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Pharmacology (Winter) > Pediatric Pain Management > Flashcards

Pediatric Pain Management Flashcards

1
Q

Studies have found that compared to adults:

A
  • children receive LESS DOSES of analgesics
  • children received INAPPROPRIATE DOSES OR MEDICATIONS for pain

Which can lead to:
* delayed healing
* altered pain perception with subsequent episodes
* stress for caregivers
* avoidance of medical procedures in adulthood

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2
Q

What are the differences in Pain Management of Children?

A
  • Differences in ADME / pharmacodynamics
  • Challenges in pain assessment
  • Individualized dosing
  • Drug administration considerations
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3
Q

What about absorption?

A
  • neonates – higher stomach pH, delayed gastric emptying
  • no issues observed with oral opioids in neonates
  • fentanyl patch avoid children < 2 years (b/c skin is thin - absorption can be unpredictable)
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4
Q

What about distribution?

A
  • relatively greater body water neonates/infants
  • opioids are lipophilic→less impact on Vd
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5
Q

What about metabolism

A
  • immature liver enzymes at birth → activity increases over first year of life
  • Phase I and II enzyme activity decreased
  • morphine metabolized morphine-6-glucuronide (active) and morphine-3-glucuronide (inactive metabolite)
  • neonates produce relative more of inactive morphine metabolite
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6
Q

What about excretion?

A
  • neonates and young infants - immature kidneys, decreased creatinine clearance
  • caution NSAIDs, morphine in neonates
  • infant < 30 days (neonate) : morphine 0.05 to 0.1 mg/kg/dose PO every 4-8 hours
  • infant > 6 months: morphine 0.1 to 0.2 mg/kg/dose PO every 2- 4 hours

(as they get older, ability to clear drug gets better so can dose higher)

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7
Q

What is the bottom line for developmental pharmacokinetics considerations?

A

Be especially cautious when evaluating or recommending doses for neonates and infants < 6 months, due to differences in ADME compared to adults particularly renal and hepatic function.

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8
Q

What are the sources of pain in children?

A
  • surgical / procedural pain
  • immunizations / bloodwork
  • musculoskeletal
  • infections
  • cancer
  • burns
  • neurologic
  • neuropathic
  • underlying disease state
  • Can be ACUTE or CHRONIC
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9
Q

What is the pain physiology?

A
  • Similar to adults
  • Exception premature neonates:
  • immature descending paint pathways until > 32 weeks gestational age
  • lower pain threshold
  • can lead to hyperalgesia

(if premature, will have low pain threshold & can feel pain if even touching skin?)

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10
Q

What is the expression of pain dependent on?

A
  • age of child
  • cognitive ability
  • previous experience with pain
  • anxiety / fear

(hard to tell if really in pain or just scared)

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11
Q

What do you assess pain using a combo of?

A
  • self-report
  • pain assessment tools
  • physiological symptoms
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12
Q

Neonates:

A

infant < 30 days old

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13
Q

Premature neonate:

A

infant born < 37 weeks gestation age

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14
Q

What are the behaviour/physiologic response of neonates & infants?

A
  • facial expressions
  • excessive crying
  • arching, restlessness
  • clenched fingers / toes
  • increase heart rate, respiratory rate, blood pressure
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15
Q

Neonatal Pain, Agitation & Sedation Scale (N-PASS) & Neonatal Infant Pain Scale (NIPS):

A

Premature & term infants

N-PASS for neonates in ICU

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16
Q

Faces Leg Activity Cry Consolability Scale (FLACC):

A

2 mo - 7 years

useful non-verbal children, relies on behavioural scale

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17
Q

FACES:

A

3 years & older

useful in pre-school children, faces maybe misinterpreted as emotional state

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18
Q

Visual Analog/Numeric Rating Scale:

A

limited evidence in children

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19
Q

Non-Communicating Children’s Pain Checklist (NCCPC):

A

cognitive impaired child

scoring done by caregiver, can be time-consuming

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20
Q

In the community, consider referring to doctor if:

