Pain assessment and management in children is not as straightforward as it is in adults; children and young babies may be unable to express their discomfort and pinpoint where it is coming from to aid diagnosis. If the root cause of the pain is not quickly or effectively treated in paediatric patients then it can lead to long term physical and psychological repercussions. Therefore it is essential for healthcare providers to understand and offer effective pain relief to young children as soon as possible (1).

What is pain?

Pain itself is multidimensional; it can be an emotional unpleasant sensation of suffering. Consequently the assessment of pain in a clinical setting should include understanding the concentration, location, duration, and description of the pain itself.

When assessing children, elements which may influence the child’s perception of pain should also be taken into account. These elements include the child’s social history, personal beliefs, and past experiences of pain. The response of parents and guardians to the child in pain can also affect the child’s perception of pain. It is important to note that it can also be challenging to differentiate between pain, anxiety, and distress in some young patients (2).

Physiological indicators of pain

These indicators should not be used alone as a measurement of pain, however they can help a healthcare provider understand in collaboration with physical, behavioural, or self-reporting methods, as to whether the patient is responding to a pain management technique.

Otherwise, if the patient is sedated then the following indicators can help determine whether the patient is in pain (2);

• Heart rate may rise
• Blood pressure may rise
• Oxygen saturation levels may fall
• Respiration pattern may change from normal patterns, either an increase, decrease or changed respiratory rate

Assessing pain in children

To be able to effectively manage pain in children, adequate and on-going pain assessment should be carried out. Ideally, patients would self-report their levels of pain; however this is not always possible for younger patients who are unable to clearly communicate or verbalise their experience. Therefore observational, physiological, and behavioural assessment tools are required (1).

One of the best ways for healthcare providers to assess pain in children is to take behavioural cues from parents or guardians in order to avoid the off-chance that pain is under-treated in children, especially those who have developmental disabilities (2).

Pain should be assessed frequently in young children to make sure that the pain management techniques are working successfully. If the patient is taking oral analgesia then pain scores should be taken every four hours. If the patient is taking complex analgesia, such as drugs which are administered intravenously or an epidural, then pain scores should be documented every hour.

Pain levels should be assessed and documented before and after the analgesia is administered, as well as when the patient carries out an activity such as physiotherapy (2).

Treatment of pain in children with drugs

The World Health Organisation (WHO) suggests that healthcare providers use the following concepts to treat pain in young children, especially with those who have medical illnesses (3);

• Use the two-step strategy in which low doses of strong opioids are administered (as outlined below)
• Dose the patient at regular intervals
• Use the appropriate route for administering medicines
• Adapt each treatment personally to individual children and their medical history

If the pain is mild, then the first step will be to offer paracetamol or ibuprofen. If the pain is moderate or severe however, then an opioid drug will be required for pain management – morphine is the preferred drug of choice for the second step. The WHO guidelines also state that concerns over the use of opioids in children should not stop healthcare providers from administering them as effective analgesics (3).

In terms of drug administration and their guidelines, they can be broken down into the following categories (3);

Non-Opioids

Paracetamol - Many sugar free preparations are available over the counter to deal with mild to moderate levels of pain. However healthcare providers need to be careful not to overdose as hepatic damage can result and not appear immediately.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) - Most commonly ibuprofen is administered. NSAIDs are most useful in cases of long term inflammatory conditions, however they can cause gastric irritation.

Opioids

Morphine is the preferred opioid drug of choice in dealing with more intense pain, acceptable for both persistent and episodic pain. Opioids can be administered orally and alternatively, however extra care and monitoring should be done when the opioid drugs are alternatively administered.
Side effects of opioids can involve nausea, vomiting, drowsiness, and constipation when there is long term use. Newborns should be carefully monitored as they are at a higher risk of respiratory depression and/or hypotension.

Other Medications

Topical anaesthetics and benzydamines can be offered when there is pain in association with the oral mucosa. If the young patient is to undergo a painful procedure or has a high phobia of needles, then nitrous oxide gas for inhalation can be offered to act as a short term analgesia. Creams which contain lidocaine can be applied topically to offer pain relief for venepunctures or after circumcisions.



Sources:

National Center for Biotechnology Information
The Royal Children's Hospital Melbourne
Patient