JURNAL ANAK

november 10 :: vol 25 no 10 :: 2010 35NURSING STANDARD

Baulch I (2010) Assessment and management of pain in the paediatric patient. Nursing Standard. 25, 10, 35-40. Date of acceptance: April 28 2010.

(Ashley 2009), and it is now recognised thatchildren can be affected by chronic pain as well as neuropathic pain (Howard 2003). Painmanagement in children is therefore a priorityand pain relief should be at the forefront ofhealthcare professionals’ minds when dealingwith a sick or injured child. A highly skilled and effective team approach will increase the likelihood that pain management will be successful.

The National Service Framework for Children, Young People and Maternity Services(Department of Health and Department for Education and Skills 2004) highlighted theimportance of caring for sick or injured childrenand providing effective analgesia. The documentprovides guidelines on the skills required to care for these children. The guidance forms thefoundation of children’s services, identifying the generic skills needed, promoting teamwork,and highlighting issues around safeguardingchildren and effective communication withpaediatric patients and their parents or carers.

Pain physiology

It has been established that infants have a neural pathway that responds to painful stimuli (ANZCA 2005). There are anatomical,physiological and biochemical prerequisites for pain perception from early intrauterine life(Cunliffe and Roberts 2004).

The distribution and density of receptors andneurotransmitters changes after birth, which has an effect on the infant’s pain perception,potentially heightening pain intensity. At birth,the pain fibres are not yet myelinated and have a low threshold for stimuli and connections in the dorsal horn are immature, resulting in poorly localised pain.

Assessment and management of pain in the paediatric patient

THE MANAGEMENT OF pain in children has changed over the past decade, and it is nowrecognised that even the youngest neonateresponds to nociceptive stimuli (Australian andNew Zealand College of Anaesthetists and Facultyof Pain Medicine (ANZCA) 2005). Paediatric painwas poorly recognised and largely undertreateduntil about 25 years ago (Howard 2003). This was because of poor knowledge of how neonatesexperience pain and how the pain pathwaydevelops as children grow (Ashley 2009), as well asfear of analgesic-related side effects. These factorsoften left patients with neglected post-operativeand procedural pain (Howard 2003).

It is well documented that untreated pain can lead to the development of chronic pain

If you would like to contribute to the art and science section contact: Gwen Clarke, art and science editor, Nursing Standard, The Heights, 59-65 Lowlands Road, Harrow-on-the-Hill, Middlesex HA1 3AW. email: [email protected]

SummaryA combination of pharmacological and non-pharmacologicalinterventions can ensure the highest standard of care in themanagement of pain in children. Nurses are in a prime position tocare for children and educate them and their parents on effectivepain management strategies.

AuthorIngrid Baulch, acute pain sister, Anaesthetic Department, WhippsCross University Hospital NHS Trust, London.

KeywordsNursing care, paediatric nursing, pain and pain management,patient assessment

These keywords are based on subject headings from the BritishNursing Index. All articles are subject to external double-blind peerreview and checked for plagiarism using automated software. Forauthor and research article guidelines visit the Nursing Standardhome page at www.nursing-standard.co.uk. For related articlesvisit our online archive and search using the keywords.

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36 november 10 :: vol 25 no 10 :: 2010 NURSING STANDARD

When a painful episode occurs and stimulatesthe pain fibres, the response of the sensory nerveendings is to over produce neurotransmitters.This creates a hypersensitivity that can last for a long time. In addition, the immaturity of thedorsal horn affects the descending pain pathway,which results in poor inhibitory copingmechanisms (Cunliffe and Roberts 2004).

In neonates, central sensitisation, where somereceptors are present in a higher concentration,plays a part in the development of neuropathicpain (ANZCA 2005, Stewart et al 2010). It cantherefore be argued that neonates feel more pain than older children and adults, and that ifthis is untreated it can lead to lowering of the pain threshold as the child grows up. This might mean that the child feels more pain than a child who has not previously been exposed to thenoxious stimuli (Cunliffe and Roberts 2004).

