7.18 (9.13) Pediatric pain control

Question 1

What document outlines the currently accepted approach to pain management in children?

How is persistent pain in children defined?

What does this document identify as two major barriers to effective pain management in children?

Answer 1

WHO guidelines on the Pharmacological treatment of persisting pain in children with medical illness

Persistent pain - duration of pain lasting beyond what one would expect from acute injury

barriers to effective pain management in kids - rigid health systems, poor education

Question 2

List four factors that make pain management different in children from adults

Answer 2

60% of patients have non-malignant disease

long, unpredictable disease trajectory necessitates combining proactive disease management with palliation

there may be increased cognitive impairment

differences in communication - interpret verbal and non verbal range of developmental and cognitive abilities

continuing cognitive and physical development throughout illness

Ethical dilemmas - children cannot legally consent, but their compliance, “assent” is important. Involve in decision making as much as possible

Complexities with med prescribing -
i.e. often outside terms of product license,
no longer term studies for dosing
changing size/surface area (pharmacoK, D)
mode of delivery
compliance

Social/situational factors
Pain assessment/treatment dependent on their caregiver/parent response/culture/beliefs etc

Role of parent/family - heavy caregiver burden, higher incidence of depression/divorce/financial issues, unemployment, extra burden on siblings

FS:
Child - changing development
Parents - decision making
Disease - non cancer
Drug - complexities

Question 3

List 4 common Myths and Misconceptions surrounding pain in children.

Answer 3

Table 7.18.1

1. “Newborns don’t have mature nervous system to experience pain” - in fact fetus can by 26 weeks
2. “Children do not feel as much pain as adults” - they can and perhaps even more
3. “Children will get used to pain or not remember it” - continuing pain can have negative effects, long term changes in nervous system
4. “Children cannot explain their pain reliably” - can report pain even at 20 months
5. “If child can be distracted, then not in pain” -children use distraction as pain coping mechanism
6. “If child reports pain but does not appear in pain, relief not needed” - child is authority on whether in pain. Adults/HCP consistently underrate/treat it.
7. “A sleeping child is comfortable” - sleep may be due to exhaustion from pain
8. “Opioid analgesics are dangerous for children/cause addiction” - no higher risk than adults

FS
- don’t feel pain
- can’t reliably explain pain
- can’t remember pain
- opioids are dangerous

Question 4

List four major conditions that comprise the pediatric palliative care population

Answer 4

respiratory*
gastrointestinal conditions*
neuromuscular*
Cancer*

congenital*
genetic

Question 5

At what age does a child develop:

• pathways necessary to feel pain?
• ability to anticipate painful situations if they experienced such situations before
• express pain language
• ability to report pain intensity
• ability to indicate location of pain on a chart

Answer 5

26 weeks in utero

Anticipate pain at 6 months

Pain language 12-30 months

report pain intensity at 3 years

localize pain on a chart - 4 years

Question 6

A child expresses pain to a parent and a parent responds by getting them toys. The child is distracted and plays with the toys.
- Does this child feel pain?
- Do young children feel as much pain as adults?

Answer 6

Yes child feels pain - children use distraction and play as coping mechanism for pain

Yes children feel as much as adults - perhaps more

Question 7

List four factors that influence a child’s pain behaviours

Answer 7

Age*
gender *
cognitive levels*
previous pain experience
family learning
culture*

**there is little evidence child’s pain perception is modified by culture/ethnic factors but expression of pain/meaning attributed to it may be

Question 8

List three factors that can be intervened upon to alter a child’s experience of pain

Answer 8

Figure 7.18.1
Cognitive factors - understanding, control, expectations, relevance, pain control strategies

Behaviourial - Overt actions, parental/staff response, physical restraint, physical activities

Emotional - Anxiety, fear, frustration, anger, depression

Question 9

What is the correlation between the objective appearance of pain in a child and their expression of pain?

What are adults/professionals tendencies when evaluating child pain?

What is the impact of this on the management of childhood pain?

Answer 9

The child is the authority on whether or not he or she is in pain

Adults and medical professionals:
◆ consistently and significantly under-rate children’s pain
◆ often have concern that children exaggerate pain which causes them to discount pain
◆ diminish the seriousness of the pain and suffering as the pain may be difficult to treat

leads to poor management in children

Question 10

How is a child responds to pain depends what is modelled by parents. What can parents encourage to try and mitigate pain?

