Timothy Horeczko, MD, MSCR, FACEP, FAAP
Associate Professor of Emergency Medicine
David Geffen School of Medicine at UCLA
Harbor-UCLA Medical Center Torrance, CA USA
Pain is multifactorial: it is comprised of physical, psychological, emotional, cultural, and contextual features. Determining which among these features is the dominant contributor to pain and distress may be difficult, especially in children. Although clinicians may focus on the physical component of pain, much time, energy, and suffering can be saved through a holistic approach. What is the age and developmental stage of the child? How is the child reacting to his condition? What are the circumstances? What is the family or caregiver dynamic?
Assessing and managing a child’s pain can be challenging, because children may not exhibit typical signs and symptoms of pain. (Srouji 2010) Further, children participate in and absorb their family’s culture and specific personality from a very young age, (Finley 2009) and we rely on how patients and families interact with us to gauge pain. For example, a very anxious caregiver can easily transmit his or her anxiety to the child, which may either inhibit or amplify the presentation of symptoms. (Bearden 2012)
The guiding principles in pediatric pain assessment and management are: know the child; know the family; and know the physiology. Children have long suffered from under-treatment of pain, due both to our incomplete recognition and acknowledgement of their pain as well as our fear of treatment. (Howard 2003) Though pain management paradigms have shifted in recent years, the central approach remains and well serves the emergency clinician caring for a child in pain: know the signs and symptoms, treat promptly, and frequently reassess for effectiveness.
Each stage of development offers a unique framework to the child’s signs and symptoms of pain. In pre-verbal children, use observational skills in addition to the parent’s report of behavior. Verbal children can self-report; younger children require pictorial descriptions, while older children and adolescents may use standard adult scales. In all ages, ask open-ended questions and allow the child to report and speak for himself whenever possible.
Neonates are a unique group in pain assessment. The neonate (birth to one month of age) has not yet acquired social expression of pain, and their nascent nervous system is only now learning to process it. Do not expect typical pain behaviors in neonates. Facial grimacing is a weak indicator of pain in this age group. (Liebelt 2000) Look for a furrowed brow, eyes squeezed shut, and an expressionless vertically open mouth. Tachycardia, tachypnea, and a change in behavior can be indicators not only of the presence of pain, but possibly suggestive of its etiology as well.
Neonatal observational scales have been validated in the intensive care and post-operative settings; ED-specific quantitative scales are lacking. CRIES is a 10-point scale, using a physiologic basis similar to APGAR: Crying; Requires increased oxygen administration (distress and breath-holding); Increased vital signs; Expression; and Sleeplessness. (Krechel 1995) CRIES (Table 1) was validated for post-operative patients; to adapt its use for the ED, substitute “preoperative baseline” with normal range for age. Although the numerical values of CRIES have not been validated to date in the ED, the clinician may find the domains included in CRIES to be a useful construct in assessing neonatal pain.
Neonatal pain pathways are particularly plastic; prompt assessment of and alertness to neonatal pain may help mitigate long-lived pain sensitivity and hyperalgesia. (Taddio 2002)
Infants and Toddlers
This group will begin to exhibit more reproducible, reliable signs and symptoms of pain.
For infants less than one year of age, the Neonatal Infant Pain Scale (NIPS) uses observational and physiologic parameters to detect pain (Table 2). A score of 0-2 indicates no pain present. A score of 3-4 indicates mild to moderate pain; non-pharmacologic techniques may be tried first in this group. A score of 5 or greater indicates severe pain; pharmacologic intervention is indicated (Lawrence 1993).
For children greater than one year who are preverbal, a well performing scale is the FLACC score: Face, Legs, Activity, Cry, Consolability (Table 3).
Contextual and caregiver features predominate in this group. Frequent reassessments are helpful, as the initial trepidation and fright in triage may not accurately reflect the child’s overall pain status.
Preschool and School-age children
Increasing language development offers the hope of more information to the clinician, but be careful not to ask leading questions. Do not jump directly to “does this hurt?” Preschoolers will say yes to anything, in an attempt to please you. School-age children may passively affirm your “statement,” if only to validate their need for care or attention. Start with some ice-breaking banter, lay down the foundations for rapport, and then ask open-ended questions. Be careful not to allow the caregiver to “instruct” the child to tell you where it hurts, how much, how often, etc. Rather, engage the parents by asking them what behavior they have noticed. Eliciting history from both the child and the parent will go a long way in constructing a richer picture of the etiology and severity of the pain, and will help to build rapport and trust.
The Baker-Wong FACES Pain Rating scale (Figure 1) was developed with feedback from children and has been validated for use in those 3 years of age and older. (Keck 1996, Tomlinson 2010)
Adolescents vary in their development, maturity, and coping mechanisms. You may see a mixture of childhood and adult behaviors in the same patient; e.g. he may be initially stoic or evasive of questioning, then later exhibiting pseudo-inconsolability. Do what you can to see the visit from the adolescent’s perspective, and actively transmit your concern and intention to help–many will respond to a warm, open, non-judgemental, and helpful attitude. The overly “tough” adolescent is likely secretly fearful, and the “dramatic” adolescent may simply be very anxious. Take a moment to gauge the background behind the presentation.
