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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
Q

What is the dose of Acetaminophen?

A

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
Q

What is the caution of Acetaminophen?

A

hepatotoxicity when exceeding maximum doses

27
Q

What is the dosage form of Acetaminophen?

A

80mg/mL, 32mg/mL suspension, 160mg chewable tablets

325mg, 500mg tablets

120mg, 650mg suppositories

28
Q

What is NSAIDs available & used as?

A
  • 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
Q

What is the caution of NSAIDs?

A

infants < 6 months

A/E: risk of nephrotoxicity, GI bleed (especially ketorolac)

30
Q

What is the Ibuprofen (Advil) dose?

A

5 - 10mg/kg/dose orally Q6H (maximum 600mg/dose, 2400mg/day)

31
Q

Enteral administration (oral or feeding tube):

A
  • 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
Q

Rectal administration:

A
  • 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
Q

Is alternating acetaminophen and NSAIDs beneficial?

A
  • 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
Q

Scheduled vs PRN dosing:

A
  • 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
Q

What are Opioid Analgesics used for?

A
  • 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
Q

What is Morphine?

A
  • 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
Q

What are the AE’s of Morphine?

A

sedation, respiratory depression, nausea / vomiting, hypotension, pruritis

38
Q

What are the special considerations?

A

Special considerations for pediatrics: multiple dosage forms useful in pediatrics, caution patients with decreased renal function (ex.neonates)

39
Q

What is Fentanyl?

A
  • significantly more potent than morphine (50-100x)
  • available in injectable dosage form
  • faster onset and shorter half-life relative for morphine
  • ADME: hepatic
40
Q

What are the AE’s of Fentanyl?

A

sedation, respiratory depression, nausea / vomiting, hypotension, chest wall rigidity (at high doses, rapid administration)

41
Q

What are the special considerations of Fentanyl?

A

Special considerations in pediatrics: useful for short procedures, no dose adjustment required in patients with decreased renal function, no oral formulation

42
Q

What is Hydromorphone?

A
  • approximately 5x more potent than morphine
  • available as tablets, solution, injectable
  • ADME: hepatic to hydromorphone-3-glucuronide (inactive); renal elimination of metabolite
43
Q

What are the AE’s of Hydromophine?

A

A/E: similar profile to morphine

44
Q

What are the Hydromorphone special considerations for pediatrics?

A
  • not generally used in children
  • specific indication for prevention of rigors
  • metabolite associated with neurological adverse effects (ex. seizures)
45
Q

What is Codeine?

A
  • 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
Q

What are the special considerations of Codeine?

A

Special considerations for pediatrics: not recommended, not prescribed at Children’s Hospital (instead could use Morphine b/c its converted to that anyway)

47
Q

What is Tramadol?

A
  • 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
Q

What are the topical anaesthetic products on the market?

A
  • 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
Q

What are the things to consider when selecting topical agent:

A
  • application time
  • duration of action
  • adverse effects
  • contraindications
  • cost
50
Q

What is the application time of topical anaesthetics?

A
  • EMLATM – 60 minutes, Ametop 30-45 minutes, Maxilene 30 minutes
  • Pain EaseTM – 4 – 8 seconds
51
Q

What is the DOA of topical anaesthetics?

A
  • EMLATM – 2- 4 hours (longer application time increases duration) * AmetopTM 4-6 hours
  • MaxileneTM 30-60 minutes
  • Pain EaseTM– 60 seconds
52
Q

What are the AE’s of topical anaesthetics?

A
  • EMLATM – skin blanching, methemoglobinemia, skin irritation, vasoconstriction
  • AmetopTM – hypersensitivity reactions, edema, itchiness
  • Pain EaseTM – freezing of skin
53
Q

What are the CI’s of topical anaesthetics?

A
  • EMLATM – less than 37 weeks gestational age (ie. premature infants), patients at risk of
    methemoglobinemia
54
Q

What is the cost of topical anesthetics?

A
  • MaxileneTM $$$ > EMLATM $$ > AmetopTM $
  • PainEaseTM-$80/60dosebottle
55
Q

Needle Pain:

A
  • fear of needles often develops early childhood
  • can have impact on health into adulthood
56
Q

Reducing Vaccination Pain in Infants:

A
  • breastfeeding
  • sucrose 24% solution (Toot SweetTM, SweetUmsTM)
  • administer 1-2 minutes prior to vaccine
57
Q

Reducing Vaccination Pain in Older Children:

A
  • comfortposition
  • distraction (videos, toys, blowing bubbles)
  • use neutral words instead of warning words like ”sting”
58
Q

Reducing Vaccination Pain in All Children:

A
  • 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
Q

What are the top 5 drugs reported as causing harm through medication error in peds?

A
  1. Morphine
  2. Potassium Chloride (KCl)
  3. Insulin
  4. Fentanyl
  5. Salbutamol

Pharmacology (Winter) (23 decks)

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