Pain
Neil L. Schechter
William T. Zempsky
I. Definition and background. Pain is defined by the International Association for the Study of Pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” This definition implies that pain has two components—a neurophysiologically determined sensation that results from stimulation of nociceptors and the interpretation of that stimulus, which is impacted by a host of genetic, personality, cognitive, developmental, experiential, and emotional factors. These may magnify or dampen the amount of pain and suffering that the stimulus causes to the individual. Recent research suggests that previous repeated exposure to painful stimuli, for example, can significantly alter nociceptive processing. Current understanding of pain, therefore, implies that because of individual biological and experiential variation there is no set amount of pain “allowable” for a given injury or illness and, therefore, care must be individualized for each child. This section will focus on acute pain; chronic pain problems such as headache and functional abdominal pain are reviewed elsewhere in Chapters 21 and 49.
Historically, pain has been undertreated in children for a variety of complex reasons. Difficulties with pain assessment in children, social attitudes, and ethical and financial constraints on research diminished interest and allowed for the persistence of myths (“infants do not feel pain”) that denigrated the importance of treatment. There has been an outpouring of research in the last 20 years, however, and it is now clearly established that by the end of the second trimester, fetuses have in place the anatomical and chemical capabilities to experience discomfort. Preterm and newborn infants may, in fact, be hyperalgesic because they have the same number of nociceptors in a smaller surface area and because they lack descending modulation of pain through psychological means.
Inadequate pain management clearly has short- and long-term negative consequences. Untreated pain may inhibit immune function, induce stress hormone release, increase blood pressure, inhibit healing due to immobility, and decrease the pain threshold, which subsequently results in hyperalgesia and allodynia. Inadequately addressed pain in young and school-aged children with illness causes unnecessary suffering; worries about procedure pain during routine healthcare maintenance can dominate the encounter reducing the value and enjoyment of the visit for the child and the clinician. For many children with chronic conditions, inadequately treated procedure pain is the worst part of their illness, often worse than the disease itself and creates anxiety about subsequent medical encounters.
II. Diagnosis. Adequate assessment is the cornerstone of pain treatment and the individual’s self-report of his/her discomfort is the gold standard for assessment. Pain assessment typically focuses on measures of pain intensity. In adults and children older than 8 years, the visual analogue scale that quantifies pain intensity from 0 to 10 is traditionally used. Because of developmental immaturity in children aged 3-8 years, modification of the visual analogue scale is necessary. Color scales, cartoon faces, manipulatives such as poker chips representing pieces of hurt, and photographs of children in discomfort have all been used as modified visual analogue scales. Of those available, the Faces Pain Scale-Revised is the most commonly used and has the strongest psychometric properties. For children younger than 3 years who typically cannot seriate, physiologic parameters (increased heart rate, increased respiratory rate, decreased SaO2) and behavioral measures such as facial expression, body position, and crying have all been used as nonspecific indicators of pain. Attempts have been made to cluster together these parameters into clinically usable scales (examples of these include the FLACC, CHEOPS, and OBSR). Scales for term infants (N-PASS) and preterm infants (PIPP) have also been developed as well as for children with significant developmental disabilities (Non-communicating Children’s Pain Checklist—NCCPC-R). When an intervention occurs to address an elevated pain intensity rating, a repeat assessment should typically occur within an hour to ascertain the efficacy of the intervention. Pain intensity rating scales are often inappropriate for children with chronic pain who should not be queried
repeatedly about their level of discomfort. Functional scales such as the FDI and the CALI should be considered for that population.
III. Treatment.
A. General principles. The primary goal of treatment of children with acute pain is to make him or her as comfortable as possible, recognizing that it may not be possible to eliminate all discomfort. There needs to be a balance between pain relief and the side effects associated with treatment. A number of general principles have emerged, however.
1. It should be generally assumed that whatever hurts an adult will hurt a child and appropriate pain relief should be planned.
2. A preventative approach is key. Where pain is predictable, it makes much more sense to prevent pain from occurring than to ablate it once it has occurred. This suggests that around-the-clock dosing as compared with PRN dosing is preferable.
3. Pharmacologic, cognitive-behavioral, and physical approaches should be considered for all pain problems.
4. Nonnoxious routes of administration should be used, avoiding intramuscular, rectal, or intranasal routes if possible.
5. Needle sticks are extremely troubling for children and wherever possible, needle pain should be addressed. This typically involves adequate preparation, parental involvement, technical variables (such as site selection, needle length, and position), distraction, and if possible local anesthetics when procedures are nonemergent.
6. Prolonged pain may lead to sleep problems and immobilization and both of these problems can increase pain. Both should be considered when addressing pain.
B. Behavioral/cognitive/approaches. These nonpharmacologic approaches vary, depending on the type of pain and the age of the child. In situations where limited pain may be magnified by anxiety, they may be the only approach necessary. In general, however, they are used in conjunction with pharmacologic approaches.
1. Parental presence and demeanor. Parental presence during painful procedures and parental involvement in treatment decisions often has a significant impact on pain the child experiences. During procedures, parents can function as a “coach,” stroking, soothing, or talking to the child. They can be instructed in age-appropriate pain relieving techniques. In general, when parents can be included in treatment decisions, they feel less anxious and less helpless and their security is often transmitted to the child and pain is reduced. Research has shown children whose parents are overly apologetic or overly solicitous report more pain and display more pain behaviors than children whose parents are matter of fact and resolute.
2. Preparation. Knowledge about the pain and its expected time course also reduces anxiety about it, which has the effect of decreasing pain. Discussion about illness and procedures clearly improves coping. Preparation for procedures should include a description of how the child will feel as well as a more detailed description of what will happen. When preparing a child for a painful procedure, the timing of the preparation should be determined by the child’s developmental age and temperamental style. In general, the younger the child, the closer the preparation to the procedure.
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