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Current Anaesthesia & Critical Care (2004) 15, 272283

www.elsevier.com/locate/cacc

FOCUS ON: PAEDIATRICS

Pain management in children

Mary Cunliffe, Stephen A. Roberts
Department of Anaesthesia, Royal Liverpool Childrens Hospital Alder Hey, Eaton Road, Liverpool L12 2AP, UK

KEYWORDS
Pain; Children; Acute; Chronic; Multimodal analgesia

Summary Pain management in children has improved considerably in the last 10 years. Attitudes to pain in children have changed, and an improved understanding of the physiological development of the pain pathway has produced a more informed approach to managing pain. Assessing pain by using age related pain tools enables pain to be continuously monitored and treated effectively, even with a small drug armamentarium. The management of acute pain after surgery has beneted from the widespread formation of Acute Pain Services and development of protocols for analgesia using morphine infusions and epidural analgesia. Chronic pain in children is an under-recognised phenomenon and specialist services for its management have been slow to develop. For many large paediatric centres developing a multidisciplinary chronic pain service has become a priority. & 2004 Elsevier Ltd. All rights reserved.

Introduction
The International Association for the Study of Pain denes pain as an unpleasant and emotional experience associated with actual or potential tissue damage.1 This denition is qualied with a further statement that each individual learns the application of the word through experiences related to injury in early life and an acknowledgement that early experience during childhood provides the basis for understanding the meaning of the word pain. Children are an enormously vulnerable group, and it is important for any Health Care
Corresponding author.

E-mail addresses: mary.cunliffe@rlch-tr.nwest.nhs.uk (M. Cunliffe), stephen.roberts@rlch-tr.nwest.nhs.uk (S.A. Roberts).

Professional (HCP) to understand the effect that their attitude and management of a childs pain may have as a long-term inuence. When we deal with any child in pain we must treat that pain quickly and effectively to avoid long-term physical and psychological consequences. This includes managing procedural pain for events such as venepuncture and lumbar puncture. Pain in children has been under-treated for a variety of reasons. There have been many misconceptions affecting its management, such as neonates do not feel pain,2 children suffer less pain than adults do,3 and children easily become addicted to morphine. Children have been treated with much less analgesia than adults despite having the same type of surgeryit has been common to use non-opioid, oral analgesia, rather than morphine intravenously, even after major surgery.4

0953-7112/$ - see front matter & 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.cacc.2004.08.014

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Pain management in children Often HCPs have a preconception of how much pain a type of injury or operation produces and give analgesia according to that model, despite the child reporting a more severe degree of pain. 273 strated that infants who were circumcised without any form of anaesthetic or analgesia had a much lower pain threshold for months afterwards.8 Use of analgesia in infants not in pain, i.e. for sedation in Intensive Care, also has consequences which are undesirable. These children have been shown to need much higher doses of morphine in later life to achieve pain control.

Pain perception in infancy

We now know that the anatomical, physiological and biochemical prerequisites for pain perception are present from very early in intrauterine life. Even preterm infants can perceive pain comparable to older children.5 In fact neonates probably perceive pain more intensely because of differences in their neurophysiology. At birth, all pain bres are unmyelinated and have a low threshold. Pain is poorly localised because of large receptive elds within the spinal cord. Wounding of the skin produces massive sprouting of sensory nerve endings and leads to a state of hyperinnervation and eventually hypersensitivity for many weeks after wound healing. The infant has a poorly developed system for modulating pain input,6 increasing the effect of pain in an already hyper-excitable system. All infants are capable of mounting a stress response to surgery, which is related to the severity of the stimulus and the health of the baby; the sicker the infant, the more marked the response. Use of general anaesthesia, regional anaesthesia and opioids all attenuate the stress response to surgery. The use of high dose opioids reduces mortality following cardiac surgery.7 Opioid receptors are present from early on in fetal development and are responsive to exogenously administered morphine. Their numbers increase in the early neonatal period. A long-term consequence of untreated pain is a lowering of the pain threshold. Taddio demon-

Pain assessment
To manage pain effectively it is important to assess pain regularly. There are assessment tools for all ages of patient. This enables us to track the effectiveness of our analgesic regime. Pain assessment tools are usually divided into those for use in preverbal children and those for use in children who are able to self-report. Any child in severe pain should be assessed hourly to re-evaluate analgesic efcacy. It should be regularly charted alongside pulse rate, blood pressure and temperature.

