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Part
5:
Pediatric Pain Management staff education
Top
10 things you need to know about pediatric pain management:
- Infants
do have PAIN.
- If a child
is lying still, pain may be present. Children may not always be
willing or able to communicate the fact that they are in pain.
- When there
is pain, there may be nausea. Treat both.
- Don't UNDERMEDICATE.
Children often require more pain medication than adults (in milligrams/
kilogram) do to achieve pain control. Repeat patients usually
need more medication to attain the same degree of pain relief.
- Incorporate
the family into the child's care, since family insights are very
helpful at all ages and developmental stages.
- When assessing
the effect of pain medications, remember to consider the patient's
normal routine. If it's naptime the child may not arouse easily.
Pain medication may not be the problem.
- Titrate
pain medication in increments is when possible. Monitor respiratory
status if narcotics are being used.
- Always consider
other reasons for patient discomfort besides pain. Is the child
wet or hungry? Does she want her parents? Does he need to be burped?
- Communicate
at the child's level when assessing pain and response to pain,
remembering that many children regress when in pain.
- Seek other
pediatric personnel as consultants whenever necessary.
Barriers
to Effective Pain Management
Provider
Barriers
(Pain Management in Children with Cancer, Texas Cancer Center, 1999)
MYTH:
Young Infants do not feel pain. Children’s nervous systems are immature
and are unable to perceive and experience pain the way adults do.
(Texas Cancer Council, 1999)
FACT:
The Central nervous system of a 26 week old fetus possess the anatomical
and neurochemical capabilities of experiencing nociception (Anand,
1998)
MYTH:
Children easily become addicted to narcotics.
FACT:
Less than 1% of children treated with opioids (Narcotics) develop
addiction. (Foley, 1996)
MYTH:
Children tolerate pain better than adults.
FACT:
Younger children experience higher levels of pain during procedures
than older children. Children’s tolerance for pain increases with
age. (Bromme, Rehwalt and Fogg, 1998; Broome and others 1990)
MYTH:
Children are unable to tell you where they hurt.
FACT:
Children may not be able to express their pain in the same manner
as adults. Children are able to point to eh body area where they
are experiencing pain or draw a picture illustrating their perception
of pain.
MYTH:
Children become accustomed to pain or painful procedures.
FACT:
Children exposed to repeated painful procedures often experience
increasing anxiety and perception of pain with repeated procedures
(Zeltzer, 1990).
MYTH:
Children will tell you when they are experiencing pain.
FACT:
Children may not report pain due to fear of administration of a
painful analgesic (injection) or fear of returning to the hospital.
Children who have experienced chronic pain may not be aware that
they are experiencing pain. Young children may not have adequate
communication skills or others may not think it is necessary to
tell health professionals about the pain (Favaloro and Touzel, 1990).
MYTH:
Children’s behaviors reflect their pain intensity.
FACT:
Children are unique in their ways of coping. Children’s behavior
is not a specific indication of their pain level (Beyer, McGrath
and Berde, 1990).
Basic
Concepts of Pain Management
- The child
is the authority on his own pain.
It
is very important to know and recognize the child’s physiological,
psychological, and emotional responses to pain when developing
a pain management plan. Without addressing these important issues,
it is often difficult to develop an adequate pain treatment plan.
Changes
in vital signs do not occur with all children who are experiencing
severe pain. Do not rely on vital signs to determine the severity
of a childs’s pain.
Children
with pain, even severe pain, can be distracted from thinking about
their pain, and may even be able to sleep. Don’t trust that a
patient isn’t having pain because he "looks comfortable."
Always ask, and believe the patient’s assessment of his own pain.
- The child
has the right to expect a rapid and effective response to a complaint
of pain.
Treat
the pain, reassess frequently, and continue to treat until the
patient is comfortable or side effects prevent further treatment.
If this occurs, consult a pain expert- don’t leave a patient in
pain without a treatment plan.
- A history
and physical examination of the pain is very helpful. Details
of the pain’s location, duration, radiation, and character often
provide valuable clues about how to treat the pain most effectively.
- Medications
are best given orally for long-term management of pain. For short-term
management, like postoperative pain, the IV route is preferred
(especially with severe pain).
- Most pain
medications have side effects. Effective pain relief is often
accompanied by at least some of these side effects. Be prepared
to treat the side effects of opioids if they occur (e.g., nausea
or itching).
