Pain Management in Children
An Integrative Approach
Susie Gerik, MD
Children’s Center for Restorative Care
UTMB Children’s Hospital
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."
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).
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
Nocioceptors
Nocioceptors are free nerve endings
Ubiquitous distribution
Chemically activated in response to
tissue damage
Inotropic/matabotropic
Nocioceptors
Nocioceptors can be sensitized
Primary hyperalgesia
Secondary hyperalgesia
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
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
Dorsal Horn Synapses
Neurotransmitters
Glutamate
Substance P
CGRP
CCK
Opiates
Receptors
NMDA
Neurokinin-1
?
?
Endorphin (mu,
kappa, sigma)
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
Supraspinal Pain Modulation
Pain transmission can also be
modulated by descending pathways
The “analgesia” system
Analgesia System
Periaqueductal gray and periventricular
areas (enkephalin)
Raphae magnus nucleus (serotonin)
Dorsal horn interneurons (enkephalin)
A and C fiber Inhibition (pre- and postsynaptic)
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
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
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
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.
Principles
Children often cannot or will not report
pain to their health care providers
Routine assessment increases the
health care professional’s knowledge of
the child which, in turn, optimizes the
assessment of pain and its subsequent
management
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.
Principles
Techniques are now available that make
pain reduction to acceptable levels a
realistic goal in the majority of
circumstances
Factors that Modify Pain
Perceptions
Age
Cognition
Gender
Previous pain experience
Temperament
Cultural and family factors
Situational factors
Personalizing the Approach
Tailor assessment strategies to the
child’s 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)
Personalizing the Approach
Elicit from the family culturally
determined beliefs about pain and
medical care
Measure the child’s pain using selfreport and/or behavioral observation
tools.
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
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 aren’t acting
like they normally do”
Behavioral Observations
Use behavioral observation with preverbal
and nonverbal children
Vocalizations
Verbalizations
Facial expressions
Motor responses
Body posture
Activity
Appearance
FACE
LEGS
ACTIVITY
CRY
CONSOLE
No particular expression or smile
0
Occasional grimace or frown, withdrawn,
disinterested
1
Frequent to constant quivering chin, clenched jaw
Normal position or relaxed
2
0
Uneasy, restless, tense
1
Kicking or legs drawn up
2
Lying quietly, normal position, moves easily
0
Squirming, shifting back and forth, tense
1
Arched, rigid or jerking
2
No cry, (awake or asleep)
0
Moans or whimpers; occasional complaint
1
Crying steadily, screams or sobs. Difficult to console.
2
Content, relaxed
0
Reassured by occasional touching, hugging or being
talked to.
1
Difficult to console or comfort
2
F
L
A
C
C
Behavioral Observations
Interpret behaviors cautiously
Use parent’s 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 selfreport and behavioral observation (neither
sensitive nor specific as indicators of pain)
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
Pain Assessment Tools
Poker chip
Word-graphic
rating
scale
:
Adolescents
Can explain pain more clearly because
they understand words and concepts
that younger children don’t
They can use specific words to
describe the character of the pain
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
Pain Diary
Benefit of the Doubt
If there is any reason to suspect pain, a
diagnostic trial of analgesics is often
appropriate
Our profession, after all, deals partly
with guess work; we do not deal in
absolutes.
Paul Beeson, M.D.
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 patient’s room)
Allow parents to be with the child
Procedure-related Pain
Combine pharmacologic and
nonpharmacologic options when
possible and appropriate
Pharmacologic
Analgesics and/or local anesthetics
Systemic analgesics
Anxiolytics or sedatives
Barbiturates and benzodiazepines produce
anxiolysis and sedation but not analgesia
NSAIDs
Significant opioid dose-sparing effects
Must be used with care in patients with
thrombocytopenia or coagulopathies
Acetaminophen
Acetaminophen’s 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-methylD-aspartate (NMDA) receptor stimulation.
Acetaminophen
Available in various formulations, including
drops, liquid, tablets, caplets, sustainedrelease 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
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
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
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
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
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
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
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
Dosing Opioids
Offer rescue doses for breakthrough or
poorly controlled pain
Use patient-controlled analgesia for
developmentally normal children 7
years and older
Administration of Opioids
Administer opioids through intravenous
catheter or orally
Use intramuscular injections only under
exceptional circumstances
Alternative Routes of
Administration
Regional anesthesia
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
Pain Assessments Pharmacologic
What are the child’s 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?
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 child’s or parent’s
perspective?
Nonpharmacologic
Sensorimotor strategies for infants
Cognitive/behavioral strategies for older
children
Child participation strategies
Physical strategies
Distraction
Blowing bubbles
Playing with pop-up toys
Looking through a kaleidoscope
Imagining a superhero
Suggestion
“Magic glove” technique
Basic principles
Willingness to be involved
Trust in the coach
Ability to participate
Breathing Techniques
Rhythmic, deep-chest breathing
Patterned, shallow breathing
Guided Imagery
A form of relaxed, focused
concentration
Favorite place, favorite activity
Not only produce distraction, but also
enhance relaxation
Progressive Muscle Relaxation
Recognize and reduce body tension
associated with pain
Decrease anxiety and discomfort
Biofeedback
Uses instruments to detect and amplify
specific physical states in the body and
help bring them under one’s voluntary
control
Mechanism of pain relief is based on
specific physiologic changes caused by
the biofeedback
Hypnosis
Altered state of consciousness is used
Concentration is focused, narrowed,
absorbed
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
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
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
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 wellestablished and efficacious treatment
for recurrent headaches
Vaccine-related Pain
Jacobson et al Vaccine 2001
Attitude, empathy, instruction
Distraction, hypnosis
Sugar nipples
Topical anesthetics (EMLA)
56 references
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)
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
Recurrent Abdominal Pain
Gevirtz Journal of Pediatric Gastroenterology
and Nutrition 2000
Fiber, Fiber-biofeedback, Fiber-biofeedbackcognitive/behavioral intervention, Fiberbiofeedback-cognitive/behavioral interventionparental support
All groups showed improvement, but
treatment group showed more improvement
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
Pain Assessments Nonpharmacologic
What are the child’s and parent’s experiences
with and preference for the use of the
strategy?
Is the strategy appropriate for the child’s
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 child’s pain?
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?
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
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
Therapeutic Alliance
Pain is managed within a therapeutic
alliance among the child, his or her
parent, nurses, physicians, and other
health care professionals