Preverbal children
For children less than 3 years of age who are too young to self-report, pain assessment tools normally consist of pain associated behaviours; some also contain a mixture of physiological markers for stress. Children who are developmentally abnormal or on the Intensive Care Unit, who are unable to verbalise pain, need special pain assessment tools to monitor pain. Pain associated behaviour relates to facial expression, body and limb movement and cry (Table 1). Physiological markers for stress relate to the cardiovascular, respiratory and endocrine systems. They are not specic for pain and may be

Table 1

Behaviour changes seen with pain. Eye squeeze Brow contraction Nasolabial furrow Taut tongue Open mouth Reex withdrawing Grimacing Screwing up of eyes Nasal aring Curving of tongue Quivering of chin Rigidity followed by thrashing of limbs Torso squirming Finger clenching Writhing Arching of back Head banging

Facial expression

Body/limb movement

Crying

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274
Table 2 children. Pain assessment tools for preverbal

M. Cunliffe, S.A. Roberts management. It is more important that the doctor or nurse appreciates that young infants perceive pain, and has an understanding of the situations where pain occurs. They also need to be aware of the need to control pain and the methods which can be used to achieve this.

Tools based on behavioural changes Neonatal Facial Coding System (NFCS) Infant Body Coding System (IFBC) Neonatal Infant Pain Scale (NIPS)10 Pain Assessment in Neonates (PAIN) Liverpool Infant Distress Scale (LIDS)11 Childrens Hospital of Eastern Ontario Pain Scale (CHEOPS)12 Neonatal Assessment of Pain Inventory (NAPI) Tools based on physiological and behavioural changes CRIES9 Pain Assessment Tool (PAT) Scale for Use in Newborns (SUN) COMFORT score13 Toddler Preschool Postoperative Pain Scale (TPPPS)14

Older children
Once the child can verbalise, the mainstay of pain assessment is by self-reporting. In older children the traditional 10 cm Visual Analogue Scale (VAS) can be used,15 often with descriptors at each end which read no pain and worst possible pain. Alternately an upright ladder or thermometer may be used, numbered 010 or 0100.16 In children under 12 it is common to use a tool which uses a series of 57 faces to illustrate pain.17,18 The child has to pick the face which most closely represents how they are feeling at that moment. Our own faces scale is shown in Fig. 1.

Table 3 Crying

Cries score. None High pitched Inconsolable

Drug armamentarium
It is possible to manage nearly all episodes of acute pain using a small drug armamentarium. Pharmaceutical companies rarely extend drug development to include research in children, which is needed to extend the drug license for the paediatric market. These means that any doctor prescribing regularly for children will use many drugs which are off license or off label (using a licensed drug but at a different dose, for a different indication or in a different formulation). This fact should not deter us from using a drug, but we need to be sure that we use it within generally accepted parameters.

Transcutaneous oxygen saturation Oxygen requirementNone o30% 430% Vital signs Heart rate and BP at preop level o30% above preop level 430% above preop level None Grimace Grunt Normal Wakes Always awake

Facial expression

Sleep pattern

Paracetamol
Paracetamol is probably the most commonly used analgesic in children. In addition to producing analgesia, it also has antipyretic properties, but is not anti-inammatory. It does not produce respiratory depression. It is now recognised that we need to give a high loading dose at the outset than previously recommended, especially if we are using the rectal route where absorption is erratic.19 To avoid cumulative liver toxicity, the correct dose must be given at an appropriate time interval, making sure to keep within the recommended total daily dose of 90 mg/kg/day. The dose used in neonates and infants should be reduced (Table 4).

triggered by other factors affecting the child. There are a plethora of pain assessment tools to use in this age range because none is ideal. Many have been developed as research tools and are much too complicated for bedside monitoring. A list of commonly used tools is found in Table 2. A frequently used score in neonates is CRIES9 which is validated for use in the rst 72 h postoperatively (Table 3). Highly sensitive techniques of pain assessment may not always be necessary for effective pain

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Pain management in children 275

Figure 1 Faces pain scale.

