Children and pain -prevention and treatment Ann-Cathrine Bramhagen RN, PhD, Directors of studies Malmö University Senior Clinical lecturer Malmö University Hospital 1

Historically Historically the decision whether the child experienced pain or not was based on the professional’s conceptions rather than scientific evidence. One misconception has been that children do not feel pain to the same extent as adults Review – 1985 – heart surgery without pain medication 2

Children are vulnerable Age Vulnerable This is due to physical, psychological and cognitive limitations. This means that all information and preparation must be designed for each child individually. 3

What do we actually know? 4

We know that All infants are exposed to painful procedures Blood sampling Vaccination 5

We know that Pain early in life present a stronger pain response later in life Neonates exposed to 14 painful procedures/day Nurses attitudes matters Advanced education affect attitudes 6

How do we know? Pain scales - FLACC 2 months – 7 years Criteria Score 0 Score 1 Score 2 Face No expression or smile Grimace or frown Clenched jaw Legs Normal or relaxed Uneasy or tense Kicking or legs drawn up Activity Moves easily Shifting back and forth Arched rigid or jerking Cry No cry (awake or asleep) Occasional complaint Crying steadily or screams Consolability Relaxed Distractible Difficult to comfort 7

How do we know? Pain scale - Face scale > 3 years 8

How do we know? Pain scale CAS 5-16 years McGrath, PA. (1996) A new analogue scale for Assessing children´s pain: an initial validation study, Pain64:435-443. 9

What can we do? Distraction Music Storytelling 10

What can we do? Play Draw 11

What can we do? Sweet solutions Breastfeeding Stevens, B et al (2010) Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Collaboration Harrisson, D et al (2010) Efficacy of sweet solutions for analgesia in infants between 1 and 12 months of age: a systematic review Breastfeeding 12

The value of informing children prior to investigation and procedures Marie Edvinsson Månsson Lund 1992 Special psychological preparation reduced the number of anxious children needing premedication before X-ray Parents who had participated in the information to the child felt more satisfied with the information Extended information preoperative reduces the childrens fear

Aspects of prevention and assessment of neonatal pain Mats Eriksson Örebro/Linköping 2003 One ml of 30 % glucose reduces signs of pain from heel-stick and from venepuncture Glucose shown to be better than EMLA® Repeated administration did not decrease the pain relieving effect

Procedural and postoperative pain management in children Stefan Nilsson Jönköping 2010 Children require more than just analgetics in painful procedures They need to feel secure and to be participating The FLACC scale is valid and a reliable tool to measure pain Music reduced the requirement of morphine and decreased distress after minor surgery

Procedural pain reducing methods and pain assessment in newborns Maria Gradin Linköping 2004 Breastfeeding before venepuncture has no major impact on the pain score but on crying time The combination of oral glucose and breastfeeding showed the lowest pain score and significantly shorter duration of crying

Experiences, symtoms and signs in 3-11 year-old children undergoing day surgery in the context of the perioperative dialogue Berith Wennström Göteborg 2011 The perioperative dialogue might minimize distress and prepare the children The perioperative dialogue were associated with low concentrations of salivary cortisol postoperative and reduced morphine consumption Small children have difficulties in distinguishing pain, nausea and anxiety and postoperative discomfort was experienced in many different ways

What is my conclusion? We know a lot We can do a lot We can measure a lot The research question is: are children still experience pain? 11/13/2018

Studies to be started Bramhagen et al Describe children and parent´s experience regarding pain during hospital admission To examine the documentation in the child´s journal regarding pain. To interview professionals in focus groups in order to illuminate their perceptions regarding children and pain during hospital admission.

Children need to be protected 20

Nurses can make a difference 21

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