Pain Management in Children An Integrative Approach

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Pain Management in ChildrenAn Integrative
Approach

• Susie Gerik, MD
• Childrens Center for Restorative Care
• UTMB Childrens Hospital

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Definition of Pain

• As defined by the International Association for
  the Study of Pain (IASP), pain is "an unpleasant
  sensory and emotional experience associated with
  actual or potential damage, or described in terms
  of such damage."

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Categories of Pain

• associated with a disease state (eg, arthritis,
  sickle-cell disease)
• associated with an observable physical injury or
  trauma (eg, burns, fractures)
• not associated with a well-defined or specific
  disease state or physical injury (eg, tension
  headaches, recurrent abdominal pain)
• associated with medical and dental procedures
  (eg, circumcisions, injections).

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Physiology of Pain

• Nocioception is a physiologic mechanism of
  noxious stimulus transduction
• Requires a nocioceptor
• Not necessarily the same as pain
• Biologic role is protective

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Nocioceptors

• Nocioceptors are free nerve endings
• Ubiquitous distribution
• Chemically activated in response to tissue damage
• Inotropic/matabotropic

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Nocioceptors

• Nocioceptors can be sensitized
• Primary hyperalgesia
• Secondary hyperalgesia

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Nocioceptors

• Free nerve endings
• High threshold
• Slow pain
• C fibers, unmyelinated, slow burning aching pain,
  Substance P
• Fast pain
• A delta fibers, myelinated, sharp prickly pain,
  glutaminergic

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Nocioceptors

• A delta fibers project to projection neurons in
  laminas I and V
• C fibers project to projection neurons in lamina
  II
• Both also project to inhibitory and excitatory
  interneurons

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Dorsal Horn Synapses

• Neurotransmitters
• Glutamate
• Substance P
• CGRP
• CCK
• Opiates

• Receptors
• NMDA
• Neurokinin-1
• ?
• ?
• Endorphin (mu, kappa, sigma)

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Modulation of Pain Information

• Gate Control Theory
• Nocioception arises from activation of
  nocioceptors
• Pain sensation is a product of several
  interacting neural systems
• Afferent transmission relies on a balance in the
  activity of both the pain fibers and large
  proprioceptive/mechanosensory fibers
• Inhibitory interneurons are spontaneously active
  and inhibit projection neurons

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Supraspinal Pain Modulation

• Pain transmission can also be modulated by
  descending pathways
• The analgesia system

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Analgesia System

• Periaqueductal gray and periventricular areas
  (enkephalin)
• Raphae magnus nucleus (serotonin)
• Dorsal horn interneurons (enkephalin)
• A and C fiber Inhibition (pre- and post-synaptic)

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Advances, but.

• Misconception that neonates, infants, and
  children do not feel or react to pain in the same
  way as adults.
• Fears of opioid addiction and adverse effects
• RESULT ineffective pain treatment for most
  pediatric patients

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Postsurgical Stress Response

• Metabolic, hormonal, and hemodynamic response to
  major injury or surgery
• Neuroendocrine cascade with release of
  catecholamines, adrenocortical hormones,
  glucagon, and other catabolic hormones

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Postsurgical Stress Response

• Results in increased oxygen consumption,
  increased carbon dioxide production,
  hyperglycemia, and generalized catabolic state
  with negative nitrogen balance
• Occurs even in preterm infants and the magnitude
  of the response correlates with mortality

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• An inquiring, analytical mind an unquenchable
  thirst for new knowledge and a heartfelt
  compassion for the ailing - these are prominent
  traits among the committed clinicians who have
  preserved the passion for medicine.
• Lois DeBakey, Ph.D.

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Principles

• Children often cannot or will not report pain to
  their health care providers
• Routine assessment increases the health care
  professionals knowledge of the child which, in
  turn, optimizes the assessment of pain and its
  subsequent management

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Principles

• Unrelieved pain has negative physical and
  psychological consequences
• Prevention is better than treatment
• Successful assessment and control of pain depends
  partly on a positive relationship between the
  health care professionals and the children and
  their families.

