Pain management in children is the assessment and treatment of pain in infants and children. Similar to adults, a child's pain is often tied to emotional and psychological components. Many of the problems that cause children pain are undertreated. Untreated pain can greatly increase the chances of further complications and even death, making it important to identify the cause of pain quickly. Infants and children cannot readily identify pain depending on their level of development, so determining a method to intervene and treat pain is crucial at this early stage of life. Children can have significant pain related to epidermolysis bullosa, osteogenesis imperfecta, cancer, metabolic/neurologic diseases, palliative care, and sickle cell disease. Evidence-based approaches to managing pain in children are described with: "Pain management practices should be based on scientific facts or agreed best practices, not on personal beliefs or opinion. The burden of proof lies with the healthcare professional, NOT the patient." Unfortunately, many of the problems that cause children pain are undertreated. Working with children in pain predisposes hospital caregivers to burnout and stress.
Video Pain management in children
Medical uses
Identifying Pain
In the past, it was believed that expression of pain in babies was reflexive, and that due to the immaturity of the infant brain the pain could not really be perceived. Attempting to relieve pain in infants was considered futile because it was thought to be impossible to measure a child's pain. These beliefs along with cultural concerns about opiate addiction contributed to the clinician's decision to withhold pain relief. More recently, however, it was found that a person experiences pain as early as the gestational period.
In 1994, responding to the need for a more useful system for describing chronic pain, the International Association for the Study of Pain (IASP) classified pain by the:
- Region of the body involved (e.g. abdomen, lower limbs),
- System in which dysfunction may be causing the pain (e.g., nervous, gastrointestinal),
- Duration and pattern of occurrence,
- Intensity and time since onset, and
- Cause.
This system was criticized by Harvard professor of neurology and neurobiology Clifford J. Woolf and others as inadequate for guiding treatment. Woolf suggested three categories of pain:
- Nociceptive pain,
- Inflammatory pain which is associated with tissue damage and the infiltration of immune cells, and
- Pathological pain which is a disease state caused by damage to the nervous system or by its abnormal function (e.g. fibromyalgia, peripheral neuropathy, tension type headache).
Treatments can vary among health care providers according to providers' personalities, cultures, beliefs and acceptance of pain in children. Characteristics of pain typically help determine assessment, diagnosis and treatment. Pain can be acute, recurrent, chronic or a combination of these. It may occur in more than one body part simultaneously. To best assess pain in a child, the child can be asked to describe the pain before they are asked about location, intensity, quality, or tolerance. Assessing a child's pain based on the judgement of their parents or caregivers may lead to underestimation, as there is a widespread tendency for people to underestimate the pain of others. The suggested treatments for pain do not always resolve the problem, and in some cases, treatments and medications for pain actually cause pain. Minor invasive procedures often do not include a treatment plan for consequent pain. For example, during circumcision infants do not consistently receive appropriate pain control. Not only are newborn circumcisions painful, they are also associated with irritability and feeding disturbances for days after the procedure. The American Association of Pediatrics states pain with immunizations as being minor.
Maps Pain management in children
Contraindications and side effects
During labor, pain control used to control pain in the laboring woman may cause respiratory depression in the infant. 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 ibuprofen and paracetamol. The safety of opioids in children has not been established. More side effects are associated with morphine than with ibuprofen. Other side effects are constipation, fatigue, and disorientation. Children can develop opioid tolerance where larger doses are needed to have the same effect. When resistance to opioids develop, the pain responsiveness is reset and pain increases. Tolerance is likely to develop in younger children. Non-pharmacological treatments have few side effects.
Indications
Acute pain
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. 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.
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.
Examples of harmful consequences of unrelieved pain include:
- Infants who have had more than average heel pricks can have poor cognitive and motor function;
- Associations of needles with 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.
Pain can be caused by medical procedures. Acute pain can be expected in response to many if not most invasive procedures. Anticipation of pain and distress can guide pain prevention plan before treatment based on past reports of pain associated with the medical procedure. Individuals with technical expertise and experience are more likely to minimize the pain as much as possible. Preparation before a procedure with information that is understood by children and parents decreases distress. Parents can help by learning effective methods to comfort their child. Types of procedures determine the use of deep sedation or anesthesia. In some cases, the best method to prevent and relieve pain is to build self-esteem. Suggested cognitive behavioral strategies include: imagery, relaxation, massage, heat compression, calm adults, a quiet environment, and confident explanations by providers. Since distress can be addressed and controlled, some children benefit from the opportunity for self-regulation. Pain reduction during invasive procedures is closely linked to controlling distress. Distress can be treated even for minor procedures such as venipuncture.
Neuropathic pain
Neuropathic pain is associated with nerve injuries or abnormal sensitivities to touch or contact. Causes include past surgeries and amputations.
Cancer pain
Cancer pain is managed differently from other types of pain. Clinicians treating cancer pain can come from a variety of disciplines or specialties. Typically, each specialist obtains a medical history, performs physical examinations, and documents the age and overall health of the child. The type of cancer may influence decisions about pain management. The extent of the cancer, the tolerance of the child to specific medications, procedure or therapies is also taken into account. The preferences of the parent or caregiver contribute to the determining the best way to treat cancer pain. For cancer pain, opioids are helpful and can be taken orally. Others are given IV, subcutaneous, or trans-dermal. Switching medications may be necessary at times. Dosing for children is based upon studies with adults or short-term studies. Children can develop opioid tolerance where larger doses are needed to have the same effect. When resistance to opioids develop, the pain responsiveness is reset and pain increases. Tolerance is likely to develop in younger children. Cancer pain can differ from other types of pain. In addition, a child can have pain for other reasons not associated with cancer. Pain in children without cancer can present itself as headaches, muscles strains, and "as being part of being a child." Pain experienced by children is related to the stage or extent of the cancer. Children with cancer may have no pain. One child may have a different threshold for pain than another. Other sources of pain from cancer are: Sources of cancer pain include:
- A growing tumor pressing on a body organ or nerves
- Inadequate blood circulation because of blocked blood vessels
- Blockage of an organ or a tube of the organ
- The spread of the cancer
- Infection
- Inflammation
- Side effects of chemotherapy, radiation treatment or surgery
- Inactivity and stiffness
- Depression and anxiety
Chronic pain
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.