Table 4

Drug dosages.

Opioids
Weak opioids
Codeine, dihydrocodeine and tramadol are the main weak opioids used in children. Codeine and dihydrocodeine both work by a small percentage of the absorbed drug being converted to morphine. The analgesic efcacy of both these drugs has been questioned both in adults and in children.22 A percentage of the population is missing the enzyme necessary for the conversion to morphine,23 and this has led researchers to question whether we should use codeine at all. This would leave us with a very small armamentarium indeed. The analgesic league table24 produced by the Oxford evidencebased medicine group puts codeine at the bottom of the table with a Number Needed to Treat (NNT) of 16.9 patients to produce a 50% reduction in pain score for 4 h or more in one patient. If codeine is combined with paracetamol then it assumes a NNT of 2.2 and moves to very near the top of the table. By recommending that codeine is always given simultaneously with paracetamol we can make it a more effective analgesic. Tramadol has multiple mechanisms of actionthrough opioid receptors and by enhancement of serotinergic and adrenergic pathways. It is said to produce fewer side effects than other opioids, particularly less respiratory depression. An effective dose in children seems to be 1.5 mg/kg 6 hourly given orally or IV.

Paracetamol Orally 20 mg/kg loading dose, then 15 mg/kg 46 h Maximum dose 90 mg/kg/day (60 mg/kg/day in neonates) Rectally 3040 mg/kg loading dose (20 mg/kg in neonates), then 20 mg/kg 68 h Maximum dose 90 mg/kg/day (60 mg/kg/day in neonates) Drug NSAIDs Ibuprofen Diclofenac Piroxicam Codeine phosphate Morphine Dose (mg/kg) Number of doses (per day) 4 3 1 4 6

510 1 0.4 1 0.20.4

Non-steroidal anti-inammatory drugs (NSAIDs)

NSAIDs are being increasingly used as analgesics in children.20 They work through the cyclo-oxygenase (COX) enzyme system by inhibiting the formation of prostaglandins and are anti-inammatory and antipyretic as well as being analgesic. They can be given in combination with paracetamol and opioids to produce multimodal analgesia. When given with an opioid they reduce the dose of opioid needed by 30%.21 Their main side effects are renal dysfunction and gastrointestinal ulceration. They are contraindicated in children with abnormal coagulation, renal dysfunction/failure and hepatic failure. The main NSAIDs used in children are ibuprofen and diclofenac, which are non-selective drugs. There are few trials in children looking at the newer selective agents. NSAIDs are usually used from 6 months of age.

Strong opioids
Morphine is the mainstay of providing analgesia for severe pain in children. It works like all opioids, through mu receptors within the central nervous system. It has an oral bioavailability of 30%. It is metabolised in the liver to produce morphine-6glucuronide and morphine-3-glucuronide, of which only the former has analgesic action. The main opioid side effects are nausea and vomiting,

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276 itching, urinary retention, constipation and respiratory depression. Morphine metabolites accumulate in patients with renal failure leading to increasing sedation and respiratory depression. Fentanyl is a synthetic opioid with a short duration of action. It is highly lipid soluble and undergoes extensive rst pass metabolism which makes it unsuitable for oral use. It is normally given by infusion to treat postoperative pain, but can also be given transmucosally or transcutaneously. Fentanyl patches come in 4 different doses and deliver 25, 50, 75 or 100 mcg/h of active drug.25 After applying a patch, steady state is only reached in 1224 h and this makes it inexible for treating postoperative pain. Fentanyl lozenges deliver fentanyl into the bloodstream through the buccal mucosa and have been used for premedication, as analgesia for a painful procedure,26 and for breakthrough pain if using fentanyl patches. Breakdown of fentanyl produces a non-active metabolite, and is not entirely dependent on renal elimination, so it is a useful alternative in patients with renal failure. M. Cunliffe, S.A. Roberts
Severe pain PCA morphine NCA morphine IV morphine Epidural infusions + paracetamol and/or diclofenac severe pain paracetamol and oral morphine diclofenac and oral morphine moderate pain paracetamol and codeine and diclofenac paracetamol and codeine paracetamol and diclofenac mild pain paracetamol diclofenac