Sources of pain

Children, like adults, experience pain from avariety of causes. Pain can result from injury,trauma, surgery or illness with acute onset, forexample otitis media or pharyngitis. Children also experience pain from procedures such as heel pricks, immunisations, venepuncture,cannulations and lumbar punctures (Ashley 2009).

Chronic pain is more common in children than previously thought. It results not only from being exposed to repeated surgery andprocedural episodes, but also from thedevelopment of neuropathic pain in conditionssuch as complex regional pain syndrome (Ashley2009). The International Association for theStudy of Pain (2005) suggests that the influence of uncontrolled pain at an early age has an effect on nociceptive processing for the rest of the child’s life.

Pain assessment

Pain needs to be assessed before it can be effectivelymanaged. Pain assessment forms the basis of goodpain management and can be used to develop a treatment plan. The aim is to detect pain early and prevent it, or reduce the number of painfulepisodes. The aim of pain assessment is to identifythe presence of pain, estimate its severity and assess the effectiveness of any interventions(Ashley 2009). Guidelines from the Association of Paediatric Anaesthetists of Great Britain and Ireland recommend that pain assessment should be based on the following measures (Howard et al 2008):

&art & science pain series: 10 4Self-report.

4Observational, behavioural and physiological.

Self-report measures Pain is subjective. It is‘whatever the experiencing person says it is,existing whenever she/he says it does’ (McCaffery1968). Therefore, self-report is one of the bestmeasures of pain (Howard et al 2008). However,it should be noted that self-report has limitationsin children as it is dependent on cognitivedevelopment. A pre-verbal child, for example,would need to be assessed for pain throughobservational, behavioural or physiologicalchanges such as crying, altered facial expressions,and increased blood pressure, heart andrespiratory rate. Although these variables cansuggest the presence of pain in a newborn and a very young child, they are not entirely reliable(Howard et al 2008).

Self-report may be affected by factors such as personal beliefs, family influence and previous experience of pain (ANZCA 2005). Pain assessment relies on excellentcommunication between the child, family and/or carers and healthcare professionals in the multidisciplinary team.

The use of a pain assessment tool has beenshown to reduce error and bias, thus preventingany misunderstanding of the meaning of self-report (American Academy of Pediatrics(AAP) 2001). There are a variety of painassessment tools. However, the most importantconsideration is to use a validated and reliabletool that is suitable for the age, cognitive level,language, and ethnic and cultural background of the child (Howard et al 2008) (Box 1).

Neonates and younger children respond to pain by crying and through altered facialexpressions and movements. Children agedthree to seven years can verbalise where they feelpain and the strength of the sensation (Ashley2009). They tend to use words such as ‘hurt’instead of pain and assessment tools need to reflectthe ability of the child to describe pain (Figure 1).By the age of seven years, children usually canscore their pain experience with the aid ofmemories of previous injuries (Ashley 2009). Inthis older age group, observations of behaviourcan complement self-report (AAP 2001).

Pre-adolescents and adolescents are more adept in using visual analogue or numerical rating scales (Figure 2). These tools requirerespondents to mark their pain with a numberand score it using a linear scale.

To be valid, pain assessment should beongoing and performed regularly; it must also include the patient’s response to anyanalgesic medicines administered, as well as any side effects experienced. Information



should be clearly documented to ensurecontinuity of care (AAP 2001).

Pain assessment in the cognitively impairedchild is complex, and no assessment tool has beenvalidated for this particular group (Howard et al2008). The child’s family and/or carers can provevital in interpreting, for example, the child’s facialexpressions and body positions as they will befamiliar with the child’s normal behaviour.However, as Howard et al (2008) highlighted,some parents and/or carers may have anunrealistic understanding of the child’s pain,which may lead to poor analgesic control. As with all pain assessments, the approach shouldbe on an individual basis (ANZCA 2005).Observational, behavioural and physiologicalmeasures Indicators of children in pain can beobserved in their behaviour and may includecrying, and altered facial expressions and bodymovement. Children may also display individualreactions such as withdrawal or fighting toalleviate their pain. Physiological changes mayalso be observed, with increases in bloodpressure, heart and respiratory rate, and palmarsweating (ANZCA 2005).