Adolescents can often engage directly on analgesia decision-making, but if a scale is needed, the typical adult scale of 0 (no pain) to 10 (worst pain), or the Faces Pain Scale–Revised (FPS-R) can be used. The FPS-R uses more neutral and realistic faces and, unlike the Wong Baker scale, does not use smiling or crying faces to anchor the extremes of pain (Tsze 2013).
Pain includes two major components: generation and perception. Generation of pain involves the actual propagation of painful stimuli, either through nociceptive pain or neuropathic pain.
Nociceptive pain arises from free nerve endings responding to tissue damage or inflammation and follows a specific sequence: transduction (an action potential triggered by chemical mediators in the tissue, such as prostaglandins, histamine, bradykinin, and substance P); transmission (the movement of the action potential signal along the nerve fibers to the spinal cord); perception (the impulse travels up the spinothalamic tract to the thalamus and midbrain, where input is splayed out to the limbic system, somatosensory cortex, and parietal and frontal lobes); and modulation (the midbrain enlists endorphins, enkephalins, dynorphin, and serotonin to mitigate pain). (Pasero 2011) As clinicians, we can target specific “stations” along the pain route to act on the signal more effectively.
Simple actions such as ice, elevation, local anesthetics, or splinting help in pain transduction. Various standard oral, intranasal, or IV analgesics may help with pain transmission. Non-pharmacologic techniques such as distraction and re-framing can help with pain perception. The sum of these efforts encourages pain modulation.
A phenomenon separate from nociceptive pain is neuropathic pain, the abnormal processing of pain stimuli. It is a dysregulated, chaotic process that is difficult to manage in any setting. Separating nociceptive from neuropathic symptoms may help to select specific pain treatments and to clarify treatment goals and expectations.
Neonates are exquisitely sensitive to many analgesics. Hepatic enzymes are immature and exhibit decreased clearance and prolonged circulating levels of the drug administered. Once the pain is controlled, less frequent administration of medications, with frequent reassessments, is indicated.
The neonate’s vital organs make up a larger proportion of their body mass than do muscle and fat. Therefore, the volume of distribution is unique in a neonate. Water-soluble drugs (e.g., morphine) reach these highly perfused vital organs quickly; relatively small excess in dosing will have rapid and exaggerated central nervous system and cardiorespiratory effects. The neonate’s small fat stores and muscle mass limit the volume of distribution of lipophilic medications (e.g., fentanyl), also making them more available to the central nervous system, and therefore more clinically potent. Other factors that predispose neonates to accidental analgesic overdose are their decreased concentrations of albumin and other plasma proteins, causing a higher proportion of unbound drug. Renal clearance is also decreased in the first few months of life.
In the ED, neonates often require analgesia for procedures, and non-pharmacologic techniques predominate (see below). Make liberal use of local anesthetics such as eutectic mixture of local anesthetics (EMLA; for intact skin, e.g. IV access, lumbar puncture) and lidocaine-epinephrine-tetracaine gel (LET; for superficial open skin and soft tissue application). Oral sucrose (30%) solutions, administered either with a small-volume syringe or pacifier frequently dipped in solution, are effective for minor procedures, (Harrison 2010, Stevens 2013) as is distraction by mechanical means. Neonates with severe pain may be managed with parenteral analgesics, while on a monitor, and with caution.
Infants and Toddlers
With increasing body mass comprised of fat stores in conjunction with an increase in metabolism, this group will require a different approach than the neonate. For many medications, these children will have a greater weight-normalized clearance than adults (Berde 2002) and will often require more frequent dosing. Infants and toddlers have a larger functioning liver mass per kilogram of body weight, with implications for medications cleared by this organ.
Some drugs, such as benzodiazepines, will have both a per-kilogram dosing as well as an age-specific modification. When giving analgesics or anxiolytics to young children, always consult a reference for proper dosing and frequency.
School-age children and Adolescents
This group retains some hyper-metabolic features of younger children, but the dose-effect relationship is more linear. Pharmacologic clearance is improved, and from a physiologic standpoint, these children are at lower risk for adverse drug events. From a psychological standpoint, this group may need more non-pharmacologic interventions and emotional support to modulate pain optimally.
The first line of treatment in all pain management is non-pharmacologic. (Horeczko 2016) Not only are these the safest of all techniques, but often the most effective. Some are simple comfort measures such as splinting (fracture or sprain) or applying cold (acute soft tissue injury) or heat (non-traumatic, non-specific pain). Many pain control regimens are sabotaged by the failure to consider non-pharmacologic techniques, which may augment, or at times replace, analgesics.
A tailored approach based on age will allow the practitioner to employ a child’s developmental strengths and avoid the frustration that results from asking the child to do what she is not capable of doing. A brief review of Piaget’s stages of development will help to meet the child at her developmental stage for best effect (Piaget 1928, Sheppard 1977) when managing painful conditions and performing minor procedures.