Drug pharmacokinetics in infancy

Gastric emptying is signicantly slower in infants less than 6 months of age and the absorption of some drugs will be increased. Neonates have lower levels of a1 acid glycoprotein, the main drug binding protein, which means for a given dose of drug, more will be present in the free form, giving it a greater effect. The neonate has a higher total body water content with a large extra-cellular uid compartment. They have less fat and muscle as a percentage of body weight. The immature liver means that all its metabolic processes are slower in the neonate, especially if preterm. This results in a lower clearance and a prolonged half-life for many drugs. These will be compounded by the reduced renal function of these infants.

Figure 2 Modied analgesic ladder.

that size of child, at the correct time interval. All too often too small a dose at too long a time interval is prescribed, especially for morphine. The WHO analgesic ladder,27 which was originally devised for the management of cancer pain, is easily adapted to give a working plan of managing any type of pain (Fig. 2).

Pain relief during and after surgery

Day case surgery
The mainstay of providing analgesia for day surgery patients is the extensive use of local anaesthetic (LA) techniques and administration of NSAIDs and/ or codeine/paracetamol, and the doses can be found in Table 4. Suppositories of diclofenac, codeine or paracetamol can be given following anaesthetic induction. Both diclofenac and codeine are quickly absorbed via this route, providing good analgesia within 3040 min. Paracetamol has less predictable absorption when given rectally and is better given orally as a premedication. It is important to discuss the use of suppositories at the preoperative visit and seek verbal permission from the parent or child to administer drugs by this route. For children and parents who refuse permission for a suppository, an oral dose of drug can be

Use of analgesics to provide good pain relief

It is important to assess the severity of pain in order to choose which analgesic drug or drug combination may work for that patient. Multimodal analgesia should be used to reduce side effects and produce better analgesia. Morphine or codeine may be given alongside paracetamol and an NSAID. If pain is continuous, then analgesia should be prescribed to be given regularly and not as required. It is equally important that the correct dose of drug is given for

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Pain management in children given as premedication. Use of strong opioids such as morphine should be avoided as this will lead to an increased incidence of postoperative nausea and vomiting.28 277 sacrococcygeal membrane (SCM), which consists posteriorly of sacral ligaments and anteriorly of the ligamentum avum. It is important to remember that the distance from skin to epidural space is rarely greater than 20 mm, and in neonates is under 5 mm. In neonates the dural sac can end as low as S4; in older children the lower end is at S2.

Topical LA creams
Use of EMLA and Ametop can make cannulation and venepuncture painless procedures. EMLA29 is a eutectic mixture of lidocaine and prilocaine which is applied to the proposed site of injection and covered by an occlusive dressing, 60 min prior to the procedure. It penetrates the skin and produces topical anaesthesia over the area covered. It produces vasoconstriction and can make venepuncture more difcult in some children. If applied in large quantities to small infants, it may cause methaemoglobinaemia.30 Ametop31 is 4% amethocaine gel which has a faster onset of action than EMLA, needing to be applied for a minimum time of 30 min in the antecubical fossa and 40 min for the back of the hand. It produces vasodilatation and can make cannulation easier, but is associated with a higher incidence of allergy and hypersensitivity than EMLA. Following removal of the cream, topical anaesthesia will last for a period of 4 h.

