Pediatric Pain Management

Avni M. Bhalakia M.D.

St. Barnabas Hospital
 Learning Objectives
• Define & classify pain
• Understand general principles of pain
management
• Understand pharmacology of different
analgesics
• Know how to manage pain depending on
the type of pain
 Definition of Pain
• International Association for the Study of Pain
– An unpleasant sensory and emotional
experience arising from actual or potential
tissue damage or described in terms of such
damage

– Sensory, emotional, cognitive, and behavioral

components that are interrelated with
environmental, developmental, socio-cultural,
and contextual factors
 Barriers to Pediatric Pain Control
• Belief that children, especially infants, do
not feel pain the way adults do
• Lack of routine pain assessment
• Lack of knowledge in pain treatment
• Fear of adverse effects of analgesics,
especially respiratory depression and
addiction
• Belief that preventing pain in children
takes too much time and effort
Pediatrics, 18 (3) 2001
 Background
• Historically children and infants received less
post-operative analgesia than adults
• Well documented that children are often
undertreated for pain
• Specifically in neonates:
– Recent studies show that neonates can experience
pain by 26 weeks of gestation
• Mature afferent pain transmission
– Untreated pain in neonates lead to increased distress
and altered pain response in the future
 Classification of Pain
Nocioceptive Neuropathic
• Somatic • Central
– Bone, joint, muscle, skin, or – Injury to peripheral or
connective tissue central nervous system
– Well localized causing phantom pain
– Aching & throbbing – Dysregulation of the
autonomic nervous system
• Visceral (e.g. Complex regional
– Visceral organs such as GI pain syndrome)
tract • Peripheral
– Poorly localized
– Peripheral neuropathy due
– Cramping to nerve injury
– Pain along nerve fibers

http://www.med.umich.edu/PAIN/pediatric.htm
 5 General Principles of
Pain Management
• Anticipate & prevent pain
• Adequately assess pain
• Use multi-modal approach
• Involve parents
• Use non-noxious routes

Pediatrics in Review 2003; 24 (10)

 1: Anticipate & Prevent Pain
• Prepare patient and parent on what to expect
• Guide them on ways to minimize pain and
anxiety
• Utilize quiet environment
• Treat pain prophylactically when anticipated
– E.g. Following surgery or local anesthetic for lumbar
puncture
– Takes more medication to treat pain than to prevent
its occurrence
 2: Pain Assessment
• Obtain a detailed assessment of pain
– HPI, description of pain, experience with pain
medications, use of non-pharmacologic techniques,
parent experience with pain
– Quality, location, duration, intensity, radiation,
relieving & exacerbating factors, & associated
symptoms
• Use age appropriate tool
– Scales for neonate, infant, children ages 3-8, >8 years,
and children with cognitive impairments
• Directly ask child when possible
• Pain can be multi-dimensional and therefore,
tools can be limited
Assessment in Neonates & Infants
• Challenging
• Combines physiologic and behavioral
parameters
• Many scales available
– NIPS (Neonatal Infant Pain Scale)
– FLACC scale (Face, Legs, Activity, Cry
Consolability)
Neonatal Infant Pain Scale (NIPS)
FLACC scale
 Children between 3-8 years
• Usually have a word for pain
• Can articulate more detail about the
presence and location of pain; less able
to comment on quality or intensity
• Examples:
– Color scales
– Faces scales
 Children older than 8 years
• Use the standard visual analog scale
• Same used in adults
 Children with Cognitive
Impairment
• Often unable to describe pain
• Altered nervous system and experience
pain differently

• Use behavioral observation scales

– e.g. FLACC
• Can apply to intubated patients
 3: Multi-modal Approach
• Cognitive-behavioral • Physical Approach
– Education – Massage
– Relaxation, imagery – Acupuncture
– Psychotherapy, – Acupressure
counseling – Heat or Cold
– Hypnosis – TENS
– Biofeedback – Therapeutic exercise
– Music, literature, art,
play
– Prayer, meditation
 Sucrose for Infants
• Sucrose 24% oral solution
• Can be used for procedures such as heel stick,
venipuncture, catheterization, etc.
• Effective analgesic in preterm and term infants
– Not effective beyond 3 months old
• Dip pacifier in sucrose solution or give 0.2 mL to
buccal area
– May repeat but be cautious with many doses to
younger infants
 4: Patient & Parental Involvement
• Parent
– Excellent sources of information on child
– Learn techniques to help coach through pain
– Reduces anxiety

