22 Pediatric Pain Management
Pain in Children
Key factors that influence effective pain management in children include the following:
• Established pain is difficult to control; therefore, essential goals of pain management are prevention of and quick action in response to pain.
• Pediatric and adolescent patients and their families should be involved as much as possible in pain education—its assessment and management. Parents must be educated about their role in engaging and providing distraction and comfort to their child during and after painful procedures (e.g., needlesticks, ear examinations, vaccinations).
• Culture and family learning patterns must be considered (e.g., beliefs about pain, folk remedies, how pain is expressed verbally, and language barriers).
• Genetic stressors may be responsible for differing levels of neurotransmitters or medication responses.
• Children’s pain perceptions are influenced by individual, physiological and psychological differences, memories, and prenatal and perinatal stressors.
• Chronic pain is rarely associated with sympathetic nervous system arousal. Therefore children with chronic pain may not appear to be in pain. This may negatively affect their evaluation and treatment. To effectively treat chronic pain in children, physical and psychological manifestations of chronic pain must be considered.
• Developmental issues (e.g., cognitive, emotional, and physical), age, and temperament significantly affect how pain is interpreted, expressed, and controlled. Therefore, pain management must be tailored to the child’s age and developmental level.
• Cognitive issues that influence pain perception include the child’s memory and level of understanding, ability to control what will happen, attachment of meaning to a situation with regard to pain, and expectations of the intensity of pain.
• Emotional issues that affect a child’s pain perception include anxiety, fear, frustration, anger, and depression.
• Social issues, such as how others react to the child in pain, influence the treatment plan. Likewise, family harmony or conflict influences a child’s pain.
• Pain perception involves complex neural interactions that send out impulses or noxious stimuli generated by tissue damage. Melzack and Wall’s gate control theory of pain (1965) explains the four processes necessary for pain to occur (Golianu et al, 2000; Wendel, 2009):
Transduction—painful or noxious stimuli are translated into electrical signals at sensory nerve endings and forwarded to the spinal cord via A-delta fibers and C fibers. The A-delta fibers are myelinated and when activated result in sharp, stinging sensations. In contract, C fibers are unmyelinated and their activation results in vaguely located dull or burning pain.
• Health care provider’s fear of severe adverse events from pain medications, such as central nervous system and respiratory depression related to their use, often results in inadequate pain control (Kraemer and Rose, 2009).
• For a variety of reasons (e.g., fear of getting a shot), some children do not report pain to health care providers.
Barriers to Treatment of Pain in Children
• Myth that children, especially infants, do not feel pain the way adults do, or if they do, there is no consequence
• Lack of assessment and reassessment for the presence of pain
• Misunderstanding of how to conceptualize and quantify a subjective experience
• Lack of pain treatment knowledge
• The notion that addressing pain in children takes too much time and effort
• Fears of adverse effects of analgesic medications, including respiratory depression and addiction
• Personal values and beliefs as health care professionals about their meaning and value of pain
Overview of Pain
Pain Assessment
Clinical Findings
History
A careful history is necessary and requires a systematic approach. An interval history and examination are needed when pain does not abate as expected or there is a change in quality, intensity, duration, or location. Pain has a sensory and emotional component. Because pain is a subjective phenomenon, it is measured best by self-report (Zeltzer and Krell, 2007). The following information should be obtained during pain assessment:
• Pain history (symptom analysis)
• Past pain experience, including the child’s memory of the painful experience and the pain treatment
• Cultural beliefs about pain and its causes and treatment
• Self-reports of pain in the verbal child (if possible obtain pain history as noted). Use age-appropriate language. The lower age limit for successful use of a self-report pain scale is generally 3 or 4 years old (Hicks et al, 2001; Wolraich et al, 2008; Wong and Baker, 1988). Between the ages of 3 and 7 years, children’s ability to describe the location, intensity, and quality of their pain increases. Introduction to the pain scale includes an explanation that this is one way for children to express how they hurt (Wolraich et al, 2008). Providers should select reliable, valid, sensitive, and easily understood instruments that can be used consistently. The use of self-report tools, patient pain journals, and other objective pain measures help quantify pain before treatment and serve to evaluate the outcome of treatment. Selected common pain scales are shown in Table 22-1.
• Factors that influence self-report of pain include (Marie, 2009; Wolraich et al, 2008):
Situational influences may modify children’s pain scores (i.e., setting, person asking, or what they expect to happen as a result of their answer).
• Children with developmental delays may have difficulty reporting pain, may be less precise in their communications, or may be unable to verbally communicate their pain. Their pain expressions may be less precise, resulting in slower reporting of pain (Wolraich et al, 2008). However, if self-report is possible, it is always preferred over observational tools.
Children with developmental delays are no less sensitive to painful stimuli than children with normal development. Those with autism spectrum disorder may be both hyposensitive and hypersensitive to sensory stimuli (Overlander et al, 1999; Wolraich et al, 2008).
• Few scales are valid for intubated children. However, some intubated children are still able to self-report by using a faces pain tool, writing notes, and so on.
The comfort scale (Bear and Ward-Smith, 2006) has established validity and reliability for use in mechanically ventilated children. It combines six behavioral and two physiological measures.
TABLE 22-1 Common Pain Rating Scales Used to Measure Pain in Pediatric and Adolescent Patients
