Pain Management Children

Background

Pain is commonly under-recognised, under-treated and treatment may be delayed. Drug choice and dosage may also cause problems due to unfamiliarity. Recognition and alleviation of pain should be a priority when treating ill and injured children. This process should start at the triage, be monitored during their time in the Emergency Department and finish with ensuring adequate analgesia at, and if appropriate, beyond discharge. In treating pain, pay attention to the other factors distressing the child such as fear of the unfamiliar environment and people, parental distress, people in uniforms, needle avoidance, fear of injury severity etc.

Principles of pain management

Ask about pain regularly and Assess systematically
Believe the patient and family if they report pain
Choose pain control options appropriate for patient and level of pain
Deliver interventions timely, logically and coordinated
Empower patients and their family. Enable them to control their pain to the greatest extent possible.

Assessment of acute pain in children in the ED

Pain assessment should be considered as the 5th vital sign
- Performed at triage and at regular intervals
- Take account of age and cognitive understanding of the child
The assessment of pain includes a careful history and physical examination.
Pain Assessment Tools
- Self reporting (subjective pain assessment) - reliable in older, verbal children, e.g. Wong Baker FACES, Visual Analogue Scale (VAS), Numeric pain scales, Pain Ruler
- Pain rating by parent/nurse/carers (objective pain assessment), e.g. FLACC, Alder Hey Triage Pain Score, Manchester Pain Ladder.
It is important to distinguish other causes of distress in children e.g. emotional, parental separation, thirst, hunger, etc.

Children < 5 years - FLACC

Children 5-7 years Wong Baker FACES

Children >7 years - use VAS (scale 0-10[10 worse pain ever])

FLACC scale <5 years

FLACC scale	FLACC SCALE
	0	1	2
Face	No particular expression or smile	Occasional grimace or frown, withdrawn, disinterested	Frequent to constant quivering chin, clenched jaw
Legs	Normal position or relaxed	Uneasy, restless, tense	Kicking, or legs drawn up
Activity	Lying quietly, normal position, moves easily	Squirming, shifting back and forth, tense	Arched, rigid or jerking
Cry	No cry (awake or asleep)	Moans or whimpers; occasional complaint	Crying steadily, screams or sobs, frequent complaints
Consolability	Content, relaxed	Reassured by occasional touching, hugging or being talked to, distractable	Difficult to console or comfort

Wong Baker FACES (5-7yo)

Wong Baker FACES	No Pain	Mild Pain	Moderate Pain	Severe Pain
Faces pain score
	0	1 - 3	4 - 6	7 - 10
Behaviour	Normal activity No reduced movement Happy	Rubbing affected area Decreased movement Neutral expression Able to play / talk normally	Protective of affected area Decreased movement / quiet Complaining of pain Consolable crying Grimaces when affected part moved / touched	No movement or defensive of affected part Looking frightened Very quiet Restless, unsettled Complaining of lots of pain Inconsolable crying
Example	Bump on head	Abrasion / Small laceration Sprain ankle / knee # fingers / clavicle Sore throat	Small burn / scald Finger tip injury # forearm / elbow / ankle	Appendicitis Large burn # long bone / dislocation Appendicitis Sickle crisis

Pain Ruler

Once the category has been established, appropriate analgesia may be prescribed according to the flow chart.
In all cases it is important to think of using other non-pharmacological techniques to achieve analgesia.
- These may include play and distraction or other measures such as applying a dressing or immobilising a limb.
Following reassessment if analgesia is still found to be inadequate, stronger analgesics should be used along with the use of non-pharmacological measures.
Points to remember:
- Children who fall into the moderate / severe categories should also be given basic analgesia.
- Most children can and are able to use Entonox, remember this may be a valuable source of analgesia whilst waiting for oral analgesia to work

How to treat pain

Non-Pharmacological

Psychological strategies: involving parents, cuddles, child-friendly environment, and explanation with reassurance all help build trust.
- Also, distraction with toys, blowing bubbles, reading, or story-telling using superhero or magical imagery to make the pain go away
Non-pharmacological adjuncts such as limb immobilisation, dressings for burns