- A balanced
approach to pain management combines nonpharmacologic and pharmacologic
therapy, and frequently utilizes multiple analgesics which work
by different mechanisms.
Patients
with chronic pain are usually on a specific regimen of pharmacologic
and nonpharmacologic therapy. This regimen must be continued during
their hospitalization. Superimposed acute pain (e.g. acute postoperative
pain) should be treated with additional opioids (narcotics).
Assessment
and Documentation
Pain
Assessment
A
physician, nurse, and/or other health care professional will identify
the presence of pain for each patient encounter at UMHHC. If pain
is present, its intensity is scored, typically using a standardized
0 to 10 scale. (See "pain scales" below). Pain scores
are documented in writing, just like vital signs, making them
readily available to all members of the health care team. The
American Pain Society actually suggests that pain should be thought
of as the 5th vital sign.
In
the hospital setting, the patient’s pain is assessed at least
as often as vital signs are taken, because ongoing assessment
is necessary to evaluate changes in pain and the effectiveness
of its treatment. Pain should be assessed at intervals appropriate
to the severity of pain and the patient’s situation. For many
patients, this will mean assessment of pain every 4 hours, but
the time between assessments must be individualized to the patient’s
need.
In the ambulatory care setting, pain assessment should be
completed with every new episode of care. Repeated visits or contacts
for the same problem may not require repeated pain assessments
(unless a current pain problem is being followed).
Pediatric
Pain assessment should be appropriate to the developmental level.
All pediatric patients should be assessed for pain. Pain can be
communicated by words, expressions, and behavior (crying, guarding
a body part, grimacing).
Using the
QUEST Principles of pain assessment (Baker and Wong, 1987)
may be helpful in assessing pediatric pain.
Question
the child.
Use
pain rating scales.
Evaluate
behavior and physiological changes.
Secure
parent’s involvement.
Take
cause of pain into account.
Take
action and evaluate results.
Neonates:
Situations
that are painful for older children and adults can be expected
to be painful for babies. Neonates that are ill may not be able
to cry.
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Signs
Of Acute Pain
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Signs
of Chronic Pain
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Crying
and moaning
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Apathy
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Muscle
rigidity
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Irritability
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Flexion
or flailing of the extremities
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Changes
in sleeping and eating patterns
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Diaphoresis
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A lack
of interest in their surroundings
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Irritability
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Guarding
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Changes
in vital signs, and pupillary dilatation
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Older
Children:
Children less
than 3 years old or unable to communicate, clinicians should
use the FLACC scale.
Children over
3 may use the Faces scale.
Children over
5 may be able to use descriptor words (stinging, burning).
Children over
6, who understand the concepts of rank and order, can use
numerical scale, color scale, and word scale.
Factors
Influencing Pain Ratings:
Because each
child may regress when they are in pain, it is important to use
whatever tool that they are able to understand.
Children often deny pain because they fear consequences (e.g., physical
exam or injection) if they admit to having pain.
Young children may not understand the relationship between pain
assessment, treatment and the relief of pain.
Observation of a child's behavior is helpful in the evaluation of
pain. Including the patient's family or guardian may help in the
assessment of pain. Observation of a child's behavior is the only
way to assess a non-communicative child.
Pain Scales
Scales should
be developmentally, physically, emotionally and cognitively appropriate
for the given patient.
Suggested
standardized tools with 0 to 10 scoring are listed below.
Other scales may be adopted for specific UMHHC units.
- Numeric
rating scale
- Color
scale
- Word
graphic scale
- Wong-Baker
FACES Pain Rating Scale (3 years of age and older
- FLACC
(ages 3 months to 7 years)
- N-Pass
- Holden
(See
the instructions and illustrations that follow.)
Numeric
Rating Scale
Ask the patient
to rate their pain intensity on a scale of 0 (no pain) to 10 (the
worst pain imaginable). Some patients are unable to do this with
only verbal instructions, but may be able to look at a number scale
and point to the number that describes the intensity of their pain.
Color
Scale
This scale is
a colored stripe in which color gradually changes from white (no
pain) through shades of pink to dark red (worst possible pain).
Ask the patient to point to the area on the scale that shows their
level of pain. To obtain a number for documentation use the scale
parallel to the color stripe to find the number corresponding to
the area where the patient points.
