Pain Management in children by

Pharmacological and Non- Pharmacological

Approaches

Facilitator:
Rubina kousar
RN,RM,BScN Post RN
Objective
After this presentation, students will be able to,

 Define pain
 Identify signs and symptoms of pain in children.
 Discuss interventions non-pharmacological and
pharmacological
 Principles of pediatric acute pain management
 Able to know the importance of non-pharmacological pain
management in children
What is Pain

“pain is an unpleasant sensory and emotional experience associated with

actual or potential tissue damage or described in terms of such damage.”

 For infants and children the provider should recognize the potential for pain and
suspect that a child is in pain.
 Pain is whatever the person experiencing it says it is, existing whenever the
person says it does.
BELIEVE THE PATIENT
 Pain is a subjective experience and is probably the most frightening experience
kids will have.
Myths About Pain in Children

 Infants are neurologically immature and therefore cannot conduct pain impulses.
 Infants do not remember pain, because of cortical immaturity.
 Children do not report pain while playing or sleeping so they must get over it quickly
or not be experiencing it.

Explain…..
 That, if children can distract the experience of pain through play and this does not mean
that they are not in pain.
 Research demonstrate that neonates experience pain and actually there is an evidences that
repeated exposure to painful procedures results in sensitive neural pathway development.
 Sleeping is another mechanism that the body adopts to distract from pain and often it is not
restful sleep when a child is in pain.
The Golden Rule of managing child pain

 What is painful to an adult is painful to an infant

and child unless proven otherwise.
 Assessing the pain of cognitively impaired patient
is very challenging
 We have to take a pragmatic approach sometimes
and this means to consider the physical nature of
pain.
Types of Pain
 Pain Assessment
The PQRST method of assessing pain is a Severity
valuable tool to accurately describe, assess and Ask the patient to
document a patient's pain. rate their pain on
Radiation pain scale
Where is the
pain?
Does it radiate?
Quality Is there pain
Ask the patient to
anywhere else?
describe the pain,

Provoking
discomfort and its e t he
Timg has pain e
characteristics .
Factor lon d the mak
What factors o w ha ng er
H nt thi ett
participate the a t ie any r b
p e s se o
discomfort Do wor
it
Pain Assessment
Methods of assessment vary according to age
QUESTT
and cognitive level of child. pain assessed by …
 Numerical scale – 1 to 10
Question the patient/parent/carer
 FACES – can be used at all ages
 FLACC used on infants
Use pain rating scale
Physiological Indications of Acute Pain
Evaluate behavior & physiologic signs
 Dilated pupils
 Increased perspiration
Secure family’s involvement
 Increased rate/ force of heart rate Take cause of pain into account
 Increased rate/depth of respirations
 Increased blood pressure Take action and assess effectiveness
 Decreased urine output
Different pain scale
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.
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.
Pharmacological management
Treatment determined by severity of pain
Difference treatment will be offered dependent on severity.
In acute illness like , Middle ear infection, Pharyngitis
meningitis, abdominal pain and in fractures, we can
administered..
 Paracetamol
 Non-steroidal
 Opioids
 Locally applied medications
World health organizing WHO principles of pediatrics Acute pain
management

Acute pain in pediatrics can be managed ….

• By the clock
• With the child
• By appropriate route
• Who ladder of pain

BY the clock.
Regular scheduling ensure a steady blood level of drug.
Reduce PRN dosing
“PRN as little as possible”
With the child
Analgesic treatment should be individualized according to
• The child pain
• Response to treatment
• Frequent reassessment
• Modification of plan as required
By appropriate route.
Correct routes are..
• Oral
• Nebulize
• Transdermal
• Sublingual
• IM
• IV
• SC
• Rectal
WHO ladder of pain
Side Effects Monitoring
• Nausea, vomiting and pruritus are common What monitoring is required per hospital
side effects policy?
• Drowsiness
• Respiratory Depression • A cardiac / respiratory monitor is used
• Constipation with prolonged use of opioids for infants less than 7 months
• Pulse Oximetry monitors for other
Documentation patients during use of IV opioids.
• Unstable respiratory status
The assessment and measure of pain intensity
and quality, appropriate to the patient’s age, are • History of difficult airway management
recorded in a way that facilitates regular re-
• Neurologically impaired
assessment and follow-up according to criteria
.
developed by the organization
.
Post Operative Pain
• Post operatively, morbidity and mortality can be reduced by good pain treatment plans.
• Postoperative pain should be discussed before surgery
• Goal is to control the pain as rapidly as possible
• Medication will be based on the operation that is carried out but it is important that
patient/family understand how to use patient controlled analgesia prior to surgery.
• Oral administration is preferred for mild to moderate pain.
• Iv is indicated for immediate pain relief.
• For 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.
Non-pharmacologic Pain Management
Non-pharmacologic Pain Management
• Physical Massage
• Heat and cold
• Acupuncture
• Behavioral Relaxation
• Art and play therapy
• Biofeedback
• Cognitive Distraction
• Imagery and Hypnosis
Non-pharmacologic Pain Management

• Non-pharmacologic interventions may be helpful in

managing pediatric pain and decreasing medical use.
• However, many of these services are not available in
the middle of the night.
• These strategies would be important to recommend to
the day-time team and parents would need support to
help the child/ young person use them.
• Interactive games, Music, Reading, stuffed animals,
deep breathing and rewards are best distraction
technique in children.

Play and distraction is still a very important method of pain relief.