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Principles

• Techniques are now available that make pain
  reduction to acceptable levels a realistic goal
  in the majority of circumstances

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Factors that Modify Pain Perceptions

• Age
• Cognition
• Gender
• Previous pain experience
• Temperament
• Cultural and family factors
• Situational factors

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Personalizing the Approach

• Tailor assessment strategies to the childs
  developmental level and personality style and to
  the situation
• Obtain a pain history from the child and/or the
  parents.
• Learn what word that child uses for pain (hurt,
  boo-boo, owie)

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Personalizing the Approach

• Elicit from the family culturally determined
  beliefs about pain and medical care
• Measure the childs pain using self-report and/or
  behavioral observation tools.

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Infants

• There is not easy or scientific way to tell how
  much pain an infant is having
• Not crying
• Moaning or quietly crying
• Gently crying or whimpering
• Stop crying when picked up and comforted
• Not stop crying when picked up and comforted

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Toddlers

• May become very quiet and inactive while in pain
  or may become very active
• May use only one word (owie, booboo)
• Parents report that they arent acting like they
  normally do

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Behavioral Observations

• Use behavioral observation with preverbal and
  nonverbal children
• Vocalizations
• Verbalizations
• Facial expressions
• Motor responses
• Body posture
• Activity
• Appearance

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Peds pain scales...
No particular expression or smile 0
Occasional grimace or frown, withdrawn, disinterested 1
Frequent to constant quivering chin, clenched jaw 2
F
FACE
Normal position or relaxed 0
Uneasy, restless, tense 1
Kicking or legs drawn up 2
L
LEGS
Lying quietly, normal position, moves easily 0
Squirming, shifting back and forth, tense 1
Arched, rigid or jerking 2
A
ACTIVITY
No cry, (awake or asleep) 0
Moans or whimpers occasional complaint 1
Crying steadily, screams or sobs. Difficult to console. 2
CRY
C
Content, relaxed 0
Reassured by occasional touching, hugging or being talked to. 1
Difficult to console or comfort 2
C
CONSOLE
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Behavioral Observations

• Interpret behaviors cautiously
• Use parents report of pain when the child is
  unwilling or unable to give a self-report
• Use physiologic measures (eg. Heart rate and
  blood pressure) only as adjuncts to self-report
  and behavioral observation (neither sensitive nor
  specific as indicators of pain)

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School-age and Older

• Can often tell you more about pain using units of
  measure (0 is no pain and 5 is bad pain)
• Can color on body outlines where they hurt and
  show parents and health care providers where they
  hurt

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Pain Assessment Tools

• Poker chip
• Word-graphic rating scale

                                              
                    
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Adolescents

• Can explain pain more clearly because they
  understand words and concepts that younger
  children dont
• They can use specific words to describe the
  character of the pain

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Self-report Tools

• Appropriate for most children 4 years and older
• Children over 8 years who understand the concept
  of order or number can use a numerical rating
  scale or a horizontal word-graphic rating scale

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Pain Diary
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Benefit of the Doubt

• If there is any reason to suspect pain, a
  diagnostic trial of analgesics is often
  appropriate

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• Our profession, after all, deals partly with
  guess work we do not deal in absolutes.
• Paul Beeson, M.D.

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Procedure-related Pain

• Provide adequate preparation of the child and
  family
• Be attentive to environmental comfort (If
  possible, do not perform the procedure in the
  patients room)
• Allow parents to be with the child

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Procedure-related Pain

• Combine pharmacologic and nonpharmacologic
  options when possible and appropriate

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Pharmacologic

• Analgesics and/or local anesthetics
• Systemic analgesics
• Anxiolytics or sedatives
• Barbiturates and benzodiazepines produce
  anxiolysis and sedation but not analgesia

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NSAIDs

• Significant opioid dose-sparing effects
• Must be used with care in patients with
  thrombocytopenia or coagulopathies

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Acetaminophen

• Acetaminophens mechanism of action involves
  inhibition of central cyclo-oxygenase
• Additional mechanisms of action have also been
  suggested for acetaminophen, including inhibition
  of nitric oxide formation that results from
  activation of substance P and N-methyl-D-aspartate
  (NMDA) receptor stimulation.

