Management of Pain in Children 2
By Dr. R.M.Mudiyanse
Significance and background in Pain Management in Children
Pain relief is required in different settings. It may be procedure related pain, acute pain, chronic pain or pain in a terminally ill patient. Pain management should be multimodal and multidisciplinary. Anticipation, prevention and minimizing pain are essential component. Health professionals should be honest towards children about pain. There are pharmacological and non-pharmacological approaches to pain relief. Non pharmacological methods include physical and cognitive methods. Pharmacological pain relief includes local anesthesia and pain relieving drugs, sedation and anesthesia.
When a child is brought to a hospital they suffer from physical pain and have fear of mutilation and death. They are worried that they may be separated from parents. The strange environment and procedures, loss of control, their autonomy make them even more worried. They are anxious about the anticipated behavior in a hospital. Therefore, the staff should be reassuring and keep informing the child and parents when to expect pain during a procedure.
Physical methods of pain relief, e.g. splinting, are important especially in transport. Wound dressing relieve pain and distress. Other techniques that can be used to relieve pain include distraction, guided imagery, relaxation, hypnosis, and cognitive behavioral therapy.
Age-appropriate distraction can be very useful in minimizing pain especially for short procedures. Infants can be distracted by music, cuddling, rocking using a soothing, quiet tone of voice. Preschoolers can be engaged in some activity such as opening a dressing pack or holding a bandage. Singing, picture books, puppets and particularly stories are also very useful in this age. School age children are encouraged to use creative imagery. Adolescent can listen to their favorite music and they can also be encouraged to tap out or sing with it.
Various methods of cutaneous stimulation or counter irritation methods such as hot or cold application, superficial massage, acupuncture, and transcutaneous electrical nerve stimulation (TENS) can be used to relieve pain. Touch is a very effective way to communicate empathy and superficial massage of the soft tissues which helps to produce relaxation of the muscles. TENS is a method of delivering controlled low-voltage electricity to the relevant area of the body via electrodes and that increases endorphin levels, and also acts as a counter irritant causing a tingling sensation. It has been used with success in management of chronic pain in children.
Cognitive behavior therapy (CBT) will not eliminate pain. But it can change their negative thoughts, emotions, and behaviors related to pain and improve coping strategies. CBT can also change the physical stress response and its biochemical changes in the brain that makes pain worse. The most important step in cognitive behavior therapy is to get rid of the sense of helplessness. Patient should keep a tract of feeling and thoughts within him/her and develop methods of coping with the help of a therapist. For example, in CBT, child may imagine a scene of a picnic in the park or some other experience that he/she enjoys (imaginative attention), child may imagine the pain as a sensation of warmth or numbness (imaginative transformation), child may imagine that pain is occurring in a different context (context transformation) or child may pay attention to some music or a song or focusing on an object (attention diversion).
Painful procedures should be avoided or minimized. Some of the procedures can be bundled up to avoid repetition of painful events. Procedural pain should be anticipated, prevented if possible and minimized by medical and non-medical approaches. The health care team, the child and the parents should be informed about the procedure, its duration, anticipated extent of pain and what would be done to minimize pain during the procedure. Understanding the child’s previous pain experience, child’s coping styles and the family background would be essential in successful pain management. Parents’ presence and allowing them to adopt familiar comforting methods is useful. Depending on the type of procedure, the level of pain relief may vary from deep anesthesia to facilitating competent coping methods in ways that enhance the self-esteem of the child. Massage or use of heat compress may be beneficial. Strategies to minimize the stress and distress of parents, calm environment, calm adults and confidant clear instructions help in minimizing pain.
Local anesthesia includes topical applicants, regional injections of lignocain or nerve blocks.
