Pediatric Pain Management
Assessment & Interventions
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Introduction
Definition of pain: an unpleasant sensory
and emotional experience associated with
actual or potential tissue damage
Always subjective and is learned through
experiences R/T injury in early life
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Circumcision study
Can be assessed by verbal, behavioral and
physiological indicators
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Need to differentiate
“PAIN” from “DISTRESS”
Pain related to fear and anxiety
Often exhibited by children
Highly correlated with the degree of pain in
children
May reflect other emotional reactions
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Neonatal Pain Perception
Peripheral and central structures required for pain
reception and function in 1st & 2nd trimesters
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EEG patterns/ cortical evoked potentials
Cerebral glucose utilization
Newborn infants have well-developed H-P axis
Pain impulses in newborns conducted by
unmyelinated C-type fibers
Newborns lack descending inhibitory neuro
transmitters
RESULT: Infants cannot modulate their pain well.
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Developmental Reactions to Pain
Infants
Rely on caregivers to notice pain
 Give behavioral signs that they are hurting
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Change in activity—restlessness, clinging or whining,
 appetite
 Physiologic indicators—tachycardia, tachypnea,  BP
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Developmental Reactions to Pain
Toddlers
Have poor body boundaries
 Intrusive experiences, even if not painful, are
anxiety producing
 Often react intensely and physically resist
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Biting, kicking, hitting, running away
Help parents understand reactions and avoid
punishment
 Use play activities & distraction
 Use bandages but be aware of anxiety when
they
are
removed
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Developmental Reactions to Pain
Preschoolers (3-6 yrs)
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Need reassurance that pain is not a punishment
Magical thinking & egocentric
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Exaggerated ideas about illness that are worse than reality
Can lead to feelings of shame guilt, fear
May view illness as punishment for something
Resist during painful procedures: fear of mutilation and
bodily injury
Concrete thinkers; may misinterpret words
Allow to express feelings – provide play opportunities
Give simple explanations: short,simple, clear
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Developmental Reactions to Pain
Preschoolers (3-6 yrs) cont’d
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Praise for good behavior Cannot always indicate source
or location of pain
Believe in the magical nature of pain—allows for
effectiveness of some therapies e.g. kiss, bandaid. It
works because they believe in it.
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Developmental Reactions to Pain
School Age (6-12 years)
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Able to locate pain in terms of body parts
Main concern: body integrity; < concern for pain than
disability or death
Feel that injury is r/t guilt (so they deserve pain)
Want factual info & reasons for things
Adolescent (13-19 years)
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Afraid of looking like a baby
Often hesitant to express feelings of pain
Main concern: body image
Fear death as well
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Pediatric Pain Scales
http://www.med.umich.edu/yourchild/topics/pai
n.htm
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Excellent link with LOTS of great information on
pediatric pain management from the University of
Michigan.
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Neonatal Infant Pain Scale
NIPS used at BroMenn for infants
1-10 scale
 Pain score of > 6 is considered reflective of
pain
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Another resource that describes this scale
from Cincinnati Children’s Hospital
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Non-Pharmacological Pain
Management
Infants
 Tactile:
touching, stroking, patting,
swaddling
 Motion: rocking, bouncing
 Comfort: sucking/ pacifier, sucrose—
24% sucrose solution just before procedure
 Environment:
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quiet, soft music, low lights
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Non-Pharmacological Pain
Management
Toddlers & Preschoolers
Preparation: simple, sensory, developmentally
appropriate
 Caregiver presence
 Distraction: bubbles, glitter wands, books, rain
stick
 Praise: offered freely, for trying (not for
succeeding)
 Simple choices
 “One voice”—allows distraction without over
stimulating
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Non-Pharmacological Pain
Management
School Age
Preparation/ rehearsal—have “practice kits”
with real equipment to feel and get familiar
with procedure ahead of time.
 Distraction
 Relaxation techniques
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Non-Pharmacological Pain
Management
Adolescents
Preparation—allow adequate time
 Distraction
 Relaxation techniques
 Often need lots of reassurance and clarification
of the procedure.
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EMLA/LMX-4 Cream
Dosage:
0-3months: 1 gram maximum, 10 sq.cm
surface area, 1 hour duration.
 3-12 months, > 5 kg: 2 grams max, 20 sq. cm
surface area, 4 hour duration.
 1-6 years, > 10 kg: 10 grams max., 100 sq.cm.
Surface area, 4 hour duration.
 7-12 years, >20 kg: 20 grams max., 200 sq. cm.
Surface area, 4 hour duration.
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EMLA/LMX-4 Cream--techniques
Individuals with darker pigmented skin or who are
dehydrated may require longer application time.
Longer application required on thick skin
Removal of stratum corneum layer of skin may
facilitate absorption
Although maximum analgesia occurs after 1 hour,
shorter times partially effective
Application of warm compresses will lessen
blanching and bring the veins back to visibility.
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Pediatric Doses for
Acetominophen and Ibuprofen
Accepted doses for Acetominophen
10-mg/kg/dose is considered in neonates
15-mg/kg/dose is WNL in older children
 If child weighs 12 lbs, how much would you
tell mom to give per dose?
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Accepted doses for Ibuprofen
10-mg/kg/dose is considered WNL. Some
pediatricians insist the child must be able to eat
or drink to avoid irritation to the stomach.
 If child weighs 22 lbs, how much would you
tell mom to give per dose?
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How Acetaminophen is packaged
Infant Drops= 100mg/ml NO LONGER
AVAILABLE
Elixir= 160mg/5ml most common
Tylenol Chewables= 80mg/tab
Tylenol Junior Strength Chewable or
Gelcap= 160mg/tab
Give Acetaminophen every 3-4 hours prn.
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How Ibuprofen is packaged
Pediatric Drops= 100mg/2.5ml
Children’s Suspension= 100mg/5ml
Children’s Chewables= 100mg/tablet
Give Ibuprofen every 6-8 hours, not to
exceed 4 doses/day
Acetaminophen and Ibuprofen may be
safely given alternately to enhance
antipyretic effects of combined meds.
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A final thought
Use a balanced approach to
pain management
Incorporate nonpharmacologic and
pharmacologic therapy
Try multiple analgesics which work by different
mechanisms.
Use developmentally appropriate communication
& methods for providing comfort
Be aware of signs of pain at different ages
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