SYMPOSIUM

Niger J Paed 2013; 40 (1): 97 - 104

Adeboye MAN

Fakayode EAO

Adeniran MO

Adebayo AT

Paediatrics pain management

DOI:http://dx.doi.org/10.4314/njp.v40i1.21

Accepted: 28th November 2012

Abstract Pain is one of the most

common symptoms experienced the

world over. It has always received

the needed attention and care in the

adult but not until recently among

children. Several erroneous beliefs

contributed to the inadequate atten-

tion among children such as as-

sumption that children did not ex-

perience pain to the extent that

adults do, because of the immature

nervous system, or that children

would not remember the pain. A

paediatrician is expected to be

knowledgeable about pediatric pain

management principles, provide a

calm environment for painful proce-

dures, use appropriate assessment

tools and techniques, anticipate

painful experiences, use a multimo-

dal approach (pharmacologic, cog-

nitive, behavioral, and physical) to

pain management, use a multidisci-

plinary approach when possible

and involve families in creating

solutions for their child’s pain.

Studies have shown that the most

common reason for unrelieved pain

is failure to routinely assess pain

and provide pain relief. The theo-

ries, pathways, transmission, regu-

lations, classifications, assessment

scales and the treatment of paediat-

ric pain and practical issues that

arise from the use of pharmacologic

analgesic in the children were also

reviewed and highlighted.

Adeboye MAN

Fakayode EAO

Adebayo AT

(

)

Department of Paediatrics and Child

Health

Adeniran MO

Pain and Palliative Unit,

University of Ilorin Teaching Hospital,

Ilorin, Nigeria

Keywords : Paediatrics, pain,

management, Scales

Introduction

pain in the brain. This does not explain the phenomenon

of phantom limb pain when peripheral receptors no

longer exist.

Pain is a ubiquitous aspect of human experience and

epitomizes human suffering. Historically, we have done

a poor job of addressing pain especially in children.

In 1979 IASP defined pain as “unpleasant sensory and

emotional experience associated with actual or potential

tissue damage, or described in terms of such damage.”

Pain from poena-latin means punishment.

th

Pattern theory: Proposed in the late 19 century. Pain

is the result of stimulation of certain nerve impulses that

form a pattern, combine and then dumped into the spinal

cord as a lump sum of pain, a process called central

summation. However this theory does not account for

other factors of pain perception, such as the effect of

placebos on pain.

Pain is an unpleasant feeling that is conveyed to the

brain by sensory neurons. The discomfort signals actual

or potential injury to the body. Perception gives

information on the pain's location, intensity, and

something about its nature.

Gate control theory: In 1965, Melzack and Wall pub-

lished the gate control theory of pain. A mechanism in

the brain acts as a gate to increase or decrease the flow

of nerve impulses from the peripheral fibres to the cen-

tral nervous system. An “open” gate allows the flow of

nerve impulses, and the brain can perceive pain. A

“closed” gate does not allow flow of nerve impulses,

decreasing the perception of pain. Although the gate

control theory has been widely accepted since the 1970s,

it leaves unanswered questions, including chronic pain

issues, sex-based differences, stress effects, and the ef-

fects of previous pain experiences.

Historical perspective: Several theories proposed

Straight channel theory: In 1644 Descartes proposed a

theory of pain exits from the skin to the brain. During

th

the 19 century, Von Frey theorized that pain pathways

move from specialized receptors in body tissues to a

pain center in the brain.

Specificity theory: Based on the presence of specialized

peripheral receptors rather than a central mechanism of

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Neuromatrix theory: In 1999, Melzack and Wall pre-

sented a newer theory of pain, consistent with the idea of

gate control that addresses some of these unanswered

questions. This “new and improved” theory, the neuro-

matrix theory, says that each person has a genetically

built-in network of neurons called the “body-self neuro-

matrix. Just as each person is unique in physical appear-

ance, each person’s matrix of neurons is unique and is

affected by all facets of the person’s physical, psycho-

logical, and cognitive makeup, as well as his or her ex-

perience. Thus, the pain experience does not reflect a

simple one-to-one relationship between tissue damage

and pain.

sheath. The C fibers are the ones that produce constant

pain. According to the gate control theory, stimulation

of the fibers that transmit non-painful stimuli can block

pain impulses at the gate in the dorsal horn. For exam-

ple, if touch receptors (A beta fibers) are stimulated,

they dominate and close the gate. This ability to block

pain impulses is the reason a person is prone to immedi-

ately grab and massage the foot when he or she stubs a

toe. The touch blocks the transmission and duration of

pain impulses. Since the mechanosensory pathway as-

cends ipsilaterally in the cord, a unilateral spinal lesion

will produce sensory loss of touch, pressure, vibration,

and proprioception below the lesion on the same side.