Pharmacological

Pain Management Children Algorithm — Pain manaagement - Meds

Pharmacological agents, via a variety of routes: see attached algorithm.
- Use TAC in preference to EMLA for topical anaesthesia [BestBets]
- For superficial wounds, topical anaesthesia should be used in preference to Lignocaine infiltration [BestBets]
- Also local or regional anaesthesia are useful (e.g. femoral and auricular blocks).
- For procedures, departments may consider conscious sedation using Ketamine (IV / IM) (more on Ketamine sedation)
PO/IV/IN options include, Non-opioid, Opioid (including intra-nasally delivered Fentanyl) and inhaled (N₂O)

Contra-indications

Ibuprofen / Diclofenac: avoid if previous reactions to NSAIDs or in moderate or severe asthmatics.

Intravenous morphine: use with caution if risk of depression of airway, breathing or circulation.

Oral and parenteral analgesia

Drug

Dose per kilo

Times a day

Paracetamol

15mg/Kg orally
Up to 30mg/kg PR

4-6 Hrly
Max 60mg/kg/day

Ibuprofen
(beware in asthmatics)

10mg/Kg orally

QDS to max 20mg/Kg/24 hrs

Diclofenac

1mg/Kg PO or PR

TDS to max 3mg/Kg/day or 150mg daily

Codeine

1mg/Kg orally to max 30mg each dose

4 - 6 Hrly

Morphine

0.1mg/Kg IV

200 mcrg/kg PO in <1yo

400 mcrg/kg PO in 1-2yo

PRN (Reverse with Naloxone 10mcg/Kg then 100mcg/Kg)

Sucrose

>1500g child: 0.2-0.25ml of 24% Sucrose (Sweetease) dropped on the anterior tongue in divided doses 2 minutes before procedure, continue during procedure for a total dose of 2mls (action lasts approximately five minutes)

Maximum of 4 doses in 24 hours

Fentanyl Intranasal

IN 1.5 mrcg/kg/dose (use 50 mcrg/mL soln.)

Weight	IN Fentanyl Dose (1.5mcg/kg)	Volume(ml)
10	15	0.3
11	15	0.3
12	20	0.4
13	20	0.4
14	20	0.4
15	24	0.5
16	24	0.5
17	24	0.5
18-24	30	0.6
25-29	40	0.8
30-34	45	0.9
35-39	55	1.1
40-44	60	1.2
45-49	70	1.4
50-54	75	1.5
55-59	85	1.7
60-64	90	1.8
65-69	100	2

Local anaesthetics

Ametop

Can be used in children over 1 month old

Leave in situ for 30 mins for venepuncture

Remove after 1 hour

Lasts 4 - 6 hours after removal

Do not use on mucous membranes

Emla

Children over 1 year of age

Should be left in situ for minimum 1 hour

After 2 hours will provide anaesthesia to 6 mm depth

Lignocaine 1%

Max 3mg/Kg

Adrenaline & cocaine gel

1ml of gel per 1cm of wound

To max 4mls

Not on mucous membranes or abrasions

Controlled drug

Links

IAEM Clinical Guideline 2012 - Analgesia in Children (Local copy)
BAEM Clinical Effectiveness Committee Publication on Management of pain in Adults Here. Local Version
BAEM Clinical Effectiveness Committee Publication on Management of pain in Children Here. Local Version.
British Association for Emergency Medicine. Royal College Surgeons England. 35-43 Lincoln's Inn Fields. London WC2A 3PE, UK
Bier's Block Regional Analgesia
Clinical Effectiveness Committee. January 2002.
Emergency Triage. BMJ Publishing Group, 1997.
McGrath PJ et al, CHEOPS: A behavioural scale for rating postoperative pain in children. Advances in Pain Research and Therapy, vol 9, Ed. Fields, Raven Press, 1985.
Wong-Baker Faces Pain Scale. Adapted from Whaley L, Wong DL. Nursing care of infants and children. 3rd ed. St Louis: The CV Mosby Company, 1987.
Advanced Paediatric Life Support, 3rd ed. BMJ Publishing Group, 2001