Answer 10

encouraging their children to engage in normal everyday activities

support behaviours that encourage as much familiarity and routine as possible

enable the child to maintain normality which can improvement pain management

Question 11

You are taking care of a 5 year old with pain. The parents ask you for information about pain management so they can help care for the child.

What are four info points you can provide to assist them with engaging in the pain management plan?

Answer 11

rationale for treatment

how DISEASE processes and situational factors impact upon pain

what to expect from MEDS in terms of benefits and side effects

NON-PHARM pain control techniques

how parent responds to pain is critical - offer calm and consistent APPROACH

Question 12

List 5 questions that are pertinent in the evaluation of childhood pain

Answer 12

Box 7.18.1

1. What words does child/family use for pain?
2. What verbal/behavioural cues does child use to express pain?
3. What do parents do when child has pain?
4. Usual pain assessment - OPQRST
5. Is the pain disturbing the child’s sleep/emotional state?
6. Is the pain restricting child’s ability to perform normal physical activities?
7. Is it restricting child’s willingness to interact with others/ability to play?

FS:
- LOPQRSTUV
- Understanding: words and behaviour
- Impact: sleep, physical activity and social interaction

Question 13

As part of a comprehensive assessment of a child’s pain, one needs to assess the impact of the pain on various elements of the child’s life.

List 5 such elements

Answer 13

the impact of pain upon:
Sleep
Physical function
Relationships
Development
behaviour
emotional state

FS: heads
Home - Behaviour and emotion
Education - Development
Activity - physical function and sleep
Diet
Drugs
Suppports - relationship

Question 14

Without using language, what are two ways an infant may express pain?

What physical behaviour indicates the presence of pain in an infant?

Answer 14

• facial expression and pitch of cry are the characteristics used to assess pain in infants
• a deviation from the norms of behaviours that indicate the baby is experiencing pain.

-Most babies cry when they experience pain
- may attempt to pull away from a painful experience or ‘guard’ or protect the painful limb or area*

FS
- facial, vocal, behaviour (like patients with dementia)

Question 15

What type of thinking do preschool children exhibit that may complicate their understanding of pain? How is this best addressed?

Answer 15

• ‘magical thinking’ with blurring of boundaries between fantasy and reality
• CREATIVE PLAY can be a helpful way to discover a child’s understanding and interpretation of pain

(Preschool child with chronic pain may also stop thinking of their pain as abnormal, stop reporting, become withdrawn)

Question 16

As abstract thinking becomes more common in school aged children, what are they able to do in terms of understanding pain?

What risk do these children have if they develop chronic pain?

Answer 16

• They are able to link cause and effect and understand concepts of time
  (e.g. define pain intensity, explain why it hurts)
• Are able to learn more detail about their pain and explanation of facts can assist understanding and allay fears and misconceptions
• Younger children in this age group may perceive their pain as a punishment
• Neg emotions and feelings of persecution may arise with chronic pain and internalization resulting in withdrawal and a label of ‘DEPRESSION’ can be a feature

Question 17

1. How does the adolescent understanding of pain differ from younger ages in terms of coping strategies?
2. What are 2 important approaches to pain management in this group?

Answer 17

1. Are able to think in an abstract way about pain

• Understand the PSYCHOLOGICAL element of the pain experience as well as the physical
• Have insight and are able to reflect upon their pain experiences in a more systematic and flexible way, drawing upon their individual coping strategies to support this process
• Around age 15, shift from strategies focused on emotions —> focus on causative problem

2. Address teens individually (may downplay pain in front of parents/peers)

Are receptive to being taught coping strategies

Question 18

How are pain behaviours markedly different in malnourished children?

