Pain: Pediatric Flashcards
Principles of pain in children
It is likely that pain receptors are well
developed by 20-24 weeks of gestation in the
fetus/neonate
Many painful procedures are done on
neonates, some with minimal or no pain
control
Research shows that many painful procedures
may affect how the child responds to pain for
years in the future.
Pain responses
Neonates may respond to pain with increased
heart rate, RR, BP and ICP
Os sats and peripheral blood flow decreased
Skin color changes, vomiting, gagging,
hiccuping and diaphoresis are common
Older children with persistent pain may
withdraw and become very quiet
Different sites use different pain scales to
assess
Pain control
Nonpharm measures include:
Distraction
Hypnotherapy
Biofeedback
Yoga
Massage therapy
Individual psychotherapy
Education
Physical therapy
Acupuncture
TENS
Music/art/dance therapy
Pharmacologic measures in peds for pain
Sucrose
Acetaminophen
Aspirin
NSAIDS
Opioids
Topical analgesia/local analgesia
Psychotropic medications
World Health organization
Analgesic ladder
Mild to moderate pain
Treat with nonopioid
Moderate severe pain, or fail step 1.
Use oral opioid + nonopioid
Severe pain or fail 2nd step, treat with opioid
for severe pain with or without nonopioid
Practice round the clock dosing.
Adjuvant medications
Sucrose
Sucrose has an effect similar to that of morphine
when given prior to painful procedures
MOST effective under 1 month of age, but some
effect has been seen up to 6 months old
Thought to release endogenous opioids
Should be given 2 minutes before painful
procedure
24% to 75% sucrose solution has been used in
studies
Best if followed by pacifier or breastfeeding
during procedure
Acetaminophen
Generally very safe nonopioid effective for
analgesia and antipyresis
Can be given oral or rectal
Pain control by inhibiting the synthesis of
prostaglandins in the CNS, peripherally
blocks pain impulse generation
Controls fever by inhibition of hypothalamic
heat regulating center
No anti-inflammatory effect
No adverse reactions related to platelet or gastritis
Can be highly toxic if single high dose or excessive
cumulative dosing given.
Dose: 10-15 mg/kg/dose q 4-6 hrs
In Neonates, no more than every 6-8 hours due to slow
clearance
In older patients, NOT to exceed 650 mg q 4 hrs or 1000
mg q 6 hrs
Max 4 grams/day of Acetaminophen containing products
If dosing by weight, no more than 5 doses/24 hrs (or 4
grams)
s/e: rash, blood dyscrasias, renal injury (chronic
use), liver injury (40%)
FDA Warning and APAP
FDA warnings (2014):
FDA recommends that no prescriber gives form of
Acetaminophen that exceeds 325 mg/tablet
Products containing >325 mg/tablet will likely be
slowly removed from the market
FDA warning (2013):
Acetaminophen was associated with Stevens-
Johnson syndrome, toxic epidermal necrolysis
(TEN), and acute generalized exanthematous
pustulosis (AGEP).
Consider acetaminophen (and NSAIDS) as a cause of treating these skin eruptions
Aspirin
Effective for pain and fever
In pediatrics, primarily used for antiplatelet
effects, also useful in Rheumatoid arthritis
Works by inhibition of prostaglandin synthesis.
Also works on hypothalamus heat regulation
center to reduce fever.
Blocks prostaglandin synthetase to prevent
formation of thromboxane A2 which causes
platelet aggregation.
Can have prolonged antiplatelet effects
Can cause gastritis
NEVER give in children recovering from
Influenza or varicella due to the risk of
Reye’s syndrome
Dose: 10-15 mg/kg every 4 hours for pain or
fever
Anti-inflammatory: 80-100 mg/kg/day
divided q 6-8 hours
s/e: rash, urticaria, GI bleeding, ulcers,
tinnitus, bronchospasm.
NSAIDS
Nonsteroidal anti-inflammatory drugs.
Effective in pain and fever (ibuprofen) control
Excellent safety profile in children with short
term use
Inhibit cyclo-oxygenase (COX) which leads to
decreased prostaglandin precursors
Drugs in this class:
Ibuprofen
Naprosyn
Ketorolac
diclofenac
(Choline magnesium salicylate)
Ibuprofen
Highly effective for migraines, JRA, mild to
moderate pain, fever, dysmenorrhea, gout
Dose:
Analgesia: 4-10 mg/kg/dose q 6-8 hours
Anyipyresis: age 6 mo – 12 years, temp 102.5 – use 10 mg/kg/dose
Max 40 mg/kg/day
In JRA: 30-50 mg/kg/day – start low and titrate
up for effect
Also used in CF patients to slow progression of
lung disease
Max dose in adults 800 mg q 6 3.2 grams/day
Ibuprofen – side effects
Dizziness
Drowsiness
Fatigue
Rebound headache
Rash
Urticaria
Dyspepsia, n/v, GI bleeds
Blood dyscrasias
Hepatitis
Vision problems
Acute renal failure
Opioids
Use for moderate and severe pain
Outpatient used in chronic pain – sickle cell
and cancer especially
Underdosing in children common due to fear
of respiratory side effects
Opioids must be tapered if used more than
one week
Side effects should be anticipated and
managed
Tolerance develops over time – higher doses
may be needed
Opioids used outpatient
For chronic pain – Oxycontin most common
Tramadol “other class”
Percocet for acute pain
0.05-.15 mg/kg/dose up to 5 mg every 4 -6 hours
of oxycodone component
Tylenol # 3 may be used for acute pain
0.5-1 mg/kg/dose of codeine q 4-6 hrs
** see previous information on codeine**
Tramadol
= Ultram
Use for moderate to severe pain
Nonnarcotic but has opioid-like properties
Binds to opiate receptors in the CNS causing
inhibition of ascending pain pathways.
Inhibits reuptake of norepinephrine and
serotonin
Dosing: 1-2 mg/kg/dose q 4-6 hours of short
acting formulation
Max in adults is 400 mg/day
Drug tolerance and dependence can occur
over time
Needs to be tapered if will be discontinued
after chronic use
s/e: flushing, somnulence, confusion,
hallucinations, rash, constipation, dry
mouth, nausea, urinary retention.
Great caution should be used in liver or
kidney disease!!!
Avoid use in patients on MAO inhibitors
