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Course: Pediatric Nursing

Topic: Pain Management in Children

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COPYRIGHT

© 2013-2024 Nurses International (NI). All rights reserved. No copying without permission. Members of the Academic Network share full proprietary rights while membership is maintained.

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Module Goals

Learners will be able to:

  • Describe classification / types of pain
  • Discuss factors that influence perception of pain in children
  • Explain the principles of pain assessment as they relate to children
  • Identify utilization of pain rating scales
  • Discuss physiologic and behavioral assessment tools for assessment of pain in children
  • Identify developmental considerations in pain management among children
  • Discuss the role of the nurse in pediatric pain management

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Pain

MedlinePlus, 2018

  • 5th vital sign
  • A signal in our nervous system that something may be wrong
  • Unpleasant sensation, such as a prick, tingle, sting, burn, or ache
  • Sensation may be sharp or dull
  • May be intermittent or constant
  • May be helpful in diagnosing a problem

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Types of Pain

  • Visceral pain: Diffuse, difficult to locate, and often referred to a distant, usually superficial, structure.
  • Deep somatic pain: Initiated by stimulation of nociceptors in ligaments, tendons, bones, blood vessels, fascia, and muscles and is a dull, aching, poorly localized pain.
  • Superficial pain: In the skin or other superficial tissue and is sharp, well-defined, and clearly located.
  • Neuropathic pain: Caused by a lesion or disease of the somatosensory nervous system.

Ernstmeyer & Christman, 2021

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Factors Affecting Pain

Biological

  • Age
  • Brain function
  • Source of pain
  • Illness, Injury
  • Genetic sensitivity
  • Hormones
  • Inflammation
  • Obesity
  • Cognitive function

Ernstmeyer & Christman, 2021

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Factors Affecting Pain

Physiological

  • Mood/affect
  • Fatigue, Stress
  • Coping, Trauma
  • Sleep, Fear, Anxiety
  • Developmental stage
  • Meaning of pain
  • Memory, Attitude
  • Beliefs, Emotional status, Expectations

Ernstmeyer & Christman, 2021

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Factors Affecting Pain

Social

  • Culture, Values
  • Economic, Environment
  • Social support
  • Coping mechanisms
  • Spirituality
  • Ethnicity
  • Education

Ernstmeyer & Christman, 2021

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Children and Pain

  • Pain experience varies across the life span
  • Newborn and infants feel pain but cannot verbalize
  • Toddlers and preschoolers often have difficulty describing, identifying, and locating pain
  • May demonstrate behaviorally with crying, anger, physical resistance, or withdrawal
  • School-age children and adolescents may try to be “brave” and rationalize the pain; they are more responsive to explanations about pain

Ernstmeyer & Christman, 2021

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Piagetian Stages of Cognitive Development and the Experience of Pain

Sensorimotor children (birth to about 2 years old)

  • Mostly preverbal, no capacity to explain their experiences
  • Most likely to demonstrate pain by social withdrawal or changes in their patterns of sleep, eating, and level of activity
  • By 18 months, makes an effort to localize pain and seek reassurance from adults
  • 2-year-old; often be able to use specific words to indicate the presence of pain

Emerson & Bursch, 2020

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Piagetian Stages of Cognitive Development and the Experience of Pain (Continued)

Preoperational children (about 2–7 years old)

  • Use words and understand basic concepts of cause and effect
  • May view pain as a punishment
  • Are not able to use self-generated coping strategies and tend to rely on their environment (i.e., the support of adults)
  • Have difficulty using rating scales of pain
  • Have difficulty differentiating pain from anxiety or fear

Emerson & Bursch, 2020

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Piagetian Stages of Cognitive Development and the Experience of Pain (Continued)

Concrete operational children (about 7–11 years old)

  • Can apply logic to their perceptions in a more integrative manner
  • Interventions that are concrete will make more sense to children at this stage.
  • Are likely to use a rating scale for pain assessment
  • Have an increased ability to use self-initiated coping strategies such as distraction or guided imagery

