Measurement

• Behavioral (neonates-4yo)

  • FLACC scale

    • Face, Legs, activity, cry, comfortability

• Self-Report (>4 yo)

  • Wong-Baker FACES (little kids who can understand instructions and point)

  • Numeric

  • PQRSTU

• Multidimensional (7-10+ y)

Assessment of Chronic and Recurrent pain

• usually multidimensional

  • pain intensity

  • functional assessment

  • pain diaries: sees patterns

Children with Chronic Illnesses and Complex Pain

• components of assessment

  • trusting relationship with child and family

  • onset of pain

  • pain duration or pattern

  • effectiveness of current treatment

  • PQRSTU

  • Interference with child’s mood, function, interactions

  • reassess once interventions are given, see what other measures can be given

Children with Communication and Cognitive Impairments

• at greater risk for undertreatment of pain

• primary caregiver is important source of info

• Pain measurement tools

  • FLACC

  • Pain Indicator for Communicatively Impaired Children (PICIC)

  • Noncommunicating children’s pain checklist

Responses to Pain: Neonates and Infants

• Neonates:

  • Physiologic changes: Vitals

  • Behavioral

• Older Infants

  • Crying

  • Deliberate withdrawal from painful stimuli

• Considerations: maturity, behavioral state, energy to respond, risk factors for pain

Response to Pain: Children and Adolescents

• Young kid: loudly cry and scream; thrashing

• School Age: similar behavior; time wasting behaviors

• Adolesence: less vocal, less physical; increased verbal expressions

Pain Management

• nonpharm management

  • Sucrose

  • nonnutritive sucking

  • containment/swaddling

  • distracitons

  • parent involvement

  • heat

  • art therapy

  • pet therapy

  • Choice words/language

• Complimentary and Integrative Health

• Pharmacologic management

  • nonopioids, opioids, coanlgesics

  • Patient-controlled (have to be mature and cognitively in control), epidural

    • Transmucosal and transdermal anesthesia

      • EMLA, LMX4, needle-free lidocaine injection, sucrose, cold vibration device

Pharmacological

• Individualizing treatment to child

• World Health Organization - 2 step strategy

  • Dosing at regular intervals

  • using the appropriate route of administration

• Safety Alert Box: optimum dosage of analgesics is one that controls pain without undesired side effects. Usually requires titration, gradual adjustment of drug dosage till optimum pain relief without excessive sedation is achieved.

• Nonopioids: Acetominophen and ibuprophen (can’t give to kids under 6 months bc weak kidneys)

  • 10-15 mg/kg/dose

  • 5-10 mg/kg/dose

• Coanalgesic: used alone or with opioids

• Opioids:

  • Moderate to severe pain

  • Morphine, most commonly used

  • Fent (100x stronger than morphine)

  • Hydromorphone: longer duration than morphine

  • Methadone

  • Oxycodone

    • "Codeine no longer used in children” because of the efficacy

Always use least invasive option first.