Answer 18

Severe malnutrition associated with developmental delay
Lack of facial expression, verbalization, physical response

May present with whimpers/faint moans for this reason

Question 19

List four indicators of acute pain in children

Answer 19

Facial expression

Vocal:
Crying
Groaning
Inability to be consoled

Body movement and posture

Question 20

List 5 indicators of chronic pain in a child

Answer 20

Abnormal posture
Fear of being moved
Lack of facial expression
Lack of interest in surroundings
Undue quietness/withdrawn/passive
Increased irritability
Low mood, labelled as “depressed” or even “well-behaved”
Sleep disruption
Anger/aggression/labelled as “difficult”
Changes in appetite
Poor school performance
Catastrophic thinking
Functional disability

FS: think of impact of pain (heads)

Behaviour - irritable or well behaved
Emotion - angry or depression

Development - poor school performance

Physical activity - fear of being moved
Sleep - disrupted

Social interaction - withdrawn, passive

Question 21

List 3 reasons why chronic pain may be more challenging to assess in children (vs acute pain)

Answer 21

1. Overt signs of pain dissipate with long term pain
2. Greater variability to expression of chronic pain in different individuals
3. More complex behaviours likely to manifest in chronic pain states
4. Children may not disclose/under-report pain if associate outcome with negative impact (i.e. hospital visit, inpatient stay, injection, worrying parents)

FS
- Facial - signs of pain dissipate
- Vocal - children may under report
- Behaviour - more complex behaviours manifest

Question 22

When choosing a scale to measure pain severity in a child what key factor needs to be considered?

What are three approaches of pain assessment for children? Not specific tests

Answer 22

developmental age/cognitive ability
necessity for carer to report

self-report - child
observational or behavioural - caregiver
physiological (HR, RR) - health care professionals

(Physiological changes loosely correlated to painful events and do not distinguish between pain and anxiety)

Question 23

List two self report pain severity scales that can be used for children

Answer 23

Scales recommended for the quantification of
acute pain and persisting pain in children over 3 years are:
-Wong Baker Faces Pain Scale - Revised*
-Poker Chip Tool
-Visual Analogue Scale*
-Oucher Photographic
-Numeric Rating Scale

Question 24

In the Social Communication Model of Pain what are the four domains that are reviewed as part of a pain assessment in a child?*

**not in 6th edition

Answer 24

This model describes four domains:
the child’s experience and expression of pain, together with
the adult’s assessment and action taken

Question 25

Outline the 4 steps of an integrated approach to a child’s pain.

Answer 25

Figure 7.18.2

1. Assess pain (4 steps***)
   - assess sensory characteristics
   - evaluate contributing social factors
   - evaluate central and peripheral mechanims
   - exam/diagnostic tests
2. Diagnose (primary/2ndary nociceptive activity)
3. Develop treatment plan
   - analgesic OR anaesthetics
   PLUS
   - cognitive +/- physical +/- behavioural
4. Implement plan

Question 26

You assess a patient and create a plan for managing their pain.

What are 2 steps you will take to ensure that the plan is implemented well and remains dynamic?

Answer 26

Education x 2 steps
* Provide feedback on cause and contributing factors to child and parents
* Provide rationale for integrated treatment plan

Follow up x 3 steps
* Measure child’s pain regularly
* Evaluate effectiveness of treatment plan
* Revise plan as necessary

FS: education (disease, meds, non pharm meds, approach) + follow up (pain, meds)

Question 27

List three general categories of non-pharmacologic approaches to pain management in children. Provide two examples of each

Answer 27

Cognitive
-Psychotherapy*
-Hypnosis*
-Imagery
-Distraction and attention
-Choices and control
-Information

Physical
-TENS/acupuncture*
-thermal stimulation
-physio*
-massage*

Behavioural
-behavioural modification
-biofeedback
-relaxation therapy*
-exercise

FS - similar to adults
Physical: massage, accupuncute, exercise
Mind body: CBT, meditation
Mindfulness based: MSBR

Question 28

The 2012 WHO approach to management of persistent pain in children outlines what 5 keys principles?

Answer 28

1. Ensure that detailed assessment has occurred.
2. Dose analgesia at regular intervals when pain is constant (‘by the clock’).
3. Make sure medication is available for ‘break through’ pain episodes.
4. Use the simplest route of administration (‘by the appropriate route’).
5. Tailor treatment to the individual (‘by the child’).

FS: assess, regular, PRN, simple, tailored

Question 29

How many rungs are there on the WHO pain management ladder for children? Why?

