Pain Management in Pediatrics
Hannah O’Handley RN MSN CPNP
Mt. Carmel College of Nursing
Assessing
Pain
in Children
Behavioral Measures
• Distress Behaviors:
– Vocalization
– Facial expression
– Body movements
• Helpful with children/infants who
cannot communicate
• Drawbacks:
– More reliable with procedural pain.
– Less reliable in older children
– Should NOT be used in children who can
communicate their pain (self-report)
Physiologic Measures
• Physiologic measures of stress
– Increased HR
• Bradycardia in stressed infants
– Increased RR
• Apnea in very stressed infants
– Increased BP
– Decreased oxygenation with premature
infants
• Multiple reasons for these elevations.
• NOT specific to pain
• Do not rely on physiologic measures
only for pain assessment
Full Term
Objective Pain Scales
Premies
3 Months
D
o
N
o
t
U
s
e
Neonatal Pain, Agitation & Sedation Scale
N-PASS (next slide)
Self-report Pain Scales
• Patient self report >3-6 years
old
– Oucher
– Poker Chip Tool
– FACES scale
• Visual analog scales
• Color analog scales
• <5 yrs – tend to choose extremes,
confuse pain and unhappiness
• >7 yrs – conventional VAS;
memory accurate over time;
strong affective componentanger anxiety, depression;
secondary gain
Oucher Scale
Measuring pain
by its intensity
alone is like
describing music
only in terms of
its loudness.
Carl Von Beyer 2003 ISPP
What to include in a Pain
Assessment
•
•
•
•
Onset
Location
Duration
Characteristics
•
•
•
•
Aggravating Factors
Relieving Factors
Treatment
Severity (Pain Score)
– Post-op pain
– Neuropathic pain
– Musculoskeletal pain
Treatment Options
• Non-pharmacologic Measures
–
–
–
–
Distraction
Heat/Ice
Massage, touch
Breathing exercises
–
–
–
–
Opioids (intravenous, oral)
NSAIDS (ibuprofen, ketorolac)
Muscle Relaxants (valium)
Neuropathic Pain Tx (gabapentin, tricyclic
• Pharmacologic Measures
antidepressants, methadone)
– Opioid side effect mgmt (nausea, itching,
constipation)
Topical Anesthetics
• Numb the area to prevent pain with injections or
procedures.
– EMLA: Best choice
• Has deeper penetration for IM injections
• Leave on for at least 1hr, up to 4hrs, peaks 2-3hrs.
• Numbs area for 1-2hrs after cream removed.
– LMX: 2nd choice w/ time constraints
• Shallow penetration (IV insertion, SQ inj)
• Effective after 30min, peaks 60min. Numbs area for 1hr
after removal.
• Never clean skin prior to application.
• Rub in small amount 1st (30sec), then apply.
– Cold spray
• Spray area immediately prior to injection.
• Shallow penetration.
• Careful to not “frost” the skin.
– Lidocaine Gel (urojet)
• Policy to use lidocaine gel prior to urine cath.
– Viscous lidocaine (for NG placement)
• Policy to use prior to all NG placements (see policy)
Four A’s for Pain Treatment
Outcome Assessment
• Analgesia (Pain relief)
• Activities of daily living
• Adverse events
• Aberrant drug-taking behavior
What you can do….
• Assess pain on the
frequency the prn
medications are due
and give if needed.
• Are the any
contributing
situational factors?
• Set pain goal with your
patient.
MYTH #1: Children are at
high risk for addiction to
narcotics.
• FACT: Addiction occurs when
narcotics are used for
psychological effects and not for
medical reasons. The use of
narcotics for pain relief is not
addiction. The risk of addiction
is less than 1% in children.
MYTH #2: Physical dependence
on a narcotic is the same as
addiction.
• FACT: Physical dependence
(withdrawal syndrome) is not the
same as addiction. While withdrawal
symptoms may occur after one week
of narcotic use, it does not indicate
that a child is addicted to the drug.
It simply means that the drug is
having some effect on the child’s
pain and should be withdrawn
gradually.
MYTH #3: Tolerance is the
same as addiction.
• FACT: After giving a narcotic
repeatedly, a given dose may lose
it’s effectiveness; therefore, an
increased dose may be needed to
obtain a desired effect. This does
not mean that the child is addicted
to the drug, it simply means that
the child’s body has adjusted to the
analgesic effect of the drug, and
requires a higher dose for
effectiveness.
MYTH #4: A teenager who is
laughing with friends and talking
on the phone after receiving
narcotics must be addicted to
pain medication.
• FACT: Returning to “normal
behavior” after pain medication is
given, is indicative of effective pain
control. When pain is well controlled,
children and teenagers are able to
return to their normal activity.
MYTH #5: Narcotic induced
respiratory depression is more
common in children than adults.
• FACT: Infants 3 months of age or
older are at no increased risk for
narcotic induced respiratory
depression. In fact, some studies
indicate that infants and children
metabolize narcotics faster, and
therefore need higher doses of
narcotics to achieve desired effects.
MYTH #6: Low doses of
narcotics will minimize narcoticinduced respiratory depression.
• FACT: Low doses do not mean safe
doses. Drug interactions and additive
effects of other sedating medications
should be considered when dosing
narcotics. If a narcotic is given alone,
and at the correct dose, narcoticinduced respiratory depression will be
at a minimum.
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