Assessments and Advancements in Pediatric Pain Management Mohanad Shukry, MD Associate Professor in Anesthesiology Director, Pediatric Pain Management Service The Children’s Hospital

Objectives Name pain assessment tools Choose the appropriate pain assessment tool Appropriately reassess pain scores Discuss new advancements from the past 5 years in Pediatric Pain Management

2009 JCAHO Standards for Pain The organization respects the patient's right to pain management. "The organization plans, supports, and coordinates activities and resources to ensure that pain is recognized and addressed appropriately and in accordance with the care, treatment, and services provided including the following: Assessing for pain, Educating all relevant providers about assessing and managing pain, Educating patients and families, when appropriate, about their role in managing pain and the potential limitations and side effects of pain treatments." Chapter: Rights and Responsibilities of the Individual patient:  Standard #8

Assessment of Pain Optimal pain management begins with accurate and thorough pain assessment Pain assessment should be carried out at regular intervals Disease process and influencing factors change Permits measurement of the efficacy of different treatments Pain assessment process includes child, caregiver, and health-care providers

Effective Pain Management Requirements Pain intensity/relief is assessed/reassessed Preferences respected Children cannot/will not report pain High suspicion Evaluate effectiveness of pain assessment Random monthly checks on wards

Pain Assessment Detailed medical history: Non-verbal language Previous pain experiences Previous analgesia Treatment Current pain experience Non-verbal language Developmental level Activity level (sleep, play, feed) Physical examination Get detailed assessment History of primary illness Description of pain Experience with pain medications Use of non-pharmacologic approaches Parent personal experience with pain meds Social and spiritual factors

Expression of Pain Depends on: Age Cognitive development Sociocultural context Sedatives or hypnotics may blunt behaviors Physiological measures such as heart rate and blood pressure are neither sensitive nor specific

Behavioral Indicators of Pain Facial expression Body movement Body posture Inability to be consoled Crying Groaning

Criteria for Pain Assessment Tool Appropriate for age, developmental level, and sociocultural context Easy to understand and explain Process of scoring is easy, short, and quick The data obtained is recordable and easy to interpret Readily available and inexpensive Require minimal material or equipment Easy to carry Evidence based

Effective Pain Management Principles Negative physical and psychological if untreated Need aggressive pain prevention and control Prevention is better than treatment Established pain – difficult to control Positive relationship between HCP Information – welcome to discuss preferences Actively involved both children and families May not eliminate all pain Reduction to acceptable levels

Birth-2 Years Neonates as young as 24- weeks feel pain Ascending nerve tracts develop earlier than the pain inhibiting nerve tracts Neonates exposed to repeated painful stimuli show increasing sensitivity No understanding of pain and unable to self report Neonatal/Infant Pain Scale (NIPS) meaning that neonates may experience a greater intensity of pain than older children

NIPS

2 - 4 years CNS fully developed Development of autonomy continues Significant language development Limited logic and reasoning Three levels of pain expression (little, some, a lot) Visual analog (Wong-Baker Faces)

FLACC Scale

Faces Pain Scale Simple and quick to use No instructions needed Easy to administer and score Readily available by photocopying Wong, 2001

Faces Pain Scale

7 - 11 Years Logic and reasoning far more developed Imagination and creativity Finalism and concept of death Number pain scale (scale 1-10)

Adolescents (11+ years) Cognitively adults Same pain assessment methods as adults Abstract thinking and understanding hypo Situations Emotional needs Include them in the process Respect their privacy Respect their pain reports

Numeric & Visual Scale Retrospective self report More recall bias Verbally without any written material

The Word-Graphic Rating Scale Point the finger where there is no pain and run your finger to the worst possible pain! USA DHHS

Pediatric Pain Assessment Tools Neonatal Infant Pain Score (NIPS) FLACC Scale (< 5 years old) FACES Pain Scale (5-13 years old) Verbal rating (older than 13 years old) Numeric scale Visual analogue scale

Pain Assessment Hospitals should use a standard pain scale for various age groups to allow continuity Self report scores (e.g. numerical rating scale) can be misleading Pain can be worsened by anxiety, depression, spiritual crisis A score of 4 may denote severe pain for one adolescent while 8 may be severe to another

Pediatric Pain Advancements Top 5 from the past 5 years

Top 5 Release of the 2012 WHO pediatric pain guidelines; particularly the removal of codeine from the step ladder FDA approval and availability of IV Acetaminophen Methadone to manage chronic and complex pain Topical anesthetics prior to painful procedures Comfort measures

Removal of Codeine from the Step Ladder Codeine is a “weak” opioid previously recommended for moderate pain Codeine is converted into active metabolite morphine Poor metabolizers = poor pain control Over metabolizers = increased risk for over sedation and respiratory depression One of the most constipating opioids

FDA Approval & Availability of IV Acetaminophen Approved in November 2010 for management of mild to moderate pain, moderate to severe pain with adjuvants, and reduction of fever Approved in patients 2 years and older Helpful because sometimes PO, RC routes are not an option IV route has faster onset time (~15mins) Infuses over 15 minutes

Methadone to Manage Chronic & Complex Pain “Rediscovered” to treat moderate to severe non cancer and persisting pain 1940’s – first synthesized as an analgesic 1960’s – used for treatment of opioid addicted patients Dosage needs to be titrated clinically and patient monitored closely Prescribed for pediatric patients who have inadequate responses or contraindications to first line opioids

Methadone to Manage Chronic & Complex Pain Potent analgesic properties Good oral bioavailability Long duration of action Low cost

Topical Anesthetics Prior to Painful Procedures J-Tip Maxilene Pain Ease Buzzy

Comfort Measures Great way to get multi-disciplinary team involved Call Child Life Specialist Positions of Comfort for painful procedures Allowing parent/caregiver to stay with child during a painful procedures with an active role in distraction and positioning

Thank you!

References Bieri D, Reeve RA, Champion GD, Addicoat L, Ziegler JB. Faces Pain Scale for the self-assessment of the severity pain experienced by children: development, initial valid and preliminary investigation for ratio scale properties. 1990; 41 (2): 139-50. Friedrichsdorf SJ, Kang TI. The management of pain in children with life-limiting illnesses. Pediatric clinics of North American. 2007;54: 645-672. Tomlinson D, Baeyer CL, Stinson JN, Sung LA system review of Faces scales for the self-report of pain intensity in children. Pediatrics. 2010; 126:e1168.