Acute pain in pediatrics Flashcards
How to assess for pain in nonverbal children (<3 y/o)
FLACC scale - face, legs, activity, cry, consolability
score of 1-3 = mild
4-6 = moderate
7-10 = severe
r-FLACC^2 (if cognitively impaired)
How to assess pain in younger children (3-8 y/o)
- Faces Pain Scale (FPS) - 7 faces, 0-6 score
- FPS revised (4+ y/o) - 6 faces, 0-10 score
- Wong Baker Faces Pain Rating Scale (WBFPRS) 3-6y/o+ - created with children, 6 faces, 0-10 score
- Oucher pain scale - uses photos, shows diff ethnicities
- Colour analog scale (CAS) - 4-5+ y/o, darker colour = more intense
- Verbal Numeric rating scale (vNRS): 6+ y/o (usually 8+), rate from 0-10
Pain assessment in older children (8-11 y/o)
vNRS - rate their pain along a horizontal/vertical numeric scale
Pain assessment in adolescents
Numeric rating scale without pointing at scale
Tips for Using Self-Report Pain Scales
- Ensure age-appropriateness
- introduce the scale to the child when they are not in pain
- obtain successive pain ratings over time to track events known to cause pain as well as the efficacy of interventions (how does _ compare to last time)
- Judge the severity of the pain and the efficacy of the interventions
What are the goals of therapy for managing pain
- Relieve the pain until the cause is managed
- Identify and treat the cause of pain
- If possible, prevent the pain
Physical non-pharmacologic strategies for pain
- heat or cold therapy
- acupunture
- immobilize fractures
- massage therapy
- breastfeed infant
- sucrose
Behavioural non-pharm strategies
- relaxation
- exercise
- art and play therapy
cognitive non-pharm strategies
distraction
imagery
hypnosis
Monitoring for pain relief
- desired outcome = reduction in pain
- change expected within 1-2 hours of taking analgesic
- patient monitors daily
- RPh follow up in 2-3 days
What is teething
Eruption of deciduous (“milk”) teeth through gingival tissues
When does teething start
4-12 months (avg 6 months)
When does the full set of primary teeth occur
3 years
when do you start losing primary teeth
5-6 years
When does teeth development begin
- in the womb
- pregnancy nutrition vital (calcium, phosphorus, vitamin C, vitamin D)
- Avoidance of certain medications while pregnant (ex. tetracycline harmful to developing teeth)
What is the first tooth to erupt
central incisor on lower teeth
How many teeth erupt a month
1 tooth/month
What is the timeline of primary tooth eruption
7+4 mnemonic
•at 7 months: first teeth
•at 11 months (4 months later): 4 teeth
•at 15 months (4 months later): 8 teeth
•at 19 months (4 months later): 12 teeth
•at 23 months (4 months later): 16 teeth
•at 27 months (4 months later): 20 teeth
What is the order of teeth that are erupted
central incisor - lateral incisor - first molar - canines - second molar symmetrical eruption (upper teeth erupt after 1-2 month after the same tooth on lower teeth)
When does secondary/permanent dentition eruption start
6 - 7 years
continues for 6 years
symmetrical eruption
How many teeth are in the primary dentition
20
how many teeth in permanent dentition
32
Who is likely to have delayed tooth eruption (DTE)
Premature and low birth weight babies
Racial, ethnic, sexual and individual factors can influence eruption
If eruption does not occur by 12 months, should be referred
What are associated signs and symptoms of teething
- Gum redness, swelling +/- tenderness
- Gum rubbing, biting or chewing on hard objects
- Drooling (causes facial irritation)
- Irritability, restlessness, crying, insomnia
- Decrease in appetite (for solids), increased thirst
What is NOT associated with teething
- Vomiting
- Diarrhea
- Malaise
- Fever
- Rashes (on stomach, etc)
Do all babies experience symptoms of teething
No, only 2/3 of infants
What is the teething window
8 days
- 2-5 days before teething breaks skin
- few days afterwards
- symptoms usually resolve 3 days after tooth erupts
Does teething cause fever
not really, (poor quality studies)
some association of fever with day of eruption +/- 1 day
fever on any other day should be assessed for other sources
What are eruption cysts
Dome-shaped, soft, bluish, swollen area filled with tissue, fluid and blood
localized to gum overlying erupting tooth
not infection
lasts <1 week (disappear if left alone)
see dentist if lasts longer, or causes pain/feeding problems
Red flags that require dental consult when possible
Pericoronitis (wisdom tooth infection)
Delays of >6 mo in a primary tooth eruption (ex. at 12 months)
Delays of >12 mo in a permanent tooth eruption (ex. at 7 y/o)
Eruption cysts (do not disappear or causing pain/problems with feeding)
Red flags that require URGENT dental consult
Pericoronal abscess
- caused by pericoronitis
- can spread infection to cheeks, face, neck
- compromised airway
Red flags that require medical consult when possible
Suspected systemic illness in a young child (diarrhea, fever)
Goals of therapy for teething
- Minimize/relieve gum pain and irritation
- Reduce child’s irritability
- Minimize sleep disturbances - Prevent complications
- Involve medical or dental professionals when indicated
Prevention measures for teething
Wipe gums of infants BID
Brush primary teeth BID (when beginning solid foods)
Monitor teeth
No bottles in bed with milk, formula or juice - Baby Bottle Tooth Decay
Assessment by dentist within 6 months of first tooth eruption or by 1 y/o and every 6 months after
Nonpharm therapy for teething
ROKD
R - rub the gums (with clean finger, damp washcloth, cold spoon)
O - offer the rings (teething rings)
K - keep it cool (cold washcloth, COLD not frozen teething ring, cold foods)
D - dry the drool
What oral analgesics can be used for teething
acetaminophen and ibuprofen
Acetaminophen dosing for teething
10-15mg/kg/dose by mouth Q4-6H prn
MDD=75mg/kg/day
do not exceed 5 doses/day
Ibuprofen dosing for teething
5-10mg/kg/dose by mouth Q6-8H prn
MDD=40mg/kg/day
no more than 4 doses/day
What topical anesthetics can be used for teething
NOT RECOMMENDED (benzocaine = Orajel)
- max 4 times/day
- cannot eat/drink 10-30 mins after application
- risk of disabling gag reflex if swallowed
- risk of MetHb (methemoglobenemia)
What is MetHb
blood contains too much methoglobin (form of hemoglobin that does not bind oxygen properly)
- therefore, affected person does not get enough O2
symptoms of Methemoglobinemia
weakness, confusion, headache, difficulty breathing and/or pale, gray or blue-coloured skin, lips and nail beds.
the greater the concentration, symptoms become more severe
(>10 g/dl MetHb = death)
NHP for teething
no studies to support efficacy, therefore do not recommend
examples: Orajel homeopathic, camilia teething liquid, hyland’s baby oral pain relief
What to avoid for teething treatments
Alcohol
Teething biscuits (cariogenic - too much sugar)
Aspirin (Reye’s syndrome)
Rubbing oral pain relievers directly on the gums
Topical anesthetics
Frozen items
Monitoring and follow up for teething
follow up 3-5 days
refer if non-pharm and pharm treatment both ineffective or if symptoms uncharacteristic of teething
What is the 1st therapy for teething
non-pharm
2nd line is for relief - oral analgesics
