Children Flashcards
Why should we view pain in children differently to pain in adults
Different types of pain, prevalence
King et al., Pain, 152: 2729-2738, 2011
Headaches: median prevalence 23%, about half of headaches are migraines, the rest are tension-type headaches.
Musculoskeletal/limb pain: median prevalence 28%. Prevalence also
increases with the age of children, and it is larger in girls than boys.
Prevalence of different types of pain, accidental or chronic, is much
larger in children with mental impairments compared to healthy children (Breau et al., Arch. Med. Adolesc. Med., 157: 1219, 2003)
Pain assessment
Children dependent on their caregivers
Pain perception at different developmental stages and specific
pain issues at different ages
0-3 months No apparent understanding of pain, pain memory likely – imprinting?; reflex responses
3-6 months Pain response accompanied by sadness and anger
6-18 months Develops fear of painful situations; localisation of pain develops; words associated with pain (e.g. owie, booboo)
24-36 months Begins to describe pain, and attribute an external cause to the pain
36-60 months Gives a gross indication of intensity of pain, use of descriptive adjectives, uses emotional terms such as “sad” and “mad”
5-7 years Can differentiate levels of pain intensity more clearly; beginning to use cognitive coping strategies
7-10 years Can explain why pain hurts
11 years Can explain the value of pain
Goldschneider et al., 2001
Children younger than 2 years react in S-R manner, have no sense of permanence, no anticipation of pain, no sense of causality. The pre-toddler positively reacts to swaddling, cuddling, warm environment and soothing voices.
Toddlers already have some sense of permanence, and approach the world in egocentric manner. Pain is viewed as punishment, the intensity of pain correlates with how “bad” the child was.
A school child can well express the pain. Pain is not a punishment any longer. Children have a sense of causality, and therefore the Patient Controlled Analgesia can be successfully used.
The school children worry much about their body image, and have a feeling of invulnerability.
In stress, such as hospitalisation, regression to a previous development stage can occur
Pain in neonates
Brain measures
Slater et al., Semin. Perineonat., 2007
The pain pathways are complete at the time of birth:
first nociceptors: 7-10 weeks of gestation
primary afferents to the spinal cord: week 19
thalamo-cortical synapses in the cortex: week 21-28
At the week of 25, it is possible to record cortical response to pain.
Pain pathways developed but inhibitory pathways still not, and therefore:
neonates feel pain more strongly than adults
pre-term neonates feel even more pain than normal
newborns
Sources of neonatal pain:
colic
heal lance, circumcision
neonatal diseases (e.g., infections)
Premature babies
Prematurely born infants show sensitisation to repeated noxious stimuli (unlike adults). The closer are the preterm newborns to the normal gestational age, the more likely they show habituation to repeated noxious stimuli (Fitzgerald et al., Dev. Med. Child. Neurol., 30: 520-526, 1988).
Preterm infants are exposed on average to 50 painful procedures/day, compared to 14/day in full-term babies
Only 20% of neonatal units in UK have a protocol for analgesia in newborns
Less than 60% of units use any analgesia in preterm infants
(Slater et al., 2007)
Slater et al., Semin. Neonat., 31: 298-302, 2007.
Cortical responses correlate with facial expressions of pain in infants
Concentration of hemoglobin in the
somatosensory cortex correlates
with the PIPP, an established pain index.
PIPP = Premature Infant Pain Profile, composite measure of 3 facial action units: broadening the nose base, eye closure, lowering eye brows
Slater et al., NeuroImage, 52: 583-589, 2010.
Pre-term infants show stronger response to heel lance than normal term infants
Effect of early pain experience on subsequent acute pain
Long-term consequences of early life exposure to frequent pain
Taddio et al. (Lancet, 1997) analysed behavioural pain responses to vaccinations in
4-6 months old boys having gone through circumcision at day 5. There were three
groups: circumcision, circumcision plus analgesic cream, circumcision plus placebo
cream. Circumcision without analgesic cream was associated with greater pain during
vaccination compared to circumcision with cream.
Hermann et al., Pain, 125: 278-285, 2006
A retrospective study compared different pain measures in children 9-14 years who were born prematurely and were at a Neonatal Intensive Care Unit (NICU), or were born at normal gestation age and were also at NICU, or control babies (normal age, no NICU).