The pathways for pain and temperature, however, cross

the midline to ascend on the opposite side of the cord.

This pattern is referred to as a dissociated sensory loss

and (together with local dermatomal signs; helps define

the level of the lesion.

Pain Pathways and Transmission

Previously, pain pathways were seen as having three

components:-

•

A first order neurone (cell body in dorsal root

ganglion) which transmits pain from a peripheral

receptor.

A second-order neurone in the dorsal horn of the

spinal cord, which axon crosses the midline to

ascend in the spinothalamic tract to the thalamus.

A third-order neurone projects to the postcentral

gyrus (via the internal capsule).

Regulators of Pain

Chemical substances that modulate the transmission of

pain are released into the extracellular tissue when tissue

damage occurs. They activate the pain receptors by irri-

tating nerve endings. These chemical mediators include

histamine, substance P, bradykinin, acetylcholine, leu-

kotrienes and prostaglandins. The mediators can produce

other reactions at the site of injury, such as vasoconstric-

tion, vasodilatation, or altered capillary permeability.

For example, prostaglandins induce inflammation and

potentiate other inflammatory mediators. Aspirin a non-

steroidal anti inflammatory medications, and the new

cyclooxygenase-2 (COX-2) inhibitors block cyclooxy-

genase-2, the enzyme needed for prostaglandin synthe-

sis, thus reducing pain. Consequently, these medica-

tions are often prescribed for painful conditions due to

inflammation.

This scenario, while partially correct, is now known to

be horribly over-simplified. The pathways that carry

information about noxious stimuli to the brain, as might

be expected for such an important and multifaceted

system, are complex. The major pathways are

summarized in the following figure which omits some of

the less well understood subsidiary routes. Because

projections from non-nociceptive temperature-sensitive

neurons follow the same anatomical route, they are

included in this description, even though they are not

part of the pain system. Nociceptors, or pain receptors,

are free nerve endings that respond to painful stimuli.

Nociceptors are found throughout all tissues except the

brain, and they transmit information to the brain. They

are stimulated by biological, electrical, thermal,

mechanical, and chemical stimuli. Pain perception

occurs when these stimuli are transmitted to the spinal

cord and then to the central areas of the brain. Pain

impulses travel to the dorsal horn of the spine, where

they synapse with dorsal horn neurons in the substantia

gelatinosa and then ascend to the brain.

Fibers in the dorsal horn, brain stem, and peripheral tis-

sues release neuromodulators, known as endogenous

opioids that inhibit the action of neurons that transmit

pain impulses. β-endorphins and dynorphins are types of

natural opioid-like substances released, and they are

responsible for pain relief. Endorphins are the modula-

tors that allow an athlete to continue an athletic event

after sustaining an injury. Endorphin levels vary from

person to person, so different persons experience differ-

ent levels of pain. This endogenous opioid mechanism

may play an important role in the placebo effect. A pla-

cebo is an inactive substance or treatment used for com-

parison with “real” treatment in controlled studies to

determine the efficacy of the treatment under study. De-

spite the lack of any intrinsic value, placebos can and do

produce an analgesic response in many persons. Placebo

analgesia can affect nociceptive mechanisms in the cor-

tex of the brain and descending pathways of the spinal

cord.

Two types of fibers are involved in pain transmission:

The large A delta fibers produce sharp well-defined

pain, called “fast pain” or “first pain,” typically stimu-

lated by a cut, an electrical shock, or a physical blow.

Transmission through the A fibers is so fast that the

body’s reflexes can actually respond faster than the pain

stimulus, resulting in retraction of the affected body part

even before the person perceives the pain.