These indicators should not be used on theirown, but in conjunction with self-report.

Pharmacological pain management

Choosing suitable analgesics and othermedicines can be challenging because children’sbody fat composition differs in relation to their body size, compared with adults. Thechild’s body composition is mainly made up of brain and viscera, unlike adults where fat and muscle are the major components (Stevens1999). There are also differences betweenchildren and adults in plasma protein bindingand liver and kidney function that need to

be considered (ANZCA 2005) when prescribinganalgesics and other drugs. The child’s changingweight and developmental age should thereforebe taken into account to ensure optimum dosingof analgesic medicines (ANZCA 2005).

The pharmaceutical industry has conductedminimal research on the use of its medicines inchildren. Although using drugs ‘off-licence’ is not illegal, the prescribing physician has to take responsibility for both the medicine and the dose given to the child (Ashley 2009). Theaim of analgesics is to use a combination of drugs in the smallest doses that offers analgesiaand is associated with the fewest side effects, but still interrupts most pain pathways. This is commonly referred to as the multimodalapproach (Ashley 2009).

The World Health Organization (2010) painrelief ladder forms the basis of the analgesic pain relief plan.Paracetamol and non-steroidal anti-inflammatorydrugs Mild medicines, such as paracetamol andibuprofen, are initially given on their own or in combination with each other (Ashley 2009). Both drugs are known to have opioid-sparingeffects. This means that the requirements ofopioids are decreased when paracetamol or non-steroidal anti-inflammatory drugs(NSAIDs) are given separately or in combination.Therefore the child will need less morphine, forexample, reducing the risk of experiencing anyopioid-related side effects (Ashley 2009).

BOX 1

Self-report pain assessment tools

4PIPP (Premature Infant Pain Profile) (Stevens et al 1996).

4CRIES (Crying, Requires oxygen administration,Increased vital signs, Expression, Sleeplessness)(Krechel and Bildner 1995).

4FLACC (Face, Legs, Activity, Cry and Consolability)(Merkel et al 1997).

4FACES pain rating scale (Hockenberry and Wilson 2009).

4Poker Chip (Hester et al 1990).

4Pieces of Hurt (Hester et al 1990).

4Visual analogue and numerical rating scales (Collins et al 1997).

FIGURE 1

Wong-Baker FACES pain rating scale

Point to each face using the words to describe the pain intensity. Ask the child to choose the face that best describes own pain and

record the appropriate number

0 1 2 3 4 5

No hurt Hurts Hurts Hurts Hurts Hurtslittle bit little more even more whole lot worst

(From Hockenberry MJ, Wilson D: Wong’s Essentials of Pediatric Nursing, ed. 8, St. Louis, 2009, Mosby. Used with permission. Copyright Mosby.)

FIGURE 2

Example of a numerical rating scale

Ask the patient on a scale of 0-10, where 0 = no pain and 10 = worst possible pain, to choose a number that best places

his or her current level of pain

0 1 2 3 4 5 6 7 8 9 10

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(Table 1) and are contraindicated in certainsituations (BNF 2010).Opioid medicines Codeine phosphate is effectivefor moderate pain in most children, but 10% of the population do not have the enzymecytochrome p450, which metabolises codeine intomorphine, and thus do not attain the analgesiceffect (BNF 2010). Codeine is available as an oralsuspension and as an intramuscular injection, butthe injection route should be used only if the childis anaesthetised, and then care is needed as it cancause rapid hypotension (Ashley 2009).

Severe pain in children should be treated withstrong opioids, such as morphine, fentanyl oroxycodone (BNF 2010), which work on the μ-receptors in the central nervous system.However, care must be taken in children withhepatic and renal impairment (BNF 2010).Neonates may need reduced doses and prolongedintervals between administration (Ashley 2009).The pharmacokinetics of opioids change as thechild grows; a neonate can have an unpredictableresponse, while a one-month-old infant cantolerate a much larger dose without respiratorydepression (BNF 2010).