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Acetaminophen

• Available in various formulations, including
  drops, liquid, tablets, caplets,
  sustained-release tablets and suppositories.
• When dosing acetaminophen for pediatric use,
  consider its concentration in other medications
  that the patient may be taking, including weak
  opioids and over-the-counter flu, sinus or
  allergy medications

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Opioids

• Cornerstone of management of moderate to severe
  acute pain
• Tolerance and physiologic dependence are unusual
  in short-term postoperative opiate-naïve patients
• Psychologic dependence and addiction are
  extremely unlikely to develop after the use of
  opioids for acute pain

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Opioids and Dependence

• There is no known aspect of childhood development
  or physiology that indicates any increased risk
  of physiologic or psychologic dependence from the
  brief use of opioids for acute pain management

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Morphine

• Morphine is the standard for opioid therapy
• If morphine cannot be used because of an unusual
  reaction or allergy, another opioid such as
  hydromorphone can be substituted

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Meperidine

• Should be reserved for very brief courses in
  patients
• Contraindicated in patients with impaired renal
  function or those receiving antidepressants of
  the monoamine oxidase inhibitor class

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Meperidine

• Normeperidine is a toxic metabolite of meperidine
  and is excreted through the kidney
• Normeperidine is a cerebral irritant
  accumulation can cause effects ranging from
  dysphoria and irritable mood to seizures in
  otherwise healthy people

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Dosing Opioids

• Titrate the opioid dose and interval to increase
  the amount of analgesia and reduce the side
  effects when necessary
• Children vary greatly in their analgesic dose
  requirements and responses to opioid analgesics,
  and the recommended starting doses may be
  inadequate

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Dosing Opioids

• Use relative potency estimates to select the
  appropriate starting dose, to change the route of
  administration, or to change from one opioid to
  another
• Provide opiates around the clock or by continuous
  infusion rather than as needed

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Dosing Opioids

• Offer rescue doses for breakthrough or poorly
  controlled pain
• Use patient-controlled analgesia for
  developmentally normal children 7 years and older

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Administration of Opioids

• Administer opioids through intravenous catheter
  or orally
• Use intramuscular injections only under
  exceptional circumstances

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Alternative Routes of Administration

• Regional anesthesia

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Neonates and Infants

• Particularly susceptible to apnea and respiratory
  depression
• Appears to be dose-related
• However, neonates and infants DO experience pain,
  and adequate analgesia is ESSENTIAL

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Pain Assessments - Pharmacologic

• What are the childs and parents previous
  experience with pain?
• Is the child being adequately assessed?
• Are analgesics ordered for the prevention or
  treatment of pain?
• Is the analgesic dosage appropriate for the pain
  being experienced or expected?
• Is the timing of administration appropriate for
  the pain being experienced or expected?

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Pain Assessments - Pharmacologic

• Is the route of administration appropriate for
  the child?
• Is the child adequately monitored for the
  occurrence of side effects?
• Are the side effects appropriately managed?
• Has the analgesic regimen provided adequate
  comfort from the childs or parents perspective?