Classification of Pain

After this first pain, the smaller C fibers transmit dull

burning or aching sensations, known as “second pain.”

The C fibers transmit pain more slowly than the A fibers

do because the C fibers are smaller and lack a myelin

Pain can be divided into

(

A) nociceptive (B) neuropathic (C) a mixture of these

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two types. Pain can also be divided into acute or

amputation.

chronic.

•

Chronic central neuropathic pain: can follow

traumatic spinal cord injury or diseases of the brain

itself, like stroke.

Nociceptive pain: In this type of pain, so-called

‘nociceptors’ play a central role. Nociceptors are the

Other causes

receptors of sensory neurons that are located in the skin,

mucosa or internal organs. Pain arises when these

receptors are activated by a possibly damaging stimulus.

Different types of nociceptors perceive different types of

stimuli, and these include; thermal nociceptors activated

by noxious heat or cold; mechanical nociceptors notice

excess pressure or deformation;chemical nociceptors are

sensitive to chemical substances.

Mixed pain: In this type of pain both nociceptive and

neuropathic pain mechanisms are involved. For instance

in cancer pain, the pain can be due to the tumour causing

inflammation of tissue around the tumour (nociceptive)

and causing entrapment of a nerve (neuropathic). Also

chronic low back pain is often a combination of

nociceptive and neuropathic pain. The back itself may

hurt with a constant aching (nociceptive pain) and there

may be additionally sudden burning and hurting

sensations extending into the legs, which are called

sciatiae and are of neuropathic origin.

Nociceptive pain can be further divided according to the

part of the body into: Somatic pain which originates

from bones, muscles, tendons or blood vessels and is

often known as musculo-skeletal pain, usually sharp,

well-localized can be reproduced by touching or moving

the involved area usually of longer duration. Cutaneous

pain is due to injury of the skin or the superficial tissues

usually well-described, localised pain of short duration

e.g. paper cut, minor burns.Visceral pain originates from

the internal organs of the body’s cavities such as thorax

Other classifications include

Acute Pain: Everyone have experienced acute pain. Bee

stings, bumped knees, and bone fractures are simple

examples. Most acute pain serves a clear purpose: some

problem needs to be addressed It is practically

automatic. Acute pain is characterized by help-seeking

behavior. In most cases people cry out and move about

in a very obvious manner. Physiologic responses to

acute pain include tachycardia, tachypnea, and sweating

due to discharge in the sympathetic nervous system. It is

easy to recognize and empathize with acute pain. We

wince if we see severe, acute pain and respond with our

own "sympathetic" discharge.

(

heart and lungs), abdomen (liver, kidneys, spleen and

bowels) and pelvis (ovaries, bladder and womb).

Visceral pain is more aching, vague and often difficult

to localise, usually of longer duration sometimes colicky

or cramping such as gastro-intestinal spasms.

Neuropathic pain: This pain type follows damage to

the central or peripheral nervous system. There are no

specific receptors involved and pain is generated by

nerve cell dysfunction. Chronic, often intractable pain

due to injury to the peripheral nerves is known as

neuropathic pain. According to Devor and Seltzer, this

pain is a paradox. Injury to peripheral nerves should

deaden sensation, much as cutting a telephone wire

leaves the phone line dead, but the opposite occurs in

neuropathic pain. Injury to the peripheral nerves can

cause spontaneous paresthesias, numbness, pain with

movement, tenderness of a partly denervated part and

pain that is electric shock–like, burning, shooting, or

tingling. Types of neuropathic pain include-

Chronic Pain: Chronic pain is very different from acute

pain. It serves no biological purpose. While the suffering

engendered may be as great as is that in acute pain, it is

subjectively experienced and objectively displayed in a

very different way. For reasons not well understood,

chronic pain is characterized by physical and mental

withdrawal.