Sensorimotor stage (from birth to age 2): Children use the five senses and movement to explore the world. They are egocentric: they cannot see the world from another’s viewpoint. At 6 to 9 months, object permanence is established: understanding that objects (or people) exist even without seeing them.
Preoperational stage (from ages 2 to 7): Children learn to use language. Magical thinking predominates. They do not understand rational or logical thinking.
Concrete operational stage (from age 7 to early adolescence): Children can use logic, but in a very straightforward, concrete manner (they do well with simple examples). By this stage, they move from egocentrism to understanding another point of view.
Formal operational stage (early adolescence to adult): children are capable of abstract thinking, rationalizing, and logical thinking.
It is important to assess the child’s general level of development when preparing and guiding her through the minor procedure or utilizing distraction until pain is controlled. It is not uncommon for an acutely ill or injured child to regress temporarily in their behavior as a coping mechanism.
Neonate and Infant (0-12 months)
Involve the parent, and have the parent visible to the child at all times if possible. Make advances slowly, in a non-threatening manner; limit the number of staff in the room. Use soothing sensory measures: speak softly, offer a pacifier, and stroke the skin softly. Swaddle the infant and encourage the parent to comfort her during and after the procedure. Engage their developing sensorimotor skills to distract them.
Toddler to Preschooler (1-5 years)
Use the same techniques as for the infant, and add descriptions of what she will see, hear, and feel; you can use a doll or toy to demonstrate the procedure. Use simple, direct language, and give calm, firm directions, one at a time. Explain what you are doing just before doing it (do not allow too much time for fear or anxiety to take root). Offer choices when appropriate; ignore temper tantrums. Distraction techniques include storytelling, bright and flashy toys, blowing bubbles, pinwheels, or having another staff member play peek-a-boo across the room. The ubiquitous smart phone with videos or games can be mesmerizing at this age.
School age (6-12 years)
Explain procedures using simple language and (briefly) the reason for the procedure (understanding of bodily functions is vague in this age group). Allow the child to ask questions, and involve them when possible or appropriate. Distraction techniques may include electronic games, videos, guided imagery, and participation in the minor procedure as appropriate.
Adolescent (13 and up)
Use the same techniques for the school age child, but can add detail. Encourage questioning. Impose as few restrictions as possible – be flexible. Expect more regression to childish coping mechanisms in this age group. Distraction techniques include electronic games, video, guided imagery, muscle relaxation-meditation, and music (especially the adolescent’s own music, if available).
No amount of knowledge of physiology, pharmacology, or developmental theory will help your pediatric patient in pain without a well constructed and executed plan. Identify and reverse the source of the pain, if possible. Frequent reassessments are paramount to ensure that breakthrough pain is recognized and medication re-administration is indicated, or when a change of plan is necessary. This is the time to involve parents or caregivers: deputize them to notify you when the patient needs additional analgesia, and let them know what the next steps are, and what to expect.
Start with the least invasive modality and progress as needed. After non-pharmacologic treatments such as splinting, ice, elevation, distraction, and guided imagery, have an escalation of care in mind (Figure 2).
From a pharmacological perspective, many options are available. The pain management plan will differ depending on whether a painful procedure is performed in the ED (Table 4; see also Procedural Sedation in Children). Once pain is addressed, create a plan to keep it managed. Consider the trajectory of illness and the expected time frame of the painful episode. Include practicalities such as how well the pain may be controlled as an outpatient. Poorly controlled pediatric pain is more often managed as an inpatient than the same condition in an adult. Speak frankly with the parents about what drug is indicated for what type of pain and that treatment goals typically do not include absence of all pain, but increased function and comfort, in anticipation of clinical improvement.
A special note on codeine: Codeine (often prescribed as acetaminophen with codeine – “T3”) is a comparatively ineffective analgesic, and up to 10% of patients lack enzymatic activity to metabolize it into morphine, its active form. (Crews 2014) More importantly, recent evidence demonstrates that some children are ultra-rapid-metabolizers of codeine to morphine, which causes in effect a “bolus” of the available drug, with respiratory depression and death reported. (Ciszkowski 2009, Racoosin 2013) Codeine, including codeine combination preparations such as acetaminophen/codeine, should not be used for children and we recommend that codeine be removed from the formulary in pediatric hospitals or pediatric units.
Head and neck pain
Most common non-traumatic head and neck complaints can be managed non-pharmacologically (e.g. headache: improved hydration, sleep, stress management, nutrition) or with PO medications, such as NSAIDs. The anti-inflammatory properties of ibuprofen (10 mg/kg PO q 6 h prn, up to adult dose), for example, will often treat the cause as well as the symptoms of ear pain, sore throat, and muscular pain. Ibuprofen is more effective than acetaminophen for odontogenic pain, (Bailey 2013) and other painful conditions (MSK pain, migraine headache (Pierce 2010, Clark 2007, Hamalainen 1997) but evidence suggests equivalency or near-equivalency of ibuprofen and acetaminophen for most applications. The combination of both NSAIDs and acetaminophen is likely to be more effective than either agent individually. (Smith 2012, Ong 2010, Kraglund 2014, Pickering 2002)
Migraine headache may be treated with all of the above, and rescue therapy may include prochlorperazine (0.15 mg/kg IV, up to 10 mg) (Brousseau 2004), often given with diphenhydramine (1 mg/kg PO or IV, up to 50 mg) and IV fluids. Ketorolac (0.5 mg/kg IV, up to 15 mg) may be substituted for ibuprofen (Paniyot 2016).