Answer 29

‘two-step analgesic approach’ (mild pain vs moderate to severe pain)

Tramadol and codeine have been excluded from the guidelines based upon the safety and efficacy of these medications in children. There is no available evidence for the effectiveness and safety of tramadol in children. Codeine has varied metabolism across the population and in neonates and children it has a very low analgesic effect but a significant side effect profile

Question 30

1. List two medications that can be used for mild persistent pain in a child (what age can each be used)
2. List 1 caution to exercise with each drug

Answer 30

1.Paracetamol (neonates and children under three months)
and ibuprofen (over the age of 3 months)

2. Paracetamol
   - hepatotoxicity is rare
   - risk factors: hepatic/renal disease, malnutrition, drug-drug interaction (i.e. rifampicin, anti-convulsants)

Ibuprofen
- risk of renal/GI/cardiac side effects is low
- but be careful if dehydrated or if cancer (platelet dysf –> inc risk of bleeding)

Question 31

What is the first line opioid used to treat children with moderate to severe pain?

How to dose short acting opioids?
- < 1yo
- >1 yo
- renal impairment

How to dose long acting?

Answer 31

Morphine

< 1 yo: q6-8h due to decreased renal clearance

> 1yo: q4h dosing (although theoretically half life of morphine is less than adults)

if impaired renal: q8-12 h or even PRN until requirements/tolerated interval known is reasonable

some children may benefit from q8h dosing of LA opioids as opposed to q12h

Question 32

What is the least invasive route for opioid administration in children? When is this route not appropriate?

Answer 32

oral route

Not appropriate when:
◆ poor absorption: vomiting, disordered gastrointestinal motility
◆ inability to comply: unconscious; severe nausea, poor swallow, risk of aspiration, medication refusal
◆ pain crisis requiring rapid titration of opioids

Question 33

List three other routes of medication administration that are possible in children.

List one route that should never be used and why

Answer 33

subcut
transdermal
IV
sublingual/buccal
nasal
rectal

IM - avoid as painful and kids may underreport pain to avoid injection

Question 34

What are the three phases of individualizing a treatment plan for a child?

Minimal MEDD to use fentanyl in child ?

Answer 34

INITIATION - calculated based on body weight (up to 50kg)

TITRATION - generally increased by 50% dose increments (in non-naive patients)

MAINTENANCE - long acting formulation

***Minimum TDD of oral morphine 30-40 mg required prior to starting fentanyl 12 mcg patch (ratio 2.4) - this can prohibit use in many small children

Question 35

List five treatments for urinary retention (other than catheterization) secondary to opioids in a child

(Non med and med)

Answer 35

external bladder massage/pressure

heat packs

voiding in warm bath

opioid rotation

cholingeric agent

Question 36

Name one rare side of opioids in children.

What is the treatment?

Answer 36

paradoxical agitation

dose reduction or opioid rotation

Question 37

List four common side effects of opioids in child

List one less common side effect that is common in adults

Answer 37

sedation
constipation
Urinary retention
pruritis, esp around nose and face
myclonus

Nausea seems rare (or perhaps overlooked if children can’t describe it). Generally anti-emetic not automatically prescribed with opioids

Question 38

What is the dosing for naloxone if a child develops opioid-induced respiratory depression?

Answer 38

In opioid tolerant patients, starting dose of 1mcg/kg titrated over time (e.g. q3min) until child is breathing spontaneously

Question 39

1. What is the level of evidence for adjuvant analgesics in the pediatric population?
2. List 5 adjuvants that are used in clinical practice

Answer 39

1. Very limited data available to make evidence-based recommendations

2.
Gabapentinoids
TCA’s
Corticosteroids for bone pain
NMDA antagonist - ketamine
alpha-2 adrenergic agonists - clonidine and dexmedetomidine

**insufficient data to support the use of cannabinoids in neuropathic pain, but some families may self-medicate. Be aware of D-D interactions

Question 40

1. Name 2 common conditions in which children experience muscle spasms.
2. List 2 other possible sources of muscle spasms

Answer 40

1. Neuromuscular conditions
   Severe neurological impairment

2.
constipation*
GERD
seizures*
discomfort from orthotic supports

Question 41

List two treatments for muscle spasm in children.

What is the relationship of opioids and muscle spasm?