Emerson & Bursch, 2020

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Piagetian Stages of Cognitive Development and the Experience of Pain (Continued)

Formal operational children (11+ years old)

  • Able to use abstract reasoning to discuss body systems and can conceptualize multiple causation of pain
  • Potentially more aware of the biopsychosocial model and psychological aspects of pain
  • Ability to focus on future events may lead to greater worries and concerns about the pain
  • Most adults engage in abstract reasoning only in areas of their own expertise

Emerson & Bursch, 2020

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Critical Thinking Question

Reflect on the factors (biological, physiological, social) that affect the perception of pain.

  • Why is it important for the nurse to understand and consider these factors?

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The QUESTT Principle of Pain Assessment

  • Question the child and parent/caregiver
  • Use pain rating scales
  • Evaluate behavior and physiological changes
  • Secure parent or caregiver’s involvement
  • Take the cause of the pain into account
  • Take action and evaluate the results

Bettercare, 2020

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The QUESTT Principle of Pain Assessment

The ‘Q’ in QUESTT: Question the child and parent/caregiver

  • Verbalization of pain by the child for example, a ‘hurt’ or an ‘eina’
  • Pain intensity, subjective and individual response of the child
  • Subtle behavioral changes
  • Parents motivated to recognize pain in their child in order to help alleviate it
  • Ask them to
    • Point to where it hurts
    • Point on a teddy bear/doll of their choice where they hurt
    • Colour the area of hurt in on a drawing of a human figure
    • Ask their caregiver to ask on nurse’s behalf

Bettercare, 2020

Queensland Government, 2021

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The QUESTT Principle of Pain Assessment

The ‘U’ in QUESTT: Use pain rating scales

  • Useful for establishing a baseline and for measuring response to treatment
  • Age related appropriate pain scale
  • Consider ease and time taken to administer the scale
  • Use one that is comfortable to for the client
  • Consider children may deny pain for fear of consequences

Bettercare, 2020

Queensland Government, 2021

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The QUESTT Principle of Pain Assessment

The ‘E’ in QUESTT: Evaluate behavior and physiological changes

  • Physiological responses:
    • Increased pulse,BP,sweating, tone
    • Pallor or flushing, decreased oxygen saturation, dilated pupils, rapid shallow respiration and hyperglycaemia
  • Adaptation
  • Children’s response to pain

Bettercare, 2020

Queensland Government, 2021

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The QUESTT Principle of Pain Assessment

The ‘S’ in QUESTT: Secure parent or caregiver involvement

  • Listen to mothers, fathers and caregivers as they know their child the best
  • Include them in the decision-making process
  • They are more tuned to subtle changes in their child’s behavior
  • They know what works best to comfort their child

Bettercare, 2020

Queensland Government, 2021

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The QUESTT Principle of Pain Assessment

The ‘T’ in QUESTT: Take the cause of the pain into account

  • Consider the pathophysiology of the underlying problem i.e., the cause of the pain
  • Identify whether the pain may be unrelated to the disease or condition, e.g. toothache
  • Descriptions of the type of pain help to determine its cause and management

Bettercare, 2020

Queensland Government, 2021

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The QUESTT Principle of Pain Assessment

The ‘T’ in QUESTT: Take action and evaluate the results

  • Assess pain
  • Develop the treatment plan
  • Treat the identified pain according to its cause
  • Re-assess the pain by using the pain rating scales
  • Revise the treatment plan
  • Pain diaries are also helpful for constant re-evaluation in children with chronic pain

Bettercare, 2020

Queensland Government, 2021

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Take Action and Evaluate Results

Queensland Government, 2021

Pain

0

1-3

4-7

8-10

Action

No action required

  • Consider simple analgesia such as paracetamol and ibuprofen.
  • Consider implementing non-pharmacological options
  • Prompt medical review
  • Administer analgesia as prescribed. Consider oral opioids.
  • Urgent medical review
  • Consider opioids (Intravenous or intranasal options)

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Critical Thinking Question

Imagine you are the nurse taking care of a 5-year-old who fell from a tree and presents with swelling and a deformity of the right forearm.