Assessment
The decision to assess and treat pain is influenced the beliefs and cultural background of the clinician. Ongoing and frequent assessment between all those involved in the treatment plan is documented in a readily accessible format - usually the patient record. 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".
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.
Misconceptions
The indications that treatment is needed are not always clear for children because of poor assessments and the tendency to undertreat pain..
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 over-medicated 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, however, alternative interventions have slowly been introduced to adolescents.
Different treatment options include:
- Participation in focus groups
- Group and individual therapy
- Classes structured around living with chronic pain
All of these are examples of mindfulness-based interventions, which are currently being explored as alternatives to pharmacotherapy. These interventions explore different ways for children and adolescents to manage pain and relieve emotional distress without relying on opioids. However, other interventions include medications classified as non-opioid analgesics, which are useful in post surgical treatment.
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 pain management
Non-pharmacological methods to manage discomfort during immunizations include putting sugar on a pacifier, comforting the child during and after the injection, chest-to-chest hugging, and letting the child choose the injection site. Other non-pharmacological treatments that have been found to be effective include:
- Carefully explaining a procedure with pictures or other visual aids
- Allowing the child to ask questions of medical staff
- Touring the place where the procedures will occur
- Allowing small children to play with dolls or other toys with a clinician to understand the procedure
- Allowing older children to watch a video that explains the procedure
- Providing distraction with songs, stories, toys, color, videos, TV, or music
- Using relaxation techniques such as deep breathing or massages
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
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.
Pharmacotherapy
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. The most effective approach to pain management in children is to provide pain control around the clock instead of providing pain relief as needed. Regional anesthesia is also effective and recommended whenever possible. Opioids are effective too but often depress breathing in infants. Recent evidence-based studies indicate that morphine is not superior to ibuprofen for managing children's pain after some surgical procedures. A needle-free powder lignocaine delivery system has been shown to decrease the pain during of venipuncture in children.
Chronic pain treatment
Chronic pain is treated with a variety of medications and non-pharmacological interventions. The American Association of Pediatrics has suggested that parents be educated about providing round-the-clock medication after their children receive surgery. Opioid tolerance and withdrawal can be seen in the neonatal and pediatric intensive care units. Other side effects of opioid use can include cognition deficits, altered mood, and disturbances of endocrine development. Opioid misuse can occur in adolescents and is associated with the use of alcohol, cigarettes and marijuana.
Non-pharmacological treatment for children to help relieve periodic pain includes counselling and behavior modification therapy.
Acute pain treatment
For acute pain, multiple medications given at the same time is proven to be most effective. This results in lower pain scores, provides greater relief, allows lower dosing and side effects, targets different nerve pathways, and can be tailored to the child.
Cancer pain treatment
Cancer pain is managed differently in children. Clinicians treating cancer pain can come from a variety of disciplines or specialities. 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. Opioids are helpful for cancer pain and can be taken orally. The side effects are constipation, fatigue, and disorientation. Others children are given intravenous injection, either subcutaneous or trans-dermal. Switching medications may be necessary at times. Dosing for children is based upon studies with adults or short-term studies. Children can develop opioid tolerance where larger doses are needed to have the same effect. When resistance to opioids develops, the pain responsiveness is reset and pain increases. Tolerance is likely to develop in younger children.
Pharmacotherapy abuse
Over the past 30 years, opioid prescription rates for pain management treatment in children and adolescents have increased by almost 50% across the United States. Currently, the rates of reported pain remain steady, but abuse and subsequent teen death rates have risen.
The number one way teens obtain opioids is from a previous prescription or from a friend or relative with an opioid prescription, however other routes of obtaining opioids include:
- Stealing from a friend or relative,
- Purchasing from a friend of relative, and
- Purchasing illegally
To combat the opioid epidemic, interventions have been taken across the United States. Collection centers for unused opioids and medications have been created as well as protocols for disposing of opioids appropriately so that they do not recycle back into the community. Most law enforcement offices contain a drop box for opioids with a no questions asked policy. A large force in preventing abuse of opioids is social media which has detected illegal sales of opioids in recent years.
In culture
The control of pain in children is thought to be an ethical 'imperative'. The undertreatment of the pain in children has been a 'global concern' for some time. Those who have been critics of controlling pain in children have been criticized by others: "Effective pain management...involves an interdisciplinary therapeutic approach with a combination of pharmacologic, cognitive-behavioral, psychologic, and physical treatments." Cultures that value stoicism may discount the pain experienced by children. Greater than 60% of children are prescribed an opiate after outpatient treatment in the US.
References
Bibliography
- Henry, Norma (2016). RN nursing care of children : review module. Stilwell, KS: Assessment Technologies Institute. ISBN 9781565335714.
- Roberts, Michael (2017). Handbook of pediatric psychology. New York: The Guilford Press. ISBN 9781462529780.
- Twycross, Alison (2014). Managing pain in children : a clinical guide for nurses and healthcare professionals. Hoboken: Wiley Blackwell. ISBN 9780470670545.
External links
- Wong-Baker Faces Foundation
- Various Wong-Baker pain scales
- International Children's Palliative Care Network
- Palliative Care
- WHO guidelines on persisting pain in children
Source of the article : Wikipedia
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