Pain management in infants and children

Pain management:
Pediatric Patients
Rita P. Raman, MD, MS, JD, MACN, FCLM
Professor of Pediatrics
University of Oklahoma Health Sciences Center

Learning Objectives
• Review experience of pain neonates, infants
and children
• Assess the factors that limit evaluation and
management of pain in neonates, infants and
children
• Review some of the methods by which pain
can be prevented and/or managed in neonates,
infants and children

Pain: What is it?
• Pain: unpleasant sensory and emotional
experience associated with actual or potential
tissue damage
• Pain is subjective
• Pain is both a sensory and emotional
experience: several different assessment
strategies are needed to provide qualitative
and quantitative information about pain.

Pain: Pediatrics
• Pain in children is under-recognized and undertreated.
• Reasons:
1. Myths about pain and pain management,
2. Fears held by parents and health professionals
3. Perceived lack of pain assessment tools
4. Lack of knowledge about pain assessment.
• Neonate’s expression of pain does not fit the
strict definition due to the lack of self report.

Pain Assessment
• Qualitative assessment : location, duration and
character of the pain, and factors affecting the pain.
• Quantitative assessment : evaluate intensity - pain
scale.
• Clinical assessment of pain: assess pain at regular
intervals and systematically.
• Empower patients and their families: involve them
in the decision making for pain control.
• Pain control : timely, logical and coordinated.

QUESTT Principles
• Question the child.
• Use pain rating scales.
• Evaluate behavior and physiologic
changes.
• Secure parents' involvement.
• Take cause of pain into account.
• Take action and evaluate results.

Pain management
• Concepts: by the ladder, by the clock, by the
route
and by the child
• Pain management in children be administered
on a scheduled basis, be given by the least
invasive route, and be tailored to the individual
child's circumstance and needs

•

The Consensus Conference on the Management of
Pain in Childhood Cancer
• Invasive procedures are documented as the most
painful and traumatic events experienced by
children.
• Procedure-related pain: acute, short-lived , but
accompanied by a great deal of fear and anxiety.
• Children often experience depression, insomnia,
and anorexia before the clinic or hospital visit
which includes a procedure.
• Goal: provide comfort and support during all
procedures experienced by the child

Pain management
• Non-pharmacologic interventions: highly
effective for some children and for some
procedures.
• Distraction, muscle relaxation, and guided
imagery are easy techniques to learn and can be
used with young children.
• Interventions requiring specialized training
include therapeutic touch and acupressure.
• Non-pharmacologic interventions are often an
adjunct to pharmacological interventions.

Pain: ill child
• Pain varies with degree/location of tissue damage, &
the psychological, social, and cultural factors unique
to each child.
• Children may experience metastasis and may present
with pain of mixed etiologies, e.g., bone, brain,
viscera etc
• Children with sickle cell disease experience recurrent
severe pain related to sickle crisis
• Patients may require a combination of opioids,
adjuvants, and invasive therapies to provide adequate
pain relief.

Curative to palliative shift
• Terminally ill child: should receive the same level
of monitoring and assessment of pain and
discomfort throughout the terminal phase of the
illness.
• Goal shifts from curative to palliative: inform
child and parents of the options available for
managing pain and other symptoms.
• Continued attentive care and support :
management of pain and discomfort and
enhancement of the quality of the time remaining
to the child and family.

Neonates and Infants
• Barriers to treatment of pain in infants and
neonates:
• The myth that infants do not feel pain
• Lack of pain assessment & reassessment tools
• Failure to conceptualize/quantify subjective
experience
• Lack of knowledge of pain treatment
• Notion that addressing pain in children takes too
much time and effort
• Fears of adverse effects of analgesic medications

Neonates feel pain!
• Neuroanatomical components and neuroendocrine
systems are sufficiently developed to allow transmission
of painful stimuli in the neonate
• Procedure painful in adult, be considered painful in
neonate
• Exposure to prolonged or severe pain may increase
neonatal morbidity
• Compared with older age groups, newborns may
experience a greater sensitivity to pain and are more
susceptible to the long-term effects of painful
stimulation
• Severity of pain and effects of treatment can be assessed
in the neonate

NICU Pain
• Diagnostic procedures: Arterial punctures, heel lancing,
lumbar puncture, ROP exams
• Therapeutic procedures: bladder catheterization,
peripheral IV and central line insertion, dressing changes,
OG/NG tube insertion, IM injections, mechanical
ventilation, removal of adhesive tape, tracheal suctioning
• Other sources
• Localized infections/inflammation
• Post-operative pain
• Burns or abrasions from probes, leads & topical agents
• Circumcisions

Pain Assessment Tools:
Unidimensional
• Neonatal Facial Coding System (NFCS)
• Infant Body Coding System (IBCS)
• Clinical Scoring System (CSC)
• Modified Behavioral Pain Scale (MBPS)

Neonatal Facial Coding System
0 Points 1 Point
Brow bulge Absent Present
Eye squeeze Absent Present
Deepened
nasolabial furrow
Absent
Present
Open lips Absent Present
Stretched mouth Absent Present
Lip purse Absent Present
Taut tongue Absent Present
Chin quiver Absent Present

Pain Assessment Tools:
Multidimensional
• Multidimensional: Evaluation of pain is done
by means of combinations of objective and
subjective measurements; particularly
appropriate for individuals for whom selfreporting
is compromised
• Neonatal Infant Pain Scale (NIPS)
• Premature Infant Pain Profile (PIPP)
• CRIES Scale

*EDIN - Échelle Douleur Inconfort Nouveau-Né

• Developmentally appropriate non-pharmacological
interventions:
• Swaddling/facilitated tucking before, during and after
procedure
• Alternative distraction (music, light, conversation)
• Pacifier during and after procedure
• Assisting with hand-to-mouth
• Tactile stimulation and massage therapy
• Positioning with proper flexion and midline orientation
• Cuddling, holding in upright position
• Decreased environmental stimulation: light and noise
• Deceased handling, increased rest periods between
procedures
• Rhythmic activities: stroking, patting, rocking
Non-Pharmacological Pain Management

Facilitated Tucking
• Facilitated tucking: gentle motoric containment of an
infant’s arms and legs in flexed, midline position close to
the infant’s trunk with the infant in a side-lying or supine
position
• JOGNN, 1995; Corff, Seideman, Venkataraman, Lutes, Yates
• Prospective, repeated measure, random sequencing and
experimental, baby served as his own control
• 30 preemies, 25-35 weeks underwent heel-sticks, with and
without facilitated tucking
• Significantly lower heart rate (p

Pharmacologic Pain Control
• Sucrose for analgesia
• Pharmacological analgesia should be chosen
carefully based on patient, medication and
environment
• Subsequent doses should be modified based on
cause of the pain, previous response, clinical
condition, concomitant drug use, and
pharmacodynamics of the drugs used
• Wean pain medications

Summary
• Neonates, infants and children experience
pain
• Pain in pediatric patients can be assessed
and managed
• Failure to provide pain relief and/or avoid
unnecessary pain is unethical