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Nonpharmacologic

• Sensorimotor strategies for infants
• Cognitive/behavioral strategies for older
  children
• Child participation strategies
• Physical strategies

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Distraction

• Blowing bubbles
• Playing with pop-up toys
• Looking through a kaleidoscope
• Imagining a superhero

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Suggestion

• Magic glove technique
• Basic principles
• Willingness to be involved
• Trust in the coach
• Ability to participate

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Breathing Techniques

• Rhythmic, deep-chest breathing
• Patterned, shallow breathing

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Guided Imagery

• A form of relaxed, focused concentration
• Favorite place, favorite activity
• Not only produce distraction, but also enhance
  relaxation

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Progressive Muscle Relaxation

• Recognize and reduce body tension associated with
  pain
• Decrease anxiety and discomfort

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Biofeedback

• Uses instruments to detect and amplify specific
  physical states in the body and help bring them
  under ones voluntary control
• Mechanism of pain relief is based on specific
  physiologic changes caused by the biofeedback

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Hypnosis

• Altered state of consciousness is used
• Concentration is focused, narrowed, absorbed

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Transcutaneous Electric Nerve Stimulation

• Involves stimulation pulses produced by a battery
  operated unit delivered to skin electrodes
  surrounding the area where the pain is occurring

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Acupuncture

• Based on a theory that energy (Chi) flows through
  the body along channels (meridians) which are
  connected by acupuncture points
• Pain results when flow of energy is obstructed
• Acupuncture restores that flow and eliminates or
  reduces pain

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Headache

• Duckro and Cantwell-Simmons Headache 1989
• Biofeedback and Relaxation in the Management of
  Pediatric Headache
• Summary and interpretation of controlled studies
  supports behavioral approach as a potent
  alternative

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Headache

• Holden, Deichmann, and Levy Journal of Pediatric
  Psychology 1999
• Review of research on behavioral treatments for
  recurrent headaches
• Relaxation and self-hypnosis is a
  well-established and efficacious treatment for
  recurrent headaches

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Vaccine-related Pain

• Jacobson et al Vaccine 2001
• Attitude, empathy, instruction
• Distraction, hypnosis
• Sugar nipples
• Topical anesthetics (EMLA)
• 56 references

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Fracture Reduction

• Iserson Journal of Emergency Medicine 1998
• Hypnosis used to diminish pain and anxiety in
  patients with angulated forearm fractures (no
  other form of sedation or analgesia available)

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Postoperative Pain

• Polkki et al Journal of Advanced Nursing 2001
• Emotional support, helping with activities,
  creating a comfortable environment used routinely
• Other nonpharmacologic measures used less
  frequently
• Related to background of the nurses

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Recurrent Abdominal Pain

• Gevirtz Journal of Pediatric Gastroenterology
  and Nutrition 2000
• Fiber, Fiber-biofeedback, Fiber-biofeedback-cognit
  ive/behavioral intervention, Fiber-biofeedback-cog
  nitive/behavioral intervention-parental support
• All groups showed improvement, but treatment
  group showed more improvement

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Rheumatic Illnesses

• Field et al Journal of Pediatric Psychology 1997
• Massage helpful for JRA marked decrease in
  subjective pain, observed pain, and tender
  trigger points

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Pain Assessments -Nonpharmacologic

• What are the childs and parents experiences
  with and preference for the use of the strategy?
• Is the strategy appropriate for the childs
  developmental level, condition, and type of pain?
• Is the timing of the strategy sufficient to
  optimize its effects?
• Is the strategy effective in preventing or
  alleviating the childs pain?

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Pain Assessments Nonpharmacologic

• Are the child and parent satisfied with the
  strategy for prevention or relief of pain?
• Are the treatable sources of emotional distress
  for the child being addressed?

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AAP Recommendations

• Expand knowledge about pediatric pain
• Provide a calm environment for procedures
• Use appropriate pain assessment tools and
  techniques
• Anticipate predictable painful experiences,
  intervene, and monitor

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AAP Recommendations

• Use a multimodal approach to pain management
• Involve families, tailor interventions to
  individual child
• Advocate for child-specific research in pain
  management
• Advocate for effective use of pain medication in
  children to ensure compassionate, competent
  management of their pain

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Therapeutic Alliance

• Pain is managed within a therapeutic alliance
  among the child, his or her parent, nurses,
  physicians, and other health care professionals

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