Answer 41

baclofen*
Botox*
Dantrolene
surgical intervention
IT drug delivery

consider rotating opioid as could be a side effect

Question 42

List 4 causes of bone pain in children

Answer 42

• chronic neurological conditions such as cerebral
  palsy or neuromuscular conditions, bone pain associated with secondary distortion of the normal skeletal structures may occur, especially during periods of growth

-non-ambulatory children with chronic neurological conditions have low bone density and an increased propensity to non-traumatic fracture, or fracture with minimal trauma

-inherited metabolic disorders of childhood with pathological involvement of bone from systemic disease, mucopolysaccharhidosis

-primary defects of structural bone proteins, osteogenesis imperfecta.

-Osteopenia from secondary distortion of the normal skeletal structures may occur as an effect of systemic treatments such as prolonged steroid use in cancer

-in HIV may predispose to osteomyelitis or
septic arthritis, also osteopenia

-Cancer-induced bone pain (primary bone tumour, mets, hematologic malignancy)

FS: (vindicate - NP)

Infection - Osteomyelitis from HIV
Neoplasm
Iatrogenic - steroids
Congenital - metabolic disorder
Neurological - CP or neuromuscular condition

Question 43

What is the predominant feature of cerebral irritability in children?

List three ddx for this behaviour

List three populations where this syndrome is commonly seen

Is pain present in this condition?

Answer 43

persistent, unremitting agitation and distress

-DDX - pain, acute illness, terminal delirium

most commonly seen in non verbal child:
- infants* presenting with an acute illness
- severe neurological impairment*
- children with progressive, often neurodegenerative disorders
- children with malignancy at EOL*

difficult to know if child is experiencing pain -> must rule out, if no pain thought to be related to abnormal brain and processing

Question 44

List 4 presentations cerebral irritability

Answer 44

Classical symptoms in an infant or non-verbal child with severe neurological impairment include:

an unrelenting high pitched scream
increase in tone
seizures
sleep-wake cycle disruption
autonomic dysfunction (sweating, paradoxical bradycardia) increase in secretions
vomiting
retching
‘feed intolerance’

FS: 6S (screaming, seizure, spasm,
sleep disruption, sweating, secretions)

F - retching/feed intolerance, secretions
L - increase tone, spasm, seizure
A - sleep wake cycle disturbance
C - screaming
C - inconsolable

Question 45

List 3 conditions on the DDx for idiopathic (persistent) distress in a non-verbal child

Answer 45

1. Cerebral irritability
2. Central pain
3. Visceral hyperalgesia

Question 46

What is the source of central neuropathic pain?

What are the 2 most common causes in children?

Why does this cause pain physiologically?

Answer 46

Central pain arises from damage to any part of the central somatosensory system

Common causes in children:
- Neurodegenerative conditions (congenital)
- (hypoxic or traumatic) brain injury (acquired)

Cause pain due to impaired processing?

disordered structure, abnormal neuronal migration and myelination, and/or abnormalities of normal neurological systems at the molecular level

Question 47

1. Define visceral hypersensitivity or hyperalgesia.
2. What is the underlying mechanism?
3. List 3 clinical signs associated with it.
4. What two conditions need to be treated before a diagnosis of visceral hypersensitivity syndrome can be made

Answer 47

1. Altered response to visceral stimulation resulting in activation of pain sensation.
2. Often associated with gut motor abnormality and exaggerated intraluminal pressures and pain sensation (gut nociceptors activated at lower threshold)**. Aberrant neuromodulation in abnormal brain resulting in pathological pain pathways
3. Chronic cerebral irritability related temporally to GI symptoms and signs:
   pain, feed intolerance, flatus, retching, vomiting (FS kind of like MBO)
4. Constipation and GERD

Question 48

List 3 first line treatments for visceral hypersensitivity syndrome in children.

What is the role of opioids?

List 3 treatments when it comes intractable?

List 1 non pharm treatment

Answer 48

TCAs, anticonvulsants, and NMDA receptor antagonists - first line

-opioids not first line but have been shown to improve pain in some central neuropathic conditions

intractable symptoms - benzos, phenobarbital, levomeprazine, haloperidol

-feeding programmes, jejunal feeding

Question 49

List four causes of low bone density in children

Answer 49

lack of sun*

feeding difficulty/malnutrition *

Anticonvulsant use

non ambulatory status *

chronic neuro condition*

FS: think vit D, calcium, exercise

V
I
N - bone malignancy
D - non ambulatory
I - steroids
C
A - poor absorption of nutrients (IBD, celiac disease)
T
E - T1DM
N/P - neuro condition