and Daniela Cristina Stefan2
(1)
Université Mohammed VI des Sciences de la Santé Cheikh Khalifa Hospital, Casablanca, Morocco
(2)
South African Medical Research Council, Cape Town, South Africa
Keywords
Nociceptive painNeuropathic painAcute painChronic painVisual analogue scale (VAS)Face scaleObjective pain scale (OPS)AnalgesiaMild, moderate and severe painCase Presentation
A 2-year-old boy is admitted for suspicion of neuroblastoma after complaining of a vague pain in his limbs for 15 days. His mother reports that he no longer plays and that it is difficult to bathe him. The child also changes his position frequently. Examination is difficult because the child is not allowing this. Abdominal palpation found an abdominal mass.
How will you assess the pain in this child?
What treatment do you suggest?
What information would you give to the parents regarding the use of the proposed treatment?
A bone marrow aspiration is planned. What do you recommend to prevent procedural pain?
Pain is one of the main symptoms in pediatric oncology . It is an unpleasant sensory and emotional experience caused by physical or perceived injury. The development of neoplastic diseases is revealed or complicated by pain, and may be related to the underlying disease, but more often linked to diagnostic or therapeutic procedures. In Africa, because of late-stage diagnosis of the disease, pain control is one of the priorities of caregivers. This is important, as it contributes significantly to humanizing care, improving the quality of life, and improving adherence to the treatment program by patients and their families.
Mechanisms of Pain
There are two main mechanisms of pain that can sometimes be identified.
Nociceptive pain is related to tissue damage causing excess painful stimulation. In this type of pain neurological pathways are intact. These pains are most frequently encountered and correspond to those observed in trauma, burns, or compression. The intensity is usually proportional to etiological factors.
Neurogenic or neuropathic pain is related to peripheral or central nervous system damage. The neoplastic (or other) lesion causes inhibition of sensory neurological stimuli. In this situation, slight stimulation (hyperpathia ) or non-painful stimulation (allodynia ) give rise to intense pain. The patient may also describe abnormal sensations of tingling or prickling (paresthesias ), sometimes an unpleasant sensation (dysesthesia ), or shooting pains. Examination may reveal hypoesthesia (a reduced sense of touch) or anesthesia (no sensation of touch or pain).
Clinical Expression of Pain in Children
Pain signs and symptoms vary according to the age of the child, the sociocultural context, the mechanism of pain and whether it is acute or chronic in character. Therapeutic tests may sometimes be necessary for the diagnosis of an unusual painful condition.
An infant experiences pain as anxiety or agitation. This may be interpreted as an aggression or punishment and is expressed as anger by the small child. Teenagers are more discreet, and the pain may even be denied, especially when it comes to a boy. Previous painful experiences can also have an impact on the mode of expression, as well as the sociocultural and family context, which may be encouraging or suppressing the complaint.
Acute pain is easy to diagnose, particularly when related to a diagnostic or invasive treatment. The child thus expresses pain through agitation, shouting, or by inconsolable crying. The child may also exhibit an antalgic gait, protect the painful area or be able to point to the location of pain.
Chronic pain has a more discreet expression, and is often linked to underlying cancer. The child unexpectedly becomes quiet, and sometimes confined to bed. He/she may also be sad and apathetic and can develop psychomotor inertia. The pain is sometimes denied by the child and/or the parents.
Nociceptive pain is easier to diagnose, while neuropathic pain sometimes requires careful investigation.
Assessment of Pain
The assessment of pain is an important step in order to provide adequate treatment and to monitor its effectiveness. The assessment must take into account the opinions of the parents regarding possible changes in behavior and the quality of sleep, especially in infants and small children. The caregiver should explain to the child, according to his/her ability of understanding, the principles of the assessment and its objectives.
Pain should be self-assessed by the patient and should also be assessed by a health care worker.
Self-Assessment
Self-assessment can only be performed when the child has reached a certain level of maturation to do so, and in practice this will not be possible in a child younger than 5 or 6 years old. There are multiple ways of evaluation, but the principle is not to simply ask the child whether there is pain or not, but obtain information about the intensity of the pain.
The simplest way is the simple verbal scale which is to ask the child if the pain is mild, moderate, or severe, but this is still a very rough estimate.
The Visual analogue scale (VAS) is the most commonly used tool for self-assessment (Fig. 27.1). The side with a triangle of which the base is the maximum pain (10) and the summit is the absence of pain (0) is shown to the patient. The child has to move the cursor at the level of the triangle corresponding to the intensity of the pain. The scale is placed vertically, with the base of the triangle positioned at the top. On the other side is a scale ranging from 0 to 10 corresponding to pain intensity.
Fig. 27.1
Visual analogue scale for self-evaluation of pain. S severe pain; M moderate pain; L mild pain
The faces scale is also used in the self-assessment of pain (Fig. 27.2). A series of faces expressing increasing degrees of pain are shown to the child. Each face corresponds to a score of 0, 2, 4, 6, 8, or 10. This method presents the risk of confusion by the child between his/her emotional state and pain.
Fig. 27.2
The faces scale for the self-assessment of pain
Other questionnaires, and more or less playful tools can also be used to reach the best way of quantifying pain.
Heteroassessment
Heteroevaluation is pain assessment performed by the caregiver. Because of their inability to use self-assessment tools, this assessment is required in small children and infants. In older children with mental retardation or difficulties of expression, this method is also preferred. Good communication with parents is a valuable aid in this assessment. The evaluation takes into account behavioral changes, verbal and body expression and changes of some physiological constants. Evaluation methods vary according to the acute or chronic characteristics of pain. Various scales are used.
The evaluation of acute pain in the newborn and infant may be made depending on facial expressions according to the Neonatal Facial Coding System (Table 27.1). The objective scale of pain (OPS) (Table 27.2) may be used in older children.
Table 27.1
Neonatal facial coding system (NFCS) for the heteroevaluation of acute pain of the newborn and infant
Criterion | Score: absent 0/present 1 |
|---|---|
Eyebrow bulging | |
Eyelids squeezed tight | |
Nasolabial furrow accentuated | |
Mouth open |
Table 27.2
Objective pain scale (OPS) for the heteroevaluation of acute pain in infant and small child
Score | 0 | 1 | 2 |
|---|---|---|---|
Crying | Absent | Present and responds to nurturing | Present but does not respond to nurturing |
Movements | None or relaxed | Restless, changes position constantly | Disorderly and intense unrest with a risk of trauma |
Agitation | Child asleep or calm
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