Pain in the Pediatric Population

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Pain in the Pediatric Population
Bob Bash, MD Assoc. Prof. Ped.
Hematology-Oncology U.T. Southwestern Medical
Center, Director,
Pediatric Palliative Care Program Childrens
Medical Center of Dallas
Interdisciplinary Approaches to Pain Management
across the Lifespan, U.T. Tyler Office of Nursing
Research and Scholarship April 17, 2009
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Objectives

• 1. Review differences in interactions with
  pediatric and adult patients.
• 2. Discuss tools to elicit causes of pain in
  pediatric patients
• 3. Differentiate between pain and suffering, and
  offer appropriate medical and psychosocial
  interventions.

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Physical
Psychological
PAIN
Spiritual
Emotional
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Perspective
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Perspective
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Perspective
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Familys Perspective

• Is pain accurately accessed?
• What may be alternative sources of pain?
• What does it say about me as a parent?
• a. Did I miss something?
• b. Am I the cause of my child suffering?
• What are the side effects of treatment?
• Is addiction a concern?

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Medical Team Perspective

• What is the cause of the pain?
• Can I assess across disciplines?
• How do I approach the child?
• How do I handle the parent(s)?
• Did I cause the childs pain/suffering?
• Am I creating a little addict?

Note Consider extra observer in room
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Childs Perspective

• Who are these scary people?
• Im already hurtingnow whats going to happen?
• Can the pain really go away?
• Am I a bad kid and deserve to hurt?
• Am I a disappointment because Im not tough
  enough?

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Establish most effective pathway to the child.
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Pain Management

• Differentiate pain from suffering
• Establish mutual goals of therapy
• Include childs / familys cultural, religious,
  and medical
• interpretation of pain in decision-making
  process
• effective intervention typically requires
  interdisciplinary
• team approach

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Pain Management
Myths

• Infants and young children do not feel pain
• Children are unable to tell you when they hurt
• Children become accustomed to pain
• Childrens behavior reflects their level of pain

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Develop Trust from child

• Listen first
• Establish trust from Parent
• Body Positions
• Initially indirect contact
• Give choices/grant control

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Types of Listening

• Competitive (Combative) Listening
• more interested in promoting our own point of
  view than in understanding or exploring someone
  elses view.
• listen for openings to take the floor, or for
  flaws or weak points we can attack.
• pretend to pay attention, however, impatiently
  waiting for an opening,
• internally formulating our rebuttal

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Types of Listening

• Passive or Attentive Listening
• genuine interest in hearing and understanding the
  other persons point of view.
• Attentive, but passive listening.
• assume that we heard and understand correctly,
  but stay passive and do not verify it

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Types of Listening

• Active or Reflective Listening
• single most useful and important listening skill.
  
• genuine interest in understanding what the other
  person is thinking, feeling, wanting
• restate or paraphrase our understanding of their
  message and reflect it back to the sender for
  verification.
• formulate own message and deliver

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Listening

• Preparation
• Determine participants
• Parent/family
• Medical team
• Determine setting
• Free of distractions
• Equalize power
• Determine state-of-mind
• Set time with family
• Clear mind / focus

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Develop Trust from child

• Listen first
• Establish trust from Parent
• Body Positions
• Initially indirect contact
• Give choices/grant control

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Pain Management
Non-pharmacologic interventions

• biofeedback, relaxation exercises
• music therapy
• parental presence (storytelling, massage)
• heat / cold
• exercise active and passive
• transcutaneous electrical nerve stimulation
  (TENS)
• acupuncture

