Pediatric Pain

Management

Challenges with
Pediatric Pain Control
Fear of adverse effects with pain medications
addiction and respiratory distress
Contributing factors
Psychological
Psychosocial
Sociological
Family dynamics
Broad approach is necessary to avoid

incorrectly associating pain to one physical

cause.

Classes of Pain

Nociceptive
Somatic
Well localized, aching,
throbbing
Ie. Muscle, joints,
skin, connective
tissue

Visceral
Poor localization,
cramping
Ie. Visceral organs

Neuropathic
Central
CNS or PNS injury or
ANS dysregulation
Ie CRPS

Peripheral
Neuropathy 2/2 nerve
injury

Pain Assessment
History

of Pain Sx

Detailed HPI, current and past pain

experiences

Pain

scales

Utilized to standardize pain measurements

Most institutions utilize pain scales stratified
by age
Type of pain scale is less important than using
one type consistently

Neonates & Infants

Scales that combine psychological and

behavioral parameters
NIPS (Neonatal Infant Pain Scale)
FLACC scale (Face, Legs, Activity, Cry,
Consolability)

Neonates & Infants

FLACC Scale

Children 3-8 years old

Articulate presence and location of pain
Difficulty describing quality, severity
Wong-Baker FACES

Children >8 years old

Able

to utilize visual analog scale

used in adults

Special Considerations
Cognitive

Impairment

Challenges:
Unable to communicate pain effectively
Require frequent assessment (q1-2h)
Behavioral observation scales (ie.

FLACC)

Acute Pain
Acute

pain

Identifiable source
Efficacy of treatment is reflective of

severity of the injury

Common causes are trauma or
iatrogenic (ie. surgery) in the inpatient
setting

Approach to
management
Multi-modal
Physical
Massage
Heat and cold
Cognitive-Behavioral
Education
Psychotherapy
Relaxation
Biofeedback
Pharmacological

Pain Management

Treatment
Non-Opioid Analgesics
Acetaminophen
Antipyretic
most commonly used
Oral route provides more
predictive effects than
rectal
Around the clock better
than PRN dosing for
minor and major pain
Causes hepatic liver
toxicity and hepatic
failure with overdose

NSAIDs
Antipyretic
For mild to moderate
pain
Anti-inflammatory
Ie. Ibuprofen,
Naproxen, Ketorolac

Side Effects of NSAIDs

Gastritis
Nephropathy (ATN)
Bleeding diathesis

Pain Management
Treatment
Opioid Analgesics
For moderate to severe pain
Various forms of administration
Infants <3mo, increased risk of
hypoventilation and respiratory distress
Low risk of addiction children

Pain Management
Treatment
Side Effects of Opioids
Respiratory distress
Constipation
Nausea, and vomiting
Pruritis
Urinary retention

Pain Management
Commonly

used opioids:

Oxycodone
mild to moderate pain
Morphine
moderate to server pain
Fentanyl
sever pain
Rapid administration may cause glottic and chest wall
rigidity
Codeine
Weak opioid, and anti-tussive
Codeine least recommended (P-450 metabolism*)

Pain Management
Treatment
Severe pain not managed with oral

opioids
Consider IV opioids
Choices of pain management are guided by
location, severity and age
Forms of IV opioid administration
IV bolus
continuous infusion
patient controlled analgesia

Pain Manement
Treatment
Patient Controlled Analgesia (PSA)
Patient controls IV analgesic administration
for quicker relief
Can be used as young as 6yo with proper
education, instructions
Morphine and hydromorphone most
commonly used
Useful in postoperative pain, cancer pain,
palliative care, sickle cell VOC

References

American Medical Association, Module 6 Pain Management:

Pediatric Pain Management. September 2007.
American Pain Society, The Assessment and Management of
Acute Pain in Infants, Children, and Adolescents. Pediatrics 2001;
18 (3): 793-797.
Berde CB, Sethna NF. Analgesics for the treatment of pain in
children. N Engl J Med. 2002; 347: 1094-1103.
Polaner, David. Acute Pain Management in Infants and Children.
Pediatric Hospital Medicine, 2nd Edition. 743-754.
University of Michigan, Pediatric Pain Management Staff
Education, http://www.med.umich.edu/PAIN/pediatric.htm.
Zeltzer Lonnie and Heather Krell. Pediatric Pain Management.
Nelsons Textbook of Pediatrics, 18th Edition. 475-484.