Word
Graphic Scale
This scale
can be used with patient as young as 6 years of age. It uses a
line with words to describe pain intensity from "no pain"
to "worst possible pain". Show and explain the scale
to the patient and then ask him or her to point (or mark) anywhere
along the line that shows how much pain they have. To find a number
for documentation count the black dots, starting with zero at
the far left, to the area where the patient points, up to ten
at the far right.
Wong-Baker
FACES Pain Rating Scale
From Wong
DL, Hockenberry-Eaton M, Wilson D, Winkelstein ML, Ahmann E, DiVito-Thomas
PA: Whaley and Wong’s Nursing Care of Infants and Children, ed.
6, St. Louis, 1999, Mosby, p. 1153.
This scale
can be used with young children (sometimes as young as 3 years
of age). It also works well for many older children and adults
as well as for those who speak a different language. Explain that
each face represents a person who may have no pain, some pain,
or as much pain as imaginable. Point to the appropriate face and
say:
(0) "This
face is happy and does not hurt at all."
(2) "This
face hurts just a little bit."
(4) "This
face hurts a little more."
(6) "This
face hurts even more."
(8) "This
face hurts a whole lot."
(10) "This
face hurts as much as you can imagine, but you don’t have
to be crying to feel this bad."
Ask the patient
to choose the face that best matches how she or he feels or how
much they hurt.
FLACC
Scale
This is a behavior scale that has been tested with children age
3 months to 7 years. Each of the five categories (Faces, Legs, Activity,
Cry, Consolability) is scored from 0-2 and the scores are added
to get a total from 0-10. Behavioral pain scores need to be considered
within the context of the child's psychological status, anxiety
and other environment factors.
| Face |
0
No particular expression or smile
|
1
Occasional grimace or frown, withdrawn disinterested
|
2
Frequent to constant frown, clenched jaw, quivering chin
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| Legs |
0
Normal position or relaxed
|
1
Uneasy, restless, tense
|
2
Kicking, or legs drawn up
|
| Activity |
0
Lying quietly, normal position, moves easily
|
1
Squirming, shifting back and forth, tense
|
2
Arched, rigid, or jerking
|
| Cry |
0
No cry
(awake or asleep)
|
1
Moans or whimpers, occasional complaint
|
2
Crying steadily, screams or sobs, frequent complaints
|
| Consolability |
0
Content, relaxed
|
1
Reassured by occasional touching, hugging or "talking
to, distractible
|
2
Difficult to console or comfort
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The FLACC is
a behavior pain assessment scale
©University of Michigan Health System (can be reproduced for clinical
or research use)
N-Pass
tool used in Holden Neonatal Unit
This is a new tool specifically
for neonates by Pat Hummel and Mary Puchalski of Loyola University
being used with permission. It uses a combination score of assessment
criteria that includes crying/irritability, behavior state, facial
expression, extremities tone, and vital signs. The tool and scoring
criteria are below.
Click
here for N-Pass tool
Pain
Documentation
Pain
assessment results can be charted in a variety of places:
Inpatient:
- 24
hour flow sheet
Place
pain score below the charting area for vital signs. Updates
can be entered every hour. (See sample)
On the reverse side of the flow sheet is an area labeled
"cognitive/perceptual" or "rest and comfort". (See sample)
This charting space allows documentation of pain score,
comfort level AND patient satisfaction with their current
level of pain. Any additional information can be noted in
the "other" section at the bottom of this page.
- Analgesia
flow sheet
When a PCA or Epidural is being utilized, pain scores
can be documented here.
- Progress
notes and discharge summary
The note may indicate th eintensity and characteristics
of the patient's pain, along with current treatment and
future pain plan.
Ambulatory Care
1) Clinic notes
Classification
of Pain by Inferred Pathology
Two
Major types of Pain
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I Nociceptive
Pain
a.
Somatic Pain
b.
Visceral Pai
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II Neuropathic
Pain
a.
Centrally Generated Pain
b.
Peripherally Generated Pain
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Nociceptive
Pain: Normal processing of stimuli that damages normal tissues
or has the potential to do so if prolonged; usually responsive
to nonopioids and/ or opioids.
A. Somatic Pain: Arises from bone, joint, muscle, skin
or connective tissue. It is usually aching or throbbing in
quality and is well localized.
