Outline

1. Pediatric Pain ManagementKaren Hewson, R.N., M.N.College of Nursing, University of Saskatchewan

2. Outline • Problem of Pediatric Pain • Myths/Misconceptions: Fact or Fallacy? • Pain In Children’s Lives • Assessment of Pain • Pain Management Principles • Procedural Pain • Special Challenges: Neonates, Chronic Pain, End of Life • Leadership and Advocacy

3. Pain in Children’s Lives (Kuttner, 2010) • Pain part of growing up • Pain part of exploring the world • Preschoolers during play experience an average on one “owie” every 3 hours • Children frequently fall in playgrounds, riding bikes • Children often experience pain as a result of dental care • Some children and adolescents struggle for years with painful diseases and hospital treatments

4. The Problem of Pediatic Pain • Perpetuation of myths • Lack of knowledge –pre professional, professional, • Lack of interprofessional collaboration • Knowledge transfer challenges • Challenge of pain assessment in children • Institutional barriers • Everyone’s Problem Yet Nobody’s Problem

5. Fact or Fallacy? • Infants and young children do not experience pain like adults • Infants and young children will not have memory of painful experiences • Neonates do not feel pain like older children and adults due to immature nervous systems • Self report is always accurate in pediatric pain assessment • Narcotics (opioids) should be avoided in infants and children due to risk factors such as respiratory depression and addictions

6. Fact or Fallacy(con’t) • Opioids should be avoided in adolescents due to the problem in society with substance abuse • The harmful effects of analgesics are more serious than the harmful effects of unrelieved pain • PRN (as needed) analgesics are more effective than scheduled analgesics • Parental presence usually results in a lack of cooperation by the child • Topical anesthetics such as EMLA or Ametopp make it more difficult to draw blood and perform procedures, such as IV insertion

7. Misguided Beliefs About Pain in Infants • Infants do not have the capacity to experience or remember pain • Infants are neurologically immature and therefore cannot conduct pain impulses. • Infants do not remember pain, because of cortical immaturity. • Sleeping infants are not experiencing pain (Kuttner,2010; Twycross, A., Dowden, S., & Bruce, E. 2009)

8. Infants and Children do not express pain the same way as adults • Self report is gold standard in pain assessment • “Pain is what the experiencing person says it is, when and where it is…” • Challenges with non-verbal individuals * rely on physiological and behavioural measures (and the belief there is a reason for the pain!) • A number of validated and reliable non-verbal pain scales based on these measures:PIPP, NIPP, FLACC (Kuttner, 2010; Twycross, A., Dowden, S., & Bruce, E. 2009)

9. Long term effects • Unrelieved pain in infants can result in long term developmental problems • Unrelieved pain in infants can permanently change their nervous system and may “prime” them for having chronic pain (Kuttner,2010; Twycross, A., Dowden, S., & Bruce, E. 2009)

10. Infant Memory of PainInfants undergoing circumcision without pain relief compared to those who had pain relief had increased pain responses at subsequent routine vaccinations (Taddio et al., 1997)

11. Infants feel pain equally and perhaps more severely than older children and adults • The anatomical, physiological and biochemical prerequisites for pain perception are present in early part of intrauterine life • Infants have larger receptive fields and possibly a higher concentration of substance P receptors (neurotransmitter related to sensation of pain) • Nonmyelinatedtransmission: lack of inhibitory neurotransmitters (Mathew & Mathew, 2003)

12. Harmful Effects of Untreated Pain in Children • Respiratory (lungs)compromise • Cardiovascular (heart) compromise • Increased stress hormones • Increased glucose secretion • Slowing of gastrointestinal/genitourinary systems • Poor nutritional state • Muscle tension, spasm and fatigue • Behavioural and psychological disturbances, PTSD • Long term neurological effects • Chronic pain syndromes (Kuttner,2010; Twycross, A., Dowden, S., & Bruce, E. 2009)

13. Pain Related Concerns in infancy Childhood and Adolescence • Acute illness • Chronic Illness • Unintentional injuries ex trauma • Child abuse *These children experience pain d/t disease, injury, treatments and procedures

14. PrematureInfant Pain • Average 10-16 painful procedures per day and in some infants up to 300/week • 40-90% receive no effective treatment (Stevens et al., 2003)

15. Chronic Pain in Children and Adolescents • Affects 15 -20 % of children and adolescents • Reported as young as 3 years of age, however most prevalent in early teens • Can be part of a chronic medical condition, develop following surgery, illness or injury or have no obvious cause • Despite the significant physical, psychological, social and economic impact on children and families, chronic pain is often under-recognized and undertreated Physical and psychological impact of chronic pain in school age children can impact overall health and persist throughout adolescents and adulthood • Children and teens with chronic pain have an increased incidence of anxiety and depression (Stinson & Bruce, 2009; Kuttner, 2010)