Use the QUESTT principle to simulate a pain assessment for this child.

Think about what questions you would ask or actions you would take for each letter of the acronym.

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Pain Assessment Tools

Gai et al, 2020

Tool

Target population

Scoring System

Scale

Pain word scale

3–7 years old, or older children who are unable to use the NRS

Ask the child to quantify the severity of pain using words such as “none”, “a little”, “medium”, “a lot”

Descriptive words

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Pain Assessment Tools

Gai et al, 2020

Tool

Target population

Scoring System

Scale

Numeric Rating Scale (NRS)

7 years and older

Ask the client to assign a number to their pain, with 0 being no pain and 10 the worst pain ever

0–10

Mild= 0–3, Moderate= 4–6

Severe= 7–10

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Pain Assessment Tools

Gai et al, 2020

Tool

Target population

Scoring System

Scale

Faces Pain Scale—Revised (FPS-R)

5–12 years old

Picture-based scale where child selects 1 of 6 faces to represent their pain experience

0–10

Mild= 0–3, Moderate= 4–6

Severe= 7–10

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Pain Assessment Tools

The Wong-Baker FACES Pain Rating Scale as cited in Ernstmeyer & Christman, 2021

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Pain Assessment Tools: The FLACC Scale

  • The FLACC scale- Face, Legs, Activity, Cry, Consolability scale is a measurement used to assess pain
  • Suitable for children between the ages of 2 months to 7 years
  • Applicable for individuals who are unable to verbally communicate their pain
  • Has five criteria, which are each assigned a score of 0, 1, or 2
  • Scored in a range of 0–10 with “0” representing no pain.

Gai et al, 2020

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Pain Assessment Tools

  • Tool: Revised Face, Legs, Activity, Cry, Consolability (r-FLACC)
  • Target population: 2 months–7 years old, or non-verbal/cognitively impaired patients of any age
  • Scoring System: 5 behavior items each scored from 0 to 2 to a total of 10 points
  • Scale: 0–10 (mild: 0–3, moderate: 4–6, severe: ≥ 7)

Gai et al, 2020

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The FLACC Scale

Ernstmeyer & Christman, 2021

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Pain Assessment Tools

Gai et al, 2020

Tool

Target population

Scoring System

Scale

Premature Infant Pain Profile (PIPP-R)

Preterm and term infants

Combines 5 items (3 behavioral—brow bulge, eye squeeze, nasolabial furrow; 2 physiologic—heart rate, oxygen saturation) with gestational age

0–21 (mild: 0–6, moderate: 7–13, severe: 13–21)

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Pain Assessment Tools for Children

Physiological Pain Assessment Tool: Changes in blood pressure and heart rate may indicate severity of pain experienced through an objective lens.

Behavioral Pain Assessment Tool: Facial, verbal expressions, muscle tone response.

Pande, 2020

Chu, 2017

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Factors Affecting Pain Assessment

Emotional Factors: What child feels about pain

Presence of stress and anxiety

Fear, frustrations, underlying anxiety and depression issues

Behavioral Factors

Reaction may vary with age, expectations, emotions and belief system: anger, fear, denial and anxiety

About Kids Health, 2009

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Factors Affecting Pain Assessment

Cognitive factors:

What examiner, parents, and child understand and believe about pain

Psychological factors:

A child’s emotions affect how they behave and respond to pain

About Kids Health, 2009

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Barriers to effective Pain Assessment

Barriers of parents or children may include:

  • Language
  • Cultural beliefs, views, ideas
  • Denial of the child’s condition or prognosis
  • Financial cost
  • Parent’s resistance for medication
  • Child’s reluctance to take medication

