established. [47]

A 2014 Cochrane Review for nalbuphine for postoperative pain treatment in children, reported insufficient evidence of the efficacy and adverse events of nalbuphine in this population; further research is needed in this area. [48]

Other side effects of opioids are constipation, fatigue, and disorientation. Children can develop opioid tolerance, where larger doses are needed to have the same effect. Tolerance occurs earlier in children than in adults, especially with prolonged use. [49] When tolerance to opioids develop, it takes a larger dose of the opioid to achieve the same analgesic effect. [50] Non-pharmacological treatments have few side effects.[ medical citation needed ]

Treatment for children and adolescents with conditions that are life limiting

For children with lifelimiting conditions including cancer, the evidence supporting or refuting specific treatment approaches is very weak. [51]

Society and culture

The indications that treatment is needed are not always clear for children because of poor assessments and the tendency to undertreat pain.

Misconceptions about pain in children
IncorrectValidReferences
Infants cannot sense pain like adultsNerve pathways exist at birth, albeit immature
Newborns experience physiological changes and surges in hormones that indicate stress 		[52]
Infants cannot feel pain because their nerve fibers are not myelinated Complete myelination is not necessary for the transmission of pain impulses to the brain [52]
Young children cannot indicate where pain originatesYoung children may have the cognitive ability to use a body chart and explain where their pain is coming from [52]
A child able to sleep must not be in painSleep occurs because of exhaustion [52]

Research

The use of virtual reality devices has been suggested as a non pharmacological option for distracting children during certain painful procedures, however, further research is required to determine if this approach is effective and also to identify any unwanted effects. [53] The effectiveness and potential side effects or adverse effects associated with many commonly used pain medications in children and adolescents such as paracetamol have not been well studied in the pediatric population as most of the high quality studies showing effectiveness have been conducted in adults. [54]

See also

Related Research Articles

<span class="mw-page-title-main">Analgesic</span> Any member of the group of drugs used to achieve analgesia, relief from pain

An analgesic drug, also called simply an analgesic, pain reliever, or painkiller, is any member of the group of drugs used to achieve relief from pain. Analgesics are conceptually distinct from anesthetics, which temporarily reduce, and in some instances eliminate, sensation, although analgesia and anesthesia are neurophysiologically overlapping and thus various drugs have both analgesic and anesthetic effects.

<span class="mw-page-title-main">Ketoprofen</span> Chemical compound

Ketoprofen is one of the propionic acid class of nonsteroidal anti-inflammatory drugs (NSAID) with analgesic and antipyretic effects. It acts by inhibiting the body's production of prostaglandin.

<span class="mw-page-title-main">Nonsteroidal anti-inflammatory drug</span> Class of therapeutic drug for relieving pain and inflammation

Non-steroidal anti-inflammatory drugs (NSAID) are members of a therapeutic drug class which reduces pain, decreases inflammation, decreases fever, and prevents blood clots. Side effects depend on the specific drug, its dose and duration of use, but largely include an increased risk of gastrointestinal ulcers and bleeds, heart attack, and kidney disease.

<span class="mw-page-title-main">Paracetamol</span> Common medication for pain and fever

Paracetamol is a non-opioid analgesic and antipyretic agent used to treat fever and mild to moderate pain. It is a widely used over the counter medication and common brand names include Tylenol and Panadol.

<span class="mw-page-title-main">Cold medicine</span> Medication taken to relieve cold symptoms

Cold medicines are a group of medications taken individually or in combination as a treatment for the symptoms of the common cold and similar conditions of the upper respiratory tract. The term encompasses a broad array of drugs, including analgesics, antihistamines and decongestants, among many others. It also includes drugs which are marketed as cough suppressants or antitussives, but their effectiveness in reducing cough symptoms is unclear or minimal.

<span class="mw-page-title-main">Sore throat</span> Medical condition

Sore throat, also known as throat pain, is pain or irritation of the throat. Usually, causes of sore throat include:

<span class="mw-page-title-main">Tension headache</span> Medical condition

Tension headache, also known as stress headache, or tension-type headache (TTH), is the most common type of primary headache. The pain can radiate from the lower back of the head, the neck, eyes or other muscle groups in the body typically affecting both sides of the head. Tension-type headaches account for nearly 90% of all headaches.

<span class="mw-page-title-main">Pain management</span> Interdisciplinary approach for easing pain

Pain management is an aspect of medicine and health care involving relief of pain in various dimensions, from acute and simple to chronic and challenging. Most physicians and other health professionals provide some pain control in the normal course of their practice, and for the more complex instances of pain, they also call on additional help from a specific medical specialty devoted to pain, which is called pain medicine.

<span class="mw-page-title-main">Peripheral neuropathy</span> Nervous system disease affecting nerves beyond the brain and spinal cord

Peripheral neuropathy, often shortened to neuropathy, is a general term describing damage or disease affecting the nerves. Damage to nerves may impair sensation, movement, gland, or organ function depending on which nerves are affected; in other words, neuropathy affecting motor, sensory, or autonomic nerves result in different symptoms. More than one type of nerve may be affected simultaneously. Peripheral neuropathy may be acute or chronic, and may be reversible or permanent.