16. Chronic Pain in Children • “Chronic pain in children is the result of a dynamic integration of biological processes, psychological factors and socio-cultural context, considered within a developmental trajectory” (American Pain society Position Statement on Chronic Pain in Children, 2006) • Has no apparent protective purpose and often the consequence of damaged, abnormally functioning nerves • Despite the significant physical, psychological, social and economic impact on children and families, chronic pain is often under-recognized and undertreated (Stinson, 2009).

17. Fundamental Principles of Pain Management in Children • A child’s pain is to be believed and acknowledged • Pain is real, and children and adolescents are the true authorities on their pain • Treating children in pain requires a thorough understanding of the interaction of biological, psychological and social systems impacting the pain experience (Kuttner, 2010)

18. Guidelines in Pediatric Pain Management • “First do no harm” • Understand developmental influences • Be honest! • Give choices when possible • Involve parents and caregivers • Take a pain history

19. Guidelines (con’t) • Respect “safe places”ex. child’s bed, playroom • Choose the most appropriate analgesic, route and schedule • Observe and prevent side effects of analgesics • Use non-pharmacological methods • Use a team approach

20. Self report of Pain in Children and Adolescents • Studies show that children can give a reliable self report of pain as early as age 3 (Twycross, 2009; Kuttner, 2010) • Self report of pain is most reliable if the child is not overly distressed (Ibid.) • Self report of pain is more reliable when parental support is present (Ibid.) • A number of reliable and valid self report tools have been tested in children based on their developmental age and stages (Stinson, 2009; Kuttner, 2010)

21. Pain Perception in ChildrenBio-Psycho-Social Model (Twycross, A., Dowden, S., & Bruce, E. 2009)

22. Pain Assessment : Have we missed the mark? • Pain as the “5th Vital Sign” • Pain scores: the concept of interpretability Clinical meaning must also be assessed: mild, mod or severe -treatment threshold, satisfaction with analgesia (Stinson et al., 2006)

23. Pain Scales • Practice in advance • Use same tool for same child • Evaluate at rest and with activity • Document , including response to interventions

24. Standard Pain Scales • Numerical Rating Scale (NRS) 0-10 • Faces Pain Scale – Revised (FPS-R) 0 -10 • FLACC behavioural scale

25. Reprinted with permission

26. *reprinted with permission

27. Factors in the Denial of Pain in Children • Developmental stage • Believe the pain is punishment • Influence of parent/health care professional (HCP) • Adolescent sense of “imaginary audience” • Longer hospital stay • Fears of unknown, worsening pathology, death, addictions, ‘drugs are bad’ • Challenge of chronic pain – not identified by child (Kuttner,2010; Twycross, A., Dowden, S., & Bruce, E. 2009)

28. Behavioural Responses • Variable • Facial expression, body posture, vocalization • Child may sleep in presence of pain • Children use distraction well • Judgments can lead to poor pain control

29. Observational Scales • Face Legs Arms Cry Consolability (FLACC) 0-10 • Neonatal/Infant Pain Scale (NIPS) • Premature Infant Pain Scale (PIPP) • Non-Communication Children’s Pain Checklist (NCCPC) • Parent’s Post-operative Pain Measure • Pediatric Pain Profile

30. FLACC Behavioural Scale

31. Facial Expression of Physical Distress NASO- LABIAL FOLD deepened

32. Behavioral Response Facial expression of pain.

33. Infant Crying in Pain • Cry of infant in pain is higher pitched, less melodious and more harsh • Only relevant in infants that vocalize cry • Neonates and infants with ‘silent crying’ are not taken into consideration (Wong et al, 2009)

34. Pain AssessmentSpecial circumstances • When children are Limited English proficient (LEP), pain assessments must be conducted in the language the child is most familiar (Boyd, Bee & Johnson, 2009; Dowden, S., & Bruce, E. 2009 Twycross, 2010). • Children with developmental or communication disabilities are often under assessed and under treated for pain (Kuttner, 2010).

