Hockenberry: Wongs Nursing Care of Infants and Children, 10th Edition

Chapter 05: Pain Assessment and Management in Children

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The Pediatric Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials
(PedIMMPACT) recommends specific core domains to assess pain in children that include
pain intensity, global judgment of satisfaction with treatment, symptoms and adverse
events, physical recovery, and emotional response. Although the ability to measure pain in
children has improved dramatically in recent years, assessment of pain in children
continues to be complex and challenging.
Behavioral assessment is useful for measuring pain in infants and preverbal children
who do not have the language skills to communicate that they are in pain, or when mental
clouding and confusion limit a childs ability to communicate. Behavioral pain
assessment may provide a more complete picture of the total pain experience when
administered in conjunction with a subjective self-report measure.
Physiologic measures are not able to distinguish between physical responses to pain and
other forms of stress to the body. Physiologic parameters, such as heart rate, respiratory rate,
blood pressure, palmar sweating, cortisone levels, transcutaneous oxygen, vagal tone, and
endorphin concentrations, reflect a generalized and complex response to stress. They are not
localized response to pain, but they provide useful information about general distress levels
of children experiencing pain.
The number of pain measures that are available for use in infants and young children has
increased dramatically and adds a layer of complexity to the assessment of pain in
children.
Important components of assessment include the onset of pain; pain duration or pattern;
effectiveness of the current treatment; factors that aggravate or relieve the pain; other
symptoms and complications concurrently felt; and interference with the childs mood,
function, and interactions with family.
Chronic pain is defined as pain that persists for 3 months or more or beyond the expected
period of healing. Complex regional pain syndrome and chronic daily headache are the
most common types of chronic pain conditions in children. Recurrent pain is pain that is
episodic and recurs. The time frame within which episodes of pain recur is at least 3
months. Recurrent pain syndromes in children include migraine headache, episodic sickle
cell pain, recurrent abdominal pain, and recurrent limb pain.
Pain is often associated with fear, anxiety, and stress. A number of nonpharmacologic
techniques, such as distraction, relaxation, guided imagery, and cutaneous stimulation, can
help with pain control.
The administration of sucrose with and without nonnutritive sucking has been demonstrated
to have calming and pain-relieving effects for invasive procedures in neonates.
One of the most significant improvements in the ability to provide atraumatic care to children
is the use of anesthetic creams such as LMX (lidocaine) or EMLA (a eutectic mix of local
anesthetics).
Nonopioids, including acetaminophen (Tylenol, Paracetamol) and nonsteroidal
antiinflammatory drugs, are suitable for mild to moderate pain; opioids are needed for
moderate to severe pain. A combination of the two analgesics acts on the pain system on
two levels: nonopioids primarily act at the peripheral nervous system, and opioids primarily
Copyright 2015, 2011, 2007, 2003, 1999 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

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act at the central nervous system. This approach provides increased analgesia without
increased side effects.
Several drugs, known as coanalgesics or adjuvant analgesics, may be used alone or with
opioids to control pain symptoms and opioid side effects. Drugs frequently used to relieve
anxiety, cause sedation, and provide amnesia are diazepam (Valium) and midazolam
(Versed); however, these drugs are not analgesics and should be used to enhance the effects
of analgesics, not as a substitute for analgesics.
Other adjuvants include tricyclic antidepressants (e.g., amitriptyline, imipramine) and
antiepileptics (e.g., gabapentin, carbamazepine, clonazepam) for neuropathic pain, stool
softeners and laxatives for constipation, antiemetics for nausea and vomiting,
diphenhydramine for itching, steroids for inflammation and bone pain, and
dextroamphetamine and caffeine for possible increased analgesia and decreased sedation.
A significant advance in the administration of intravenous, epidural, or subcutaneous
analgesics is the use of patient-controlled analgesia. As the name implies, the patient
controls the amount and frequency of the analgesic, which is typically delivered through a
special infusion device.
Although respiratory depression is the most feared side effect of opioids, constipation
is a common, and sometimes serious, side effect of opioids, which decrease peristalsis
and increase anal sphincter tone.
Several harmful effects occur with unrelieved pain, particularly when pain is prolonged.
Poorly controlled acute pain can predispose patients to chronic pain syndromes.
Surgery and traumatic injuries, such as fractures, dislocations, strains, sprains, lacerations,
and burns, generate a catabolic state as a result of increased secretion of catabolic
hormones. This leads to alterations in blood flow, coagulation, fibrinolysis, substrate
metabolism, and water and electrolyte balance and increases the demands on the
cardiovascular and respiratory systems.
Because burn pain has multiple components, involves repeated manipulations over the
injured sites, and has changing pattern over time, it is difficult and challenging to control.
Burn pain includes a constant background pain that is felt at the wound sites and
surrounding areas. Burn pain is exacerbated (breakthrough pain) by movements such as
changing position, turning in bed, walking, or even breathing. Areas of normal skin that
have been harvested for skin grafts (donor sites) also are painful.
Recurrent abdominal pain (RAP), or functional abdominal pain, is defined as pain that
occurs at least once per month for 3 consecutive months, accompanied by pain-free periods,
and is severe enough that it interferes with a childs normal activities. Management of RAP
is highly individualized to reflect the causes of the pain and the psychosocial needs of the
child and family.
The acute painful episode in sickle cell disease is the only pain syndrome in which opioids
are considered the major therapy and are started in early childhood and continued
throughout adult life. A source of frustration for patients and clinicians is that most current
analgesic regimens are inadequate in controlling some of the most severe painful episodes.
A multidisciplinary approach that involves both pharmacologic and nonpharmacologic
modalities (cognitive-behavioral intervention, heat, massage, physical therapy) is needed.
Pain in children with cancer is present before diagnosis and treatment and may resolve after
initiation of anticancer therapy. Pain may be related to an operation, mucositis, a phantom
limb, or infection. Pain can also be related to chemotherapy and procedures such as bone

Copyright 2015, 2011, 2007, 2003, 1999 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Key Points - Print

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marrow aspiration, needle puncture, and lumbar puncture. Tumor-related pain frequently
occurs when the child relapses or when tumors become resistant to treatment.
Several harmful effects occur with unrelieved pain, particularly when pain is prolonged. Pain
triggers a number of physiologic stress responses in the body, and they lead to negative
consequences that involve multiple systems. Unrelieved pain may prolong the stress
response and adversely affect an infants or childs recovery, whether it is from trauma,
surgery, or disease.
The effectiveness of analgesics can be enhanced by a supportive attitude toward the child.
By reinforcing the cause and effect of the medication and analgesia, the nurse can condition
the child to expect pain relief, provided the regimen is likely to be effective. A pain relief
scale or periodic ratings of pain intensity should be used for evaluation of effectiveness of
pain regimens.
Several painful and invasive procedures require the administration of anesthetics and
analgesics. Severe pain associated with invasive procedures and anxiety associated with
diagnostic imaging can be managed with sedation and analgesia.
Many patients at the end of life require doses of opioids that make them sedated but
arousable as their disease progresses (cancer, AIDS, cystic fibrosis, neurodegenerative
disease). Patients achieve comfort with a combination of opioids and adjuvant analgesics in
most situations. Parents need reassurance that the opioids are treating pain but not causing
the childs death and that the childs advancing disease is the cause of death.

Copyright 2015, 2011, 2007, 2003, 1999 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.