Morphine can be given intravenously, as a bolusor via a nurse-controlled or patient-controlledanalgesia system, depending on the child’s age. It can be administered orally as a slow release or immediate release formulation, or as asubcutaneous infusion (Ashley 2009). Carefulmonitoring for opioid-related side effects isessential (ANZCA 2005) (Table 1).

Nausea and vomiting in children can occur as a side effect of taking opiates and are also more likely in particular types of surgery, such astonsillectomies and ear operations (Ashley 2009).It is important to treat nausea and vomiting tominimise distress (AAP 2001); cyclizine is oftenused for this purpose (Ashley 2009). Local anaesthesia and regional blockade Epiduralanalgesia is a common post-operative pain relieftechnique, administered either as a one-off dose of local anaesthetic or as an infusion or bolus ofopiates mixed with local anaesthetic (Ashley 2009).Care is required because peri-operative epiduralanalgesia modifies the child’s stress response tosurgery, so a larger amount of local anaestheticsmust be given to achieve analgesia, which can leadto toxicity (ANZCA 2005).

Local anaesthetics can be used to prevent painbefore a procedure. Procedural pain, for example,from heel pricks and/or cannulations has beenrated as more distressing than cancer pain bychildren, their parents and physicians (ANZCA2005). ANZCA (2005) recommends that if thefirst painful episode is controlled, subsequentepisodes will not be as traumatic for the child, so prevention or minimising of painful episodes is essential. Topical local anaesthetic gels such as

&art & science pain series: 10

Paracetamol has few side effects (Table 1) anddoes not cause respiratory depression, making it a useful medicine (Ashley 2009). Its action is not fully understood, but it is believed that itinhibits production of substance P, which is aneurotransmitter that stimulates the nerves in the spinal cord to increase pain messages(Mosby 2006) and so reducing pain (ANZCA2005). Paracetamol can be given orally (tablets or suspension) or rectally, and an intravenouspreparation (Perfalgan) has been licensed for use inchildren (British National Formulary (BNF) 2010).

Ibuprofen is a NSAID that interrupts the painpathway by blocking the enzymes produced bythe inflammatory response that occurs after all tissue injuries (Ashley 2009). Ibuprofen isavailable orally as tablets or syrup (BNF 2010).Care should be observed with NSAIDs, such asibuprofen, as they may have serious side effects

TABLE 1

Side effects of common analgesics

Analgesic Side effect

Paracetamol 4Although rare, hepatoxicity may occur if the patient fasts for too long or overdoses

4Vomiting

4Dehydration

4Systemic sepsis or pre-existing liver disease

Ibuprofen 4Platelet dysfunction

4Gastrointestinal bleeding

4Renal dysfunction

4Exacerbation of asthma

Codeine phosphate 4Respiratory depression

4Drowsiness

4Nausea, vomiting

4Itching

4Constipation

4Hypotension

4Tolerance

Morphine 4Respiratory depression

4Drowsiness

4Nausea, vomiting

4Itching

4Constipation

4Hypotension

4Tolerance



EMLA and Ametop can be used beforecannulation and other painful procedures –nursesshould remember that EMLA requires a longerapplication time than Ametop (ANZCA 2005).

Chronic pain management

Treating chronic pain in children can bechallenging. While some children can be treatedwith simple analgesics and reassurance, othersmay develop problems that are difficult to treat. It is therefore essential to involve themultidisciplinary team, including psychologicalinput, in the treatment plan (Howard 2003).

Non-pharmacological pain management

The use of non-pharmacological techniques is valuable in children’s pain management. Ininfants, oral sucrose therapy is commonly usedfor procedural pain such as heel pricks andvenepuncture, with good effect. A recentlypublished systematic review revealed that theadministration of sucrose or glucose beforeimmunisation reduced the incidence and durationof crying in infants aged 1-12 months (Harrison et al 2010). The older child can be taught slowbreathing and relaxation techniques, or may bedistracted by music, art, video games and TV.Hypnosis has also been successfully used inreducing distress resulting from procedural pain(ANZCA 2005). The most successful approachesare those that combine pharmacological and non-pharmacological therapy (ANZCA 2005).