A
  • concurrent symptoms potentially indicative of other conditions ex. fever, rash, nausea/vomiting, neurological symptoms
  • severe pain
  • pain not relieved by current medications
  • decreasing mobility
  • unknown cause of pain
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21
Q

Non-pharmacologic treatment for Neonates/Infants:

A
  • quiet, low light environment
  • swaddling
  • skin to skin contact
  • music
  • pacifier
  • sucrose solution (Toot SweetTM, SweetUmsTM) - release of endogenous opioids & a distraction (lasts 3-5 mins)
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22
Q

Non-pharmacologic treatment for Toddler/Pre-School Children:

A
  • child friendly room (decor, pictures)
  • comfort position
  • explaining procedure / allow questions
  • distractions (blowing bubbles, toys, books,
    phone, non-procedural conversation)
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23
Q

Non-pharmacologic treatment for Older Children:

A
  • education about procedure (ex: ask which side they want vaccine)
  • distractions (videos, music, singing, reading)
  • positive reinforcement
  • breathing exercises
  • imagery
  • Buzzy Pain Relief SystemTM (above arrow of needle - block the sensation of pain (b/c travel to area the same))
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24
Q

What is Acetaminophen used for?

A

useful for mild pain and as adjunct in more severe pain

25
What is the dose of Acetaminophen?
10 - 15mg/kg/dose orally Q4-6 H PRN (maximum 5 doses or 75mg/kg/day, up to 4 grams/day) 15 - 20mg/kg/dose rectally Q4-6H PRN
26
What is the caution of Acetaminophen?
hepatotoxicity when exceeding maximum doses
27
What is the dosage form of Acetaminophen?
80mg/mL, 32mg/mL suspension, 160mg chewable tablets 325mg, 500mg tablets 120mg, 650mg suppositories
28
What is NSAIDs available & used as?
* useful for mild - moderate pain * available in various dosage forms (tablet, liquid, suppository, injectable) * anti-inflammatory effect (in addition to analgesic effect) * ibuprofen, naproxen, ketorolac most commonly prescribed
29
What is the caution of NSAIDs?
infants < 6 months A/E: risk of nephrotoxicity, GI bleed (especially ketorolac)
30
What is the Ibuprofen (Advil) dose?
5 - 10mg/kg/dose orally Q6H (maximum 600mg/dose, 2400mg/day)
31
Enteral administration (oral or feeding tube):
* ask caregivers what child prefers (liquid, chew tab, tablet) * liquid preparations most useful in children < 6 years * most palatable flavour * immediate release formulations can be administered via feeding tubes
32
Rectal administration:
* acetaminophen 120mg and 650mg suppositories * dose in 1⁄2 or full suppository size * ex. J.D. 16kg Acetaminophen PR dose: 15-20mg/kg x 16kg = 240 – 320mg Recommend: 1⁄2 of 650mg suppository or 2 x 120mg suppository
33
Is alternating acetaminophen and NSAIDs beneficial?
* some evidence may be superior when monotherapy ineffective * theoretical increased risk for adverse effects ie. hepatic and renal toxicity * consider: - is the dose of single agent optimized? - try one agent scheduled and the other for breakthrough pain (Yes - can decrease use of opioids - but theoretical risk of AE's but hasn't really seen it in hospitals)
34
Scheduled vs PRN dosing:
* consider SCHEDULED INITIALLY to keep pain under control * switching to PRN will allow assessment of improvement in condition (can check record & see when given & will gauge improvement)
35
What are Opioid Analgesics used for?
* useful for moderate to severe pain * act on μ and ĸ receptors * risks of respiratory depression, sedation, hypotension, constipation * no ceiling effect * tolerance and physiologic dependence can develop (taper it down)
36
What is Morphine?
* most frequently prescribed opioid in children * available in tablets, liquid, injectable; and immediate and sustained release formulations * ADME: metabolized morphine-6-glucuronide (active) / morphine-3-glucuronide (inactive); renal excretion
37
What are the AE's of Morphine?
sedation, respiratory depression, nausea / vomiting, hypotension, pruritis
38
What are the special considerations?
