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Pediatric Pain Management and SedationView this Special Issue Review Article | Open Access Academic Editor: Keira Mason Received30 Jan 2010 Accepted04 May 2010 Published25 Jul 2010 Pain perception in children is complex, and is often difficult to assess. In addition, pain management in children is not always optimized in various healthcare settings, including emergency departments. A review of pain assessment scales that can be used in children across all ages, and a discussion of the importance of pain in control and distraction techniques during painful procedures are presented. Age specific nonpharmacological interventions used to manage pain in children are most effective when adapted to the developmental level of the child. Distraction techniques are often provided by nurses, parents or child life specialists and help in pain alleviation during procedures. 1. IntroductionFor pediatric patients presenting to the emergency department, medical procedures are often painful, unexpected, and heightened by situational stress and anxiety leading to an overall unpleasant experience. Although the principles of pain evaluation and management apply across the human lifespan, infants and children present unique challenges that necessitate consideration of the child’s age, developmental level, cognitive and communication skills, previous pain experiences, and associated beliefs [1]. According to the International Association for the Study of Pain, “Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage”. Perception of pain in pediatrics is complex, and entails physiological, psychological, behavioral, and developmental factors [1]. However, in spite of its frequency, pain in infants, children, and adolescent is often underestimated and under treated [2]. It has also been shown that infants and children, who experience pain in early life, show long-term changes in terms of pain perception and related behaviors [2]. Health care professionals in this setting have a responsibility to reduce pain and anxiety as much as possible while maintaining patient safety. Pain in infants and children can be difficult to assess which has led to the creation of numerous age-specific pain management tools and scores. Health care workers need to be able to detect the symptoms and signs of pain in different age groups and determine whether these symptoms are caused by pain or other factors [1]. It is difficult for health care professionals to foresee which measurement systems apply to accurately measure pain in the pediatric population [1]. Health care professionals often prefer practical methods, which reliably track the child’s pain experience and pain control over time whereas researchers tend to focus on tools, which are meticulously proven for reliability with different observers. Thus a balance may be hard to achieve [1]. Barriers to pain management in children are numerous and include inaccuracies regarding pathophysiological mechanisms of pain with statements such as “children do not feel pain the way adults do” [3], fears regarding the use of pharmacological agents and deficits in knowledge of methods of pain assessment [3, 4]. These myths and other factors such as personal values and beliefs, prevent adequate identification and alleviation of pain for all children [2, 3]. Effective care in pediatrics requires special attention to the developmental stage of the child. Current research does not adequately discuss the effectiveness of certain tools and measurements used to assess pain in children at various ages [5]. The experience of pain and coping strategies from developmental perspective is also limited. In this paper, our aim is to address potential sources of pain measurement, and responses to pain control and distraction based on pediatric developmental stages. Pharmacological pain management will not be discussed, as it is beyond the intended scope of this article. 2. Pain Assessment ToolsAccurate pain measurements in children are difficult to achieve. Three main methods are currently used to measure pain intensity: self report, behavioral, and physiological measures. Self-report measures are optimal and the most valid [4]. Both verbal and nonverbal reports require a certain level of cognitive and language development for the child to understand and give reliable responses [4]. Children’s capability to describe pain increases with age and experience, and changes throughout their developmental stages [4]. Although, observed reports of pain and distress provide helpful information, particularly for younger children, they are reliant on the individuals completing the report [6]. Behavioral measures consist of assessment of crying, facial expressions, body postures, and movements. They are more frequently used with neonates, infants, and younger children where communication is difficult [7]. Physiological measures include assessment of heart rate, blood pressure, respiration, oxygen saturation, palmer sweating, and sometimes neuro-endocrine responses [8]. They are however generally used in combination with behavioral and self-report measures, as they are usually valid for short duration acute pain and differ with the general health and maturational age of the infant or child [8]. In addition, similar physiological responses also occur during stress which results in difficulty distinguishing stress versus pain responses. A summary of the following pain assessment tools by age can be found in Table 1. 