Better Care, 2020

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Barriers to Effective Pain Assessment

Barriers of professionals may include:

  • Lack of assessment of factors that affect pain
  • Believing the pain is same for everyone
  • Lack of knowledge of developmental stages
  • Lack of knowledge about pain management
  • Miscommunication or lack of communication between staff

Better Care, 2020

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Case Study

A nurse is taking care of a 10-month-old infant after surgery for a cleft lip and palate repair. The nurse notes that the infant is withdrawn and appears restless and tense, frequently shifting to different positions. The infant occasionally frowns and has been quietly whimpering since waking up. Neither the mother or the nurse have been able to console or distract the infant.

  • Using the FLACC scale, what is the infant’s current pain score?
  • How should the nurse categorize the infant’s level of pain (mild, moderate, severe)?
  • What pain management plan should the nurse anticipate based on the infant’s pain score?

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Principles of Pain Management in Children

  • Thorough assessment and treatment
  • Non-pharmacological pain management strategies
  • The correct choice and dose of analgesia
  • Regular use of analgesics to prevent and treat pain
  • Oral pain medication should be used whenever possible
  • Give clear written instructions of dosage and frequency
  • Reassess pain and review the pain management plan
  • Manage other factors
  • Include parents in process

Better Care, 2020

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Non-Pharmacological Pain Management in Children

For Newborns:

  • Swaddling:
    • Use a thin sheet and do not swaddle higher than the shoulders
    • Feet and legs should be able to move and the hips should be able to bend
    • Ensure the baby does not get too hot
  • Breastfeeding during procedures
  • Non-nutritive sucking such as breastfeeding or baby pacifier

(etter Care, 2020

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Non-Pharmacological Pain Management in Children (Continued)

Pain in babies and older children

  • Proper positioning
  • Handle calmly and without sudden movements or noises
  • Any heating method, such as a warm (not hot) heating pad or a very gently heated ‘happy hugger’ or ‘beanbag’
  • Distractions
  • Aromatherapies, massages, music, arts
  • Elevation and splinting of injuries

Better Care, 2020

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Pharmacological Pain Management in Children

Use the World Health Organization (WHO) broad principles of analgesic use:

  • By the appropriate route: Oral, buccal, rectal, subcutaneous
  • By the clock: Regularly at fixed time (for persistent pain)
  • By the child: Adjust the dosage as per the response and possible side effects
  • By the ladder: Choose analgesia according to the child’s level of pain severity

Better Care, 2020

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Pain Management in Children

The original World Health Organization (WHO) pain ladder as cited in Better Care, 2020

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Pain Management in Children: By The Ladder

  • For mild pain (grade 1 to 3 years): Non-opioid like acetaminophen (Paracetamol) and/or a non-steroidal anti-inflammatory drug (NSAID)- 1st step
  • For moderate pain (grade 4 to 7 years): A weak opioid like tilidine, with or without co-analgesia- 2nd step
  • For severe pain (grade 8 to 10 years): A strong opioid such as morphine, with or without co-analgesia- 3rd step

Better Care, 2020

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General Approach to Pain Management in Children

  • Reverse the reversible
  • Determine the type of pain
  • Use medications to address the cause of the pain
  • Use pain medications to manage the pain
  • Use non-pharmacological measures
  • Address associated psychosocial distress such as separation anxiety
  • Continually re-evaluate the pain and its response to treatment

Better Care, 2020

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Nurses Role in Pain Management of Children

  • Be kind and treat the client and family members with respect
  • Acknowledge and accept the differences
  • Acknowledge that pain is subjective
  • Identify the source of pain
  • Identify barriers for assessment and pain management
  • Perform thorough assessment of pain
  • Use age based assessment tool for pain assessment
  • Use both pharmacological and non-pharmacological methods of pain interventions

Maryland.gov, n.d.