Psycho-social interventions in neonatal pain (McGrath, 2004
Environmental adjustments:
decreasing overall lighting, proper day/night cycle
decreasing noise from equipment/staff
decreasing handling
limiting painful procedure to those inevitable for child’s
health
Behavioural interventions: nesting, swaddling allowing flexed postures non-nutritive suckling of a pacifier sucrose rocking (sensory stimulation)
Pain in children 1-12 years
types of pain;
minor injuries
routine medical procedures (immunisation)
beginning of recurrent pains
behavioural interventions;
distraction of attention during painful procedures (e.g. video)
pain-management techniques feasible >9 years
(relaxation, parent-child programs to decrease sick
behaviour)
a strong role of parents and family in pain behaviour
pain assessment methods
Neonates and pre-verbal children: behavioural and physiological responses
Self-report pain instruments should be appropriate to the development and cognitive capacities of a child:
~ 3 years : categorical scale (“Does your belly hurt?”)
> 4 years : Poker Chips (4 pieces representing pain)
> 5 years : Colour Analogue Scale (shades of red)
> 6 years : Visual Analogue Scale
> 6 years : FACES (series of 6 faces from neutral to most painful)
> 6 years (school children) : numerical scales
Oucher (vertical series of 6 facial expressions of pain, and numerical scale ranging from 0 to 100), can be used from age 3 to 12 years.
Beyer (1984).
NFACS = Neonatal Facial Action System (Grunau and Craig, 1987).
CFACS = Child Facial Action Coding System (Breau et al., 2001): for children 1.5-6 years
Both methods have excellent reliability and validity, and are relatively free of learning effects.
PIPP also utilises three facial action units in addition to two physiological measures (heart rate, oxygen saturation): suitable for preterm and full-term neonates
Validated behavioural observation scales for children
The scales evaluate gross body (e.g. diffuse movements, withdrawal of the limb, kicking, touching painful limb), vocalisation, facial expressions, physiological parameters, body postures, and interactions with environment.
CHEOPS (Children’s Hospital of Eastern Ontario Pain Scale): evaluates pain using 6 categories: cry, facial, verbal, torso, touch, and legs
EVENDOL (Evaluation Enfant Douleur): suitable for assessment of procedural pain in children 0-7 years (emergency units, postoperative care)
FLACC (Face Legs Activity Cry and Consolability): suitable for children 0.5-5 years in acute pain and in crtically ill children.
Overview and comparisons of different observation scales can be found in Beltramini et al., Pediatric Annals, 46: e387, 2017 (on Vital)
Parents’ pain behaviour affects child’s perception of pain
Goodman and McGrath (Pain, 104: 559-565, 2003) analysed the pain responses of
children to cold pressor test. The children were tested after they have watched an
exaggerated, normal or minimised pain response of their mother.
Pain reported by children and observed from facial reactions was stronger in the
group which observed exaggerated pain response of their mother compared to the group observing minimisation of pain by mother.
Parent’s reassurance worsens child’s experimental pain
If mothers showed pain promoting behaviour (reassuring, empathy, apologies, mild criticism) during cold pressor testing of their daughters, their children have experienced more pain than if mother showed pain-reducing behaviour (humour, distraction, couching) (Chambers et al., J. Ped. Psych., 27: 293-301, 2002).
Prevailing studies show equal spontaneous verbalisations of mothers in sons and daughters (review in McMurtry et al., J. Pediatry, 48: 560-561,2006), and no difference in fathers’ verbalisations when attending sons or daughters either (Moon et al., J. Pain, 12: 1174-1181, 2011).
Distress-promoting and coping-promoting parent’s behaviour
Distress-promoting behavior: reassuring (‘You’ll be ok’), empathy, apologising, giving a child the control over the procedure, or criticism have been shown to increase child’s distress and pain during immunisation
(Cohen et al., Child. Hlth Care, 2000; Manimala et al., Child. Hlth. Care, 2000;
Moon et al., J. Pain, 11: 1174-1181, 2011).
Coping-promoting behavior: distraction, non-procedural talking, humour, coping commands (“focus on your breathing”) are associated will smaller fear
of immunization and smaller distress (Manimala et al., Child’s Hlth Care,
29: 161-177, 2000).
Reassuring constitutes ¼ of spontaneous verbalisations to children’s
painful procedures.