Role of the nurse

Nurses are in an ideal position to educate children and parents about pain managementstrategies. The nurse has a legal and professionalduty of care to patients to prevent any suffering or neglect (Nursing and Midwifery Council2008). The nurse can fulfil this duty byanticipating painful experiences, regularlymonitoring patients’ condition and recordingpain scores (AAP 2001). This approach issupported by the Royal College of Nursing(2009), which states that: ‘Nurses should be ableto recognise and assess pain understand painresponses as well as being aware of copingstrategies that can be indicative of pain.’

Guidelines from the Association of PaediatricAnaesthetists of Great Britain and Ireland(Howard et al 2008) note that nurses and otherhealthcare professionals can be influenced by their own bias while assessing pain. It has also been suggested that nurses may be at risk ofunderestimating children’s pain and overestimatingthe effect of analgesics, leading to poor analgesiccontrol (Helgadóttir and Wilson 2004). It is

recommended that nurses receive training in painassessment and adopt a flexible and positiveattitude. Further, by documenting the assessmentand reassessment of pain, and by evaluating theoutcome of pain management strategies, nurses are likely to be successful in pain management(Howard et al 2008). Hospital policies andstandardised analgesia schedules can help toreduce the risk of poor analgesic control(Helgadóttir and Wilson 2004).

The nurse is well placed to establish a goodrapport with the child and his or her parents. By using the child’s self-report to form the basis of pain assessment, the nurse communicates thathe or she believes the child is in pain and so sets the cornerstone for good rapport and a trustingnurse-patient relationship (AAP 2001).

Parents tend to recognise that their child is inpain but, like nurses, are at risk of underestimatingpain and may therefore give insufficient analgesia.They are likely to require emotional support andeducation about their child’s pain as well asreassurance on their role in pain assessment(Howard et al 2008).

It is the nurse’s role to educate parents and somaximise the chances that children continue toreceive adequate analgesia even after dischargefrom hospital (Helgadóttir and Wilson 2004). By giving parents and children appropriate verbaland written information on the type of drug, doseand duration of treatment, as well as reassurance that the medicine is not harmful in the prescribed dose, the nurse is likely to ensure that the childcontinues to have his or her pain well managed(Helgadóttir and Wilson 2004).

Conclusion

Historically, pain in children has been poorlyrecognised and underestimated, and mismanagedas a result. The pain pathway is now betterunderstood, and there is growing recognition thatchildren can experience acute as well as chronicpain (ANZCA 2005).

USEFUL RESOURCES

4Centre for Pediatric Pain Research (Canada)http://pediatric-pain.ca

4Institute of Child Health, University College of London (UK) www.ucl.ac.uk/ich/homepage

4Royal Children’s Hospital, Melbourne (Australia)http://tiny.cc/aapm

4American Pain Society (United States)www.ampainsoc.org

4Australian and New Zealand College ofAnaesthetists (Australia and New Zealand)www.anzca.edu.au

(Last accessed: October 28 2010)



side effects. The nurse plays an important role in ensuring that the child’s pain is managedeffectively and that it continues when the child is discharged from hospital NS

Acknowledgement Each of the articles in this series has been written by a member of the Royal College of Nursing London Pain Interest Group. Nursing Standard would like to thank FeliciaCox, senior nurse in pain management, Royal Brompton and Harefield NHS Foundation Trust and chair of the Royal College of Nursing London Pain Interest Group, for co-ordinating and developing this series.

&art & science pain series: 10

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References

It is important to choose an appropriate painassessment tool for children, bearing in mind the child’s developmental age as well as any cognitive impairment. It should beacknowledged that self-report of pain is reliablefrom a young age and should be the goldstandard of pain assessment. Evidence suggeststhat when the pain assessment, reassessment and evaluation are documented, an overallimprovement in pain management occurs.Analgesia should be multimodal in approach to ensure optimal pain relief with minimal


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