Niger J Paed 2013; 40 (1): 97 - 104  
Adeboye MAN  
Fakayode EAO  
Adeniran MO  
Adebayo AT  
Paediatrics pain management  
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  
Adeniran MO  
Pain and Palliative Unit,  
University of Ilorin Teaching Hospital,  
Ilorin, Nigeria  
Keywords : Paediatrics, pain,  
management, Scales  
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.  
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  
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  
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  
A first order neurone (cell body in dorsal root  
ganglion) which transmits pain from a peripheral  
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  
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  
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  
two types. Pain can also be divided into acute or  
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  
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  
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-  
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  
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).  
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  
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  
Area of emphasis for intervention:  
Neonate/ infant- Sensory  
Preschooler-Sensory/ Behavioral  
Sensory/ Behavioral/ Cognitive  
Adolescent-Sensory/ Behavioral/ Cognitive  
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-  
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  
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  
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  
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  
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  
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  
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  
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.  
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.  
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scending inhibitory pathways in  
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5. McGrath PA. Pain in Children:  
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