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Pain Medicine > Pediatric pain > Flashcards

Pediatric pain Flashcards

1
Q

What are the pediatric pain demographics?

A

Acute pain 90% (70% surgical, 30 medical; sickle cell, mucositis)
Chronic 10% (palliative, headache, neuropathic, CF, arthritis)

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2
Q

What is the difference in pain fibers in C&A?

A

higher A-fiber in dorsal cord vs A-delta and C fibers that grow later.
A-beta into lamina I and II in C fibers
receptive fields larger in
A fibers respond to lower threshold frequency

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3
Q

what is the development of the neural tissues?

A 
functional pain capablities does not exist before 28-29 weeks
all neurons present at 20 weeks
at 22 wks
at 30 wks - thalamic myelination
37 wks cortical myelination
40+ weeks descending inhibitory tracts
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4
Q

what signs of pain are present in newborns?

A

transcutaneous O2
palmar sweating
changes in cardiovascular parameters
increase in catecholamines, insulin, cortisol, aldosterone

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5
Q

What are the differences in reactions to local anesthesics?

A

delayed half-lives (secondary to low albumin levels, lower amount of blood and increased risk of toxicity

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6
Q

What functional goals of chronic pain treatment?

A

school attendance
social interactions
extracurriclular activities
family dynamics

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7
Q

What are compounding factors?

A

lack of physical activity
anxiety
sleep disturbance
Stress

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8
Q

Differnces in cancer

A

leukemia, lymphome, use more IV opioids, pain is mainly bone marrow, lumbar puncture

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9
Q

chronic pain states in peds?

A

sickle cell, IBD, JRA, CF, headaches, childhood FM, chronic fatigue syndrome (CFS)

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10
Q

What scales to use?

A 
WAS
Oucher scale <3 yo
Colored analogoie scale 
FACES
Body outlien 
poker chip scale
CRIES/COVER (newborn)\PIPP
CHEOPs/FLACC (Procedural pain)
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11
Q

FLACC

A

used from 2m to 7 y/o
older cognitive impairment too
Face Legs, Activity, Cry, Consolability

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12
Q

Non-pharm treatments for chronic pain

A

CBT - biofeedback, stress management, structured counselling, coping strategy
Counselling - focus on depression, anxiety, family dynamic, school phobia
PT and rehab

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13
Q

CBT components

A
  1. psychoeducation
  2. self-monitoring
  3. coping skills training for children (squeezing lemons, deep breathing)
  4. parent training
  5. relapse prevention
  6. homework
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14
Q

Physical therapy benefits

A

improve body image, sleep and mood
improve range of motion
improve strength
don’t use ultrasound - can close growth plates

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15
Q

sickle cell pain can be precipitated by

A

infection, hypoxia, acidosis, dehydration, hypothermia, stress, menses, pregnancy

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16
Q

sickle cell managed by:

A

Outpatient - NSAIDs and oral opioids
Inpatient - PCA or PCEA for chest pain, oral opioids preferable (1st line codeine, OXY then MOR or HM)
Hydration!
TENS, relaxation training, OT and PT, CBT
patient and family education to prevent LTOT

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17
Q

CRPS in pediatrics

A 
F>M
Ages 8-16
More common lower extremity (85%)
less likely to have precipitating event
more responsive to conservative therapy
DDx: JRA, polymyositis, rheumatic fever, SLE, OM, neoplasia, inflammation
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18
Q

Medciations for CRPS

A 
NSAIDS
coticosteroids
TCAs
Anti-epileptics
pentoxifylline
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19
Q

Pediatric headaches incidence?

A

90% of school aged children have them

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20
Q

headache prophylaxis meds?

A 
AMI or NOR
TOP
TRAZ
PROP
Calcium channel blockers
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21
Q

chronic abdominal pain

A 
monthly q3m with at least 3 activities of pain
no known cause
affects function
not related to GI habits, food intake
no systemic symptoms
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22
Q

Pediatric cancers

A

Ewing’s sacroma - onion peel appearance, codman’s triangle

Osteoid Osteoma - ages >5, night pain, benign focal pain

23
Q

Cancer Meds

A 
methadone
oxycontin
fentanyl patch
NSAIDs
GPN, PGN
24
Q

JRA

A

pauci-articular (50%), poly-articiular (40%), systemic (Still’s disease 10%)
begins with limping then swelling of affected joints

25
Q

FM in kids

A 
age of onset - 12
1.3% of children
F>M
>5 tender points
3/10 symptoms
Treatment - CBT or insight oriented, medications (ADs, muscle relaxants)
26
Q