• Patient
– Age & developmentally appropriate
– Gives them control in their pain experience
– Learn techniques to help with pain control
– Reduces anxiety
 5: Non-noxious Routes
• Administer analgesia through most
painless route
– Avoid IM injections
– Oral and Intravenous routes are preferred
• Oral route for mild to moderate pain
• Intravenous route for immediate pain relief and
severe pain
Pharmacology of Pain
Management
 Principles of Pharmacology
• Consider patient’s 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
• Recognize synergistic effects
NEJM 2002; 347 (14).
 Non-opioid Analgesics
• Mild to moderate pain
• No side effects of respiratory depression
• Highly effective when combined with opioids

• Acetaminophen
• NSAIDs
• COX-2 inhibitors
• Aspirin
– No longer used in pediatrics
 Acetaminophen
• Antipyretic
• Mild analgesic
• Administer PO or PR
• Pediatric Oral dose 10-15 mg/kg/dose
every 4 hr
– Infant dose is 10-15 mg/kg/dose every 6-8 hr
– Adult dose 650 mg-1000 mg/dose
• Onset 30 minutes
 Acetaminophen
• Per rectum dose 40 mg/kg once followed
by 20 mg/kg/dose every 6 hours
– Uptake is delayed and variable
– Peak absorption is 60-120 minutes
– Unreliable to cut suppositories
• Maximum daily dosing
– Infants: 60-75 mg/kg/day
– <60 kg: 100 mg/kg/day
– >60 kg: 4 grams/day
 Side Effects of Acetaminophen
• Generally a good safety profile
– Do not use in hepatic failure
• Causes hepatic failure in overdose
– Infant drops are MORE concentrated than the
children’s suspension
• Infant’s Acetaminophen 80 mg/0.8 mL
• Children’s Acetaminophen 160 mg/5 mL
 NSAIDs
• Antipyretic
• Analgesic for mild to moderate pain
• Anti-inflammatory
– COX inhibitor  Prostaglandin inhibitor
• Platelet aggregation inhibitor
 NSAIDs: Ibuprofen
• Dose 10 mg/kg/dose every 6 hours
– Adult dose 400-600 mg/dose every 6 hours
• Onset 30-45 minutes
• Maximum daily dosing
– <60 kg: 40 mg/kg
– >60 kg: 2400 mg
• May use higher doses in rheumatologic disease
 NSAIDs: Ketorolac
• Intravenous NSAID (also available P.O.)
• Dose 0.5 mg/kg/dose every 6 hours
• Onset 10 minutes
• Maximum I.V. dose 30 mg every 6 hours

