Pediatric Pain Management: Issues & trends
Sherry Nolan, RN,MSN
2009
Historical Perspective
Misconceptions about pain in children
Taxonomy
Case Study
4 Components of the Pain Experience
Myth: CNS is Immature in kids
so they don’t feel pain as much
 Fact: All structures
are in place for the
transmission of pain
by the 30th week of
gestation.
 Fact: substance P
(neurotransmitter for
pain) -16 wks; cutaneous
sensory receptors - 20
wks; synaptic connections
-24 wks; nociceptive
nerve tracts completely
myelinated-30 wks
Taxonomy
 Nociception
 Plasticity
 Expansion of
Receptive field size
 Gate Control Theory
 Sleeping nociceptors
 Addiction
 Sensitization
 Physical Dependence
 Chronic pain
 Acute pain
Nociception
“the activity produced in the nervous
system by potentially tissue-damaging
stimuli”
OR
* “the activation of nerve axons by thermal,
chemical or mechanical energy sufficient
to threaten the integrity of the cell”
Plasticity
 Different responses to the same stimulus,
presumably as a result of different environmental
& psychological factors that can moderate the
signals initiated by noxious stimuli & thereby
change the individual’s perception & experience
of pain
 The younger the organism, the greater the
plasticity!
Gate Control Theory
 Ascending &
descending painsuppressing or pain-
enhancing systems are
activated by
situational factors
Active children cannot be in pain
“Play is the
work of
children”
It is unsafe to administer opioids to children
as they become addicted
Physical Dependence
 A physiological state in which
the body develops a need for
the opioid drug in order to
maintain equilibrium.
Manifested by a drug-specific
withdrawal syndrome that can
be produced by abrupt
cessation, rapid dose reduction,
decreasing blood level of the
drug, &/or administration of an
antagonist. Does NOT =
addiction.
Addiction
 Refers to overwhelming
preoccupation with
obtaining and using a
drug for its’ psychic
effects, not for pain relief
 Include one or more of
the following:impaired
control over drug use,
compulsive use,
continued use despite
harm, and craving (4 Cs)
EQUIANALGESIA
Refers to the fact that, when substituting one
drug for another, use an equianalgesic
chart so that the pain-relieving effects of
the new drug will deliver the same
response.
Overwhelmingness of the Pain Experience
 Physiological
disequilibrium
 Behavioral
disorganization
 Long term
consequences of
under-treated pain
 Overall stress
response
Children will always tell if they have pain
Narcotics Always depress respirations in kids
Pain is a potent respiratory stimulant
Respiratory tolerance escalates along with
the need for medication
Sedation level check very important
The best way to administer analgesia is by
injection-not!
 IV bolus gives a
predictable peak
action & duration of
action.
 IVCD provides a
steady blood level
without peaks &
valleys with their
accompanying SEs.
Infants & children don’t remember pain
 Remembered pain &
currently experienced
pain are different
 Infant with heel stick
 Aversion/anticipatory
vomiting
Children can’t tell you where they have pain
 Good assessment
skills are the
cornerstone of
adequate pain
management
4 components of pain
Nociception
Pain
Suffering
Pain behaviors
Pain behaviors
suffering
pain
nociception
nociception
Definition of pain
“Pain is whatever the experiencing person
says it is, existing wherever and whenever
he or she says it does.” (McCaffery)
Chronic Pain: Pain that has outlived it’s
usefulness
Acute Pain: An adaptive, beneficial
response necessary for the preservation of
tissue integrity
Topicals
 ANE-cream (noscream
Cream)/proper
application
 Pain-Ease
 New trials coming
up, new products;
zingo, synera,etc
 Sweet-ease-new P&P
TJC standards
 Recognize the right of
 Record results of
pts. to appropriate
assessment &
management of pain.
 Screen for existence,
nature & intensity of pain.
 Make pain management a
priority
 Perform a comprehensive
pain assessment; if pain is
present, include location,
quality, onset, frequency
& intensity
assessment in a way that
facilitates regular reassessment & follow-up.
 Determine & ensure staff
competency in pain
assessment & management. Address
competency in orientation
& continuing education.
 Establish P&Ps that
support attentive &
aggressive pain
management
TJC standards (cont’d)
 Educate pts & families
about importance of
effective pain
management.
 Promise pts. effective
pain relief upon
admission.
 Remember, while TJC
accredits health care
organizations, it is
individual healthcare
providers who manage
pain.
 Address pt needs for
symptom
management in
discharge planning.
 Include pt. outcomes
in measuring
effectiveness of pain
assessment &
management.
Ethical Considerations
As nurses we are bound morally and
legally to act as patient advocates.
Thus, not to do good
(beneficence=relieving pain), avoid
harmful conditions (non-maleficience), or
include pts in their own plan of care
(respect for autonomy) is clearly
unethical behavior.
placebos
Don’t order, don’t give
Steps to take
 Believe the patient!!!
 Preventive approach is
best.Rethink the meaning
of prn>ATC
 Treat anxiety & teach
colleagues;empower &
teach parents & pts about
pain & rx
 Involve pts/parents in the
plan of care; initiate
standardized MPC if pt.
c/o pain
 Use equianalgesia charts
 Use a combination of
strategies,
pharmacological & nonpharmacological.
 Don’t forget palliative
care team!
 Make a commitment to be
aware of current trends in
assessment & treatment
of pain in children.
 Make pain management a
priority.
You be the one to say:
The pain
Stops here!!!!!!!!!