EMLA is a mixture of 2.5% lidocaine and 2.5% prilocaine in a cream base. The specific concentration gradient promotes penetration of intact skin. It is applied under an occlusive dressing. Depth of anesthesia ranges from 3 mm after 60 min, to 5 mm after 90 minutes of application. It is very useful in IV annulations and lumbar puncture. However, it is not recommended in IM injection or heal prick in neonates. It is safe and recently been approved for use in newborns. Prilocaine in EMLA has a risk of causing methemoglobinemia but not when used in local anesthesia as a single dose.
Tetracaine cream (Ametop gel - Smith & Nephew, 1997) has 4% Tetracaine cream. It has rapid onset of action after 30-40 minutes which lasts up to 4 hours. It is also applied under occlusive dressing. Unlike EMLA it is not recommended for neonates due to irritation and due to possibility of causing blisters.
Subcutaneously injected buffered lidocaine 1% (1/10 with Bicarbonate solution of 1meq/ml) using 30-gauge needle, reduces struggling during LPs in newborns and children. EMLA or Ametop (>1mo) can be used prior the procedure. The pain caused by the injection of local anesthetic can be reduced by non-pharmacological measures such as distracting the patient. Using 30 (for infants) or 27 gauge needles, warming the anesthetic to body temperature prior to administration and avoiding intradermal injection will help to minimize the pain. Buffering the lignocaine solution expedites the onset of analgesia without affecting efficacy or duration
Pharmacological methods of pain relief
Paracetamol: Paracetamol is the most widely used drug in clinical practice. It is used as an antipyretic as well an analgesic. Careful attention should be paid to dose. Rectal administration produces delayed and variable uptake therefore, after the initial dose of 35 to 45 mg per kilogram (20 mg per kilogram for preterm babies), subsequent rectal doses should be only 20 mg per kilogram given only at six to eight hours interval. Daily cumulative paracetamol dose by the oral or rectal routes should not exceed 100 mg per kilogram for children, 75 mg per kilogram for infants, 60 mg per kilogram for term and preterm neonates beyond 32 weeks of post conceptional age, and 40 mg per kilogram for preterm neonates from 28 to 32 weeks of postconceptional age. An appropriate rectal regimen for a preterm neonate of 30 weeks of postconceptional age would be 20 mg per kilogram every 12 hours. Excessive dosing has produced hepatic failure in both infants and children.
Aspirin: Pediatric use of aspirin has declined since the 1970s, after reports of its association with Reye's hepatic encephalopathy. Aspirin remains useful for rheumatologic conditions and for inhibition of platelet adhesiveness. A comparison of aspirin with ibuprofen in childhood arthritis found that both were equally effective, but that there was better compliance and fewer adverse reactions with ibuprofen. The recommended aspirin dosage is 10 to 15 mg per kilogram every four hours by mouth.
Non-Steroidal Anti Inflammatory Drugs (NSAIDS): Ibuprofen, diclofenac sodium, indomethacin and mefenamic acid can be used for pain and fever relief. Ibuprofen is widely used. NSAIDs have better analgesic effects than paracetamol and result in lower opioid requirements. However, NSIDS have higher incidence of adverse gastro intestinal and renal involvements. NSAIDs may increase the risk of bleeding. Use of rectal diclofenac sodium for fever relief is contraindicated. Selective cyclooxygenase-2 (COX-2) inhibitors have anti-inflammatory effects similar to NSAIDs with lower risk of gastric irritation and bleeding.
OPIOIDS: Opioids are used to relieve moderate to severe pain. Opioids should be used with caution in children with impaired respiratory functions, hypotension, and obstructive or inflammatory bowel disease, diseases of biliary tract, liver failure or renal failure. Doses should be adjusted in liver failure and renal failure. Side effects include nausea, vomiting, dry mouth and constipation. Drug dependence is rare in therapeutic usage.
Morphine: Morphine is available as oral preparation (syrup or tablets), suppositories or parenteral preparation. Parenteral preparation is given subcutaneously or intravenously as boluses or infusions. Intravenous infusions can be given as patient, parent or nurse controlled infusions.
Diamorphine (HEROIN): Diamorphine is used to relieve chronic pain in children, given as orally, intravenously or intranasally.