B.
Visceral Pain: Arises from visceral organs, such as the
GI tract and pancrease. This may be subdivided:
1. Tumor
involvement of the organ capsule that causes aching and
fairly well-localized pain.
2. Obstruction of hollow viscus, which causes intermittent
cramping and poorly localized pain.
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Neuropathic
Pain: Abnormal processing of sensory input by the peripheral
or central nervous system; treatment usually includes adjuvant
analgesics.
A.
Centrally Generated Pain
1. Deafferentation
pain. Injury to either the peripheral or centeral nervous
system. Examples: Phantom pain may reflect injury to the
peripheral nervous system; burning pain below the level
of a spinal cord lesion reflects injury to the central nervous
system.
2. Sympathetically maintained pain. Assoicated with dysregulation
of the autonomic nervous system. Examples: May include some
of the pain associated with reflex sympathetic dystrophy/causalgia
(complex regional pain syndrome, Type I, Type II)
B.
Peripherally Generated Pain
1. Painful
polyneuropathies. Pain is felt along the distribution of
many peripheral nerves. Examples: Diabetic neuropathy, alcohol-nutritional
neuropathy, and those associated with Guillain-Barre' syndrome.
2. Painful
neuropathies. Usually associated with a known peripheral
nerve injury, and pain is felt at least partly along the
distribution of the damaged nerve. Examples: nerve root
compression, nerve entrapment, trigeminal neuralgia.
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From McCaffery
M, Pasero C: Pain: Clinical manual, p 19. Copyright 1999, Mosby,
Inc.
Basic
Pharmacologic Pain Managment Princples
- Oral or
intravenous administration of pain medication is the preferred
method. Most children would rather have pain than an intramuscular
injection. Avoid IM injections.
- Base the
initial choice of analgesic on the severity and type of pain:
|
Pain
Severity
|
Analgesic
Choice
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Examples
|
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Mild (pain
score 1-3)
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Acetaminophen,
Nonsteroidal Anti-inflammatory Agents
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Tylenol®
, ibuprofen (Motrin® ), naproxen (Naprosyn® )
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Moderate
(pain score 4-6)
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IV Ketorolac,
oral acetaminophen/opioid combinations
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Toradol®
, Vicodin® , Tylox® , Tylenol® with codeine #3
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Severe
(pain score 7-10)
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Opioid
|
Morphine,
hydromorphone (Dilaudid® ), fentanyl
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- IV opioids
Morphine can be safely titrated to effect in the pediatric setting.
- Use Meperidine
with caution. Meperidine should not be used in patiens with decreased
renal function.
- PCA or
NCA are acceptable methods of administering pain medications.
Patients and families should be educated on PCA delivered medication.
Parents should be instructed never to push the PCA button when
the child is asleep.
Use
Of The Equianalgesic Table
APPROXIMATE
OPIOID EQUIANALGESIC DOSES (PEDIATRIC)***
|
DRUG
|
DOSE
(mg)
Parenteral
|
DOSE
(mg)
Oral
|
DURATION
(hour)
|
|
Morphine
|
1
|
3
a
|
4
-6
|
|
Morphine
– Sustained Release
(MS Contin,
Oramorph SR)
|
---
|
3
|
8
–12
|
|
Morphine
– Sustained Release (Kadian)
|
---
|
3
|
24
|
|
Hydromorphone
(Dilaudid)
|
0.15
|
0.75
|
4
- 5
|
|
Meperidine
(Demerol) b
|
7.5
|
30
|
2
- 4
|
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Fentanyl
(Sublimaze)
|
0.01
|
|
1
|
|
Codeine
c (Tylenol with codeine #2,
#3 or #4)
|
12
|
20
|
4
- 6
|
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Hydrocodone
d (Vicodin, Lortab)
|
---
|
3
|
4
- 6
|
|
Oxycodone
e
(Percodan,
Percocet, Tylox, Roxicet, Roxicodone))
|
---
|
3
|
4
- 6
|
|
Oxycodone
Controlled Release (Oxycontin)
|
---
|
3
|
8
- 12
|
|
Methadone
(Dolophine)
f
|
|
0.3
|
4
– 8
|
|
These
following agents are NOT opioids. In general, they are weaker
analgesics. The equianalgeisa dose is for information only
and, with the exception of ketorolac, it is NOT a reasonable
or appropriate dose.