Psoriatic Arthritis

A

HLA-B27, tendinitis, dactylitism spondylitis, seroneg spondylarthropathy

27
Q

CP (spastic and non-spastic) complications

A

hip displasia and subluxation
osteopenia
neurologocal conditions
treat with Botox, oral agents (dantrolene, baclofen, benzos, tizanidine), surgical treatments

28
Q

Legg-Calves Perthe disease

A

M>F, avascular necrosis and flattening of femoral head, obese ages 4-12, hip/grain pain worse at night. Tx: PT rest, cast, NSAIDs, surgery

29
Q

Osgood Schlatter disease

A 
ages 11-15, active kids, M>F
self-limited
patellar rtendon fractire
pain wth knee extension
edema at tibial tubercle
30
Q

Sickle cell pathophys and epidemiology:

A

caused by genetic inheritance of Hb S, Hb S, Hb C or thalassemia or other structural variants

  • causes production of unstable, sickle-shpaed red blood cell.
  • most common single gene disorder in black Americans (1 in 675 births; 0.15%)
  • onset of symptoms 6-12 months
31
Q

systemic manifestations of sickle cell?

A

hemolysis, vaso-occlusive disease (painful), skeletal(painful), cardiopulmonary (cardiomegalym acute chest syndrome), neurological (stroke, cranial neuropathies), genitourninary (renal infarction, hematuria, etc.)

32
Q

Sickle cell pain crises are caused by what primarily?

A

multifocal bony vaso-occlusive events primarily in the bone marrow cavity
initially in the small bones of hands and feet then proceed to joints (hips and knees) and chest wall and back
Later: Osteonecrosis, chronic pain (assoc. with osteonecrosis of the femoral head)

33
Q

Adjuvant medications (non-opioid or NSAIDs) in the treatment of sickle cell crises?

A

antihistamines (hydroxazine, diphenhydramine)
BZD (DIA, AVP)
TCAs
AEDs (PHEN, CARB, GPN, TOP, CLON)
phenothiazines (promethazine, prochlorperazine)

34
Q

FM in children

A

similar incidence to adults (6.2%) in adults 4-6%
M:F 1:6
IBS found in 50-80%
Tension headaches, RLS, TMD and raynaud’s common
Prognosis if better than in adults

35
Q

Functional Dyspepsia?

A
  • Persistent or recurrent pain or discomfort in the upper abdomen
  • not relieved by defecation or associated with the onset of a change in stool frequency
  • no evidence of an inflammatory, anatomic, metabolic or neoplastic process
36
Q

IBS?

A

Abdo discomfort or pain associated with 2 or more of the following
Recurrent abdominal pain or discomfort** at least 3 days/month in the last 3 months associated with two or more of the following:
. Improvement with defecation
. Onset associated with a change in frequency of stool
. Onset associated with a change in form (appearance) of stool

37
Q

Abdominal migraine criteria?

A

A. Paroxysmal, intense, periumbilical pain lasting greater than one hour.
B. Interferes with normal activities.
C. Associated with two or more of the following:
- Anorexia, nausea, vomiting, headache, photophobia, pallor
D. Intervening periods of health (weeks–months)
E. No evidence of an inflammatory, anatomic, metabolic, or neoplastic process

38
Q

What analgesics do you avoid in children?

A

Acetaminophen with G6P deficiency
Aspirin
Other NSAIDs other than ibuprofen (no other NSAIDs have been studied in children)
Can use ibuprofen after 3m old
Tramadol - no health Canada approval in children

39
Q

What are the core outcome measures does the WHO and IMMPACT recommend?

A

FACES pain scale revised and VAS

40
Q

What are the symptoms if neonatal withdrawal syndrome?

A 
Fever
Yawning/sneezing
RR>60 
Mottling
tachypenia
Sweating
GI: projectile vomit8mg, regurgitate, weight loss, poor feeding, excessive suckling, loose or watery stool
CNS: high pitched cry, irritability, sleep disturbance, tremor, increased tone, myoclonic jerks, seizures, excoriation
41
Q

What are two main effects of uncontrolled pain during the critical period in neonates or infants?

A

Global hypoalgesia

Local hyperalgesia

42
Q

What parental factor could perpetuate chronic pain in kids?

A

Over protective parent behaviours
Increased distress
Hx of chronic pain
Poor family functioning (eg. more conflict)

43
Q

Factors modulating pain in children?

