PRINCIPLES OF PAIN MANAGEMENT: PEDIATRIC GUIDE

Assessment and Diagnosis Treatment Management and Monitoring

All patients should be screened for pain. Once identified, a complete Goals General
assessment, including physical, emotional, social, and spiritual components,  Treat acute pain aggressively to avoid chronic pain  Reassess regularly
is necessary to determine cause of pain and appropriate therapy.  Treat chronic pain thoughtfully and systematically  Measure “5th vital sign” using tools (i.e. numeric
History: Assess  Identify and address the cause of pain scale, face scale); respond urgently to pain ≥8
 Onset, location, quality, intensity, temporal pattern, aggravating and  Maintain alertness, ability to function safely/productively  Follow amount and duration of response
alleviating factors, associated symptoms  Allow emergence of feelings other than pain  Assess performance status
 Characteristics of pain*  Intervene as noninvasively as possible  Partner with patient/family in setting goals of care
 Previous methods of treatment  Negotiate target with patient/family  Balance function vs. complete absence of pain
 Other medical and surgical conditions. Non-Pharmacological Therapy Referrals and Management
 Substance use  Patient/Family Education Acute pain
Psychosocial History: Assess Community & Web-based Support Groups  Refer early to appropriate specialist or Pain Center,
 Depression, anxiety, PTSD, sleep pattern**, suicide risk  Cognitive Behavioral Therapy; Supportive Psychotherapy if diagnosis unclear or pain refractory to treatment
 Impact on quality of life, ADLs & performance status***  Physical Therapy; Chiropractic/Osteopathic Care; Massage Chronic pain
 Patient, family, and caregiver’s cultural and spiritual beliefs  Exercise: Yoga, Tai Chi, Qi Gong, Walking, Water Therapy  Set realistic chronic care goals
 Secondary gain: psychosocial/financial  Cutaneous Stimulation: Ice, Heat; Counterstimulation: TENS  Transition from passive recipient to patient-directed
 Acupuncture & Acupressure (trigger point Rx) management of therapies
Assessment  Relaxation techniques: Biofeedback, Music, Hydrobath, Reiki,
 Order and evaluate appropriate diagnostic testing  Refer “difficult to treat” cases (H/O substance
Therapeutic Touch, Healing Touch abuse, neuropathic pain, rapidly escalating opioid
 Evaluate pain on all patients using the age/developmentally appropriate scale:  Meditation, Mindful Practice, Visualization/Interactive Guided doses) to MD with palliative care or pain expertise
1. Numeric scale & FPS-R: Adolescents and older children
Imagery; Prayer; Spiritual & Pastoral Support
A. mild pain: 1-3 Neuropathic pain
B. moderate: 4-7 (interferes with work or sleep**) Pharmacological Therapy  Use anti-epilepsy drugs (AEDs) first
C. severe: 8-10 (interferes with all activities***)  Use WHO/AHCPR step care as “ramp” (see reverse side)  Use step 2 drug to help Rx
2. Faces Pain Scale-Revised (FPS-R): Younger children (~6-10 years old)  Use adjuvant therapies prn
Special Situations
3. FLACC-revised scale: <6 years old/developmentally delayed  Avoid Demerol® (meperidine)
Anxiety and depression
4. NIPS: Neonatal Infant Pain Score  Use care with combinations (consider total consumption of
 Refer to Depression Guidelines
APAP from multiple Rx and OTC sources)
 Use ONE short-acting med for acute pain exacerbation Verbally non-communicative patients
 Switch to ONE long-acting meds when pain stabilized  Infants, children & cognitively impaired all feel pain
Avoid multiple agents of similar duration  Evaluate patient’s non-specific signs: noisy
breathing, grinding teeth, bracing, rubbing,
Chronic moderate or severe pain
crying, agitation
 Give baseline long acting opioid around the clock
 For breakthrough, give 10% of total daily dose as prn Infants (use appropriate pain scale)
 PRN interval: 1-2 h oral, and 30-60 min parenteral  Start at ½ usual dose
 Adjust baseline upward daily by total amount of prns  Watch carefully for toxicity from accumulation
 When converting from one opioid to another, reduce total Patients with substance abuse history
Diagnostic Terms dose by 1/3-1/2 to account for incomplete cross tolerance  May need higher starting dose (tolerance)
*Somatic pain: localized; ache, throb, or gnaw
Adjunct therapy and anticipate side effects  Use prescribing contracts for outpatient use
*Visceral pain: often referred; cramp, pressure, deep ache, squeeze
 Prevent constipation: start senna or polyethylene glycol  Consider abuse-deterrent formulations
*Neuropathic pain: burns, electric shock, hot, stab, numb, itch, tingle
Cancer Pain: associated with cancer, HIV  Nausea: treat with antiemetics or change meds Be aware of potential for addiction and misuse
Non-cancer pain: e.g. arthritis or musculoskeletal disorders  Pruritus: treat with antihistamines or change meds  Encourage established functional goals