|
|
|
|
|
Ketorolac
(Toradol)
|
1-3
|
1
|
6
|
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Ibuprofen
(Motrin)
|
---
|
130
|
6
– 8
|
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Acetaminophen
(Tylenol)
|
---
|
390
|
4
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a
IM:PO ratio is 1:6 (1mg IM = 6mg po) with single or intermittent
dosing. With chronic dosing, the ratio changes to 1:3 (1mg IM =
3mg PO).
b
Not recommended for pain management. Keep doses under 600mg/day
and do not use for > 48 hours.
c
Most preparations contain either 15, 30 or 60mg of codeine
with 300mg acetaminophen. Do not exceed 75mg/kg/day or 2.6 grams/day
in children under 12 years of age. Do not exceed 4 grams/day of
acetaminophen in children > 12 years of age.
d
Preparations contain either 5, 7.5 or 10mg of hydrocodone in combination
with acetaminophen (500, 650 or 750mg). Do not exceed 75mg/kg/day
or 2.6 grams/day in children under 12 years of age. Do not exceed
4 grams/day of acetaminophen in children > 12 years of age.
e
Preparations contain 5mg oxycodone in combination with acetaminophen
(325 or 500mg). Do not exceed 75mg/kg/day or 2.6 grams/day in
children under 12 years of age. Do not exceed 4 grams/day of acetaminophen
in children > 12 years of age.
f
Methadone is much more potent than previously described in the
literature and it accumulates with repeated dosing. A highly individual
and cautious approach when switching from another potent opioid
must be taken. Please consult the Acute Pain Service.
Equianalgesic
Dose Conversion Formula ***
Dose
for current drug
(from equianalgesic chart) |
= |
24-hour
dose of current drug
(scheduled and rescue doses) |
|
|
|
Dose
for new drug
(from equianalgesic chart) |
= |
24-hour
dose of new drug |
|
|
|
* ** This
table is 1/10 of the value of the equianalgesic doses for adults.
These are NOT suggested starting doses; these are doses of opioids
that produce approximately the same amount of analgesia. Published
trials vary in the suggested doses that are equianalgesic to morphine.
By using this table, you can determine a dose of a new opioid and/or
route of administration that is approximately equal in analgesic
effect to the dose of the former opioid. Titration to clinical response
is necessary. Recommended doses do not apply to patients with renal
or hepatic insufficiency or other conditions affecting drug metabolism
and kinetics.
Selected
References:
Principles of
Analgesic Use in the Treatment of Acute Pain and Cancer Pain, American
Pain Society, 1999
Acute Pain Management
in Adults: Operative Procedures. Quick Reference Guide for Clinicians.
AHCPR Pub. No. 92-0019. 1992
Micromedex ®
Healthcare Series Drugdex Drug Evaluations
Preventing
and Managing Common Opioid Side Effects
The use of
opioids is associated with the occurrence of drug side effects,
which become more common as doses of opioids are increased to treat
severe pain. These side effects include nausea and vomiting, constipation,
pruritus (itching), mental confusion, sedation, respiratory depression
and hypersensitivity reactions. Proper use of opioids includes management
of these side effects, rather than discontinuation of opioids in
a patient with severe pain.
1. Nausea and
Vomiting
- If analgesia
is satisfactory, reduce opioid dose by 10 %- 25%
- Add or increase
nonopioid or nonsedating adjuvant for additional pain relief so
that the opioid dose can be reduced.
- Ondansetron
0.1 mg/kg IV or metoclopramide 0.1 - 0.2 mg/kg IV or droperidol
0.03- 0.075 mg/kg IV.
2. Constipation
- Begin all
patients on ATC opioids with one of the combined pediatric stool
softener and mild peristaltic stimulants (start postoperative
patients as soon as permissible).
3. Pruritus
- If analgesia
is satisfactory, reduce opioid by 10% - 25%.
- Add or increase
nonopioid or nonsedating adjuvant for additional pain relief so
that the opioid dose can be reduced.
- Diphenhydramine
1 mg/kg IV or butorphanol 0.03 - 0.05 mg/kg IV.
- Naloxone
0.5 mg/kg/h by IV infusion only after steps 1 - 3 have failed.