2.1. Neonates and InfantsDespite early studies, current research supports that infants possess the anatomical and functional requirements to perceive pain [9]. Recent studies also demonstrate that infants elicit certain behavioral responses to pain perception [10]. Pain in infants, despite this data, remains under-treated and often mismanaged [11]. The most common pain measures used for infants are behavioral. These measures include crying, facial expressions, body posture, and movements. The quality of these behaviors depends on the infant’s gestational age, and maturity [12]. Preterm or acutely ill infants, for example, do not illicit similar responses to pain due to illness and lack of energy. In addition, interpretation of crying in infants is especially difficult as it may indicate general distress rather than pain. Cry characteristics are also not good indicators in preterm or acutely ill infants, as it is difficult for them to produce a robust cry [12]. Numerous scales are currently available to measure behavioral indicators in infants, the most common being the Neonatal Facial Coding System (NFCS) and the Neonatal Infant Pain Scale (NIPS). Other scales used with infants are composite measurement scales, meaning they use a combination of behavioral and physiological measures. Some scales also take into consideration gestational age and the general behavioral state of the infant [13]. Examples of these scales are The Premature Infant Pain Profile (PIPP), Crying Requires Increased Vital Signs Expression Sleeplessness (CRIES), and the Maximally Discriminate Facial Movement Coding System (MAX) [14–16]. Neonatal Facial Coding System (NFCS) Neonatal Infant Pain Scale (NIPS) The Premature Infant Pain Profile (PIPP) Crying Requires Increased Vital Signs Expression Sleeplessness (CRIES) Maximally Discriminate Facial Movement Coding System (MAX) 2.2. ToddlersIn toddlers, verbal skills remain limited and quite inconsistent. Pain-related behaviors are still the main indicator for assessments in this age group. Nonverbal behaviors, such as facial expression, limb movement, grasping, holding, and crying, are considered more reliable and objective, measures of pain than self-reports [26]. Most children of this age however are capable of voluntarily producing displays of distress, with older children displaying fewer pain behaviors (e.g., they cry, moan, and groan less often). Most two-year-old children can report the incidence and location of pain, but do not have the adequate cognitive skills to describe its severity [27]. Three-year-old children, however, can start to differentiate the severity of pain, and are able to use a three-level pain intensity scale with simple terms like “no pain, little pain or a lot” [27]. Children in this age group are usually able to participate in simple dialogue and state whether they feel pain and “how bad it is” [27]. The following section describes common scales used for this age group. The Children's Hospital of Eastern Ontario Pain Scales (CHEOPS) The Faces Legs Activity Cry Consolability Scale (FLACC) The COMFORT Scale The Observational Scale of Behavioral Distress (OSBD) Observational Pain Scale (OPS) The Toddler-Preschooler Postoperative Pain Scale (TPPPS) 2.3. PreschoolersBy the age of four years, most children are usually able to use 4-5 item pain discrimination scales [43]. Their ability to recognize the influence of pain appears around the age of five years when they are able to rate the intensity of pain [44]. Facial expression scales are most commonly used with this age group to obtain self-reports of pain. These scales require children to point to the face that represents how they feel or the amount of pain they are experiencing [45]. The following section describes scales commonly used with this age group. The Child Facial Coding System (CFCS) Poker Chip Tool Faces Pain Scale The OUCHER Scale 2.4. School-Aged ChildrenHealth care professionals depend more comfortably on self-reports from school-aged children. Although children at this age understand pain, their use of language to report it is different from adults. At roughly 7 to 8 years of age children, begin to understand the quality of pain [57]. Self-report visual analogue and numerical scales are effective in this age group. A few pain questionnaires have also proven effective for this age such as the pediatric pain questionnaire and the adolescent pediatric pain tool [58, 59]. A brief discussion of these tools is presented here. Visual Analogue Scale (VAS) Paediatric Pain Questionnaire Adolescent