Pain Perception in

Pediatrics and Geriatrics

M. S. El Ansary

• Prof. of Pain Medicine, Al Azhar University

• President of Egyptian Pain Society for Pain Medicine

• President of African Pain Association

• S. General of AUPM

• Former Council Member of IASP

Pediatric Pain in Ancient Civilizations

• Greeks, Romans and Spartans.

– Infanticide the father’s right

– Infant care A.D, Soranus and Galen

• A.E suspend the dead infant for 3 days (milk nurse)

• Babylonians Hammurabi Code

– Amputation of the milk nurse’s breast

• Arabs female infanticide (slave and heritage).

History of Pediatric Pain

• (Moses Pbuh) The Egyptian pharaoh killed all the newborn Jew males

• (Jesus Christ Pbuh) Saint Marry fled to Egypt for fear of killing him.

• Judaism, Christianity and Islam 1. Gave an early message for the children rights.

2. This issue still a matter of debate to the preparation of this work.

Pediatric Care in Holly Koran and Hadith

1. And when the girl child that was buried alive is made to ask for what crime she had been slain

At-Takwir, 81(8,9)

2. (Feed) or Play with him 7 years, correct him 7 years, a friend of him 7 years and then leave the cord loose.

3. Praying and carrying Imam Al-Hassan & Al- Hussein. (grand children)

4. To embrace the children and orphans. The off springs of the martyrs.

-وإذا انًىئىدح سئهت ثأي ذَت قتهت 1. (9و 8) 81سىرح انتكىير

سجع و أدثه سجع و ( اطعًه)العجه 2.صبدقه سجع ثى اترك نه انحجم عهي

انغبرة

كبٌ يصهي حبيالحفيديه األيبييٍ 3. انحسٍ و انحسيٍ

يعبَق األطفبل و األيتبو يٍ أثُبء 4. انشهداء

Al Canon of Medicine (Ibn Sina) 11th. Century Gregorian, 6th. Century Hejri

• Handle gently by the finger tips

• While asleep don’t twist:

– Any part of body (neck, arms, legs or trunk)

– Clean (eyes and body) with soft cloths

– Put sweet oil in the nose

• Good sedation

– Very clean Mother’s Nipple + rocking

– Movements are good for the body

– Music is good for the soul and mind

• Most of the studies on middle age group

• Pediatrics special case

They have different

`

Pain Perception in Pediatrics (1)

Anatomy & Physiology

Pathology, Measurement

and Pharmacology

Pain Perception in Pediatrics (2)

• Pain in Neonates & Infants (ICU)

• Present in pre & full term, neonate & infant

Causes STRESS

1. Separation from mother or father

2. Exposure to light & sounds

3. Variable thermal environment

4. Poor nutritional support

5. Invasive (Diagnostic & Monitoring)

Pain Perception in Pediatrics (3)

Pain is under estimated & under treated ?

• Pre and full term can not self report pain,

and (mentally & verbally handicapped)

• Weak and ill neonate can not express his

pain properly or to PROTEST

• wrong assumption that the CNS is

underdeveloped

Pain Perception in Pediatrics (4)

Stimulus (heal steak) Physio. Response

• High O2 consumption, limb withdrawal

• Kicking other limb

• Writhing body movements

• High pitched crying, specific facial

expression

• Stress BP, HR, ICT, RR

Pain Perception in Pediatrics (5)

Continuous Pain: Passive behavior

FLAT RESPONSE to circumcision (shock)

• Passive response

• Limited body movements

• Expressionless face

• Low HR, RR, ICT, O2 consumption

Pain Threshold in Pre term Neonates (6)

Proportional in pain threshold from pre full term.

Pre-term:

1.Immature descending inhibitory control

2.High activity of DHN Trans. Release

3. Non painful (handling, change napkins) Painful

4. Pre term males ♂ more susceptible than females♀

5.High doses of analgesics and anesthetics /s. area

Pain Perception in Pediatrics (7)

Male circumcision without anesthesia :

• Irritability (2-7 days)

• Attentiveness & orientation (2-7 days)

• Poor regulation of behavioral state(2-7 days)

• Change in pattern of feeding and sleep(2-7 days)

• Repeated pain in pre term pain threshold

in late adult life.

Female mutilation present but crime

Painful Circumcision

•This operation was

performed in young adults

just before marriage and

without local analgesia.

•The operator says to the

assistant “Hold him well do

not let him fall down”

Pain would induce

syncope.

Health and Healing in Ancient Egypt,

Ghalioungi P, Chapt.III., Fig. 87-89, 1965

Ancient Egypt

Pharaonic Medicine

Painless Circumcision

The surgeon rubs in with

an ovoid instrument, while

the patient says: “rub well

the part”. The operator

answers : “I shall make it

so that it is agreeable”.

They used Stone of

Memphis = Ca carbonate

+ Acetic Acid.

Co2 local cooling

analgesia Health and Healing in Ancient Egypt,

Ghalioungi P, Chapt.III., Fig. 87-89,

1965

Ancient Egypt

Pharaonic Medicine

Female Genital Mutilation

• It is performed without anesthesia

• Girls aged between 2-12 years.

• Occasionally later before marriage

• Seen as an act of passage to womanhood

• Deeply rooted cultural tradition

• No religious basis

• Can have serious health consequences

• WHO –violation of human rights

Dar al-Ifta stopped Female Genital Mutilation

Pain Perception in Pediatrics (8)

Repeated pain:

• Loss of hypocampal neurons

• Hypoth. Pituit. Aden. Axis (HPA) response to

emotions.

• Tendency for alcohol and drug addiction

• Rapid formation of neuronal plasticity and high

C- fos protein in the sensory cortex

Follow up in Ex Pre term Neonates (10)

• Mental retardation

• Poor motor performance

• Visual and auditory deficits

• Learning curves

• Impaired learning processing

Follow up in Ex Pre term Neonates (11)

• low activity and attention

• Low social control and inability to cope

with new situations and poor adaptive

behavior

• Increased somatization in relation to

duration of stay in the (N.ICU)

• More score to develop psychosis

Pain in Geriatrics (1)

Pain in geriatrics is different from

young adults and pediatrics

They have special

Anatomy, physiology

Pathology and Pharmacology

Pain In Geriatrics (3)

Classification of the WHO

• 60 - 74 Yrs. Young old

• 75 - 84 Yrs. Old old

• 85 Yrs. and above Oldest old

Pain In Geriatrics (4)

Less pain in spite of arthritis due to:

– Sensory discriminative pathway

– Affection, motivation and interpretation of pain

– High threshold of pain (20%)

Why ??

Pain In Geriatrics (5)

• Loss of activity of A- fibers

(sharp rapid discrimination of pain)

• Active C fibers

(Slow dull prolonged poorly localized)

• Cerebral Event Related Potential (CERP)

Low response to thermal CO2 laser

Pain In Geriatrics (6)

Geriatrics have higher incidence of :

• Arthritic pain

• Cancer pain

• Post herpetic & Trigeminal Neuralgias

• Post stroke (central) pain

• Depression more than anxiety

Pain In Geriatrics (7)

• Pharmacokinetics:

Delayed absorption, distribution,

metabolism and excretion

• Pharmacodynamics:

Exaggerated response to drug action

Pain In Geriatrics (8)

• Pain processing in Geriatrics is delayed

than in young adults.

But • It has more harmful effects on border

line vital body systems (C.V.S, R.S,

Kidney, Liver, Blood coagulation)