After ruling out important pulmonary (e.g. pneumothorax) and cardiac (e.g. pericarditis, myocarditis) etiologies, many chest complaints are amenable to NSAIDs. There is often a component of anxiety in children with chest pain and in their parents as well; no amount of medication will assuage them without addressing these concerns.
Abdominal pain in children is common and generally benign, but the evaluation can be challenging. For patients with mild pain, consider acetaminophen as indicated (15 mg/kg/dose, up to 650 mg, q 4-6 h prn). The oral route is preferred, but intravenous acetaminophen is an option for patients unable to tolerate PO, or for those in whom the per rectum (PR) route is contraindicated (e.g. neutropenia). (Babl 2011, Dokko 2014) For children with moderate to severe acute abdominal pain who are unable to tolerate oral intake, consider intravenous rehydration/volume repletion, and small, titrated aliquots of an opioid. Surgical pain is not masked by opioids (Thomas 2003, Poonai 2014); in fact treating pain improves diagnostic specificity to certain surgical emergencies. (Manterola 2007) If there is inter-departmental concern about prolonged effects, sedation, limitation in the physical exam, or there is a need to “see if the pain will come back,” fentanyl is an option due to its shorter half-life, and more frequent re-assessments may help the surgical team in its deliberations.
Fracture pain should be addressed immediately with splinting, ice, and analgesia. Oral, intranasal, and intravenous routes are all acceptable, depending on the severity of the injury and pain.
Intranasal (IN) medications offer the advantage of a fast onset for patients with moderate-to-severe pain, (Graudins 2015) either as monotherapy or as a bridge to intravenous treatment (Table 4). The ideal volume of IN medication is 0.25 mL/naris, with a maximum of 1 mL/naris. Common concentrations of fentanyl limit its use to the school-aged child; intranasal ketamine may be used for pain (i.e. in sub-dissociative dose) up to adult weight.
Patients with long-bone injuries are amenable to analgesia with nebulized fentanyl, which can be administered quickly and simply. Clinically significant improvement in pain is achieved with 3 mcg/kg/dose of fentanyl administered via standard nebulizer. (Miner 2007, Furyk 2009) Early data suggests that nebulized fentanyl is a rapid, non-invasive alternative to the IN route for older children, adolescents, or adults, in whom the volume of IN medication would exceed the recommended per naris volume (Deaton 2015).
Consider an aggressive, multi-modal approach to control pain up front. For example, in a simple forearm fracture, consider an oral opioid, perform a hematoma block, and offer inhaled nitrous oxide for fracture reduction, rather than a formal intravenous procedural sedation (Luhmann 2006).
Ultrasound-guided peripheral nerve blocks are an effective pain control adjunct, after initial treatment, and in communication with downstream consultants (Ganesh 2009, Suresh 2014) who may rely on serial exams of the region.
Skin and Soft tissue
Skin and soft tissue injuries or abscesses often are best managed with non-pharmacologic analgesia in addition to local anesthetics. For IV cannulation, consider EMLA if the patient is stable and a minor delay is acceptable.
Topical ethyl chloride vapo-coolant offers transient pain relief due to rapid cooling and may be used just prior to an IV start. (Farion 2008) Engage a young child’s imagination to distract her and say, “have you ever held a snowball? You are in luck – it’s just like that – here, do you feel it?”
Vibratory adjuncts such as the “BUZZY” bee can be placed near the IV cannulation site to provide mechanical and cognitive distraction. (Moadad 2016)
Needleless lidocaine injectors may facilitate IV placement without obscuring the target vein (Spanos 2008, Lunoe 2015). The medication is propelled into the dermis by a CO2 cartridge that makes a loud popping sound. Just before using it, say “your skin looks thirsty – it needs a drink – there you are!”
As with any minor procedure, when you tell the child what you are doing, be sure to do it right away. Do not delay or build suspense.
Lidocaine-epinephrine-tetracaine gel (LET) is used for open or mucosal wounds. Apply as soon as possible in the visit. The goal of LET is to pretreat the wound to allow for a painless administration of injectable anesthetic. Applying LET two or three times at 15-minute intervals for deeper anesthesia may avoid the need for injection anesthesia altogether.