Pediatric Pain Tool (APPT) 2.5. AdolescentsAdolescents tend to minimize or deny pain, especially in front of friends, so it is important to provide them with privacy and choice. For example, they may or may not choose to have parents present. They expect developmentally appropriate information about procedures and accompanying sensations. Some adolescents regress in behavior under stress [3]. They also need to feel able to accept or refuse strategies and medications to make procedures more tolerable. To assess pain and, specifically chronic pain, the adolescent pediatric pain tool (see above section) or the McGill pain questionnaire are helpful. The McGill Pain Questionnaire (MPQ) 3. Minimizing Pain during Procedures: Nonpharmacologic MethodsPain is one of the most frequent complaints presented in paediatric emergency settings. The emergency department itself is a very stressful place for children. Thus it is important for health care providers to follow a child centered or individual approach in their assessment and management of pain and painful procedures [70]. This approach promotes the right of the child to be fully involved in the procedure, to choose, associate, and communicate. It allows freedom for children to think, experience, explore, question, and search for answers, and allows them to feel proud for doing things for themselves. It is essential to focus on the child rather than the procedure and avoid statements such as “let’s just get it over with” [70]. The child and family should be active participants in the procedure. In fact, allowing parents or family members to act as positive assistants rather than negative restraints helps to reduce stress in both children and parents and minimizes the pain experience [70]. It is also essential to ensure that all procedures are truly necessary, and can be performed safely by experienced personnel. Ideally procedures should be done in a child-friendly environment, using appropriate pharmacologic and nonpharmacologic interventions with routine pain assessment and reassessment [70]. Distraction is the most frequent intervention used in the emergency department to guide children’s attention away from the painful stimuli and reduce pain and anxiety. It is most effective when adapted to the developmental level of the child [71]. Distraction techniques are often provided by nurses, parents or child life specialists. Current research has shown that distraction can lead to the reduction in procedure times, and the number of staff required for the procedure [72]. Distraction has also proven to be more economical than using certain analgesics [73]. Distraction is divided into two main categories: passive distraction, which calls for the child to remain quiet while the health care professional is actively distracting the child (i.e., by singing, talking, or reading a book) [74]. Active distraction, on the other hand, encourages the child’s participation in the activities during the procedures [74]. Interventions used to minimise pain are classified into three main categories (cognitive, behavioral, or combined) [75]. Cognitive Interventions Behavioral Interventions Current studies are beginning to take into consideration children’s different responses to distraction interventions based on their developmental stage, maturity level, and age. Our goal in this section is to provide various forms of distraction that are proven effective with different age groups. 3.1. Neonates and InfantsWhen performing painful procedures on infants, it is important to take into consideration the context of the procedure (i.e., is the procedure really necessary, how many painful procedures has the infant had in the past, and what was their previous pain experience) [85]. The procedural environment should also be developmentally sensitive [86]. In fact, reducing noise and lighting, use of soothing smells and clustering procedures to avoid over handling, reduces pain reactions in infants [86]. Distraction techniques used with this age group are mostly passive. Cognitive strategies used to reduce pain perception in infants are either visual or auditory interventions. Visual aids can include pictures, cartoons, mobile phones, and mirrors [87]. Auditory aids include music, lullabies sung by parents or health care professionals [88]. Music is more frequently being used to improve painful outcomes in infants [89]. Studies suggest that music can significantly impact behavioral reactions to pain, but not physiological measures [89]. Behavioral strategies are more common for this age group, and involve either “direct or indirect” interventions that engage the caregivers in handling the infants [90]. The combination of different strategies to provoke different senses has been shown to be more effective [91]. Examples of behavioral strategies include the following.