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17 Articles in Volume 20, Issue #3
20/20 with Dr. Suzanne Amato Nesbit: Clinical Pharmacy Roles and Disparities
A Clinician’s Guide to Treating Chronic Overuse Injuries
Adhesive Arachnoiditis: No Longer a Rare Disease
Analgesics of the Future: Cebranopadol as an Opioid Alternative
Ask the PharmD: What role do vitamin D supplements play in treating dysmenorrhea?
Behavioral Pain Medicine: Managing the Affective Components of Pain
Chronic Fatigue Syndrome: Naltrexone as an Alternative Treatment
Chronic Pain and Coronavirus
Connecting the Dots: How Adverse Childhood Experiences Predispose to Chronic Pain
Editorial: Why Are ER Opioids Out of Favor?
Fibromyalgia as a Neuropathic Pain Disorder: The Link to Small Fiber Neuropathy
How the COVID-19 Pandemic Is Transforming Pain Care
Hydroxychloroquine Use and Risk in the Management of Systemic Lupus Erythematosus
Management of Trigeminal Neuralgia in Multiple Sclerosis
Optimizing Care Using a Trauma-Informed Approach
Pediatric Pain Management: A Review of Clinical Diagnosis and Management
The Use of Low Dose Naltrexone in the Management of Chronic Pain

Pediatric Pain Management: A Review of Clinical Diagnosis and Management

Countering misconceptions and preconceived notions about pain in children will go a long way toward easing suffering and anxiety in this vulnerable population.
Pages 32-35

While there have been advances in pain research and pain management in the pediatric patient population, many infants and children continue to suffer due to inadequate identification and relief of their pain. To this day, the medical community continues to place a greater emphasis on pain management in adult and senior populations, leaving pediatric pain often misunderstood, under-diagnosed, and under-treated.

Many children experience unnecessary suffering due to poorly controlled pain, increasing their risk of chronic persistent pain in their adult lives. (Image: iStock)

Pediatric Pain Prevalence and Approach

There is a false consensus that children suffer less pain than adults.1 It has been documented that humans begin to feel pain early in intrauterine life.2 Unfortunately, if a child is not evaluated appropriately and frequently, healthcare workers may overlook his or her pain. Consequently, many children can experience unnecessary suffering due to poorly controlled pain, increasing their risk of chronic persistent pain in their adult lives (see “Connecting the Dots.”). Suboptimal analgesia can also result in medical phobias, delayed wound healing, and behavioral changes in children.3

The incidence of pain is common among infants and children, with an estimated 33% to 82% of hospitalized pediatric patients experiencing moderate to severe pain, especially following surgery.4 About 1.5 million children undergo surgery every year worldwide, and many receive inadequate pain relief, leading to chronic pain in about 20% of the patients.5 Statistics also fail to include unreported pain. There is a high susceptibility of under-reporting pediatric pain on the part of the patients and/or caregivers due to either atypical manifestations or fear of unnecessary medications and injections.6

Clinicians have taken great strides to advance the diagnosis and treatment of children with pain. Strategies include the improvement of various age-related scales and significant progress in understanding the physiology of specific pain pathways.7 Practitioners tend to use both pharmacologic and nonpharmacologic modalities to relieve acute and procedural pain in children.8 Chronic pain such as musculoskeletal pain, headaches, abdominal pain, and cancer pain is more complex in children, just as it is in adults, and requires a multimodal and multidisciplinary approach.9

This article provides an overview of pediatric pain management to date, and discusses ways in which the medical community has tried to address its inherent challenges.

Pain Assessment Scales for Children

Ranging from intrauterine life to early teens, the foundation of pediatric assessment is age-related communication, which can be challenging. Assessment of pain is strongly linked to the patient’s stage of development, with younger patients facing increased difficulty in identifying the problem area. Nearly 50% of patients with nontraumatic injury self-identify the wrong location. The age-related barrier can be complicated by additional factors such as cognition, sex, temperament, cultural background, and situational components that all impact varying perceptions of pain and tolerance.5

The ability to assess pain appropriately in children by using standardized pain scores has improved dramatically. Three widely used behavioral indicators of pain are:5

  • Global rating scale (GRS): observation of typical signs of distress such as crying, wincing, or shouting
  • Behavioral observation scales (BOS): documentable physiological markers of stress (eg, elevated heart rate)
  • Indirect measures: verbal requests made by patients to have more or less medication based on how they feel.