Methadone: Oral or intravenous methadone is useful because of its prolonged duration of action. However, because of slow and variable clearance, methadone requires careful assessment and titration to prevent delayed sedation. Methadone elixir is useful as a long-acting opioid for patients unable to swallow whole sustained-release opioid tablets.
Fentanyl: Fentanyl is useful for severe chronic pain, available as transdermal patches or transmucosal applicants or lozenges. Transdermal patches release a regular dose as indicated in the product. For example, fentanyl 25 releases 25 micrograms of fentanyl per hour.
Tramadol hydrochloride: Tramadol hydrochloride can be given orally or intravenously to relieve post-operative pain.
Pethidine hydrochloride: Pethidine is given as subcutaneous or intramuscular injection. It is not suitable for chronic pain relief.
Ketamine: Ketamine has profound analgesic; sedative, amnesic effect and it immobilize the patient for procedures making it an ideal drug for minor OPD procedures. Ketamine preserve upper-airway muscular tone, protective airway reflexes. It should be given slowly (over a period of one to two minutes) to prevent respiratory depression. Unpleasant hallucinations and dreams seen in adults are rare in children.
Nitrous Oxide: Nitrous oxide is an inhalational anesthetic. It is very useful as administration is non-invasive and provide rapid onset of sedation and recovery.
The availability of specific benzodiazepine and opioid antagonists (reversal agents) has greatly increased the safety of procedural sedation, since over sedation leading to respiratory depression can often be rapidly reversed if necessary. Naloxone is a short-acting opioid antagonist with a well-established safety profile. Flumazenil, the benzodiazepine antagonist, appears to be safe in the absence of contraindications.
Patient-Controlled Analgesia in Children: Patient-controlled analgesia (PCA) allows patients to decide on the dose depending on the intensity of pain and self-administer the drug by triggering a devise. The maximum dose and frequency is predetermined to avoid over dosage. A basal continues infusion can also be given. Patient-controlled morphine treatment in children typically starts with a bolus dose of 0.02 mg per kilogram with a maximum frequency once in seven minutes (lockout time), a four-hour maximum of 0.3 mg per kilogram and a basal infusion rate of 0.01 to 0.015 mg per kilogram per hour. As younger children and those who are disabled are not capable of deciding on triggering the devise a nurse or parents can be entrusted to inject a dose of analgesia. Parents should be educated about the devise and analgesia.
Care for Parents of children suffering in pain
Parents of children who are subjected to pain also suffer. Caring and empathetic attitudes of health care workers would be essential. Sometimes, they need physiological consoling. A parent, who is emotionally well equipped to calmly helping a child work through pain, may be the child’s best tool for recovery.
Establishing Policies for Pain Management in Children
Establishing successful pain management policies is an essential step for good quality health care. Proper management of pain and suffering of children is an ethical requirement. It is inhuman to ignore pain. Children have right to receive immediate pain relief as soon as possible with no discrimination. Children have the right to be heard specially when they are in pain.
Pediatricians are responsible for eliminating pain and suffering in children when possible. Education programs to create awareness about pain in children and its implications would be the most important initial step. Health care personal should appreciate that children do suffer from pain that has immediate as well as long term sequelae. Appropriate tools for evaluation should be made available and health care personal should be trained and be familiarized with these tools. Pain management protocols should be established locally by respective consultant units or nationally by respective colleges. Drugs should be made available. Proper implementation and sustainability of policy will depend on monitoring and clinical auditing. Therefore, adoption and implementation of pain management policies should couple with monitoring and clinical auditing which can be facilitated by colleges.
Pain experience and its management have influences from the culture, attitudes and beliefs of the society. Therefore, pain assessment and pain management need to be researched in the local context. With time, new strategies may evolve that are suitable for local needs.
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Sri Lanka Association for the Study of Pain
The Sri Lankan Chapter of the International Association for the Study of Pain