Technique
Caudals are normally performed in the left lateral position, though the prone position may be used. Under aseptic conditions, a needle is inserted at right angles to the skin until a pop is felt on passing through the SCM. The needle is then re-angled 20301 to the skin and inserted 24 mm into the epidural space. It is then left open for 10 s to allow detection of blood or cerebrospinal uid. Following an aspiration test, the LA is injected looking for supercial swelling and feeling for increased resistance which may indicate sub-periosteal injection. The choice of needle is between a standard IV cannula or a blunt regional anaesthesia needle. The insertion of a cannula over a needle is less likely to cause dural tap or nerve damage. Use of a blunt needle gives an improved pop on penetrating the SCM and may decrease the likelihood of IV injection. Ultrasound can be used to guide the procedure, visualising the caudal opening, anatomical abnormalities, the dural sac and LA distending the epidural space.37 Contra-indications to caudal anaesthesia are sacral dysraphism, local or systemic infection, a bleeding disorder and raised intracranial pressure. A preoperative coagulation screen is necessary in neonates or premature infants less than 45 weeks postconceptual age.

LA blocks
Pain after many operations can be managed with a denitive nerve block, e.g. penile block for circumcision,32 ilio-inguinal block for hernia repair33 and orchidopexy34 and nerve plexus blocks for limb surgery.35 Simple wound inltration can be used for skin lesions or removal of plates and screws from previous fractures. Detailed discussion of these techniques is beyond the scope of this article and can be found in a separate article on LA techniques. Use of caudal anaesthesia is a popular analgesic technique for both inpatient and day case surgery, and we will discuss this in more detail.

Drugs and dosages

Bupivacaine is the most common LA used, usually in a concentration of 0.25% or 0.125% for a shorter motor block. Depending on the level of surgery the following guide for volume of injectate is suggested; lumbosacral block 0.5 ml/kg, thoracolumbar block 1 ml/kg and for midthoracic block 1.25 ml/kg. To prolong analgesia without using an additive, a two shot technique using half the total LA prior to surgery and half prior to emergence has been described.38 Levobupivacaine39is the S-enantiomer of bupivacaine and produces a similar block. A single caudal dose of 2 mg/kg in children under the age of 2 years

Caudal anaesthesia
Caudal anaesthesia provides intraoperative and postoperative analgesia for operations below T10, e.g. inguinal herniotomy, lower abdominal and lower limb surgery.36

Anatomy
The sacral hiatus is a failure of the 5th sacral neural arch to fuse posteriorly. It is covered by the

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278 gives a peak plasma concentration within the safe limit described for bupivacaine. Ropivacaine,40 which was the rst enantiomer developed, has a similar onset and duration of action as bupivacaine but with less motor weakness. Peak plasma concentrations are achieved more slowly compared to adults, which may be due to greater buffering properties of and lower clearance from the epidural space in the child. The drug may also have some vasoconstrictor properties. A dose of 12 mg/kg at a 0.2% concentration provides the best analgesia without causing prolonged motor block.
Table 5

M. Cunliffe, S.A. Roberts

Complications of caudals.

Failure to locate space Subcutaneous injection Subperiosteal/intraosseous injection Inadequate analgesia Dural tap Total spinal Intravascular puncture Leg weakness Urinary retention

Complications of caudals36 Additives41

One shot caudals have a limited duration of action. This can be improved by the addition of various adjuvants, with ketamine, opioids and clonidine being the most successful. Additives should be limited in their use to infants over one year of age. Ketamine in a dose of 0.5 mg/kg provides a good compromise between length of analgesia and incidence of side effects. It must be preservative free to avoid neurotoxicity. The introduction of Sketamine42 may prove to be superior, with greater analgesic potency and reduced behavioural side effects. Ketamine will prolong the analgesia of a caudal to around 16 h. Clonidine,43 an a2 agonist, in a dose of 1 mcg/kg increases the duration of the block without causing cardiovascular complications. Sedation is seen with higher doses, though this may be seen as an advantage in the recovery period. Clonidine has been shown to increase the duration of block by 616.5 h in different studies. A recent study comparing the same dose of clonidine given caudally or IV in combination with caudal bupivacaine, showed no difference in the duration of analgesia between the 2 groups.44 Morphine45at a dose of 50 mcg/kg prolongs the duration of action of the caudal the longest, to 20 h. The risk of respiratory depression and the increased incidence of unpleasant side effects make it an unsuitable additive for day surgery patients. Epinephrine in a dose of 5 mcg/kg is used to decrease vascular absorption of LA. It does not prolong the duration of analgesia produced. There has been promising work on tramadol, midazolam and neostigmine as adjuvants, but the safety issues of these drugs are less well documented and therefore cannot be recommended. See Table 5.

