Module 6: Pain Management C C E E N N L L E E End-of-Life Nursing Education Consortium Pediatric Palliative Care C C E E N N L L E E

C C E E N N L L E E Pain Defined Pain is a subjective response Pain in childhood can be acute or chronic Children's pain is influenced by many factors

C C E E N N L L E E Pediatric Palliative Care Scope of the Problem Children’s pain experience Effect of pain on quality of life

C C E E N N L L E E Pediatric Palliative Care Populations at risk  Chronic conditions  Trauma/injury  Neurological impairment  Neonates/infants  Non-English speaking  Cultural, gender stereotyping

C C E E N N L L E E Pediatric Palliative Care Barriers to Pain Relief Healthcare professionals Healthcare system Related to parents/children

C C E E N N L L E E Pediatric Palliative Care Myths Related to Pain and Pain Management in Children Respiratory depression Addiction Child that is sleeping/or playing does not have pain Presence of pain indicates worsening of disease and approaching death

C C E E N N L L E E Pediatric Palliative Care Facts About Childhood Pain Opioid addictions are rare Repeated exposure to painful procedures leads to increased anxiety and perception of pain Studies have shown that children as young as 3 years old can use pain scales Carter et al., 2004; Goldman et al., 2006; Hockenberry & Wilson, 2006; Schecter, 2003

C C E E N N L L E E Pediatric Palliative Care Myths Related to Neonatal/Infant Pain Incapable of feeling pain Immature nervous system Incomplete myelinization No memory Objective assessment impossible Neonates cannot communicate pain Analgesics unsafe

C C E E N N L L E E Pediatric Palliative Care Facts About Neonatal/Infant Pain Pain perception occurs early in life Neonates exhibit physiologic and behavioral cues

C C E E N N L L E E Pediatric Palliative Care Modifying Contextual Factors of Pain Expression in Infants Behavioral state Postnatal age Severity of medical illness Technician effects/procedural modifiers Environmental stress Sensitization after repeated stimulation Total number of invasive procedures Time since last painful procedure

C C E E N N L L E E Pediatric Palliative Care Impact of Pain Research asked ‘What is it like to have a child with pain?’  Unendurable  Sense of helplessness  Sense of total commitment  Unprepared/unknowledgeable  Horrible/frightening  No pain in heaven Ferrell et al., 1994a & 1994b

C C E E N N L L E E Pediatric Palliative Care Developmental Aspects of Pain Infants Toddlers

C C E E N N L L E E Pediatric Palliative Care Developmental Aspects of Pain Pre-school School age

C C E E N N L L E E Pediatric Palliative Care Developmental Aspects of Pain Adolescents

C C E E N N L L E E Pediatric Palliative Care Special Populations Injury/trauma  ER  PICU

C C E E N N L L E E Pediatric Palliative Care Special Populations Cancer pain Chronic non-malignant pain

C C E E N N L L E E Pediatric Palliative Care Special Populations Sickle cell  Numerous complications of SCD result in pain  Vaso-occlusive crisis, priapism, dactylitis, splenic sequestration, spinal cord compression and avascular necrosis of joints

C C E E N N L L E E Pediatric Palliative Care Special Populations Pancreatitis Musculoskeletal/rheumatic  Juvenile Primary Fibromyalgia  Juvenile Idiopathic Arthritis  Complex Regional Pain Syndrome

C C E E N N L L E E Pediatric Palliative Care Special Populations Neurocognitive impairment  Pain experience  Pain indicators  Effect of uncontrolled pain  Assessment  Knowing child  Recognizing patterns  Intersubjective process with HCP