Pain

Question 1

In neonates and infants how do we assess pain

Answer 1

By observation and scoring on a EBM pain score

Infants plasticity pain may effect the development of the nervous system and lead to long term consequences

Question 2

Chronic pain /complex pain features

Answer 2

>1/12 or 3/12 
Neuropathic pain 
Lead to maladaptive behavior 
Inappropriate biological responses 
Abnormal baseline sensation 
Can be a symptom or the primary disorder
Does cause suffering and disability

Question 3

Chronic pain teams take

Answer 3

Medical
Physio
Psychologist response

Question 4

Vancristine neuropathy is an example of neuropathic pain that can occur in children true or false

Answer 4

True

Question 5

Pain assessment scales in neonates and children older children

Answer 5

Essential for the correct diagnosis and treatment of children
CRIES
Cry/ factual expression /sleep/ resp O2 sat/ HR/BP
Face/legs/activity/cry/ consolability. In infants and cognitively impaired children

Children from 4yrs can use faces and circle the one
>=7years can score the pain 0-10
Mild pain 0-4. 4-6 is moderate >6-10 is severe

Question 6

Name the 4 principals of pain management

Answer 6

1 pain assessment and pain severity measurement
2 appropriate analgesia
3 appropriate route and dose
4 management of side effects

Question 7

WHO have a 2 step ladder

Answer 7

1 non opioids for mild pain (0-4)
2 opioids (4-10)
Recommended for children and adults 
NO. CODEINE for children /adults 
Hypo/hyper metabolism

Question 8

Paracetamol

Answer 8

Oral/rectal /iv 
15mg/kg/dose Q6hourly 
Never exceed 4gm per day 
60mg/kg/day  ( 4x15mg =60)
Review after 48hours  consider reducing the dose 
Hepatotoxicity is the concern

Question 9

Children at increased risk of hepatotoxicity with paracetamol 7 points

Answer 9

1 febrile child
2 younger child
3 prolonged fasting or V or dehydration 
4 chronic under nutrition 
5 hepatic impariement 
6 prior paracetamol intake
7 use of adult or older child forumalation

Question 10

Non opioids choices for children

Answer 10

Paracetamol 15mg /kg/dose Q6hourly
Diclofenac 3mg /kg/dose q8hourly PR
Ibuprofen 10mg/kg/dose

CI to NSAI GIT ulcers/ hepatic involvement /renal involvement
Asthma/ coagulation abnormality/ some ortho procedures as may effect bone healing

Question 11

Opioids

Answer 11

Oral Fast or SR
Rectal well tolerated/ parent consent/ useful in the NBM
Transdermal Not acute but good chronic pain
IV rapid and lets you titration the dose
Pump pt run from 7 years
Nurse run <7yrs
Epidural/ regional infusions/ peripheral blockers

Question 12

Side effects of opioids and treatment

Answer 12

Itch antihistamine/ gabopentin/ naloxone/ swap options
Constipation fluids and laxatives movicol
Vomiting odensetron/ dexamethazone/ droperiodol
Respiratory depression usually in the naive opioid patient
Naloxone 0.5-1ugms /kg may need to give a 2nd dose
And should halve the dose of the opioid