Pain management after major surgery

Opioid infusions
Morphine is the most commonly used opioid given by infusion.46 From 4 months of age we can use a standard protocol in all children. The infusion is made up according to body weight as follows. Body weight in mg of morphine made up to 50 ml=20 mcg/kg/ml of morphine. For children over 50 kg body weight, a solution containing 1 mg/ml should be used. A loading dose of 80160 mcg/kg should be given followed by an infusion of 1040 mcg/kg/h (0.52 ml/h). For infants less than 4 months of age, a halfstrength solution should be made, giving a concentration of 10 mcg/kg/ml. The loading dose and infusion rate should also be halved to 4080 mcg/kg loading dose and an infusion of 520 mcg/kg/h. If a high pain score is recorded, it is common for the infusion rate to be increased by 0.5 ml/h. For pharmacokinetic reasons, this will result in poor pain control, as to achieve a new steady state will take 5 times the half-life of morphine (5 3) which is 15 h. In neonates and young infants this will be even more prolonged. To achieve rapid analgesic control a bolus of morphine should be given alongside the increase in infusion rate. This is not easy to manage using a simple infusion pump. What we need is a smart morphine infusion, otherwise known as Nurse Controlled Analgesia (NCA).

Nurse controlled analgesia

NCA47 using a standard Patient Controlled Analgesia (PCA) pump allows us to give a smart morphine infusion. The morphine solution is made up in the

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Pain management in children
Table 6 PCA/NCA programmes. NCA programme 13 months of age Drug concentration 10 mcg/kg/ml Loading dose 40100 mcg/kg Infusion rate 10 mcg/kg/h Bolus dose 5 mcg/kg Lockout time 60 min PCA programme Drug concentration 20 mcg/kg/ml Loading dose 80140 mcg/kg Infusion rate 4 mcg/kg/h Bolus dose 20 mcg/kg Lockout time 5 min

279

NCA programmeNeonates Drug concentration 10 mcg/kg/ml Loading dose 4080 mcg/kg Infusion rate 5 mcg/kg/h Bolus dose 5 mcg Lockout time 60 min NCA programme-3 months of age Drug concentration 20 mcg/kg/ml Loading dose 80140 mcg/kg Infusion rate 20 mcg/kg/h Bolus dose 20 mcg/kg Lockout time 15 min

same way and contains 20 mcg/kg/ml. A mid-range background infusion of 20 mcg/kg/h is set with boluses of a further 20 mcg/kg able to be given up to 4 times per hour. Typical programmes for NCA and PCA can be found in Table 6. In very young infants again we would use a lower infusion rate and bolus size with a much longer lockout time. The nursing staff are instructed to give a top up bolus if the child has a raised pain score and no signs of respiratory depression. They are also allowed to give preemptive analgesia before moving the child or performing a painful procedure. NCA should be used in all children unable to cope with PCA either because of age or disability.

tion of the stress response, decreased bleeding and improved wound healing.

Anatomical considerations

      

Patient controlled analgesia

PCA can be used from about 6 years of age. A much lower background infusion is used, with a standard bolus dose of 20 mcg/kg and a lockout of 5 min.48 In children a small background infusion of 4 mcg/kg/h is used to improve analgesia, without increasing the risk of respiratory depression.49 As with adults, the inherent safety of PCA depends on the fact that only the child should press the button. Following major surgery a morphine infusion will normally be needed for 24 days.

At birth the cord is found at L3 and the dura at S3/4 At 1 year the cord is found at L1/2 and the dura at S2 Sacrum lies higher so the intercristal line in neonates is at L5/S1 and in children at L5 Softer spinal ligaments Vertebrae are cartilaginous and so easily penetrated Epidural space is less densely packed so aiding spread of injectate Neonatal skinepidural distance is 415 mm.

