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

2. 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

4. 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

5. 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

6. 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

7. 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

9. 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

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

11. 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

12. 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

13. 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

14. NIPS

15. 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)

16. FLACC Scale

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

18. Faces Pain Scale

20. 7 - 11 Years Logic and reasoning far more developed
Imagination and creativity
Finalism and concept of death
Number pain scale (scale 1-10)

21. 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

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

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

24. 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

25. 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

26. Pediatric Pain Advancements Top 5 from the past 5 years

27. 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

28. 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

29. 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

30. 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

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

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

33. 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

34. Thank you!

35. 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):
Friedrichsdorf SJ, Kang TI. The management of pain in children with life-limiting illnesses. Pediatric clinics of North American. 2007;54:
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.