Pain in Children

Until the 1970s, pain in children was ignored in health

care research. The common assumption was that chil-

dren did not experience pain to the extent that adults do,

because of the immature nervous system, or that chil-

dren would not remember the pain. Consequently, chil-

dren were often under-medicated or not medicated at all

for pain. This practice continued until the late 1980s,

when changes began to occur in pain management in

infants and children as a result of research, consumer

demands, and legislation to promote development of

drugs for these patients. Substantial evidence now indi-

cates not only that children experience pain but that the

pain experience may have long-term adverse conse-

quences perception. The misperception that infants have

immature nervous systems and therefore do not feel pain

is still common. All nerve pathways necessary for pain

transmission and perception are present and functioning

by 24 weeks’ gestation. Research in both animal models

and human newborns confirms that a lack of analgesia

•

Peripheral neuropathy: means that the peripheral

nerves are not working properly. It is usually the

result of an injury to or a disease process, such as

diabetes associated with loss of function in the

nerve. Often starts in the hand and feet, and tends to

affect the body symmetrically.

Entrapment of nerve: pinched or trapped nerve

due to compression in the spine or elsewhere in the

body, such as elbow, shoulder, wrist or foot.

Phantom limb pain: sensation of pain from a limb

that has been lost or from which no longer physical

signals are being received, reported after

amputation or in quadriplegics.

After amputation of a limb, a patient may experi-

ence painful sensations in the missing limb. As

many as 70% of amputees report this phantom limb

pain, and usually within the first week after

•

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for pain causes “rewiring” in the nerve pathways in-

volved in the transmission of pain. Consequently, an

infant or child who experiences pain once will have

greater pain perception during later painful experiences.

Taddio et al found that babies who did not receive anal-

gesia or anesthesia during circumcision later had greater

behavioral and physiological disturbances during immu-

nization.

been alleviated. Fear of what will happen next.

Children cannot describe and locate their pain. McGrath

reports children as young as 18 months being able to

report their pain verbally and localize it. Children as

young as three years old have used self- report tools to

describe and locate their pain. Children can demonstrate

on an outline of the body where they hurt without know-

ing the names of the body parts.

Another common myth is that children do not experi-

ence chronic pain. Indeed, children do experience

chronic pain syndromes such as: complex regional pain

syndrome, as well as acute forms of pain related to

chronic conditions such as sickle cell anemia. They also

experience various forms of recurrent pain, most com-

monly headache, abdominal pain, back pain, chest pain,

and limb pain. Surgical interruption of a particular tract

to abolish chronic pain is not usually effective; the pain,

although initially alleviated, tends to return. Indeed,

there is often no completely successful treatment for

these unfortunate patients.

Clinical Assessment of Pain

Pain is both a sensory and an emotional experience. In

older children, the character, location, quality, duration,

frequency, and intensity of their pain can be assessed.

Behavior and physiologic signs are useful, but can be

misleading. A child who is experiencing significant

chronic pain may play “normally” as a way to distract

attention from pain. This coping behavior is sometimes

misinterpreted as evidence of the child “faking” pain at

other times. Investigators have devised a range of be-

havioral distress scales for infants and young children,

mostly emphasizing the patient's facial expressions, cry-

ing, and body movement. In assessing a child’s pain, a

measuring tool must take into account: child’s age, cog-

nitive level, type of pain, situation in which the pain is

occurring, no single measure is useful for all children

with all types of pain.

Development of pain apparatus: The neural progres-

sion of pain transmission begins with the development

of skin and mouth sensory neurons by the end of the

first 2 wk of gestation. There is a progression in the

growth of the neural apparatus involved in pain trans-

mission throughout fetal development until the appear-

ance of the beginning of the pain inhibitory apparatus,

starting at approximately 32 week of gestation and con-

tinuing into the newborn period.

Behavioral Observational Scales

The primary method of pain assessment for infants, chil-

dren aged less than three years, and developmentally

disabled patients.

CRIES: Assesses Crying, Oxygen requirement, In

creased vital signs, facial expression, Sleep

FLACC: Face, Legs, Activity, Crying, Consolability

scale has been validated from two months to

seven years. FLACC uses 0-10 scoring.

Sources of Pain: Repeated heelsticks, indwelling cathe-

ters, necrotizing enterocolitis, nerve injury, thrombo-

phlebitis. Almost all children with a diagnosis of cancer

will experience pain from illness or a procedure. More

than 70% suffer from severe pain at some point in their

illness experience.