Children under 8 years of age are cardiovascularly unaffected by sympathetic blockade, because of reduced sympathetic tone, smaller blood volumes in the lower limbs and splanchnic circulation, and higher vagal tone. Above 8 years the response is variable.

Technique
The epidural catheter tip should be at the level of operation for optimal pain relief at low infusion rates. A mid-line approach is commonly used, even for thoracic catheters. An estimate of depth to epidural space can be made using a variety of formulae, e.g. distance in mm=(2 age in years)+10 mm. The space is located using a loss of resistance to air or saline, applying a continuous pressure to the syringe. The advantage of using air is a greater sensitivity, however air emboli have occurred, and its use has been implicated in patchy blocks and nerve root compression.53 Ultrasound has been used in adults to identify epidural level and measure the skin to epidural distance

Epidural infusions
Epidural analgesia without doubt provides the gold standard for postoperative analgesia. The potential complications can be catastrophic and so there has to be a risk benet assessment prior to its undertaking.50,51 As children are less likely to cooperate, the majority are placed under general anaesthesia. Epidurals can be inserted using the thoracic, lumbar or sacral routes,52 and their use intraoperatively is vapour/opioid sparing, allowing early extubation. Additional advantages include attenua-

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280 reliably.54,55 Its application for paediatric epidurals is evolving. In the majority of children an 18G Tuohy needle is used, although in neonates a 20G is more appropriate. Prior to threading the catheter it should be ushed to ensure patency and remove air. The catheter is inserted 24 cm into the epidural space. An aspiration test is performed, and if used, a test dose injected. Test doses used to detect intravascular placement are not reliable in anaesthetised children.56,57 It is important to inject any bolus of LA slowly. Catheters may be threaded up the epidural space from a caudal or lumbar insertion. This technique is most reliable in infancy.58 Any difculty in threading the catheter can be overcome by injecting a small volume of saline and/or exion/extension of the spine. A styletted catheter and use of nerve stimulation may allow more accurate positioning of the catheter.59
Table 7

M. Cunliffe, S.A. Roberts

Complications of epidurals.

Neurological damage Dural tap Hypotension Urinary retention Pressure sores Infection Haematoma Epidural site leakage Catheter occlusion Catheter disconnection

Drug administration
Intra-operatively, it is common to produce analgesia using boluses of LA. Postoperatively, infusions are more advantageous as they provide continuous analgesia and are less labour intensive. It is common to use an infusion of LA with an opioid, such as 0.125% levobupivacaine with 2 mcg/ml of fentanyl. In children sensitive to the respiratory depressant effects of opioids, a solution containing LA and clonidine may be used, the latter usually in a concentration of 0.5 or 1 mcg/ml. At this concentration little sedation normally occurs, and anecdotally it may relieve muscle spasm in children with cerebral palsy after major lower limb surgery. The infusion regimen should administer less than the maximum dose of LA within any 4 hourly period. Infusion rates should be reduced by 2530% each day to avoid accumulation and LA toxicity. In neonates a plain solution of bupivacaine is used without additives, and is limited to a maximum duration of 48 h to avoid LA toxicity.60

tory depression should be assessed using level of sedation, respiratory rate and oxygen saturation (it is rare for children to receive oxygen therapy postoperatively). Some assessment of nausea and vomiting should be recorded, and pump functioning should be monitored by recording the volume of solution left in the syringe regularly. Recording the number of demands made alongside the number which are successful helps to assess whether the child is using the device well and whether the programme is optimal. Epidural sites should be regularly checked for leakage and signs of infection.

Non-pharmacological methods of pain control

Distraction makes pain more bearable by putting it at the periphery of awareness. It does not reduce pain intensity. It is most useful in helping the child to deal with short duration pain such as lumbar puncture and venepuncture. Some useful distraction therapies are blowing bubbles, singing together, having a story told, watching a video or playing a computer game. Relaxation reduces the distress associated with pain. Pain tolerance is usually increased in the relaxed patient. Patients with chronic pain or ongoing pain can use the technique many times during the course of a day. Simple techniques involve deep breathing or rhythmic movement of a limb. The technique should be taught and practised prior to being needed. Guided imagery uses a combination of distraction and relaxation to modify the response to pain. It requires training in how to use the technique. The child is guided through an intense sensory image which has produced pleasure in the childs past. Massage involves manual manipulation of soft tissues within the body to produce relaxation of the muscles and a feeling of well being.