Special considerations for pediatrics: multiple dosage forms useful in pediatrics, caution patients with decreased renal function (ex.neonates)
39
What is Fentanyl?
* significantly more potent than morphine (50-100x) * available in injectable dosage form * faster onset and shorter half-life relative for morphine * ADME: hepatic
40
What are the AE's of Fentanyl?
sedation, respiratory depression, nausea / vomiting, hypotension, chest wall rigidity (at high doses, rapid administration)
41
What are the special considerations of Fentanyl?
Special considerations in pediatrics: useful for short procedures, no dose adjustment required in patients with decreased renal function, no oral formulation
42
What is Hydromorphone?
* approximately 5x more potent than morphine * available as tablets, solution, injectable * ADME: hepatic to hydromorphone-3-glucuronide (inactive); renal elimination of metabolite
43
What are the AE's of Hydromophine?
A/E: similar profile to morphine
44
What are the Hydromorphone special considerations for pediatrics?
* not generally used in children - specific indication for prevention of rigors * metabolite associated with neurological adverse effects (ex. seizures)
45
What is Codeine?
* available as tablets, solution, injection; combination products (ex. Tylenol #3) * ADME: hepatic, converted by CYP2D6 enzymes to morphine - patients may be fast or slow metabolizers - slow metabolizers→ineffective analgesic effect - fast metabolizers→increased morphine concentrations, cases of fatalities reported
46
What are the special considerations of Codeine?
Special considerations for pediatrics: not recommended, not prescribed at Children’s Hospital (instead could use Morphine b/c its converted to that anyway)
47
What is Tramadol?
* for children > 12 years for moderate-severe pain * works on μ receptors and inhibits serotonin * caution: risk of respiratory depression, may lower seizure threshold
48
What are the topical anaesthetic products on the market?
* EMLATM - eutectic mixture of lidocaine / prilocaine cream * AmetopTM - tetracaine 4% gel * MaxileneTM - liposomal lidocaine 4% cream * Pain EaseTM - Pentafluoropropane / Tetrafluoroethane vapocoolant spray * useful for immunizations, IV insertion, blood work, minor procedures
49
What are the things to consider when selecting topical agent:
- application time - duration of action - adverse effects - contraindications - cost
50
What is the application time of topical anaesthetics?
* EMLATM – 60 minutes, Ametop 30-45 minutes, Maxilene 30 minutes * Pain EaseTM – 4 – 8 seconds
51
What is the DOA of topical anaesthetics?
* EMLATM – 2- 4 hours (longer application time increases duration) * AmetopTM 4-6 hours * MaxileneTM 30-60 minutes * Pain EaseTM– 60 seconds
52
What are the AE's of topical anaesthetics?
* EMLATM – skin blanching, methemoglobinemia, skin irritation, vasoconstriction * AmetopTM – hypersensitivity reactions, edema, itchiness * Pain EaseTM – freezing of skin
53
What are the CI's of topical anaesthetics?
* EMLATM – less than 37 weeks gestational age (ie. premature infants), patients at risk of methemoglobinemia
54
What is the cost of topical anesthetics?
* MaxileneTM $$$ > EMLATM $$ > AmetopTM $ * PainEaseTM-$80/60dosebottle
55
Needle Pain:
* fear of needles often develops early childhood * can have impact on health into adulthood
56
Reducing Vaccination Pain in Infants:
* breastfeeding * sucrose 24% solution (Toot SweetTM, SweetUmsTM) - administer 1-2 minutes prior to vaccine
57
Reducing Vaccination Pain in Older Children:
* comfortposition * distraction (videos, toys, blowing bubbles) * use neutral words instead of warning words like ”sting”
58
Reducing Vaccination Pain in All Children:
* topical anesthetics (EMLA, Ametop, Maxilene) * avoid pre-medicating with acetaminophen prior to vaccine * inject most painful vaccines last (MMR, PrevnarTM, HPV) * educate parents about options for reducing pain (or have 2 nurses inject at same time but diff site)
59
What are the top 5 drugs reported as causing harm through medication error in peds?
1. Morphine 2. Potassium Chloride (KCl) 3. Insulin 4. Fentanyl 5. Salbutamol

Pharmacology (Winter) (23 decks)

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