• Monitor renal function

• Do not use more than 5 days
– Significant increase in side effects after 5 days
 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?
 COX-2 inhibitors
• Selectively inhibits Cyclooxygenase-2 which
reduces risk of gastric irritation and bleeding
• Same risk for nephropathy as non-selective COX
inhibitors
• Shown to have increased cardiovascular events
in adults
• More studies needed in pediatric patients
– COX-2 inhibitors used in rheumatologic diseases
 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
 Principles of Opioid Use
• Work at opioid (mu) receptors in the CNS
and peripheral nervous system
• Each opioid has different affinities for
different receptors, so there is variability
in response among patients
 Side Effects of Opioids
• All opioids have side effects that should
be anticipated & managed
– Respiratory depression
– Nausea, vomiting
– Constipation
– Pruritis
– Urinary retention
 Opioids
• Codeine
• Oxycodone
• Morphine
• Fentanyl
• Hydromorphone
• Methadone
 Codeine
• Oral analgesic (also anti-tussive)
• Weak opioid
– Used often in conjunction with
acetaminophen to increase analgesic effect
• Metabolized in the liver and demethylated
to morphine
– Some patients ineffectively convert codeine to
morphine so no analgesia is achieved
• Dose 0.5-1 mg/kg every 4-6 hours
 Oxycodone
• Oral analgesic
• Mild to moderate pain
• Hepatic metabolism to noroxycodone and
oxymorphone
• Can be given alone or in combination with
acetaminophen
• Dose 0.05-0.15 mg/kg every 4-6 hours
• Maximum 5-10 mg every 4-6 hours
 Morphine
• Available orally, sublingually, subcutaneously,
intravenous, rectally, intrathecally
• Moderate to severe pain
• Hepatic conversion with renally excreted metabolites
– Use in caution with renal failure
• Duration of I.V. analgesia 2-4 hours
– Oral form comes in an immediate and sustained release
• Dose dependent on formulation
• I.V. Dose 0.05-0.2 mg/kg/dose every 2-4 hours
• Onset 5-10 minutes
• Side effect of significant histamine release
 Fentanyl
• Available intravenous, buccal tab, lozenge and
transdermal patch
– Use buccal tabs, lozenges and patch only in opioid
tolerant patients
• Severe pain
• Rapid onset, brief duration of action
– With continuous infusion, longer duration of action
• I.V. Dose 1 mcg/kg/dose every 30-60 minutes
• Side effect of rapid administration may produce
glottic and chest wall rigidity
• Careful observation, CRM and immediate
availability of airway equipment and skills
 Other Opioids
• Hydromorphone
– 5 x more potent than Morphine (IV)
– Available P.O. or I.V.
– Used in patients with renal insufficiency
• Methadone
– Very long half-life with slow peak
– Good for steady level of analgesia
– Accumulates slowly and takes days to reach
steady state
Patient Controlled Analgesia (PCA)
• Programmable pump that allows patient control
of intravenous analgesia
• Patient can choose when to deliver a dose of
opioid and achieve relief quickly
• Inherent safety in the PCA: patient will fall
asleep when over sedated and is unlikely to
administer too much drug
• Teaching is integral and essential
• Control of the button rests solely with the
patient, NOT the parent
 When to use PCA
• Useful for sickle cell vaso-occlusive episodes,
postoperative pain, cancer pain, palliative care
• Take patient’s age, maturity, and medical
condition into the decision
• Bray et al (1996) compared morphine infusion
and PCA in children
– Children over 5 able to use PCA
– Children between 5-8 years showed no difference in
analgesia
– Children over 8 years had better analgesia with PCA
 How to set up a PCA
• Loading dose if patient is in pain so that there is a
therapeutic serum level to start
• Basal infusion rate can deliver continuous background
dose of opioid to maintain therapeutic level
• Patient demand dose is the dose administered with each
patient activation of the pump (usually small)
• Lockout interval (5-10 min) prevents a second PCA dose
before the previous bolus has taken effect (important to
prevent overdosing)
• Maximum hourly limit can be set based on the average
hourly use of morphine