Complications
See Table 7.

Monitoring the child having an opioid infusion

All children on opioid infusions by whatever route should be monitored hourly.61 Adequacy of analgesia should be monitored using pain scoring. Respira-

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Pain management in children Sucrose administration to infants prior to heel lance procedures reduces pain and distress through release of endorphins, especially when combined with non-nutritive sucking.62 281 It is important to remember that if drugs are given to provide sedation for a procedure then the child needs to be continuously monitored and assessed by someone other than the person performing that procedure.64 A source of oxygen with an appropriate means of administering it, suction apparatus and emergency drugs need to be immediately available in the room. Sedation performed within the ward setting by a nonanaesthetist should always be conscious sedation (where the child is in verbal contact at all times) and not light anaesthesia.

Procedural pain
During the course of their childhood, many children will need to undergo a medical procedurevenous cannulation, lumbar puncture, cleaning of a wound or removing sutures to name a few. The procedures vary widely in their duration and invasiveness and the amount of pain they produce. Even for very simple procedures there needs to be a plan made of how it will be conducted. An explanation, which should not be lengthy, is given to the child. It should describe what will happen and what it may feel like in terms that the child can understand. Some instructions should be given to the parents on how they can support their child through it. The procedure should take place away from the bedside if possible so that the bedside can be considered a safe place. Any equipment needed for the procedure should have been prepared in advance, so that there is no delay in starting, once the child comes into the room. Depending on the procedure a combination of psychological and pharmacological techniques should be used. Many procedures will be possible using only play/distraction and topical LA creams. The choice of any pharmacological intervention should be based on the goals to be achieved. It is important to remember that if the procedure produces pain during or after it, then analgesia should always be given prior to it. Use of entonox (a mixture of 50% nitrous oxide in oxygen) is a useful method of producing analgesia of fast onset.63 It is given via a demand valve which opens on inspiration. The child can breathe the mixture via a facemask or mouth piece. Entonox can be used in children down to 3 years of age. It is contra-indicated in children with pneumothorax, obstructed bowel, head injury or chronic lung disease. Children who are extremely anxious may require an anxiolytic or sedative prior to their procedure. The child who has been sensitised by previous procedure related pain that was not well-managed may have extreme anticipatory anxiety that may not respond well to verbal reassurance. Formal psychological intervention may be needed to help the child develop coping skills, but this needs time and is not something which can be done immediately before the procedure.

Chronic pain
The spectrum of chronic pain in children is different from that found in adults, being rarely due to degenerative disease.65 The three major causes of pain in adolescence are headache, recurrent abdominal pain (RAP) and complex regional pain syndrome. Much less common is pain associated with cancer or arthritis. Children with cerebral palsy have a high incidence of chronic pain, which develops with age, due to chronic joint problems (usually dislocation, especially of hips) and chronic reux causing abdominal pain. There is much less evidence in the literature on management of chronic pain in children. Any treatment instigated should be based on adult practice for treating that condition. It is important that the family are also involved early in the childs treatment, especially if long term opioids are needed to control pain. Long-term unremitting pain may require as much psychological input in treatment as drug treatment. In particular a multidisciplinary approach needs to be taken. Chronic Pain Services for children have been slow to develop. There is a general lack of appreciation on the incidence of chronic pain in children and the effectiveness that a specialised clinic can have on their management.

Summary
Pain management in children has come a long way in the last 15 years. Enormous strides have been made in managing it effectively and safely in the postoperative period. Strategies to improve procedural pain management are being developed in many countries, including the safe use of sedation in children. More needs to be done to address the needs of children with chronic pain, and regional or supra-regional

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282 centres need to be developed to improve treatment and to conduct research in the subject. M. Cunliffe, S.A. Roberts
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