4. Sedation
- Determine
whether sedation is due to the opioid. It is most likely due to
the opioid if opioid therapy has just started or if there has
been a recent increase in dose.
- Eliminate
nonessential CNS depressant medications.
- If analgesia
is satisfactory, reduce opioid dose by 10%-25%.
- Add or increase
nonopioid or nonsedating adjuvant for for additional pain relief
so that the opioid dose can be reduced.
- Add simple
stimulants during the day, e.g., caffeine.
- Consider
giving a lower opioid dose more frequently to decrease peak concentration.
- If analgesia
is unsatisfactory or dose reduction is not viable, consider adding
a psychostimulant, e.g., methylphenidate (Ritalin) or pemoline
(Cylert).
- If excessive
sedation persists, consider:
- Switch
to another opioid.
- Switch
to an intraspinal route
- Use
of an anesthetic or neurosurgical technique to allow drug
reduction.
McCaffery,
M. Pasero, C.: Pain: Clinical manual, pp 262-264. Copyright Ó
1999, Mosby, Inc.
Non-Pharmacologic
Approaches to Pain
- Although
analgesics are the mainstay of pain relief, most pain is best
treated with a combination of drug (analgesic) and non-drug approaches.
- Non-drug
approaches to pain management can enhance comfort, promote sleep
and enhance the quality of life.
- Non-pharmacologic
interventions should routinely be used. Although these strategies
alone are frequently insufficient for moderate to severe pain,
they are usually helpful in conjunction with pharmacological therapy.
Such strategies may include:
Cognitive-behavioral
Education
Relaxation, imagery
Psychotherapy, counseling
Hypnosis
Biofeedback
Music, literature, art, play
Prayer, meditation
Physical
Massage
Acupuncture, acupressure
Application of heat or cold
TENS
Immobilization, graded mobilization
Therapeutic exercise
Nonpharmacologic interventions may be provided, based on training,
by:
Physicians
Nurses
Physical, occupational, recreation, art, music, child-life or
other therapists
Social workers
Religious or spiritual leaders
Clinical psychologists
Others
Addiction,
Physical Dependence and Tolerance
Addiction
to narcotics is rare (less than 1% of patients) and usually occurs
inpatients with a prior history of substance abuse. Addiction
is defined as the continued use of a specific psychoactive substance
despite physical, psychological or social harm.
Physical
dependence differs from addiction. Patients taking opioids
on a chronic basis develop a physical dependence, and experience
withdrawal symptoms during sudden abstinence from the drug. Addiction
is primarily a psychological problem; dependence is a physical
response to continued use of narcotics.
Tolerance
is the need for higher opioid doses to maintain a constant effect.
While this is a poorly understood phenomenon, most patients on
chronic opioids do not experience tolerance. Alternative
explanations, such as a new source of pain or progression of an
existing lesion (especially a neoplasm), should be considered
when tolerance occurs.
Addiction
is a maladaptive behavior pattern, where the need to take a drug
interferes with other life activities. The individual is preoccupied
with a continuing drug supply, despite deterioration of family,
work, and other social relationships. Addiction should be suspected
if concurrent use of alcohol or illicit drugs, frequent visits
to the ER seeking additional medications, forging or losing prescriptions,
repeated noncompliance with medication regimens, and/or the unwillingness
to discuss changes in pain medication are present. These are difficult
patients to deal with and often psychiatry or chronic pain consultation
is helpful.
Use
of opioids inpatients with a history of substance abuse is occasionally
necessary. In these cases, a treatment contract should be utilized.
This typically sets out basic terms, such as the single physician
who will prescribe medication, the medication schedule that the
patient is expected to adhere to, and the conditions which will
lead to discontinuation of narcotic therapy.
Pseudoaddiciton
must be differentiated from true addiction. Patients experiencing
continued pain will exhibit anxiety and drug-seeking behavior.
These behaviors typically disappear once the pain is relieved.
This pseudoaddictive behavior is extinguished by adequate pain
relief, unlike the continued drug-seeking behavior of true addiction.
References:
- Shapiro,
B.S., Pain in Children
- UMHHC Pain
Policies and Procedures 03/03/01
- Pain Management
in Children with Cancer, Texas Cancer Council, 1999
- McCaffery,
M., Pasero, C., Pain Clinical Manual, second edition, 1999
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