Pediatric burns should be assessed carefully and treated aggressively. Submersion of the affected extremity in room-temperature water (if possible) or applying room-temperature saline-soaked gauze will reduce ongoing thermal damage, soothe the wound, and provide foundational first-aid. Minor burns can be treated with topical and/or oral medications. Major burns generally require parenteral analgesia with opioids, ketamine, or nitrous oxide. In pediatric patients with severe or extensive burns, it is appropriate to use dissociative-dose ketamine to facilitate wound care. (Gandhi 2010) Post-traumatic psychological disorders are common in burns; effective pain management is ever-more important in these cases.
The child with chronic medical problems
Children with acute exacerbations of their chronic pain or episodic painful crises require special attention. Some examples of children with recurring pain are those suffering from sickle cell disease, juvenile idiopathic arthritis, and breakthrough cancer pain. Find out whether these symptoms and circumstances are typical for them, and what regimen has helped in the past. Previous unpleasant experiences may prime these children with amplified anxiety and perception of pain. (Cornelissen 2014) Target the disease process and do your best to show the patient and family you understand their condition and needs.
An equally challenging scenario is the child with chronic pain. Treat the entire patient with a multimodal approach and limit opioids as possible. As an opioid-sparing strategy or as rescue therapy, sub-dissociative ketamine is effective for conditions such as sickle cell crisis, autoimmune disorders, or chronic pain due to sub-acute trauma. (Sheehy 2015) Intranasal ketamine may be used for sub-dissociative pain control at 0.5 – 1 mg/kg. (Andolfatto 2013, Yeaman 2013) Intravenous infusions of ketamine at 0.1 – 0.3 mg/kg/h may be initiated in the ED and continued 4 – 8 h/d, up to a maximum of 16 h total in 3 consecutive days. (Sheehy 2015) In sickle cell patients with vaso-occlusive pain crises, dexmedetomidine is an effective adjunct for severe pain poorly responsive to opioids and/or ketamine. (Sheehy 2015b)
The child with cognitive impairment
Children with cognitive impairment such as those with genetic or metabolic syndromes, or primary neurologic conditions such as cerebral palsy are challenging to assess and treat. These children not only cannot explain their symptoms, but they also have atypical expressions of pain. Pain responses in severely intellectually disabled children include a smile (which may or may not accompany inappropriate laughter), stiffening, and non-cooperation. (Hadden 2002) Other observed behaviors include the freezing phenomenon, in which the child acutely feels the pain, and abruptly pauses without moving their face for several seconds. Look also for episodes of unexplained pallor, diaphoresis, breath-holding, and shrill vocalizations. The Face, Legs, Activity, Cry, Consolability (FLACC) scale has been revised (r-FLACC) for children with cognitive impairment and appears to be reliable for acute care. (Malviya 2006)
A distressing and perplexing presentation is the parent who brings their child with cognitive impairment for “fussiness,” “irritability,” or “I think he’s in pain.” This may occur is after significant investigations have been performed, sometimes repeatedly. Poorly controlled spasticity is an often under-appreciated cause of unexplained pain; treat not with opioids, but with GABA-receptor agonists, such as baclofen. Benzodiazepines may be effective in an acute exacerbation of spasticity, though benzodiazepine prescriptions should be used cautiously in children, for the same reasons they should be used cautiously in adults.
Take special precautions in the administration of opioids or benzodiazepines in children with metabolic disorders (e.g. mitochondrial disease) or various syndromes (e.g. Trisomy 21), as they may be disproportionately oversedated by these medications. Start with a low dose and reassess frequently, titrating in small aliquots as needed.
After careful consideration and workup to exclude occult dangerous conditions, the child with cognitive impairment who continues to be symptomatic despite ED treatment may require admission for observation. The addition of gabapentin to the typical regimen has been shown to manage unexplained irritability in these children, (Hauer 2007) perhaps by treating visceral hyperalgesia.
The use of intravenous analgesics and frequent assessments of pain and analgesic response are necessary to gauge the child’s pain trajectory. Unexplained tachycardia may be an early signs of shock, and without controlling the child’s pain, it may be difficult to distinguish whether tachycardia is from pain or blood loss.
The child under palliative care
Children undergoing palliative care require a multidisciplinary approach. This includes engaging the patient’s care team and special attention to the patient’s family who are coping with the natural course of devastating chromosomal, neurologic, and other congenital lesions; terminal cancer or other life-limiting conditions (Michelson 2007). Focus on the productive and beneficial treatments that can be offered. Treat pain promptly, but speak with the parents about end-of-life goals as early as possible, as any analgesic or sedative may have an untoward effect. You do not want to be in the position of potentially having to resuscitate a child undergoing palliative care, because of a lack of understanding of how increasingly large doses of pain medications can affect breathing and circulation. (AAP 2000)
Children with chronic or terminal pain may present with complications of chronic opioid treatment. Identify, assess and aggressively treat constipation, nausea and vomiting, pruritus, and urinary retention; (Friedrichsdorf 2007) treating side-effects of pain management may be just as important for quality of life as treating the pain itself.
PEARLS AND PITFALLS IN PEDIATRIC PAIN
Allow the child to speak for themselves whenever possible. After acknowledging the parent’s input, try “I want to make sure I understand how the pain is for you. Tell me more.”