• Sedation and vital sign assessment is mandatory

Monitor Patients receiving Opioids
• Close observation of all patients receiving
opioids
– Routine vital signs
– Sedation scales when indicated
• Particular close attention to patients:
– History of OSA
– Craniofacial anomalies
– Infants who are younger than 6 months or older
infants with history of apnea or prematurity
– Opioid-naïve patients with continuous infusions
 Naloxone
• Opioid antagonist
• 1 ampule = 0.4 mg/mL
• Use when unresponsive to physical stimulation, shallow
respirations (<8 breaths/min), pinpoint pupils
• Stop Opioid
• Mix Naloxone 1 ampule with NS 9 mL = 40 mcg/mL
– For <40 kgs: Naloxone ¼ ampule with NS 9 mL = 10 mcg/mL
• Administer slowly and observe response
– 1-2 mcg/kg/min
• Discontinue naloxone as soon as patient responds
• Duration 30-45 minutes
– Monitor the patient; repeat doses may be needed
 Local Anesthetics
• For needle procedures, suturing, lumbar puncture, etc.
• Topical or infiltration
• Acts by blocking nerve conduction at Na-channels
• If administered in excessive doses, can cause systemic
effects
– CNS effects of perioral numbness, dizziness, muscular
twitching, seizures & cardiac toxicity
– Aspirate back before injecting to avoid direct injection into blood
vessels
– Calculate maximum mg/kg dose to avoid overdose
• Buffering lidocaine can help with pain of infiltration
– 9 mL lidocaine mixed with 1 mL sodium bicarbonate
 Anesthesia
• Regional
– Blocks afferent pathways to CNS
– Good for post-operative pain relief
– Epidural and caudal anesthesia
– Peripheral nerve blocks
• General
 Types of Pain
• Procedural pain
• Post-operative pain
• Sickle cell pain
• Neuropathic pain
• Cancer pain
• Pain in palliative care
 Procedural Pain
• Consider the type of procedure, expected
duration of pain, the patient and parents
involved, and child’s pain history
• Educate the parents and patients on what to
expect
• Utilize non-pharmacologic methods and local
anesthesia
• Calm environment
• Consider anxiolytic
– Be skilled in airway management
 Post-operative Pain
• Anticipate pain depending on type of
surgery
• Utilize different classes of analgesics
• Control pain as soon as possible to allow
for steady serum levels
• Use continuous/around-the-clock dosing
at fixed times for moderate to severe pain
• Address side effects of opioid medications
 Sickle Cell Pain
• Typically vaso-occlusive crisis
– Complete careful history and physical to rule out
other causes of pain
– VOC may involve 2-3 sites and maybe migratory
• Assess pain (generally relies on self-report)
• Pay attention to degree of pain relief and any
adverse reactions
• Change medications and doses depending on
clinical response of patient
• Utilize non-pharmacologic management
• Involve patient in plan
 Vaso-occlusive Crisis
• Acetaminophen and NSAIDS typically first line for mild
to moderate pain
– Maybe combined with opioid for moderate pain
• Opioids to treat moderate to severe pain
– PCA if appropriate
• Rapid triage, physical assessment, and analgesia
– Start with appropriate dose of medication and re-evaluate
– If need more opioid, give 25-50% more of initial dose
• Once relief achieved, around-the-clock medication with
breakthrough medications available
• Adjunct management with I.V. fluids
• Monitor patients closely for respiratory depression
– Hypoventilation may precipitate acute chest syndrome
 Neuropathic Pain
• Abnormal excitability in the PNS or CNS that
may persist after injury heals or inflammation
subsides
• Acute or chronic
• Burning, shooting, tingling, or stabbing quality
• Post-traumatic, post-surgical, phantom pain
after amputation
• Responds poorly to opioids
• Best treated with TCAs and anticonvulsants
(carbamazepine, gabapentin)
• Complex Regional Pain Syndrome
 Cancer Pain
• WHO analgesic ladder
• Pain at diagnosis
• Pain during treatment
– Mucositis
– Peripheral neuropathy
– Repeated procedures
• Pain from tumor growth
– Spread to spinal cord and
nerve roots or metastasis to
organs
 Palliative Care
• Many children have sub-optimal pain control in
the last days of life
• Significant psychological impact on the child
and family
• Use WHO Analgesia Ladder
– Follow general principles of pain management
– Give medication to provide stable blood
concentrations, through least invasive routes
– Some patients will need escalated opioid doses
• Use complementary/non-pharmacologic
methods
 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
 References
American Medical Association, Module 6 Pain Management: Pediatric Pain
Management. September 2007.
American Pain Society, The Assessment and Management of Acute Pain in
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Berde, Charles and Navil Sethna. Analgesics for the Treatment of Pain in
Children. New England Journal of Medicine 2002; 347 (14): 1094-1103.
Ellison, Angela and Kathy Shaw. Management of Vasoocclusive Pain Events in
Sickle Cell Disease. Pediatric Emergency Care 2007; 23(11): 832-841.
Friedrichsdorf, Stefan and Tammy Kang. The Management of Pain in Children
with Life-limiting Illnesses. Pediatric Clinics of North America 2007,645-672.
Greco, Christine and Charles Berde. Pain Management for the Hospitalized
Pediatric Patient. Pediatric Clinics of North America 2005, 995-1027.
Hillenbrand, Karen. Pain. Pediatric Hospital Medicine, 2003, 756-771.
Polaner, David. Acute Pain Management in Infants and Children. Pediatric
Hospital Medicine, 2nd Edition. 743-754.
University of Michigan, Pediatric Pain Management Staff Education,
http://www.med.umich.edu/PAIN/pediatric.htm.
Zeltzer Lonnie and Heather Krell. Pediatric Pain Management. Nelson’s
Textbook of Pediatrics, 18th Edition. 475-484.
Zempsky, William and Neil Schechter. What’s New in the Management of Pain
in Children, Pediatrics in Review; 24 (10): 337-337-348.