Pain Assessment in the Pediatric Patient Mary E. Amrine, BSEd, BSN, RN

“ Pain is whatever the person experiencing it says it is, existing whenever, the experiencing person says it does” - McCafferey and Pasero 1999

In 1999, the American Pain Society created the phrase… “pain the fifth vital sign” with the hope to increase the importance and the awareness of pain assessment among health care professionals. Sadly, health professionals, including nurses, continue to underestimate and sporadically manage pain in infants and children. - (Vincent and Denyes 2004)

Reasons why children are under-treated for pain include: Professional’s misconceptions about pain Difficulty of pain assessment in children especially non verbal children Lack of knowledge and information regarding currently available pain reduction techniques.

This in turns allows fallacies to continue to flourish even though current literature and studies prove differently! Common fallacies revolve around the following issues: Fear of Addiction Fear of Respiratory Depression

Fear of Addiction Studies on addiction rates in patients treated with opioids found an incidence of less than 1%! (McCaffery and Pasero 1999) One of the reasons for the fear of addiction is confusion among the three terms: Physical Dependence Tolerance Addiction

According to the American Society of Addiction defines the following three terms: Physical Dependence: (of an opioid) Is a physiologic state in which abrupt cessation of the opioid, or the administration of an opioid antagonist results in a withdrawal syndrome. Physical dependence on opioids is an expected occurrence in all individuals in the presence of continuous use of opioids for therapeutic or for no therapeutic purposes. It does not in and of itself, imply addiction!

Tolerance Is a form of neuro-adaptation to the effects of chronically administered opioids or other medications that is indicated by the need for: increasing or more frequent doses of the medication to achieve the initial effects of the drug. Example: Pain control for the hospice patient. Tolerance does not in and by itself imply addiction!

Addiction When referring to the use of pain treatment with opioids, it is characterized by a persistent pattern of dysfunctional opioid use that may involve any or all of the following: Adverse consequences associated with the use of opioids Loss of control over the use of opioids Preoccupation with obtaining opioids, despite the presence of adequate analgesia.

Often, when a patient has severe unrelenting and unrelieved pain, they may become focused on finding relief for their pain. Behaviors such as “clock watching” make patients appear to be preoccupied with opioids. However, the patient is actually focusing on finding relief of pain, not using opioids for reasons other than pain control. This phenomenon is known as: “pseudo addiction” and should not be confused with real addiction.

Fear of Respiratory Depression Rare occurrence in children Evidence suggest that in children age 3 months and older, opioids cause no greater respiratory depression that in adults. (Kart, Christup, and Rasmussen 1997) Respiratory depression is most likely to occur when an opioid is administered with other sedating drugs Opioids, unlike many sedatives, have the advantage of the antidote naloxone (Narcan) However, the drug flumazenil (Romazicon) can be used to treat respiratory depression associated with the benzodiazepines, diazepam (Valium) and midazolam (Versed)

Another point to keep in mind is as tolerance to the analgesic effect of opioids occurs, tolerance to the respiratory depressant effect also occurs. Pain acts as a natural antagonist to the respiratory depressant effect of opioids. As pain increases, a patient can receive increased doses of opioids without necessarily experiencing clinically significant respiratory depression. Respiratory depression is rare in children receiving long- term opioid therapy, because tolerance to the respiratory depression develops. (Collins, 1997)

Pain Assessment in Children Baker and Wong developed a tool referred to as: “QUESTT” Question the child Use a pain rating scale Evaluate behavioral physiologic changes Secure parents’ involvement Take the cause of pain into account Take action and evaluate results

According to Dr. Wong, a golden rule to follow in pain assessment is the following: Whatever is painful to an adult is painful to an infant or child until proven otherwise

Evaluate Behavioral and Physiologic Changes: Changes in behavior are common indicators of pain and are a valuable tool in assessing pain in children especially in non-verbal children or children with cognitive impairments. Children may display behaviors that indicate local body pain, such as pulling on their ears for ear pain, or lying on their side with knees flexed for abdominal pain.

Physiologic responses to pain include: Increase in blood pressure, pulse, and respirations Increase in sweating Flushing of the skin Restlessness Dilation of the pupils If pain persists, the body begins to adapt and these responses decrease or stabilize.

Consequently, if the nurse relies on observing only those physiologic responses or expecting “pain behaviors” before believing pain actually does indeed exist - many instances of pain will go unrecognized. (Van Cleve, Johnson, and Pothier, 1996)

Other factors to keep in mind: Children’s behavioral responses to pain change with age and follow a developmental trend. Recent evidence indicates that temperament is not a useful predictor of response to pain. (Broome, Rehwaldt, and Fogg, 1998) Cultural background may also influence children’s pain response.

Remember: It is wrong to assume that certain conditions or procedures always produce a standard amount of pain. Only the child knows the intensity.

Pain Management Pharmacologic Interventions: Right Drug Right Dose Right Route Right Time Right Approach and Observing for side effects!

Right Drug: Mild to Moderate Pain : Acetaminophen or NSAIDS Moderate to Severe Pain: Opioids

By using the two in combination, it attacks pain on both the peripheral nervous system (nonopioids) and the central nervous system (opioids). This approach provides increased analgesia without increased side effects. Generally, before increasing the opioid dose – it may be better to increase the non-opioid dose first. If however, that does not relieve the pain, the pain most likely requires a stronger opioid.

Right Dose: Children, 6 months and older, metabolize drugs more rapidly than adults, thus, younger children may require higher doses of opioids to reach the same analgesic effect. The dosages for children are usually calculated according to body weight, except for children who weigh 50kg or 110 lbs or more. When a child weighs more than 110 lbs the weight formula may exceed the average adult dose.

With inadequate pain relief the initial dosage is increased usually by 25%-50% to provide better analgesic effectiveness. Decreasing the time between doses may also provide better continuous pain relief.

A significant difference between opioids and nonopioids is that nonopioids have a “ceiling effect” The ceiling effect refers to that doses higher than the recommended dose will not produce greater pain relief. Opioids do not have a ceiling effect (indirectly other than what is imposed by the side effects) thus larger doses can be given safely for increasing pain severity.

Right Route: The most effective and least traumatic route of administration should be used. IM injections are not preferred for children and should be avoided as children should not have to endure pain to have pain relieved. Children who are able to play video or computer games can usually successfully use PCA therapy.

Right Time: Important concept to remember is ATC or around the clock preventive scheduling of pain medication. This will decrease episodes of breakthrough pain that are often related to low plasma concentrations of an analgesic. When analgesics are only administered when pain returns, pain relief may take hours and require higher doses. The higher doses may lead to a cycle of over medication and sedation and drug toxicity. In addition, the poor pain control may lead to “clock watching” (because of unrelieved pain) Now the nurse erroneously thinks the patient is becoming “addicted”

Pain Management Non-pharmacologic interventions: Use to supplement pharmacological interventions not to replace them! Distraction Relaxation Guided Imagery Positive Self-Talk Thought Stopping

Side Effects: Nurses tend to over emphasize the risk of respiratory depression. Constipation is more common due to the decrease in peristaltic activity. Prevention is key Educate the parents Use of stool softeners and laxatives Increased fiber and increased fluids, although good, is not enough to promote regular bowl movement.

Safety Tips for Medication Administration To prevent medication errors: understand normal safe ranges check and recheck calculations verify doses with another caregiver. (do not do at the same time together!) Properly identify the patient. Explain what you are going to do to both patient and family.

Homegoing Instructions Review the name of the drug and why it is being prescribed How to take it When to take it Common side effects Side effects that necessitate calling physician Telephone number – where they can call if they have questions.

Questions?