Engage parents and communicate the plan to them. Elicit their expectations, and give them a preview of what to expect in the ED.
Opioids are meant for pain caused by acute tissue injury, for the briefest period of time required to diminish suffering. Older school-aged children and adolescents are increasingly at risk for opioid dependence and addiction.
Premature infants present a challenge in pain control. Their pain is under-recognized, as they often display atypical responses to painful stimuli. Treatment is equally difficult, as they are particularly sensitive to analgesia-sedation, and this high-risk group is more likely to undergo painful procedures than their peers.
Give detailed advice on how to manage pain at home. Set rational expectations. Let them know you understand and will develop a strategy that will carry them through this difficult time. Patients and families often just need a plan–map it out clearly.
- In pediatric acute pain, know the child; know the family; and know the pain trajectory.
- Use your observational skills enhanced with collateral information to assess and reassess for pain in children.
- Treat pediatric pain effectively and with frequent reassessments. Failure to address the child’s pain has long-lasting consequences.
- Non-pharmacologic treatments for all, pharmacologic treatments for many. Opioids for few. A multi-modal approach is the most effective.
- Neonates, infants and toddlers, and school-aged children and adolescents exhibit specific physiology in expression of pain and in response to treatment. Tailor your regimen to your young patient’s physiologic pitfalls and needs.
The author has no relevant conflicts of interest to disclose.
American Academy of Pediatrics. Committee on Bioethics and Committee on Hospital Care. Palliative care for children. Pediatrics. 2000 Aug;106(2 Pt 1):351-7.
Andolfatto G, Willman E, Joo D, Miller P, Wong WB, Koehn M, Dobson R, Angus E, Moadebi S. Intranasal ketamine for analgesia in the emergency department: a prospective observational series. Acad Emerg Med. 2013 Oct;20(10):1050-4.
Babl FE, Theophilos T, Palmer GM. Is there a role for intravenous acetaminophen in pediatric emergency departments? Pediatr Emerg Care. 2011 Jun;27(6):496-9.
Bailey E, Worthington HV, van Wijk A, Yates JM, Coulthard P, Afzal Z. Ibuprofen and/or paracetamol (acetaminophen) for pain relief after surgical removal of lower wisdom teeth.Cochrane Database Syst Rev. 2013 Dec 12;(12):CD004624.
Bearden DJ, Feinstein A, Cohen LL. The influence of parent preprocedural anxiety on child procedural pain: mediation by child procedural anxiety. J Pediatr Psychol. 2012 Jul;37(6):680-6.
Berde CB, Sethna NF. Analgesics for the treatment of pain in children. N Engl J Med. 2002 Oct 3;347(14):1094-103.
Brousseau DC, Duffy SJ, Anderson AC, Linakis JG. Treatment of pediatric migraine headaches: a randomized, double-blind trial of prochlorperazine versus ketorolac. Ann Emerg Med. 2004 Feb;43(2):256-62.
Ciszkowski C, Madadi P, Phillips MS, Lauwers AE, Koren G. Codeine, ultrarapid-metabolism genotype, and postoperative death. N Engl J Med. 2009 Aug 20;361(8):827-8.
Clark E, Plint AC, Correll R, Gaboury I, Passi B. A randomized, controlled
trial of acetaminophen, ibuprofen, and codeine for acute pain relief in children
with musculoskeletal trauma. Pediatrics. 2007 Mar;119(3):460-7.
Cornelissen L, Donado C, Kim J, Chiel L, Zurakowski D, Logan DE, Meier P, Sethna NF, Blankenburg M, Zernikow B, Sundel RP, Berde CB. Pain hypersensitivity in juvenile idiopathic arthritis: a quantitative sensory testing study. Pediatr Rheumatol Online J. 2014 Sep 6;12:39.
Crews KR, Gaedigk A, Dunnenberger HM, Leeder JS, Klein TE, Caudle KE, Haidar CE, Shen DD, Callaghan JT, Sadhasivam S, Prows CA, Kharasch ED, Skaar TC; Clinical Pharmacogenetics Implementation Consortium. Clinical Pharmacogenetics Implementation Consortium guidelines for cytochrome P450 2D6 genotype and codeine therapy: 2014 update. Clin Pharmacol Ther. 2014 Apr;95(4):376-82.
Deaton T, Auten JD, Darracq MA. Nebulized fentanyl vs intravenous morphine for ED patients with acute abdominal pain: a randomized double-blinded, placebo-controlled clinical trial. Am J Emerg Med. 2015 Jun;33(6):791-5.
Dokko D. Best practice for fever management with intravenous acetaminophen in pediatric oncology. J Pediatr Oncol Nurs. 2015 Mar-Apr;32(2):120-5.
Farion KJ, Splinter KL, Newhook K, Gaboury I, Splinter WM. The effect of vapocoolant spray on pain due to intravenous cannulation in children: a randomized controlled trial. CMAJ. 2008 Jul 1;179(1):31-6.