<span class="mw-page-title-main">Low back pain</span> Medical condition

Low back pain (LBP) or lumbago is a common disorder involving the muscles, nerves, and bones of the back, in between the lower edge of the ribs and the lower fold of the buttocks. Pain can vary from a dull constant ache to a sudden sharp feeling. Low back pain may be classified by duration as acute, sub-chronic, or chronic. The condition may be further classified by the underlying cause as either mechanical, non-mechanical, or referred pain. The symptoms of low back pain usually improve within a few weeks from the time they start, with 40–90% of people recovered by six weeks.

Postoperative nausea and vomiting (PONV) is the phenomenon of nausea, vomiting, or retching experienced by a patient in the postanesthesia care unit (PACU) or within 24 hours following a surgical procedure. PONV affects about 10% of the population undergoing general anaesthesia each year. PONV can be unpleasant and lead to a delay in mobilization and food, fluid, and medication intake following surgery.

<span class="mw-page-title-main">Epidural administration</span> Medication injected into the epidural space of the spine

Epidural administration is a method of medication administration in which a medicine is injected into the epidural space around the spinal cord. The epidural route is used by physicians and nurse anesthetists to administer local anesthetic agents, analgesics, diagnostic medicines such as radiocontrast agents, and other medicines such as glucocorticoids. Epidural administration involves the placement of a catheter into the epidural space, which may remain in place for the duration of the treatment. The technique of intentional epidural administration of medication was first described in 1921 by Spanish military surgeon Fidel Pagés.

Labor induction is the process or treatment that stimulates childbirth and delivery. Inducing (starting) labor can be accomplished with pharmaceutical or non-pharmaceutical methods. In Western countries, it is estimated that one-quarter of pregnant women have their labor medically induced with drug treatment. Inductions are most often performed either with prostaglandin drug treatment alone, or with a combination of prostaglandin and intravenous oxytocin treatment.

Postherpetic neuralgia (PHN) is neuropathic pain that occurs due to damage to a peripheral nerve caused by the reactivation of the varicella zoster virus. PHN is defined as pain in a dermatomal distribution that lasts for at least 90 days after an outbreak of herpes zoster. Several types of pain may occur with PHN including continuous burning pain, episodes of severe shooting or electric-like pain, and a heightened sensitivity to gentle touch which would not otherwise cause pain or to painful stimuli. Abnormal sensations and itching may also occur.

Transient tachypnea of the newborn is a respiratory problem that can be seen in the newborn shortly after delivery. It is caused by retained fetal lung fluid due to impaired clearance mechanisms. It is the most common cause of respiratory distress in term neonates. It consists of a period of tachypnea (rapid breathing. Usually, this condition resolves over 24–72 hours. Treatment is supportive and may include supplemental oxygen and antibiotics. The chest x-ray shows hyperinflation of the lungs including prominent pulmonary vascular markings, flattening of the diaphragm, and fluid in the horizontal fissure of the right lung.

Neuropathic pain is pain caused by damage or disease affecting the somatosensory system. Neuropathic pain may be associated with abnormal sensations called dysesthesia or pain from normally non-painful stimuli (allodynia). It may have continuous and/or episodic (paroxysmal) components. The latter resemble stabbings or electric shocks. Common qualities include burning or coldness, "pins and needles" sensations, numbness and itching.

<span class="mw-page-title-main">Baby colic</span> Medical condition

Baby colic, also known as infantile colic, is defined as episodes of crying for more than three hours a day, for more than three days a week, for three weeks in an otherwise healthy child. Often crying occurs in the evening. It typically does not result in long-term problems. The crying can result in frustration of the parents, depression following delivery, excess visits to the doctor, and child abuse.

<span class="mw-page-title-main">Ketorolac</span> Nonsteroidal anti-inflammatory drug (NSAID; analgesic)

Ketorolac, sold under the brand names Toradol, and Biorolac among others, is a nonsteroidal anti-inflammatory drug (NSAID) used to treat pain. Specifically it is recommended for moderate to severe pain. Recommended duration of treatment is less than six days, and in Switzerland not more than two days. It is used by mouth, by nose, by injection into a vein or muscle, and as eye drops. Effects begin within an hour and last for up to eight hours.

Cochrane Eyes and Vision (CEV) is a collaboration of researchers and healthcare professionals who prepare systematic reviews to study interventions pertaining to the treatment of eye disease and visual impairment. Though many of the systematic reviews focus on common eye diseases, reviews have been prepared for varied eye topics, including screening prevention and rarer eye diseases.

<span class="mw-page-title-main">Pain management during childbirth</span>

Pain management during childbirth is the treatment or prevention of pain that a woman may experience during labor and delivery. The amount of pain a woman feels during labor depends partly on the size and position of her baby, the size of her pelvis, her emotions, the strength of the contractions, and her outlook. Tension increases pain during labor. Virtually all women worry about how they will cope with the pain of labor and delivery. Childbirth is different for each woman and predicting the amount of pain experienced during birth and delivery can not be certain.

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