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Pain is a common childhood condition that occurs because of injury, illness, or procedures needed to diagnose or treat childhood diseases. Doctors have become increasingly focused on their abilities to diagnosis and treat disease and have overlooked pain as part of the problem requiring treatment. This is particularly true in populations, including children, where communication about pain quality and severity is difficult.
The first step in treating pain in children is to become comfortable with assessing its severity. A quick method of assessment is to ask both the parent and the child how much pain is being experienced. Children as young as age two or three are able to tell the doctor whether something hurts and where it hurts. Parents have observed their children in pain in the past and can give doctors some idea of the severity of pain in relation to previous pain experiences. Visual analogue pain scales and verbal reports of pain severity from 0 to 10 can be used in school-aged children. A description of the quality of pain being experienced is often difficult for children.
Other means of pain assessment include behavioural and physiological measures. They are most useful in pre-verbal or nonverbal individuals. Behaviours indicating pain can include crying, agitation or complete withdrawal. Physiological measures include increased heart rate, blood pressure, diaphoresis and pallor. These signs are present in the first few hours following a painful injury but soon return to normal. They are useful for acute pain only.
Treatment of pain depends on the severity. In treating pain, the goal is to alleviate it or to at least decrease it to a tolerable level, allowing the child and family to resume more normal function. Both pharmacological and non-pharmacological pain therapies, such as distraction and cuddling for the young child, should be used whenever possible. Principles of pain management include choosing a painfree route for drug administration, with either oral or intravenous routes preferred over intramuscular injections. When using the intravenous route, titrate the drug to achieve the desired degree of analgesia. Commonly used analgesics for childhood pain are shown in Table 1.
Mild pain (1 to 3 on a pain assessment scale), including minor scrapes or otalgia, can be treated with acetaminophen or nonsteroidal anti-inflammatories such as ibuprofen or naprosyn. Acetylsalicylic acid is avoided in growing children because of the association with Reye’s syndrome.
Moderate pain (4 to 6 on a pain assessment scale) severity may result from acute otitis media, burns and buckle fractures. Oral codeine may be considered in addition to or instead of acetaminophen. There is good rationale for using it in combination with acetaminophen.
Severe pain (7 to 10 on a pain assessment scale) includes moderate pain that has not responded to usual therapy and pain from more severe trauma or medical and surgical conditions. These patients are best managed with intravenous opioids, although nitrous oxide is an inhalational agent that can be used for moderate to severe pain in older children. The goal in treating severe pain is to ease the patient’s pain without causing excess side effects including respiratory depression. This is best accomplished by administering repeated small boluses every 10 mins until the pain’s severity decreases to a tolerable level.
Morphine sulfate is a commonly used opioid with a longer half-life and similar safety profile to meperidine. It can be used in repeated small boluses or by continuous infusion. These two options can be combined in patient-controlled analgesia for excellent postoperative pain control. Patients as young as age six years can safely use patient-controlled analgesia infusion pumps. Fentanyl can also be used for acute pain control but has a much shorter half-life, requiring more frequent administration, and it can cause muscular rigidity impairing ventilation if injected too quickly. It is also more expensive than morphine.
Whenever intravenous analgesia is administered, it is important that the patient be monitored closely for cardiorespiratory depression. This should include constant nursing supervision, cardiorespiratory monitoring, and taking vital signs including blood pressure, heart and respiratory rates, and pulse oximetry frequently. End tidal carbon dioxide monitoring has some advantages over pulse oximetry for monitoring the sedated patient, if possible both should be employed. In addition to monitoring the patient closely, doctors must be prepared to deal with possible respiratory depression or hemodynamic side effects of the drug used. There must be suction, supplemental oxygen and persons skilled in paediatric airway management available in the event of complications.
Procedural pain is a separate issue requiring attention. Simple manoeuvres such as education about the procedure and expected duration of pain as well as relaxation skills including deep breathing and distraction help children gain some control over painful procedures and can be quickly taught to children as part of preparation for laceration repair. These manoeuvres can be combined with the use of local anesthetics and sedation where needed. When injecting a local anesthetic it is helpful to drip a small amount into the open wound before injecting; use a 27 or 30 gauge needle and inject slowly. Adding a small amount of bicarbonate (one part 8.4% sodium bicarbonate to nine parts lidocaine changes the pH from approximately 4.5 to 7.0) to buffer the lidocaine can also help decrease the pain of injection.
Occasionally a child requires sedation for a procedure. Many different drugs have been used and recommended, which implies that none are perfect. An ideal agent would have minimal effects on the airway and hemodynamic status, be available orally, and have a rapid onset and short duration of action.
Agents used for sedation include benzodiazepines, short-acting barbiturates, ketamine, opioids, nitrous oxide and propofol. Possible routes of administration and recommended doses are shown in Table 2. For a complex laceration repair or fracture reduction, where analgesia is required as well as sedation, ketamine or a combination of benzodiazepine and opioid is most appropriate. Nitrous oxide can also be used in older children and adolescents. To sedate a child for a diagnostic test such as computed tomography, benzodiazepines, short-acting barbiturates or propofol may be used. Whatever agent is chosen for sedation it is important that appropriate monitoring of the patient occurs.
Many children are difficult to sedate if they are exceedingly anxious. The drugs may further reduce inhibitions, resulting in agitation or aggressive behaviour that is difficult to settle. The best course of action in this situation is prevention through careful attention to nonpharmacological sedatives including dim lights, a quiet environment, warmth, familiar faces and gentle handling. Once a child is agitated, the doctor is faced with the options of excessive sedation risking complications or waiting for resolution of the behaviour.
In summary, pain assessment is an important part of treatment and can be done in young children. When intravenous analgesia or potent sedatives are used, it is imperative that the clinician be familiar with the associated airway and cardiovascular effects of the drugs and be prepared to deal with them as necessary. The use of non-pharmacological pain treatment is an important part of pain management in children and is particularly effective in the paediatric age group.
Thanks to Dr Michele Kalny, Alberta Children’s Hospital, Calgary, Alberta, for her contribution to the tables.