Finley GA, Kristjánsdóttir O, Forgeron PA. Cultural influences on the assessment of children’s pain. Pain Res Manag. 2009 Jan-Feb;14(1):33-7.
Friedrichsdorf SJ, Kang TI. The management of pain in children with life-limiting illnesses. Pediatr Clin North Am. 2007 Oct;54(5):645-72.
Furyk JS, Grabowski WJ, Black LH. Nebulized fentanyl versus intravenous morphine in children with suspected limb fractures in the emergency department: a randomized controlled trial. Emerg Med Australas. 2009 Jun;21(3):203-9.
Gandhi M, Thomson C, Lord D, Enoch S. Management of Pain in Children with Burns. Int J Pediatr. 2010; 2010: 825657.
Ganesh A, Gurnaney HG. Ultrasound guidance for pediatric peripheral nerve blockade. Anesthesiol Clin. 2009 Jun;27(2):197-212.
Graudins A, Meek R, Egerton-Warburton D, Oakley E, Seith R. The PICHFORK (Pain in Children Fentanyl or Ketamine) trial: a randomized controlled trial comparing intranasal ketamine and fentanyl for the relief of moderate to severe pain in children with limb injuries. Ann Emerg Med. 2015 Mar;65(3):248-254.e1.
Hadden KL, von Baeyer CL. Pain in children with cerebral palsy: common triggers and expressive behaviors. Pain. 2002 Sep;99(1-2):281-8.
Hämäläinen ML, Hoppu K, Valkeila E, Santavuori P. Ibuprofen or acetaminophen
for the acute treatment of migraine in children: a double-blind, randomized,
placebo-controlled, crossover study. Neurology. 1997 Jan;48(1):103-7.
Harrison D, Bueno M, Yamada J, Adams-Webber T, Stevens B. Analgesic effects of sweet-tasting solutions for infants: current state of equipoise. Pediatrics. 2010 Nov;126(5):894-902.
Hauer JM, Wical BS, Charnas L. Gabapentin successfully manages chronic unexplained irritability in children with severe neurologic impairment. Pediatrics. 2007 Feb;119(2):e519-22.
Horeczko T, Mahmoud MA. The sedation mindset: philosophy, science, and practice. Curr Opin Anaesthesiol. 2016 Feb;29 Suppl 1:S48-55.
Howard RF. Current status of pain management in children. JAMA. 2003 Nov 12;290(18):2464-9.
Keck JF, Gerkensmeyer JE, Joyce BA, Schade JG. Reliability and validity of the Faces and Word Descriptor Scales to measure procedural pain. J Pediatr Nurs. 1996 Dec;11(6):368-74.
Kraglund F. Acetaminophen plus a nonsteroidal anti-inflammatory drug decreases acute postoperative pain more than either drug alone. J Am Dent Assoc. 2014 Sep;145(9):966-8.
Krechel SW, Bildner J. CRIES: a new neonatal postoperative pain measurement score. Initial testing of validity and reliability. Paediatr Anaesth. 1995;5(1):53.
Lawrence J, Alcock D, McGrath P, Kay J, MacMurray SB, Dulberg C. The development of a tool to assess neonatal pain. Neonatal Netw. 1993;12(6):59–66.
Liebelt EL. Assessing children’s pain in the emergency department. Clin Pediatr Emerg Med. 2000; 1(4):260-269.
Luhmann JD, Schootman M, Luhmann SJ, Kennedy RM. A randomized comparison of nitrous oxide plus hematoma block versus ketamine plus midazolam for emergency department forearm fracture reduction in children. Pediatrics. 2006 Oct;118(4):e1078-86.
Lunoe MM, Drendel AL, Levas MN, Weisman SJ, Dasgupta M, Hoffmann RG, Brousseau DC. A Randomized Clinical Trial of Jet-Injected Lidocaine to Reduce Venipuncture Pain for Young Children. Ann Emerg Med. 2015 Nov;66(5):466-74.
Malviya S, Voepel-Lewis T, Burke C, Merkel S, Tait AR. The revised FLACC observational pain tool: improved reliability and validity for pain assessment in children with cognitive impairment. Paediatr Anaesth. 2006 Mar;16(3):258-65.
Manterola C, Astudillo P, Losada H, Pineda V, Sanhueza A, Vial M. Analgesia in patients with acute abdominal pain. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD005660.
Maxwell LG, Malavolta CP, Fraga MV. Assessment of pain in the neonate. Clin Perinatol. 2013 Sep;40(3):457-69.
Merry AF, Edwards KE, Ahmad Z, Barber C, Mahadevan M, Frampton C. Randomized comparison between the combination of acetaminophen and ibuprofen and each constituent alone for analgesia following tonsillectomy in children. Can J Anaesth. 2013 Dec;60(12):1180-9.
Michelson KN, Steinhorn DM. Pediatric End-of-Life Issues and Palliative Care. Clin Pediatr Emerg Med. 2007 Sep; 8(3): 212–219.