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Treatment of PainWHO Pain Relief Ladder
NO PAIN
Opioid for mild to moderate pain /-
Non-opioid /- Adjuvant
Pain persisting or increasing
Pain persisting or increasing
Nonopioid /- Adjuvant
http//www.who.int/cancer/palliative/painladder/en
/
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Mild / Moderate pain Drug Therapy
Acetaminophen 10-15 mg/kg
every 4 hours Ibuprofen 10 mg every 4 - 8
hours Codeine 0.5 1 mg/kg every 4
hours Acetaminophen/Codeine 0.5 1 mg/kg every
4 hours Oxycodone 0.2 mg/kg every 4
hours Hydrocodone/acetaminophen 0.2 mg/kg every
4 hours Oxycodone/acetaminophen 0.2 mg/kg every
4 hours
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Severe Pain Drug Therapy
Morphine oral 0.3 0.6 mg/kg every 12 hours for
sustained release 0.2 0.5 mg/kg
every 2 4 hours for instant
release i.v. 0.1 mg/kg/dose Conversion
10 mg i.v. 30 60 mg p.o. No ceiling
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Severe Pain Drug Therapy
Hydromorphone oral 0.03 0.08 mg/kg every
4 - 6 hours available p.o., i.v., or
p.r. Conversion 1 mg i.v. 5 mg
p.o. Methadone oral 0.1 0.2 mg/kg every 412
hours available p.o., or i.v. Conversion
1 mg i.v. 2 mg p.o.
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Pain Management
Opiates (Truisms)

• Opioid administration titrated against pain
  does not
• hasten death. Bash Rule dont stop
  breathing unless you go
• to sleep first.
• The dose can be increased as needed without a
  fixed
• ceiling without loss of effectiveness.
• Pain does not have to be experienced to be
  relieved most
• effective therapy is around the clock
  administration.
• Side effects most often can be managed without
  stopping.
• Addiction is rarely a concern.

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Patient Controlled Analgesia (PCA)
Variations Patient controlled (PCA) Parent
Controlled (PCA by proxy)
B
PCA dose
A
PCA interval
Continuous dose
C
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Pain Management

• Keep the approach to pain management simple and
  
• consistent (p.o. preferred, alternative
  p.r., transdermal, i.v.)
• Start with one drug avoid multiple medication
  shifts
• Progress in step-wise fashion, moving on when
  side effects of
• the drug limit the effectiveness.
• Long-term memories of pediatric cancer
  survivors is often
• focused on lack of adequate pain control

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Opioid treatment-related side effects

• Sedation / Somnolence
• Histamine release
• Nausea / vomiting
• Constipation
• Pruritis
• Myoclonus

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Treatment of Pain (in children?) WHO Pain Relief
Ladder
NO PAIN
Opioid for mild to moderate pain /-
Non-opioid /- Adjuvant
intravenous
Pain persisting or increasing
Pain persisting or increasing
oral
Nonopioid /- Adjuvant
http//www.who.int/cancer/palliative/painladder/en
/
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Suffering management

• Existential Pain
• personal mortality / loss of control
• meaning of life
• meaning of own life
• disruption of natural order

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Suffering management

• Related to emotional and cultural aspects
• Important to have inter-disciplinary approach
• Often techniques that augment pain control are
  effective guided imagery, hypnosis, meditation,
  distraction, relaxation training
• Use of non-verbal techniques of communication
• puppetry, play therapy, music, art, dance,
  movement

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Palliative Care Symptom Control
Wolfe J, et. al., Symptoms and suffering at the
end of life in children with cancer, NEJM
342(5)326-333, 2000

• Childrens Hospital and the Dana-Farber Cancer
  Institute, Boston
• Interview parents of children who had died of
  cancer between 1990-1997
• 107/165 eligible parents participated
• Interviews were conducted a mean of 3.1 1.6
  (SD) years after childs death

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Palliative Care Symptom Control
Wolfe J, et. al., NEJM 342(5)326-333, 2000
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Palliative Care Symptom Control
Wolfe J, et. al., NEJM 342(5)326-333, 2000
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Conclusions

• Pain can be adequately assessed in children.
• Pain in children is typically multifactoral.
• Pain control in children typically requires a
  inter-disciplinarily approach.
• Children are able to participate in choosing the
  appropriate therapies for their pain.
• Long term memories of parents, particularly of
  children who die, are focused on lack of pain
  control.