Myths about pain in children

NIPS: Neonatal Infant Pain Scale

SUN: Scale for Use in Newborns

Infants cannot feel pain because their nervous system is

immature. The true situation is that there is considerable

maturation by 26 weeks of gestation; nociceptive path-

ways to the central nervous system are myelinated by

about gestation 30 weeks. Descending inhibitory path-

ways develop later than afferent excitatory pathways.

Extremely pre-term infants can localize and withdraw

from noxious stimuli. Neonates exhibit behavioral,

physiological and hormonal responses to pain.

CHEOPS: Children’s Hospital of Eastern Ontario Scale.

Intended for children aged one to seven years.

Faces: Children aged three years and above can rank

their pain using one of several validated scales

including the Wong-Baker Faces scale, Bieri-

Modified, and Oucher scale.

Self-report is the gold standard in the assessment of pain

intensity.

Visual pain scale: This includes the colour and other

analog scales: Horizontal or vertical ruler, on which

increasing intensity of red signifies more pain. These

scales are easy to use, are efficient, and offer values of

pain intensity that can be statistically analyzed to deter-

mine the efficacyof a pain treatment intervention.

An active or sleeping child is not in pain. The true situa-

tion is that pain may result in “exhausted” sleep. Chil-

dren may read, play or watch TV to distract themselves

from the pain. Children are particularly good at using

distraction as coping mechanism.

Several questionnaires have been developed for children

with chronic or persistent pain. These include:

Children always tell the truth about pain. This may not

be true because children are scared of injections.

Younger children may feel that pain is a punishment for

doing something wrong. Onset of pain may be gradual

so the child does not realize they have pain until it has

•

Varni-Thompson Pediatric Pain Questionnaire.

Children’s Comprehensive Pain Questionnaire.

Autonomic measures (e.g., heart rate, blood pres-

sure, heart rate spectral analyses).

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•

Hormonal-metabolic measures.

to ensure compliance.

Commonly used analgesics include acetaminophen,

NSAID (e.g. diclofenac, ibuprofen), codeine, pentazo-

cine and morphine.

Interventions For Pain Management

These include non-pharmacological and pharmacologi-

cal interventions.

Non-pharmacologic interventions: These approaches

have excellent safety profiles and increasing evidence of

Acetaminophen 10–15 mg/kg per oral q4 hourly. Has

anti-inflammatory action; no antiplatelet or gastric ef-

fects; toxic dosing can produce hepatic failure.

effectiveness. Adopt

a

child-centered approach

Aspirin 10–15 mg/kg per oral q4 hourly. Anti-

inflammatory effects; prolonged antiplatelet effects; can

cause gastritis; risk of Reye syndrome.

(

listening to the needs of the child and family) rather

than a procedure-focused “get-it-over-with” approach.

Use the least invasive equipment where possible. En-

sure that the person performing the procedure has appro-

priate technical expertise, or is closely supervised by

someone who does. Optimize waiting time: too little

time increases distress but too much time increases an-

ticipatory anxiety. Time required for preparation is child

Opioids are administered for moderate and severe pain.

Routes: oral, rectal, oral transmucosal, transdermal,

intranasal, intravenous, epidural, intrathecal, subcutane-

ous, or intramuscular route.

-

specific. Ensure that the development of anticipatory

Practical Aspects of Prescribing Opioids: Morphine is

typically regarded as the first choice for severe pain. The

right dose is the dose that relieves pain with a good mar-

gin of safety. Dosing should be titrated and individual-

ized. There is no “right” dose for everyone. Anticipate

and treat peripheral side effects, including constipation,

nausea, and itching. Give doses at sufficient frequency

to prevent the return of severe pain before the next dose.

After opioid dosing for more than one week, it should be

tapered gradually to avoid withdrawal symptoms.

anxiety is prevented as far as possible by maximising

the intervention to alleviate pain and distress for the first

procedure.

Area of emphasis for intervention:

Neonate/ infant- Sensory

Preschooler-Sensory/ Behavioral

Sensory/ Behavioral/ Cognitive

Adolescent-Sensory/ Behavioral/ Cognitive

Toddler-Sensory

S c h o o l A g e -

•

Techniques: Neonate/ infant: Positioning, swad-

dling, rocking/ cuddling, touch/ massage, dim light-

ing, visual distraction, sucking and sucrose/ water

solution on pacifier.