35. Measurement of Pain Severity in Children with Developmental or Communication Disabilities • Children with neurological disorders such as cerebral palsy or autism may have difficulty expressing their pain in a way that others understand • In addition to communication barriers, these children often have multiple medical problems and often undergo multiple medical procedures (Stinson, 2009)

36. Assessment of Pain Severity in Children with Developmental or Communication Disabilities Behavioural cues: • facial expression, • moaning, • screaming, • sweating or flushing, • changes in posture and movement, • changes in sleep and eating, • changes in mood and sociability (Stinson, 2009)

37. Keep in mind… • Children in pain may regress to an earlier stage of development • A child’s experience of illness and hospitalization may change their perception of and ability to cope with pain (Kuttner, 2010)

38. A High Index of Suspicion • In summary, assessment of a child’s pain can be very challenging. Even with a multidimensional approach, there may be uncertainty about the presence and severity of pain, particularly in infants and young children. • When a child cannot or will not report pain, a high index of suspicion may be the most helpful assessment and a trial of analgesics is usually helpful for diagnosis (McCaffery, 1996)

39. Parental Presence and Pain • “The presences of a known and trusted adult makes the experience bearable for both children and adolescents in a myriad of obvious and subtle ways, and enables them to cope” (Kuttner, 2010, p. 75). • Both children and adolescents have reported that what has counted the most when having pain is having parents with them (Kuttner, 2010) • Teens may say they can handle it on their own but it is important to offer support until they are coping (Kuttner, 2010)

40. Pharmacological Principles • Prn (as need) versus scheduled analgesia • Pre-emptive analgesia (in advance of painful procedure) • Choice of analgesic, dose range and frequency • Route of choice: considerations • Proper dosing • Prevention and management of side effects

41. Analgesics • Acetaminophen –dosing, alternating, adjunctive • NSAIDS: Ibuprofen, Naprosyn, Ketorolac • Codeine concern • Meperidine (Demerol) not recommended • Morphine “gold standard” • Hydromorphone • Other: ketamine, methadone, fentanyl Twycross, A., Dowden, S., & Bruce, E. 2009

42. The Codeine Concern • No longer recommended in children • Weak opioid with ceiling effect • Metabolized and converted to Morphine in the body • Ineffective in approximately 30% (poor metabolizers) • Approximately 5% ultra rapid metabolizers –deaths have been reported • Consider NSAID, low dose Morphine Twycross, A., Dowden, S., & Bruce, E. 2009

43. The Dark Side of Demerol • Metobolite nor-meperidine accumulates in CNS and can cause neurotoxic effects (tremor, seizures, confusion, nervousness) • Can cause seizures in children after single dose • Rapidly accumulates • Subsequent doses less effective • Higher rates of side effects Twycross, A., Dowden, S., & Bruce, E. 2009

44. Morphine • Well known, well studied • Mimics body’s endogenous opioids “endorphins” • Most frequently used opioid in moderate to severe pain in pediatrics, but still underutilized • Standard by which other opioids are compared Twycross, A., Dowden, S., & Bruce, E. 2009

45. Ketamine • Anesthetic agent with analgesic effects • Uses: anesthesia, procedural sedation, analgesia • In creased use as low dose infusion increasing use in pediatric complex acute and cancer pain • Opioid sparing; useful with kidney/liver dysfunction • Can be used solely or as co-analgesia • Adverse effects: dysphoria , increased salivation and agitation at higher doses (Twycross, A., Dowden, S., & Bruce, E. 2009)

46. Adjuvant Analgesic Drugs • Antidepressants ex TCAs • Anticonvulsants: ex. gabapentin, • Clonidine, Dexmedetomidine • Topicals ex lidocaine, NSAID (Twycross, A., Dowden, S., & Bruce, E. 2009)

47. Definitions • Addiction –psychological dependence on drugs with drug seeking and drug using behaviour • Physical dependence –physiological response to dose reduction or abrupt discontinuation of a drug leading to withdrawal symptoms • Tolerance –decreased effectiveness of a drug over time • Pseudoaddiction-drug seeking behaviour due to untreated pain Twycross, A., Dowden, S., & Bruce, E. 2009

48. Guidelines for Opioid Tolerant Patients • Do not withhold opioids • Maintain patient opioid regime as baseline • Opioid requirements are higher for acute pain • Often have less opioid side effects • Adjuvant medications may help • Assess and manage signs of withdrawal (Twycross & Dowden, 2009)

49. Placebos • Placebos administered without patient consent are considered unethical • 30 % population has placebo response • “Physical “pain and “psychological “ pain cannot be separated (Twycross, A., Dowden, S., & Bruce, E. 2009)

50. Non Pharmacologic Strategies • Parental Presence • Distraction • Relaxation • Guided imagery • TENS • Biofeedback • Heat/Cold • Self-hypnosis (Kuttner, 2010)