Pain management in children is the assessment and treatment of pain in infants and children.
Types Acute Usually, acute pain usually has an obvious cause and is expected to last a few days or weeks. It is usually managed with medication and non-pharmacological treatment to provide comfort. Acute pain indicates assessment, treatment, and prevention are needed. 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 fluid in the lungs, restricting coughing ability. 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 output, such as the inability to urinate. Pain can also slow the gastrointestinal system.
Inadequate pain management in children can lead to psychosocial 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 readmission rates, and longer recovery.
Examples of harmful consequences of unrelieved pain: Infants who have had more than average heel pricks can have poor cognitive and motor function; Associations of needles with felt distress may make later medical treatments more difficult; Children who have experienced invasive procedures often develop post-traumatic stress; Boys circumcised without anesthesia were found to have greater distress than uncircumcised boys; Severe pain as a child is associated with higher reports of pain in adults.
Neuropathic Neuropathic pain is associated with nerve injuries and abnormal sensitivities to touch or contact. Although neuropathic pain is relatively uncommon in children compared to adults, greater awareness of these conditions is on the rise. Some causes may include past surgeries and amputations, autoimmune and degenerative neuropathies, and injury to the spinal cord.
Symptoms may include tingling, shooting, prickling, or burning sensation. The pain can be intermittent or constant and is often exacerbated in the evenings.
Neuropathic pain can be peripheral or central. Peripheral neuropathic pain refers to a 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. Other options are serotonin-norepinephrine reuptake inhibitors (SNRIs). Despite limited studies in children (limited to those with depression), SNRIs such as venlafaxine are effective.
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: by the physical pressure they place on organs or by occluding normal bodily functions. Treatment such as surgery and injections can also lead to significant pain for the patient. If untreated, the pain can suppress the immune system, interfere with sleep, and increase risk of depression. Many different healthcare 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 specializing in music or art therapy, including acupuncture, biofeedback, massage therapy, and hypnosis.
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. Often, medications such as nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, or opiates are used to manage the pain. Additionally, non-pharmacological modalities can also be used to manage the child's pain, including distracting the child, massages, acupuncture, heat/cold therapy, exercise, and quality sleep.
Chronic Chronic pain in children is unresolved, affecting activities of daily living, and may result in a significant amount of missed school days. Chronic pain is present for long periods and is characterized as mild to severe. Chronic pain is also described as the pain experienced when the child reports a headache, abdominal pain, back pain, generalized pain, or a combination of these. Chronic pain can develop from disease or injury and co-occur 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.
Diagnosis
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. The following sections list signs of distress and possible pain in children by age group:
Younger infants
Inability to distinguish the stimulus from the pain Ability to exhibit a reflexive response to pain Expressions of pain Tightly closed eyes Open mouth resembling a square rather than an oval or circle Eyebrows lowered and tightly drawn together Rigid body Thrashing Loud crying Increase in heart rate, even while sleeping
Older infants Deliberate withdrawal from pain and possible guarding Loud crying Painful facial expressions
Toddlers Toddlers show signs of distress and possible pain by: Expressing pain verbally Thrashing extremities Crying loudly Screaming Being uncooperative Palpating (examining with the hands) a source of pain Anticipating a pain-inducing procedure or event Requesting to be comforted Clinging to a significant person, possibly one perceived as protective
School-age children School-age children show signs of distress and possible pain by: Anticipating the pain but less intensively, (understands concepts of time, i.e., imminent vs future pain) Stalling, trying to talk out of the situation where pain is anticipated Having muscular rigidity
Adolescent Adolescents show signs of distress and possible pain: With muscle tension, but with control With verbal expressions and descriptions
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. 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".
+ Examples of pain scales Self-report Observational Physiological Infant — Premature Infant Pain Profile; Neonatal/Infant Pain Scale — Child Wong-Baker Faces Pain Rating Scale – Revised; Coloured Analogue Scale FLACC (Face Legs Arms Cry Consolability Scale); CHEOPS (Children's Hospital of Eastern Ontario Pain Scale) 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: Prior painful episodes or treatments Age and developmental stage Disease or type of trauma Personality Culture Socioeconomic status Presence of family members and family dynamics.
During treatment
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. 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.
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. Codeine and tramadol should be avoided especially in children younger than 12 years old since metabolism varies due to genetic differences between individuals, and, in the case of tramadol, this medication has not been well studied in children. However, other interventions include medications classified as non-opioid analgesics, which are useful in post surgical treatment. 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: Allowing the parent or caregiver to be present for painful procedures Using a treatment room for painful procedures to ensure that the child's room is a place where little pain can be expected Establishing other "pain-free zones" where no medical procedures are allowed, such as a playroom Offering choices to the child to give them some control over the procedures Modelling procedures with dolls and toys Using age-appropriate anatomical terms and other vocabulary.
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): Oral treatment with a sweet-tasting solution: This can be done either by sucking on a soother (pacifier) or by placing a small amount of sweet-tasting solution in their mouths Comforting the baby during and after the injection Breastfeeding during painful procedures has been found to be more effective in controlling pain than placebo or positioning. Breastmilk or 'sugar' water has a similar effect, though studies in preterm infants have yet to be done. Skin-to-skin care (kangaroo care) is thought be effective for pain control during painful procedures. Gently rocking the baby Swaddling Suckling (non nutritive)