Toddler: Distraction devices (toys/ music/ videos,

security object (blanket/ toy/ stuffed animal), paci-

fier, touch/ massage, hugging/ holding, Imagery,

play, positioning, heat/ cold application.

School age: Heat/ cold application, touch/ massage,

play therapy, humour, distraction devices (music/

videos/breathing techniques), positioning, exercise,

hugging/ holding, imagery.

Adolescent: Hypnotherapy, heat/ cold application,

relaxation techniques, humour, breathing tech-

niques, prayers, distraction (especially music/ vid-

eos), yoga.

Tolerance: refers to decreasing effect on continued ad-

ministration of a drug or the need for increased dosing to

achieve the same effect.

Dependence: refers to the need for continued opioid

dosing to prevent withdrawal symptoms (irritability,

agitation, autonomic arousal, nasal congestion, piloerec-

tion, diarrhea and/or jitteriness; and in neonates yawn-

ing.

Addiction: refers to psychological craving with compul-

sive drug-seeking behavior. Opioid under-dosing does

not prevent addiction and may increase drug-seeking

behavior for relief of pain; good pain relief takes the

focus off opioids.

PRN versus Regular dosing: It has been shown that

when analgesic medications are given regularly on a

schedule, the cumulative dose of analgesia required is

less than that required when pain medications are given

prn. The reason is that by the time the patient asks for

the medication, a higher dose is required to alleviate the

pain.

Pharmacological Management: The general principles

of newborn physiology and its effects on the pharmacol-

ogy should be taken into consideration. Most analgesics

are conjugated in the liver hepatic enzyme systems,

which mature at varying rates over the first one to six

months of life. The glomerular filtration rates are dimin-

ished in the first week of life, and newborns have a

higher percentage of body weight as water and less as

fat compared with older patients. Newborns, and espe-

cially premature infants, have diminished ventilatory

responses to hypoxemia and hypercarbia.

Patient controlled analgesia (PCA)/ Nurse controlled

analgesia (NCA): Children as young as six to seven

years of age can independently use the PCA pump to

provide good pain relief. Patient controlled analgesia

refers to intravenous administration of analgesia, using a

programmed pump. The pump may be programmed to

give continuous medication with the ability for the pa-

tient to self-administer bolus increases, or it may be pro-

grammed only for bolus administrations. It is pro-

grammed to permit a maximum dose, so as not to cause

Pain management with pharmacological intervention

involves understanding of the pediatric doses, use of the

analgesic ladder, keep the approach simple and consis-

tent, use the oral and sublingual route in most cases,

work with the child and the family to choose medication

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over sedation.

Psychothropic Medications in Pain Management:

Children and adolescents with chronic pain with no

identified cause, as well as those with identified medical

causes of pain, have significantly more psychiatric dis-

orders than healthy children. These include depression,

sleep anxiety disorders, including generalized anxiety

disorder, separation anxiety, post-traumatic stress disor-

der and panic disorder. This increase in co-morbid psy-

chiatric disorders may be explained by the disruption of

the serotonergic and noradrenergic systems that are the

common pathways in both pain disorders and psychiat-

ric disorders. Psychotropic medications should be used

with caution. Allow the child to participate effectively in

therapies and return to normal activity as soon as possi-

ble. Side effects should be specifically addressed

Antipsychotics: Low doses of antipsychotic medica-

tions are often used to address the severe anxiety and

agitation frequently associated with chronic pain in

youth. Adverse events associated may be severe.

Responsibility of the Paediatrician

Become knowledgeable about pediatric pain manage-

ment principles.

•

Provide a calm environment for painful procedures.

Use appropriate assessment tools and techniques.

Anticipate painful experiences.

Use a multimodal approach (pharmacologic, cogni-

tive, behavioral, and physical) to pain management.

Use a multidisciplinary approach when possible.

Involve families in creating solutions for their

child’s pain.

•

Antidepressant Medications: Useful in adults with

chronic pain, including neuropathic pain, headaches, and

rheumatoid arthritis. However, limited clinical trials

have been done in children. Tricyclic anti-depressants

Institutional Responsibilities: The institutional process

of acute pain management begins with the affirmation

that children should have access to the best level of pain

relief that may be safely provided.