A

Child specific (Age, sex, temperament, prev pain experience, Cog/developmental level, Family enviro)
Behavioural Factors (Coping ability, ability to participate in routine activities @ home, school, sports, social)
Emotional (Anticipatory anxiety, fear, situation specific stress, underlying anxiety or depression)
Parental factors

44
Q

Red flags present in abdominal pain?

A

Bilious vomiting, bloody stool, fever, anorexia, Abdo pain waking them up at night, emesis, wt loss, poor growth, fjoint pains, mouth ulcers, unusual rashes, hemodynamic instability

45
Q

Abdominal Migraine (Rome III Criteria)

A

Paroxysmal, intense

46
Q

Functional Dyspepsia (Rome III Criteria)

A

ALL of:

  • Persistent/recurrent pain or discomfort upper abdo
  • NOT relieved w/ BM or assoc w/ onset of change in stool frequency, or stool form
  • No evid of inflammatory, anatomic, metabolic, or neoplastic process
47
Q

IBS (ROME III)

A
  • Abdo discomfort or pain assoc w/ 2 of (>= 25% time)
    a. Improvement w/ BM
    b. Onset assoc w/ change in stool frequency
    c. Onset assoc w/ change in stool form
  • No evid of inflamm, anatomic, metabolic, or neoplastic process
48
Q

Childhood Functional Abdo Pain

A

ALL of:

  • Episodic or continuous abdo pain
  • Insufficient criteria for other Func GI D/o
  • No evid of: inflamm, anatomic, metabolic, or neoplastic process (MAIN)
  • 1X/wk for >2m
49
Q

Childhood Functional Abdominal Pain Syndrome

A

Childhood functional abdo pain Dx w/ >=25% of time have >=1 of:

  • Interference daily function + sleep
  • Additional somatic symptoms (Eg. HA, limb pain, or difficulty sleeping)
50
Q

List Mx techniques for procedural pain Mx - non-pharmacological

A

Avoid Multiple procedures
Consider possible modifications of procedure to reduce pain eg. Venepuncture vs heel lance for blood sampling
Sedation or GA req’d?
Suitable enviro: quiet, calm location w/ toys, distractions, parents present
Appropriate personnel available: enlist additional experienced help when necessary
Allow sufficient time for analgesics and medications to take effect
Allow breast feeding during procedures where possible
Non-nutritive sucking +/- sucrose for brief procedures
Pacifier
Psychological strategies: distraction, hypnosis, guided imagery, ice or counter stimulation (in older children)
Behavioural techniques
Tissue adhesives for lacerations
Facilitated tucking
Kangaroo care

51
Q

List Pharmacological Mx techniques for reducing pain

A

Allow breast feeding during procedures where possible
Non-nutritive sucking +/- sucrose for brief procedures
EMLA
Oral sucrose
Topical LA
LA eye drops
Pacifier
Entonex (Nitrous oxide)
Combo 2 or more strategies of known efficacy (eg opioids + entonox)

52
Q

Compare/contrast SCFE vs Legg Calves perthes dz

A

Slipped Capital Femoral Epiphyses (SCFE) vs LCPD

Epid: SCFE (early adolescents, M>F 2:1, 10-15 yrs old)) vs. LCPD (M>F; 4-8 yrs old)

RF: SCFE (obesity, < 10 yrs old - metabolic endocrine d/o -hypothyroidism, hypogonadism) vs. LCPD

Etiol: SCFE (Displacement of epiphysis) vs. LCPD (AVN of femoral head)

Causes: SCFE vs LCPD (Trauma, steroid use, congenital hip disloc)

Presentation: SCFE (Painless intermittent limp, painful w/ activity in groin radN knees; decreased ROM) vs LCPD (dull ache to groin radN knee, worse w/ phys activity, decreased ROM)

Rx: SCFE (Sx ORIF) vs LCPD (Conservative Rx; Sx when indicated is femoral osteotomy)

53
Q

Dosing for Tylenol & Ibuprofen (WHO)

A 
o	Max doses:
o	Paracetamol:
	Neonates: 5-10 mg/kg q6-8h
	Infants (1-3m): 10 mg/kgq4-6h
	>3m-12 yrs: 10-15 mg/kg q4-6h
	Max daily dose: 
•	4 doses/day
o	Ibuprofen:
	Neonates: none
	1-3m: none
	3-12m: 5-10 mg/kg q6-8h
	1-12 yrs: 5-10 mg/kg q6-8h
	Max daily dose:
•	Child 40 mg/kg/day

Pain Medicine (14 decks)

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