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
  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Face No particular expression or smile Occasional grimace or frown, withdrawn, disinterested Frequent to constant quivering chin, clenched jaw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 Face - No Pain Face - Mild Pain Face - Moderate Pain Face - Severe Pain
  0 1 - 3 4 - 6 7 - 10
Behaviour Normal activity
No ↓ movement
Happy
Rubbing affected area
↓ movement
Neutral expression
Able to play / talk normally
Protective of affected area
↓ 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
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

  • 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-nasal 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 Kg Frequency
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.
More on Sucrose
Fentanyl Intranasal IN 1.5 mrcg/kg/dose (use 50 mcrg/mL soln.). Dosing below.
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




Content by Dr Íomhar O' Sullivan . Last review Dr ÍOS 4/08/21.