(

TCAs) have been most studied with relation to chronic

pain in children and have been found effective in pain

relief for symptoms including neuropathic pain, func-

tional abdominal pain, and migraine prophylaxis. It is

effective in the treatment of sleep disorders, which fre-

quently accompany pediatric pain syndromes.

Pain relief, a privilege or a right?

The fundamental principle of responsible medical care is

not “do not hurt” but “do no harm”. Harm occurs when

the amount of hurt or suffering is greater than necessary

to achieve the intended benefit.

The assessment and treatment of pain in children are

important parts of pediatric practice, and failure to pro-

vide adequate control of pain amounts to substandard

and unethical medical practice.

Side effects: Cardiotoxicity, discontinuation syndrome

including agitation, sleep disturbances, appetite changes,

and gastrointestinal symptoms. These medications

should be tapered slowly.

Serotonin Reuptake Inhibitors (SSRIs): Have demon-

strated modest improvement in the treatment of a variety

of pain syndromes in adults, leading to a supposition

that noradrenergic pathways are more significant in the

treatment of pain than serotonergic pathways. SSRIs are

indicated when symptoms of depressive or anxiety dis-

orders are prominent. These medications have a less

severe side effect profile than TCAs, with common side

effects largely transient. These include gastrointestinal

symptoms. They should also be tapered over a week

course.

Nursing Management of Pain

Pain is an unpleasant sensory or emotional experience

associated with actual or potential tissue damage, or

described in terms of such damage. Pain is always sub-

jective. It helps a child avoid more injury by warning

him of the presence of a harmful thing.

Signs and symptoms of pains: Pain may be known by

observing behavioral changes, expression by verbal or

visible discomfort such as crying, agitation, tachycardia,

hypertension, and tachypnea. Not changing position

very often to avoid the pain or positioning ones’ body in

a way that it will not hurt. Weight loss may occur due to

poor feeding, restlessness, they are not comfortable, and

move around a lot due to pain. The child tends to pull

the part of his body that is hurting away from touch or

gets upset at being touched. Sleeps more or sleeps less

than usual. Self focusing and touches, tugs, rubs, or

massages the part of his body that is painful. There is

educed interaction with other siblings and people. Hy-

perthermia or hypothermia

Anticonvulsants: Traditional anticonvulsants, such as

carbamazepine and valproic acid, are believed to relieve

chronic pain by blocking calcium channels at the cellu-

lar level and suppressing the hypersensitive sensory fi-

bers without affecting normal nerve conduction. Anti-

convulsants are useful in patients with mood disorders

and neuropathic pain.

Benzodiazepines: Benzodiazepines are anxiolytic medi-

cations that have anticonvulsant and muscle relaxant

effects. Clonazepam, a long-acting benzodiazepine, has

demonstrated efficacy in neuropathic pain. These medi-

cations are most appropriate in acute situations because

dependence, tolerance, and withdrawal may occur with

prolonged use. These medications are most appropriate

in acute situations because dependence, tolerance, and

withdrawal may occur with prolonged use.

Pain scale: These include

Body outline tool: A child marks an X or colors the

painful area on a drawing of a child's body. Different

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colors can be used to quantify the pain.

The IV tube is placed in a child's vein usually in the

arm. The child receives medicine from the pump

through the tube when he is in pain.

Colored analog scale: Colors are assigned for most or

worst hurt, a little less hurt, or no hurt. A number can

also be placed on each color.

Non Pharmacologic Intervention: A few of the most

useful methods in children are:

Facial Expression Pain Scale: This scale consists of 5

to 9 faces, ranging from happy or neutral (no pain) to

sad or distressed. Scales may vary in the number of

faces, but six faces are usually used. A child may tell

how much pain he has by pointing on the face he

chooses. Scores are easily compared to a visual analog

pain scale.

Use of heat or cold compress, distraction (music, video

games, TV, stories, blowing bubbles, puzzles), relaxa-

tion (breathing exercises, rocking chair), massage (bed

bath, gentle back rub, lotion), rest (dimming lights and

reducing noise, encouraging sleep), changing position

(use of pillows, sitting up), imagination (creating stories

and drawing pictures).

