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Pain Management in Children

Dr.Mumtaz Ahmed Qureshi


Department of Pediatric
Surgery LUMHS Jamshoro.
Pain Management in Children
Different age Groups
Neonates- 0 to 30 days.
Infants- Birth to 1 year.
Toddlers- 1 to 3 years.
Preschoolers- 3 to 5 years.
School Age- 6 to 12 years.
Adolescent- 13 to 18 years.
Pain in Children
Infants are neurologically immature
and therefore cannot conduct pain
impulses.
Infants do not remember pain,
because of cortical immaturity.
Children do report pain while playing
or sleeping.
Effects of Acute Pain
Physiologic

Metabolic

Behavioral
Physiologic Response
Increased heart rate

Increased respiratory rate

Increased blood pressure

Decrease in oxygen saturation
Metabolic Response
Increased secretion of catecholamine,
glucagon, and corticosteroids.
Delayed wound healing
Poor intake / anorexia
Impaired mobility
Sleep disturbances
Irritability

Behavioral Response
Facial expression of pain.
Infant Response to Pain
Forcefully closed eyes
Lowered brows
Deepened furrow between nose and
outer corner of lip.
Square mouth
Cupped tongue

Toddler and Pre-school
Limited in their cognitive abilities in
localizing and expressing pain
intensity, and understanding reasons
for pain.
Find out word they use to express pain
Point to pain
Faces is a good tool for them.
School-age
Increased ability to communicate pain
in more abstract terms.
They can describe pain: squeezing,
stabbing or burning
Respond well to direct questioning.
Tools: body outline, faces scale, visual
analog.
Pre-procedural Pain

Key to managing procedural related
pain is anticipation
Anticipated intensity and duration
Child / parent receive appropriate
information to minimize distress
Child / Parent Preparation
Quiet environment
Calm nurse
Clear confident instructions
Pain management according to cause
or underlying disease.
Localized anesthetics
Systemic agents
Sedatives
Classification of Pain
Nocioceptive
Somatic
Bone, joint, muscle, skin, or connective tissue
Well localized
Aching & throbbing
Visceral
Visceral organs such as GI tract
Poorly localized
Cramping

Neuropathic
Central
Injury to peripheral or central nervous system causing
phantom pain
Dysregulation of the autonomic nervous system (e.g.
Complex regional pain syndrome)
Peripheral
Peripheral neuropathy due to nerve injury
Pain along nerve fibers
Types of Pain
Procedural pain
Post-operative pain
Sickle cell pain
Neuropathic pain
Cancer pain
Pain in palliative care

Operative Pain
Morbidity and mortality can be reduced
by good pain treatment
Plans for postoperative pain should be
discussed before surgery
Goal is to control the pain as rapidly as
possible
Post-Operative Pain
Oral administration is preferred for mild to
moderate pain.
IV is indicated for immediate pain relief.
Persistent moderate to severe pain
continuous around the clock dosing at fixed
intervals is recommended.
PCA patient-controlled analgesia used
only when patient can use pump on their
own.
Side Effects
Nausea, vomiting and puritus are
common side effects
Constipation with prolonged use of
opioids

Pain Assessment
Methods of assessment vary
according to age and cognitive level of
child
Patient report
Numerical scale 1 to 10
FACES can be used at all ages
FLAC used on infants
FACES
Monitoring
A cardiac / respiratory monitor is used
for infants less than 7 months
Oximetry monitors for other patients
during use of IV opioids
Unstable respiratory status
History of difficult airway management
Neurologically impaired
Principles of Pharmacology
Consider patients age, associated
medical problems, type of pain, &
previous experience with pain
Choose type of analgesia
Choose route to control pain as rapidly
and effectively as possible
Titrate further doses based on initial
response
Anticipate side effects

NSAIDs
Antipyretic
Analgesic for mild to moderate pain
Anti-inflammatory
COX inhibitor Prostaglandin inhibitor
Platelet aggregation inhibitor


Side Effects of NSAIDs
Gastritis
Prolonged use increases risk of GI bleed
Still rare in pediatric patients compared to adults
NSAID use contraindicated in ulcer disease
Nephropathy (ATN)
Bleeding from platelet anti-aggregation
Increased risk versus benefit post-tonsillectomy
NSAID use contraindicated in active bleeding
Delayed bone healing?

Opioids Analgesics
Moderate to severe pain
Various routes of administration
Different pharmacokinetics for different
age groups
Infants younger than 3 months have
increased risk of hypoventilation and
respiratory depression
Low risk of addiction among children
Side Effects of Opioids
All opioids have side effects that
should be anticipated & managed
Respiratory depression
Nausea, vomiting
Constipation
Pruritis
Urinary retention

Key Points
Treat pain
Adhere to general principles of pain
management
Anticipate & prevent pain
Adequately assess pain
Use multi-modal approach
Involve parents & patients
Use non-noxious routes
Understand the pharmacology of non-opioid
and opioid analgesics
Approach and treat different types of pain
accordingly

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