With these measures in place, it is important to note that every child reacts differently to pain. Predictable signs of distress may be absent due to the child’s adaptation to the pain. When this is the case, providers and parents should be on the lookout for atypical signs the child may be experiencing as a result of their pain, such as:5

  • decreased physical activity
  • changes in sleep or appetite
  • increase in nonverbal cues (ie, gasping, wincing)

Medical providers should consider all known factors before tailoring an assessment and treatment plan.

Staging the Pediatric Emergency Room

Physicians can begin to address pain and anxiety as soon as a child arrives at the hospital. The patient should be welcomed in an environment that is child-friendly and calming. The development of a pediatric ER has become more common in general hospitals allowing pediatric patients to be seen in a more appropriate atmosphere.1 Private spaces designed with brightly colored walls, animated pictures, and distractible elements such as toys and games can help the child become more relaxed and comfortable.4 Structural changes in each procedure room to include distractors such as imagery projectors and music speakers can make the foreign environment feel more safe and familiar. Staff education and protocol development can further provide relief of anxiety experienced by both the patient and family members.4

Specifically, training physicians, nurses, and support staff on effective techniques that promote emotional support for the patient and family is crucial. Some of these techniques include meditative practices like deep breathing, coping plans to prepare for potential complications in the ER, and relaying information to the patient and patient’s family about the ER environment and patient diagnosis.4

Neonatal Pain Management

Pain management in premature and neonatal patients has made enormous strides. Following surgery, the NICU is available to provide neonates the most advanced monitoring. Preterm patients are at a high risk of repeated exposure to painful stimuli, which has potential for deleterious consequences. Such risks include neurodevelopmental impairments, physiological instability, abnormal stress response, and altered brain development that can persist into childhood.10 Strategies used to address neonatal pain management include utilizing pain prevention programs to reduce the number of painful procedures performed.10

A comprehensive assessment of pharmacological and nonpharmacological therapies is routinely done prior to all major procedures and surgeries. Intubated mechanically ventilated patients are treated for pain with IV medications, which include morphine, nonsteroidal, and steroidal drugs that are given incrementally.10 Nonsteroidal medications often are used in the “weaning” process for narcotic reduction.10 Nonintubated patients continue receiving IV medication with intense monitoring.

Neonatal pain can be monitored by objective signs, including grimacing, twitching, changes in blood pressure, pulse, heart rate, and temperature. There continue to be major challenges, however, in assessing pain of premature, ill, and neurologically compromised patients due to their inability to report pain. Current pain assessment tools attempt to take advantage of both physiological and behavioral responses to pain to come up with the best course of action. Only five pain scales have been subject to rigorous testing and are widely approved by the medical community for the neonate population: Neonatal Facial Coding System, Premature Infant Pain Profile, Neonatal Pain and Sedation Scale, Behavioral Infant Pain Profile, and Douleur Aiguë du Nouveau-né.10

More research is needed to determine what scale can reliably be used for specific neonate populations. All in all, neonatal pain prevention and alleviation should be emphasized not only for ethical reasoning but also due to the short- and long-term adverse effects repeated pain can have on the child’s life.

Pharmacologic Management

Pediatric patients may be treated with medication on various fronts depending on the severity of pain. The primary determination of which analgesic drug to administer should always be preceded by a clinical assessment of the patient. It is necessary to weigh the risks and benefits for all analgesics on an individual basis.

Non-Opioids

Non-opioid analgesic medications such as ibuprofen, acetaminophen, naproxen, diclofenac, and ketorolac are available for the treatment of mild pain.8 To treat moderate to severe pain, these analgesics need to be combined with other agents.5 For instance, analgesics are often administered with muscle relaxants and anti-spasmodics. Many individuals with chronic pain also benefit from concomitant selective norepinephrine and serotonin reuptake inhibitors (SNRIs) and anti-seizure medications, such as gabapentin and pregabalin when appropriate.

Intravenous (IV) patient-controlled analgesia is an effective method to achieve optimal post-operative pain relief. Young patients often deny pain to avoid injection as the sight of the needle invokes fear; topical creams and sprays, or certain flavored oral medications may be used in these instances for painless IV access.8,11 Anesthetic induction and rectal administration is an effective alternative as well.