(1)Non-nutritive sucking, an indirect intervention involving insertion of a pacifier or a nonlactating nipple into the infant’s mouth to encourage sucking behaviors, was found to stimulate the orotactile and mechano receptors, and decrease cry durations and heart rate [92]. (2)Skin to skin contact with the mother (kangaroo care), where the infant is positioned on the mother’s exposed chest during, or after the painful procedure [93]. (3)Rocking and holding the infant, where the infant is carried by a parent or caregiver during (if possible) and after the painful procedure and gently rocked [94]. (4)Swaddling the infant is another similar calming technique where the infant is wrapped with its extremities close to their trunk to prevent him/her from moving around excessively [95]. 3.2. Toddlers and PreschoolersFor young children, explaining the procedures with age appropriate information is useful, in addition to providing them with the opportunities to ask questions [70]. Examples for active distraction used with this age group include, allowing them to blow bubbles, providing toys with lots of colour or toys that light up. Initiating distracting conservations (e.g., how many brothers and sisters do you have? What did you do at your birthday party?) and deep breathing methods are also helpful for older children [74]. Passive distraction techniques include: having the parents or child life specialist read age appropriate books, sing songs, and practicing “blowing out birthday candles” with the child [74]. 3.3. School-Aged ChildrenOlder children have a better understanding of procedures and why they are being done, thus providing them with age appropriate information is also important [70]. Providing children with a choice (e.g., sit or lie down, choose which hand) helps them feel in control of the situation [70]. Asking parents about their child’s previous pain experiences and coping mechanisms helps health care professionals identify appropriate interventions to use with the child. Educating school-aged children about passive and active techniques available will help them cope with the distress and anxiety of the procedure [70]. Active techniques for this age group include blowing bubbles, singing songs, squeeze balls, relaxation breathing and playing with electronic devices [74]. Passive distraction can include watching videos, listening to music on headphones, reading a book to the child or telling them a story [74]. 3.4. AdolescentsIt is essential to always ensure a private setting for procedures with adolescents especially as they sometimes tend to deny pain in front of friends, and family. Giving them the power to choose the type of distraction, or whether they want friends and family present is helpful [70]. Striking conversations, using squeeze balls or having them play with electronic devices are examples of active techniques, while passive distractions include watching videos, training them to breathe deeply (in from the nose, count to 5 and out through the mouth), and listening to music [74]. 4. ConclusionAlthough there is an overwhelming amount of data regarding effective paediatric pain assessment and management, it is often not being effectively applied. Current studies demonstrate pain management in children remains undertreated. It is the responsibility of health care professionals to educate their peers and advocate for appropriate pain treatment in children. Infants and children present a unique challenge that necessitate consideration of their age, developmental level, cognitive and communication skills, previous pain experiences, and associated beliefs. There is a need for more research to illuminate optimal pain management and strategies that take these special needs into consideration, to improve the treatment of pain in children. References
CopyrightCopyright © 2010 Rasha Srouji et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. What is the most consistent indicator of pain in infants?In an infant, facial expression is the most common and consistent behavioral response to all stimuli, painful or pleasurable, and may be the single best indicator of pain for the healthcare provider and the parent.
Which type of pain assessment scale is especially used for infants?NIPS: Neonatal/Infants Pain Scale has been used mostly in infants less than 1 yr of age. Facial expression, cry, breathing pattern, arms, legs, and state of arousal are observed for 1 minute intervals before, during, and after a procedure and a numeric score is assigned to each. A score >3 indicates pain.
How do you assess the pain of an infant?The best way to assess pain in babies is to observe how they behave. The FLACC (faces, legs, activity, cry, consolability) scale is an easy-to-use tool that helps measure pain in children who are too young to talk.
Which drug is usually the best choice for a patient controlled analgesia for a child in immediate postoperative?Morphine is the most commonly used opioid for pediatric IV-PCA and the dose is based on the child's body weight. The optimum bolus dose (usually 0.02 mg/kg) is the minimum dose required to produce satisfactory analgesia without causing significant side effects.
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