‘No More Ouch!’: Assessing Pain In Children

By Jan Howard

A program addressing improved pain medication for children took place during the recent Sixteenth Annual Pediatrics Update conference at Danbury Hospital, sponsored by the Department of Pediatrics.

“No More Ouch!” was presented by Dr William S. Schechter, associate clinical professor of anesthesia and pediatrics, Columbia University College of Physicians & Surgeons and director of the pediatrics pain medicine program at Children’s Hospital of New York.

 Dr Schechter described the Pediatric Pain Medicine Program at Columbia, which was initiated in 1995. “The pain service began in response to a need for improved postoperative pain management on the ward,” he said.

He said changes in pain treatment have also been driven by adverse events related to sedation.

Goals for the program included uniform age-based methods of pain assessment and appropriate documentation; parent, patient and faculty education; expansion of services; and eliminated intra-muscular injections.

“We live in an age where parents ask for pain medication,” he said. “We need to make sure children get adequate pain medication in and out of the hospital. Children do better if their pain is treated efficiently and better.”

He noted that pharmaceutical companies are now required to demonstrate the safety and efficacy for new drugs that may be used for children.

 New guidelines recognize that pediatric patients have a right to pain assessment and treatment, standardized guidelines for pain assessment and treatment required for hospital accreditation, and require educational programs to improve pediatric pain management.

“Pain assessment has been termed the fifth vital sign,” Dr Schechter said. “Pain must be assessed and appropriately managed.

“Pediatric pain management begins with a realization that children feel pain. All children fee pain,” he said. “We know infants feel pain.”

 Pain is perception, he noted. Procedural pain and anxiety can be treated or prevented. Untreated pain can have adverse physiological and psychological consequences. Pain treatment should be painless, Dr Schechter said.

“We need to develop techniques to administer pain treatment in a comfortable manner. The approach is not perfect today. We need to educate ourselves about drugs.”

Pain treatment costs money, he said, but requires a commitment. “We need to raise awareness and advocacy for adequate pain treatment for children.”

He said parents are not taught how to use pain medications. “We need to ensure we teach parents how to use pain medications appropriately. They think their children will become dependent on drugs.”

Pain is a subjective experience, Dr Schechter said. “We have to believe people are feeling pain. There are many types of pain.” These include physiologic, which does not result in tissue damage; inflammatory, which follows damage to tissues and can be easily localized; and neuropathic, which follows damage to nerves or may give false signals, such as phantom limb pain following an amputation.

The most common causes of pain in hospitalized children include IV placement, procedural pain, postoperative pain, and cancer and other life-threatening illness and their therapies.

The placement of an IV can become painless through the use of a local anesthetic, which takes the sting away, Dr Schechter said.

He said having a parent present also effects the child’s pain threshold and lessons the perception of pain.

Local anesthetic blocks can help eliminate postoperative pain and may decrease the need for pain medication.

He said some ways used to decrease pain perception are focused breathing, hypnosis, relaxation techniques, and physical contact, such as holding the child’s hand.

The most common causes of pain in pediatric outpatients are circumcision, immunizations, minor procedures such as suturing, closed reduction of fractures and casting, dental procedures, acute abdominal pain, and accidental injuries.

Do babies feel pain? “Even premature patients do,” Dr Schechter said.

He explained that preterm and newborn infants were once believed not to feel pain because their nervous system was in development. It was also believed that anesthesia for the newborn was too dangerous and that they were too sensitive to analgesics.

“The opposite is true,” he said. “We now know that they have repetitive pain impulses.”

He said untreated pain can cause adverse effects and can cause long-term changes in the anatomy and physiology of the nervous system. “It may have a long-term effect on how the child perceives pain in later life and behavior.

“We believe in acting with empathy. That is reason alone to treat a child’s pain,” he said.

 He discussed ways health care workers and parents can determine if a child is in pain. A baby’s pain may be assessed through crying and activity. “There is a specific cry pattern,” he said. “A rapid, high frequency cry is most characteristic of a pain cry.”

Observation of facial action can also be used to assess pain in an infant, he said. There may be a ruffled brow and open square mouth. To gauge the pain of 3- to 5-year-olds, physicians use a Wong-Baker Faces Scale for children to indicate how much pain they are experiencing.

Assessing pain in a cognitively impaired child is difficult, Dr Schechter said. It is done mostly through observational assessment. He added that children with intellectual disabilities are excluded from most studies despite the high prevalence of pain.

 Dr Schechter also discussed some of the pain medications used to decrease pain in specific types of procedures. He also noted some pain medications should not be given to children, including aspirin because of its association with Reye’s Syndrome.