Pain in Pediatric

Pain Response

• Premature infants show metabolic stress responses postoperatively that can be blocked by intravenous opioids.

• The increasing crying and behavioural changes occur for days after circumcision can be blocked with the use of regional anesthesia.

Unfamiliarity with doses.Fear of complcation.

Inadequate training of medical professional.Limited clinical information.Limited available research.

Inadequate Pediatric Pain Management

Why treat pain ?

Treatment & alleviation of pain are a basic human right !

regardless of age

Fishman SM. Recognizing Pain Management as a Human Right: A First StepAnesthesia Analgesia 2007.

Pain management begins with an assessment of the child with pain .Not only the explicit pain features but also the situational factors that modulate pain-measurement of infant pain is just one aspect of comprehensive pain assessment.Pain in infants can only be accessed & measured by indirect method.

Pediatric Pain Assessment

Gaffney A et al. Measuring Pain in Children: Developmental & Instrument Issues.Pain in Infants,Children and Adolescents 2nd Ed 2003.

Pediatric Pain Assessment

Self-Reporting measuresBehavioural parametersPhysiological parameters

Unidimensional toolMultidimensional tool

Anand KJS.Pain and Pain Management during Infancy. Research and Clinical Forum 1998

Behavioural parameters

• Crying characteristics.• Facial expressions.• Simple motor responses.• Complex behavioural responses.

More specific and consistent than physiological

measurements.

Physiological Parameters

• Heart rate.• Respiratory rate.• Blood pressure.• Palmar sweating.• Vagal tone.• Oxygen saturation.• Transcutaneous O2/CO2.

• Intracranial pressure.

Objective,Precise , but

not specific for pain

Biochemical Parameters

• Catecholamines : Epinephrine, Norepinephrine.• Cortisol : blood, saliva, or urine.

• -Endorphin• Growth hormone, glucose, glucagon, renin,

aldosterone, and lactate have also been noted to increase with pain.

• Insulin secretion (usually suppressed).

PAIN ASSESSMENT TOOL

ReliabilityValidity

Specificity/SensitivityClinical utility/Feasibility

Self-Report Measures

• Wong – Baker Faces Pain Scale• Faces Pain Scale-Revised • Visual Analog Scale (VAS)• Pieces of Hurt Tool• MSPCT

Section 3. Pain AssessmentPediatric Anesthesia 2008, 18 (Suppl. 1), 14-18.

Self Report

Behavioural Measures• PIPP (Premature Infant Pain Profile)• CRIES (Crying Requires Oxygen Saturation Increased Vital Sign

Expression Sleeplessness)• COMFORT Scale• Neonatal Facial Coding Scale.• FLACC (Face,Legs,Arms,Cry,Consolability)• CHEOPS (Children’s Hospital of Eastern Ontario Pain Scale)• Objective Pain Scale

Section 3. Pain AssessmentPediatric Anesthesia 2008, 18 (Suppl. 1), 14-18.

Facial Expression of Physical Distress

NASO-LABIAL FOLDdeepened

Cry Spectrography

• Crying hunger,anger,discomfort ,pain ?• ABC Pain Analyzer : * Is the first cry acute ? * Are burst rhythmic ? * Is crying constant in time ?

Bellieni CV,Buonocore G, Pain Assessment and Spectral Analysis of Neonatal Crying. Neonatal Pain Springer 2007.

Pharmacologic Intervention

• Nonsteroidal antiinflammatory drugs.• Intermittent/continuous opioids.• Peripheral nerve block & Regional anesthetic

techniques.

American Academy of Pediatric,Canadian Paediatric Society,Committee on Drugs,Committee on Fetus and Newborn and Section on Anesthesiology

Prevention and Management of Pain and Stress in the NeonatePediatrics 2000

Pharmacological Consideration

• Neonates have delayed maturation of liver enzyme systems which involved in drug metabolism.

• Children have a higher percentage of body weight as water and less as fat. Dosages of water soluble drugs vs fat soluble drugs should be adjusted.

• Children have reduced plasma albumin. This result in a greater availability of active drugs and increased medication passages into the brain.

• Neonates have diminished ventilatory responses to decreased oxygen contents in the blood.

NSAIDs

• Effective for mild or moderate pain.• Anti-inflammatory & antipyretic effects.• Opioid sparing effect.• NSAIDs + paracetamol better analgesia.

Analgesia Review. Pediatric Anesthesia 2008.

DRUG LOADINGDOSE

(mg/kg)

MAINTENANCEDOSE

(mg/kg)

INTERVAL

(hours)

DAILY MAX DOSE

(mg/kg)

KetoprofenIbuprofenNaproxenDiclofenacKetorolac

210102

0.5

11051

0.25

6-86-8

8-126-86-8

5401532

NSAID Doses in Children

Kokki H. Use.Abuse and Misuse of NSAIDS in ChildrenEuropean Journal of Anesthesiology 2005

Opioids

• Morphine or Fentanyl most often used. Avoid Demerol (Meperidine)

• Requires frequent and thorough assessment of adequacy of pain relief and possible side effects

• < 6 months – continuous respiratory monitoring:

* < 1 month : 9 hours * 1-6 months : 4 hours

After the last administraton

Estimated Values for Vd – t1/2 – CL of Morphine

Vd (L/kg)

t1/2 (h)

CL (ml/min/kg)

Preterm 2.8 + 2.6 9.0 + 3.4 2.2 + 0.7

Term 2.8 + 2.6 6.5 + 2.8 8.1 + 3.2

Infants & children

2.8 + 2.6 2.0 + 1.8 23.6 + 8.5

Kart T, Lona L. Recommended Use of Morphine in Neonates,Infants and Children Based on Literature Review : Part 1 – Pharmacokinetics.

Pediatric Anesthesia 1997.

Caudal epidural analgesia

Most popular central blockEasiest & safest approach

Excellent analgesia-painfree awakening

Applicable to children of all ages

Nonpharmacological Strategies

• Behavioural interventions.• Cognitive interventions.• Distraction.• Hypnosis.• Sucrose solutions.

Thanks for Listening

Because of you…

Objective Pain ScaleObservation Observation Criteria Criteria Points Points

Blood PressureBlood Pressure

CryingCrying

Movement Movement

Agitation Agitation

Verbalizes painVerbalizes pain

+ 10% preop value+ 10% preop value>20% preop value>20% preop value>30% preop value>30% preop valueNot cryingNot cryingCrying responds to Crying responds to t.l.c.t.l.c.Crying respons to Crying respons to t.l.c. – t.l.c. – None None Restless Restless Trashing Trashing Asleep or calmAsleep or calmMild Mild Hysterical Hysterical Asleep/no Asleep/no verbalizationverbalizationCannot localize pain Cannot localize pain Localizes painLocalizes pain

001122001122001122001122001122

Children’s Hospital of Eastern Ontario Pain Scale(CHEOPS)

ScoreScore 00 11 22

CryCryFacialFacialVerbalVerbalTorsoTorsoLegsLegs

– –smile smile

++neutralneutralneutralneutral

++composedcomposed

– – shifting/tenseshifting/tensekick/squirmkick/squirm

screamscreamgrimacegrimace

pain complaintpain complaintrestraintrestraintrestraintrestraint