Miner JR, Kletti C, Herold M, Hubbard D, Biros MH. Randomized clinical trial of nebulized fentanyl citrate versus i.v. fentanyl citrate in children presenting to the emergency department with acute pain. Acad Emerg Med. 2007 Oct;14(10):895-8.
Moadad N, Kozman K1, Shahine R, Ohanian S, Badr LK. Distraction Using the BUZZY for Children During an IV Insertion. J Pediatr Nurs. 2016 Jan-Feb;31(1):64-72.
Ong CK, Seymour RA, Lirk P, Merry AF. Combining paracetamol (acetaminophen)
with nonsteroidal antiinflammatory drugs: a qualitative systematic review of
analgesic efficacy for acute postoperative pain. Anesth Analg. 2010 Apr
Patniyot IR, Gelfand AA. Acute Treatment Therapies for Pediatric Migraine: A Qualitative Systematic Review. Headache. 2016 Jan;56(1):49-70.
Pasero C, McCaffery M. Pain Assessment and Pharmacologic Management. St. Louis, Mo: Mosby; 2011.
Piaget J. Judgment and reasoning in the child. Harcourt & Brace. Oxford, England. 1928.
Pickering AE, Bridge HS, Nolan J, Stoddart PA. Double-blind, placebo-controlled analgesic study of ibuprofen or rofecoxib in combination with paracetamol for tonsillectomy in children. Br J Anaesth. 2002 Jan;88(1):72-7.
Pierce CA, Voss B. Efficacy and safety of ibuprofen and acetaminophen in
children and adults: a meta-analysis and qualitative review. Ann Pharmacother.
Poonai N, Paskar D, Konrad SL, Rieder M, Joubert G, Lim R, Golozar A, Uledi S, Worster A, Ali S. Opioid analgesia for acute abdominal pain in children: A systematic review and meta-analysis. Acad Emerg Med. 2014 Nov;21(11):1183-92.
Racoosin JA, Roberson DW, Pacanowski MA, Nielsen DR. New evidence about an old drug–risk with codeine after adenotonsillectomy. N Engl J Med. 2013 Jun 6;368(23):2155-7.
Sheehy KA, Muller EA, Lippold C, Nouraie M, Finkel JC, Quezado ZM. Subanesthetic ketamine infusions for the treatment of children and adolescents with chronic pain: a longitudinal study. BMC Pediatr. 2015 Dec 1;15:198.
Sheehy KA, Finkel JC, Darbari DS, Guerrera MF, Quezado ZM. Dexmedetomidine as an Adjuvant to Analgesic Strategy During Vaso-Occlusive Episodes in Adolescents with Sickle-Cell Disease. Pain Pract. 2015 Nov;15(8):E90-7.
Sheppard JL. The application of Piaget’s theory to physiotherapy. Aust J Physiother. 1977 Dec;23(4):133-40.
Smith C, Goldman RD. Alternating acetaminophen and ibuprofen for pain in
children. Can Fam Physician. 2012 Jun;58(6):645-7.
Spanos S, Booth R, Koenig H, Sikes K, Gracely E, Kim IK. Jet Injection of 1% buffered lidocaine versus topical ELA-Max for anesthesia before peripheral intravenous catheterization in children: a randomized controlled trial. Pediatr Emerg Care. 2008 Aug;24(8):511-5.
Srouji R, Ratnapalan S, Schneeweiss S. Pain in children: assessment and nonpharmacological management. Int J Pediatr. 2010;2010.
Stevens B, Yamada J, Lee GY, Ohlsson A. Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database of Systematic Reviews 2013, Issue 1. Art. No.: CD001069.
Suresh S, Sawardekar A, Shah R. Ultrasound for regional anesthesia in children. Anesthesiol Clin. 2014 Mar;32(1):263-79.
Taddio A, Shah V, Gilbert-MacLeod C, Katz J. Conditioning and hyperalgesia in newborns exposed to repeated heel lances. JAMA. 2002;288(7):857.
Thomas SH, Silen W. Effect on diagnostic efficiency of analgesia for undifferentiated abdominal pain. Br J Surg. 2003 Jan;90(1):5-9.
Tomlinson D, von Baeyer CL, Stinson JN, Sung L. A systematic review of faces scales for the self-report of pain intensity in children. Pediatrics. 2010 Nov;126(5):e1168-98.
Tsze DS, von Baeyer CL, Bulloch B, Dayan PS. Validation of Self-Report Pain Scales in Children. Pediatrics. 2013 Oct; 132(4): e971–e979.
Voepel-Lewis T, Merkel S, Tait AR, Trzcinka A, Malviya S. The reliability and validity of the Face, Legs, Activity, Cry, Consolability observational tool as a measure of pain in children with cognitive impairment. Anesth Analg. 2002 Nov;95(5):1224-9.
Yeaman F, Oakley E, Meek R, Graudins A. Sub-dissociative dose intranasal ketamine for limb injury pain in children in the emergency department: a pilot study. Emerg Med Australas. 2013 Apr;25(2):161-7.