Opioids

Fentanyl, a narcotic, has lollipops available but are not appropriate for all pediatric uses. Nasal administration of fentanyl can mimic an analgesic blood level comparable to that of IV use for children who have lost or do not have IV access.8

Codeine, hydrocodone, oxycodone, and morphine are four commonly prescribed opioids for acute pain management. Morphine is one of the most studied drugs for pediatric pain patients and routinely used for opioid analgesia despite relatively low oral bioavailability.5 Morphine is metabolized by the liver and produces morphine-6-glucuronide, which bonds to u-receptor sites, providing analgesic effect.11

One trial3 evaluated the analgesic effects of oral morphine to ibuprofen for at-home management of children’s post-operative pain. The interpretation was that both medications decreased the pain scores without apparent disparity in efficacy. While the group using ibuprofen required the use of acetaminophen for breakthrough pain, the group on oral morphine reported adverse effects. The most common of these effects were nausea and drowsiness. The researchers suggested that ibuprofen may be a safer first-line analgesic than an opioid due to its fewer adverse side effects while still providing analgesic efficacy and decreased clinical consequences for accidental ingestion or overdose.3

Other complications from pediatric opioid use may include respiratory distress and apnea, which should be taken into consideration when prescribing opioids.8 For these reasons, it is very important to exercise caution when opioids are used in neonates and young infants.

Nonpharmacologic Management

Healthcare professionals need to utilize all the tools at their disposal to mitigate pain in children. Nonpharmacologic interventions, described below, have proved to be effective in decreasing pain, anxiety, and distress in both children and their caregivers.12,13

Behavioral

Children have fewer coping mechanisms relative to adults but are highly receptive to coaching that helps them engage in behavioral strategies that reduce both pain and stress.14 They are extremely skilled at observing and interpreting adult behavior, reacting positively to adults who keep an optimistic mindset, provide words of encouragement, and empathize with their emotional and physical distress. Parental distress, such as punishment, criticism, and empathic comments, on the other hand, can be a significant predictor of child distress.14 Positive or negative facial expressions and tone of voice taken on by medical providers and parents can also contribute to the severity of pain felt by the child.

Cognitive

Age-based distraction is one of the most widely used techniques to help increase pain tolerance in pediatric patients. Simple techniques such as peek-a-boo, blowing bubbles, or reading books can help overwhelm toddlers with stimulus leaving them unable to discriminate the stress they feel from strange people, benign procedures, and/or a legitimately painful event.14 Preschool and early school-age children can be receptive to distractible elements such as video games, cartoons, stories, or counting to direct their attention away from the painful event.14

Studies show that both interactive and passive distraction can significantly increase pain tolerance in this patient population. For instance, a 2011 study found that pediatric patients showed an increase in pain tolerance whether they actively played (interactive distraction) or watched another person play (passive distraction) a video game.15

Physical

Physical measures may include heat or a cold compress, applying pressure or vibration, repositioning, and massage.5 For musculoskeletal conditions and for children in chronic pain, physical therapy and/or occupational therapy are vital components to managing pain. Exercises should be tailored to each patient depending on the age of the child and the severity of experienced pain. Classic modalities include electrical nerve stimulation, aerobic and weight-bearing exercises, stretching, contrast baths, and tactile desensitization.5

Integrative

Integrative medicine usage rates increase between 30% and 70% among children with medical conditions such as cystic fibrosis, rheumatoid arthritis, cancer, and asthma.16 Relief of pain and or pain-related problems are the most frequently reported reasons for the use of integrated or multimodal therapy in pediatric populations.17 These patient-centered methods combine conventional medicine with evidence-based complementary approaches to help the mind directly influence physical functionality. Studies show that diaphragmatic breathing to help stimulate the vagus nerve and promote relaxation, for example, shows promise as an adjunctive treatment.18

Conclusion

Pediatric pain continues to be misunderstood, under-diagnosed, and under-treated. Despite these challenges, the medical community has continued to make great advancements in identifying pharmacologic, nonpharmacologic and integrative techniques to help alleviate pain and anxiety. The implementations of various age-related pain scales can further help providers identify with more certainty the degree of pain experienced by a child and cater to a more personalized pain assessment and plan for each patient.

All in all, there needs to be a greater emphasis on pain management in children due to the adverse and long-term consequences unaddressed pain can have on a child’s life. Breaking down preconceived misconceptions and educating clinical providers and parents may bring us one step closer to managing pediatric pain more effectively. 

Last updated on: June 18, 2020
Continue Reading:
Connecting the Dots: How Adverse Childhood Experiences Predispose to Chronic Pain
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