1. THE NEONATE WITH PAIN

2. DO FISH FEEL PAIN? Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage.

3. OUCH !! 54 Neonates admitted to a single unit received 3000 procedures during their stay. One patient received 488 procedures before discharge.

4. PHARMACOLOGICAL STRATEGIES Opiods  Fentanyl  Highly lipophilic therefore crosses the blood brain barrier  Causes less histamine release than morphine  chest wall rigidity  Morphine  Continuous infusion or regular boluses  Has much longer half life in neonates.

5. Non Opoid  Non-steroid anti-inflammatory  Not recommended  Paracetamol  mild pain

6. Sedatives  Used in combination with analgesics  Must never replace analgesics.  Chloral Hydrate, can be given orally.  Benzodiazepines  Midazolam

7. REGIONAL ANAESTHESIA Spinal/intra thecal Epidural Local infiltration, blocks Topical  eutectic mixture of local anaesthesia (EMLA)

8. ENVIRONMENTAL AND BEHAVIOURAL PAIN MANAGEMENT STRATEGIES. Don’t replace but enhance medical/pharmacological methods Behavioural strategies  nesting, containing posture Non nutritive sucking  with or with out sucrose Avoid noxious stimuli  light, noise, handling

9. YES THEY DO FEEL PAIN!! Just because we can hold them still doesn't mean that they should not have the benefit of analgesia and sedation. Children must be nursed in safe comfortable environment. Must plan to give analgesia. Adjust according to procedure and condition of child.

10. CHRONIC PAIN

11. 60 % of ambulant patients with HIV have pain Oncology patients have similar statistics but receive more sympathy from health professionals and public.

13. PAIN ASSESSMENT Over reported (Cry baby) Under reported (Tough Kid) Miss interpretation by clinician  We can only see what we look for. No or poor advocacy to help report pain.

14. UNDER TREATED ! Fear of doing harm  “Primum non nocere ” Fear of addiction  No child will develop dependence if used appropriately Fear of euthanasia effect  Doctor’s intention to treat is all important Fear of diverted use Fear of asking for advice Fear of giving up Unclear goals.

15. PAIN THERAPY Stepwise approach Non-opioid Analgesics, Cognitive Techniques Weak Opioids Oral route Parenteral Potent Opioids Invasive therapy

16. Step One  Paracetamol 15mg/kg 6hourly regular AND/OR  Ibuprofen 10 mg/kg 8 hourly regular  Distraction therapy Step Two  Morphine sulphate 1 mg 4 hourly, titrate up according to pain. Increase dose by 50% previous dose ever 18-24 hours until pain controlled. Step Three  consult expert  continuous infusion/ patient controlled anaesthesia  Adjuncts Step Four  Invasive therapy  nerve blocks  radio therapy  resection

17. ACCURATE DIAGNOSIS Bone pain pruritus Abdominal cramps Mucocyitis Dyspnoea Neuropathy Myalgia Arthritis

18. ADJUNCTIVE TREATMENT Antihistamine steroids Benzodiazepines Opioid receptor antagonists Topical agents Baclofen Cannabis antidepressants Music, Play, Water, Distraction Therapy.

19. SUMMARY Good safe pain management has incalculable benefits to both patient, family and physician. Need carefully planned strategy tailored for each patient. Must follow step wise approach.