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Nurses Role in Pain Management of Children

  • Provide the standard of care
  • Assess pain at regular intervals
  • Evaluate the client’s response to pain
  • Evaluate the effectiveness of the treatment
  • Advocate for client and family for effective pain management
  • Educate client and family members about the pain, management options, side effects and other options available

Maryland.gov, n.d.

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What Would the Nurse Do?

A nurse is caring for an 8-year-old child admitted for a sickle cell crisis. When the nurse assesses the child, they are agitated and tearful, reporting pain of 8/10 on the numeric rating scale.

The nurse checks the child’s chart and sees that there is an order for 150 mg of oral acetaminophen every 4 hrs PRN (as needed). The last dose was administered 5 hrs ago.

According to the WHO principles of analgesic use, what should the nurse do in this situation?

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Red Flags

  • Be alert to non verbal signs of pain:
    • Facial indications
    • Holding and guarding
    • Vital signs
    • Tearful
  • Be sure parents understand the side effects of pain medication and the directions for administration

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

  • Health beliefs: In some cultures talking about a possible poor health outcome will cause that outcome to occur
  • Health customs: In some cultures family members play a large role in health care decision-making
  • Ethnic customs: Differing gender roles may determine who makes decisions about accepting & following treatment recommendations

AHRQ, 2020

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Cultural Considerations (Continued)

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

  • Religious beliefs: Faith and spiritual beliefs may effect health seeking behavior and willingness to accept treatment.
  • Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family
  • Interpersonal customs: Eye contact or physical touch may be ok in some cultures but inappropriate or offensive in others.

AHRQ, 2020

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Cultural Considerations: Examples

  • Hispanic culture often deal with discomfort in a stoic manner believing that lower pain expression is a reflection of individual strength and pride; this may also apply to the child.
  • Caucasians are more willing to report pain than the typical Asian individual; this may also apply to the child.

Wandner et al., 2012

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References:

  • Andrews, M.M., Boyle, J.S. & Collings, J. W. (2020). Transcultural Concepts in Nursing Care (8th Ed.). Wolters Kluwer, Philadelphia, PA.

  • Chu, Y., Zhao, X., Han, J., & Su, Y. (2017). Physiological Signal-Based Method for Measurement of Pain Intensity. Frontiers in neuroscience, 11, 279. https://doi.org/10.3389/fnins.2017.00279

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References:

  • Emerson, N. D., & Bursch, B. (2020). Communicating with Youth about Pain: Developmental Considerations. Children (Basel, Switzerland), 7(10), 184. https://doi.org/10.3390/children7100184

  • Gai, N., Naser, B., Hanley, J., Peliowski, A., Hayes, J., & Aoyama, K. (2020). A practical guide to acute pain management in children. Journal of anesthesia, 34(3), 421–433. https://doi.org/10.1007/s00540-020-02767-x

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References:

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References:

  • Mitra, S., Jain, K., Singh, J., Saxena, P., Nyima, T., Selvam, S. R., & Walia, M. C. (2020). Clinical Utility of the Behavioral Pain Assessment Tool in Patients Admitted in the Intensive Care Unit. Indian journal of critical care medicine : peer-reviewed, official publication of Indian Society of Critical Care Medicine, 24(8), 695–700. https://doi.org/10.5005/jp-journals-10071-23521

  • Pande R. K. (2020). Behavioral Pain Assessment Tool: Yet Another Attempt to Measure Pain in Sedated and Ventilated Patients!. Indian journal of critical care medicine : peer-reviewed, official publication of Indian Society of Critical Care Medicine, 24(8), 617–618. https://doi.org/10.5005/jp-journals-10071-23536

  • Wandner, L. D., Scipio, C. D., Hirsh, A. T., Torres, C. A., & Robinson, M. E. (2012). The perception of pain in others: how gender, race, and age influence pain expectations. The journal of pain, 13(3), 220–227. https://doi.org/10.1016/j.jpain.2011.10.014

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