Acute Pain: ↑HR, HBP, diaphoresis, pallor, fear, anxiety  Myoclonus: treat with benzodiazepine or change meds  Ensure follow-up
Chronic pain: sleep difficulties, loss of appetite, psychomotor  Mental impairment: avoid driving/hazardous situations until
retardation, depression, career/relationship change side effect profile stabilizes; reassess safety periodically
Guidelines and principles are intended to be flexible. They serve as reference points or recommendations, not rigid criteria. Guidelines and principles should be followed in most cases, but there is an understanding that, depending on the patient, the setting, the circumstances, or other factors,
care can and should be tailored to fit individual needs. Approved in July 2014; Next Scheduled Update in 2016
QUEST Principles of Pain Assessment1 Pharmacological Therapy2 Operative Pain Management
 Question the child  Oral or IV administration of pain medication is the preferred method.
 Use pain rating scales Preoperative patient assessment,
 Avoid painful IM injections.
 Evaluate behavior and physiological changes preparation, and interventions
 The initial choice of analgesic should be based on the severity and type
 Secure parent’s involvement of pain (see table below).
 Take cause of pain into account  IV Opioids can be safely titrated to effect in the pediatric setting
 Take action and evaluate results  PCA is an acceptable form of administering pain medication with proper Intraoperative anesthesia and analgesia,
2 patient and family education. with preemptive measures for
Neonates
postoperative pain control
Signs of Acute Pain Signs of Chronic Pain
Crying and moaning Apathy Pain Severity Analgesic Choice Examples
Muscle rigidity Irritability Mild Acetaminophen*(APAP) Tylenol®, Ibuprofen,
Flexion or flailing of the Changes in sleeping and  (pain score 1-3) or NSAID** Naproxen Consistent with Not explained
extremities eating patterns No pain or by surgical
 PO APAP/opioid surgical trauma
Moderate Toradol®, Vicodin®, pain not trauma
Lack of interest in their combinations
Diaphoresis (pain score 4-7) Tylox® requiring
surroundings IV/PO low dose MSO4
intervention
Irritability
Severe Morphine, Fentanyl®,
Guarding Opioid
(pain score 8-10) Hydromorphone
Changes in vital signs
and pupillary dilatation Postoperative
Reassess drug and Surgical
Older Children nondrug
Evaluation
interventions
 Children < 6 years old or unable to communicate, Drug Oral Dose
clinicians should use the FLACC-revised scale
Mild Pain Children Adolescents
 Children >~6-10 may use the Faces (FPS-R) scale
Ibuprofen** 5-10 mg/kg 400-600 mg q6 hrs prn Unacceptable Treat
 Children over 5 may be able to use descriptor words
(stinging, burning)2 side effects or
Acetaminophen (APAP)* 10-15 mg/kg 300-600 mg q4-6 hrs prn inadequate
 Children over 6, who understand the concepts of rank Assess effect of
Use APAP* or ibuprofen** to enhance analgesia analgesia interventions
and order, can use scales2
Categories of Pain3 Moderate or Severe Pain Children & Adolescents
Procedure-Related Pain Morphine 0.2-0.5 mg/kg/dose q3-4 hrs
 Anticipation of intensity, duration, coping style and Hydromorphone 0.03-0.08 mg/kg/dose q3-4 hrs Change drug Optimize dose
temperament child, type of procedure, history of pain Oxycodone 0.1-0.2 mg/kg/dose q3-4 hrs interval, interval
and family support system dose route,
Operative Pain and Trauma-Associated Pain modality, or
*Daily dosing of Acetaminophen not to exceed 15 mg/kg/dose or 5 doses add adjuvant Satisfactory
 Postoperative pain management should be discussed
prior to surgery per day (75 mg/kg/24 hrs) in children <40 kg and 3000 mg/24 hrs in or treat side response
 Control pain as rapidly as possible adolescents ≥40 kg. effect

Acute Illness Discharge

**NSAIDs – monitor in patients on anticoagulation therapy and/or history of
 Determine severity of pain by the particular illness and planning
bleeding disorder; limit use ≤5 days.
situation (e.g. otitis media, meningitis, pharyngitis, etc.)
1. Baker CM and Wong DL. 1987. Q.U.E.S.T.: A Process of Pain Assessment in Children. Orthopaedic Nursing. 6(1):11-21. http://www.wongbakerfaces.org/wp-content/uploads/2010/08/QUEST.pdf. Accessed: 25 August 2014.
2. American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health and American Pain Society, Task Force on Pain in Infants, Children and Adolescents. 2001. The Assessment and Management of Acute Pain in
Infants, Children, and Adolescents. Pediatrics 108(3): 793-797. http://pediatrics.aappublications.org/content/108/3/793.full.pdf+html. Accessed: 25 August 2014.
3. Agency for Health Care Policy and Research, United States Department of Health & Human Services. 1992. Clinicians’ Quick Reference Guide to Acute Pain Management in Infants, Children and Adolescents: Operative and Medical Procedures.
Journal of Pain and Symptom Management 7(4):229-42.