Oucher scale: A vertical numerical scale from 10 to 100

for children who can count. The numbers have a corre-

sponding vertical picture scale of expression of no hurt

to worse hurt.

Gathering information about the pain can provide infor-

mation about the extent of the pain. Assess for signs and

symptoms associated with pain such as fatigue, de-

creased appetite, weight loss, changes in body posture,

sleep pattern disturbance, anxiety, irritability, restless-

ness, or depression. Perform a comprehensive assess-

ment of pain to include location, characteristics, onset,

duration, frequency, quality, intensity or severity, and

precipitating factors of pain. Consider cultural influ-

ences on pain response (e.g., cultural beliefs about pain

may result in a stoic attitude). Reduce or eliminate fac-

tors that precipitate or increase pain experience (e.g.fear,

fatigue, monotony, and lack of knowledge).

Poker chip tool: Four poker chips are used. One chip

represents a little hurt and four chips is the most hurt a

child could experience.

Visual analog pain scale: This is a 10 centimeter line

scale with one end marked no pain and the other end

worst pain. This method may be used in children as

young as seven years old.

The Children's Hospital of Eastern Ontario Pain

Scale (CHEOPS): Is based on observation of child be-

havior by physicians or nurse. The scale assigns a point

score to 6 categories of behavior and the total score is

supposed to correlate with pain. It’s not too reliable.

Note: crying can be caused by pain, hunger, frustration,

restraints or anxiety.

Teach the use of non pharmacologic techniques (e.g.,

relaxation, guided imagery, music therapy, distraction,

and massage) before, after, and if possible during pain-

ful activities; before pain occurs or increases; and along

with other pain relief measures. This can increase the

release of endorphins and enhance the therapeutic ef-

fects of pain relief medication. Simple relaxation ther-

apy is ingineous with nurses to produce relaxation such

as yawning, deep breathing, abdominal breathing. Indi-

vidualize the content of relaxation by asking the child

what the child loves to do when relaxing.

The objective pain scale combines physiologic and be-

havioral parameter. The ability to calm the child is im-

portant when using this scale.

Pain Management

Pharmacologic

Research shows that the most common reason for unre-

lieved pain is failure to routinely assess pain and pain

relief. Evaluate the effectiveness of analgesic at regular,

frequent intervals after each administration and espe-

cially after the initial doses. Ongoing evaluation will

assist in making necessary adjustments for effective pain

management. Observe for any signs and symptoms of

adverse reaction effects (e.g., respiratory depression,

nausea and vomiting, dry mouth, and constipation).

Documentation facilitates pain management by commu-

nicating effective and non effective pain management

strategies to the entire health care team.

Non-Steroidal Anti Inflammatory Drugs (NSAIDS)

eg acetaminophen, ibuprofen: It is used for mild to

moderate pain control, such as pain coming from a

pulled tooth. It may also be used in controlling pain after

surgery.

Opioid Analgesics: These medicines may include oral

liquid morphine. It may be taken every 4 to 6 hours

(

including break through dose) for mild to moderate

pain. Morphine is given to provide longer control of

pain.

Ensure as a nurse that the drug is the: right drug, right

route, right dosage, right client, right frequency.

Anesthesia: Anesthesia is numbing medicine to control

pain and make the child comfortable. This works by

blocking the pain signals from the nerves eg xylocaine

in scorpion bites.

References

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Miser AW. Pain. 1987;29(1):73-83.

Patient controlled analgesia (PCA): A device is used

to give a child pain medicine e.g. in SCD. This device

has an electric pump connected by a tube to an IV line.

Klimach VJ, Cooke RWI. Maturation of the neonatal

somatosensory evoked response in preterm infants. Dev

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Anand KJS, Hickey PR: Pain and

its effects in the human neonate

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4. Fitzgerald M, Koltzenburg M. The

functional development of de-

scending inhibitory pathways in

the dorsolateral furniculus of the

newborn rat spinal cord. Brain

Res 1986;389:261-270.

5. McGrath PA. Pain in Children:

Nature, Assessment, and Treat-

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6. Beyer JE, Wells N. The assessment

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