Training parents to avoid reassuring during child’ painful procedures did
not abolish reassuring which constituted ~50% of parents’ distress promoting verbalisations (Chambers et al., J. Ped. Psych., 27:293-301, 2002)
Mechanisms of parental influence on child’s pain: reassurance parent catastrophising anxiety sensitivity
Cohen et al. (Child’s Hlth Care, 29: 79-86, 2000) correlated child’s distress during immnunisation with parent’s self-declared and displayed behavior.
Reassurance serves as a warning signal to the child that the
parent is anxious, or knows that something bad is involved.
Child’s quote: “If an adult tells you not to worry and you weren’t worried before,
you better hurry up and start because you are already running late”
Reassurance reinforces the distress behavior of the child. Caregiver’s positive response to child’s anxiety or distress prompts the child to issue even more signals to the caregivers.
Parental reassurance gives the child the “permission” to overtly express his/her distress.
Explanations 2 and 3 connect with the communal coping model of pain catastrophising
catastrophising
Catastrophising affects the amount of facial expressions of pain
in the presence of a caregiver (Vervoort et al., Pain, 138: 277-285, 2008)
N.B. facial expressions differ in the presence of a stranger or caregiver only in low-
catastrophising children
Child’s catastrophising predicts the unpleasantness (Page et al.,
J. Pain Res., 5: 547-558, 2012) and intensity (Esteve et al., J. Pain, 15:157-168, 2014)
of post-operative pain
Catastrophising correlates with depression in chronic pain children
(Kashikar-Zuck et al., Clin. J. Pain, 17: 341-349, 2001)
Catastrophising predicts disability in children with chronic back
pain (Lynch et al., J. Pain, 7: 244-251, 2006), recurrent abdominal pain
(Langer et al., Child Hlth Care, 38: 169-184, 2009), and mixed pain (Crombez et al.,
Pain, 104: 639-646, 2003)
Catastrophising correlates with pain anxiety and fear of pain
(Huguet et al., J. Pain, 12: 840-848, 2011)
Parental pain catastrophising affects children’s pain complaints: dyadic analysis (Birnie et al., Pain, 157: 938-948, 2016) Parent catastrophizing affected child’s pain Child’s lower catastrophizing predicted greater pain tolerance
Pediatric fear-avoidance model (Asmudson et al., Pain Res. Managm., 17: 397-405, 2012)
Parents respond to child’s pain, signalled e.g. with child’s facial expressions, with distress which response is magnified by parent catastrophising. Parent catastrophising leads to protecting the child and stopping child’s engagement in motor and life activities. The tendency of a parent to stop child’s pain-related activities serve to minimise parent’s distress. A child discouraged from motor and life activities by a catastrophising parent will develop, in combination with its own catastrophising, the avoidance and escape behaviours which leads to pain-related disabilities. The disability of a child feeds to parent’s distress.
Anxiety sensitivity: another channel affecting parental influence on children’s pain
Tsao et al. (J. Pain, 7: 319-326, 2006) hypothesised that the parent’s influence on child’s pain was mediated by anxiety sensitivity: high anxiety sensitivity in parents leads to a high anxiety sensitivity in child, which in turn augments pain intensity.
Esteve et al 2014
This study investigated the association between anxiety sensitivity and pain catastrophizing in children, caregivers’ anxiety sensitivity and catastrophizing about children’s pain and responses to children’s pain, pain intensity reported by children, and pain intensity estimated by caregivers
results indicated that children and caregivers characterized by higher levels of anxiety sensitivity reported higher levels of pain catastrophizing and catastrophic thinking about children’s pain, respectively. Caregivers with higher levels of catastrophic thinking about the children’s pain reported higher levels of solicitousness and higher estimations of the children’s pain intensity after the operation. Higher levels of children’s pain catastrophizing were associated with more frequent responses of discouragement and higher pain intensity reported after the operation. These findings highlight the relevance of catastrophizing about children’s pain and children’s pain catastrophizing in the experience of postoperative pain in children.
Some rules on psychological handling of clinical pain in children
Never lie about painfulness of therapeutic procedure.
Ensure the presence of a parent or caregiver (N.B no reassurance)
Explain the pain and the procedures leading to pain in a manner that corresponds to the development and cognitive capacities of the child.
Apply the cognitive-behavioural techniques, in addition to anesthesia, during painful procedures (books, cartoon movies, music, interesting toy, video game, virtual reality).
Older children can help as “assistants” during procedure
Do not suppress crying, it actually helps to manage pain
Never use force during procedure.
