Principles of Pediatric Pain Management

Daniel P. Mahoney, MD
Assistant Professor, Pediatric Palliative Care
Le Bonheur Children’s Hospital
Surgery Grand Rounds
5 August, 2015
 Principles of Pediatric Pain Management

Objectives:

● Briefly review physiology of acute pain

● Address attitudes about treating pediatric pain

● Teach skills to thoroughly assess and treat pediatric pain

 Principles of Pediatric Pain Management

I have no relevant conflicts of interest or financial disclosures.

Principles of Pediatric Pain Management

PHYSIOLOGY
 Principles of Pediatric Pain Management

Acute Pain:

● “An unpleasant sensory and emotional experience associated

with actual or potential tissue damage, or described in terms
of such damage.”

International Association for the Study of Pain Guidelines, Merskey & Bogduk, 1994
Principles of Pediatric Pain Management

2
 Principles of Pediatric Pain Management

Nociception1:

● Helps protect the body from potential or ongoing harm

● Descending control systems

○ Modulated by endogenous opioids, 5-HT, NE

● Nociceptive vs Neuropathic Pain

Principles of Pediatric Pain Management

ATTITUDES
 Principles of Pediatric Pain Management

Two Common Attitudes of Pediatric Pain Management:

● Kids are resilient, a little bit of pain isn’t going to hurt them.

● Opioids are not good medications to give to children.

 Principles of Pediatric Pain Management

Primum Non Nocere:

● Failure to treat a child’s pain violates the first rule of

medicine.
○ Inadequate analgesia for initial procedures in young
children diminishes effect of adequate analgesia in
subsequent procedures3
○ Treatment of pain in children with burn injuries
correlated with less severe PTSD4,5
 Principles of Pediatric Pain Management

Primum Non Nocere:

● Failure to treat a child’s pain harms the patient-physician

relationship.

○ Parents expect pain to be relieved6

○ Pain control 2nd highest parental priority after correct

diagnosis7
 Principles of Pediatric Pain Management

Primum Non Nocere:

● Failure to treat a child’s pain harms the patient-physician

relationship (ctd).

○ Parents want to protect their children from pain8

○ Parents assume that everything possible is done9

 Principles of Pediatric Pain Management

Primum Non Nocere:

● Failure to treat a child’s pain harms the patient-physician

relationship (ctd)

○ Iatrogenic pseudo-addiction10

○ Lack of trust in providers to adequately treat pain11

 Principles of Pediatric Pain Management

Primum Non Nocere:

● Failure to treat a child’s pain is a potential public health

threat and an economic liability.

○ Up to 25% of adults have a fear of needles that developed

in childhood12

○ Untreated chronic pain is costly to society13

 Principles of Pediatric Pain Management

Opioid Attitudes and Myths:

● The child will become addicted to drugs

○ Pseudo-addiction14

○ Properly maintained short term opioid use for acute pain

has not been shown to lead to addiction in children15
 Principles of Pediatric Pain Management

Opioid Attitudes and Myths:

● The child will become over-sedated

○ Goal of opioid use is to provide analgesia without

euphoria or sedation

○ Good monitoring of patient leads to analgesia without

over-sedation
 Principles of Pediatric Pain Management

Opioid Attitudes and Myths:

● Opioid medications are “too strong” for the child’s pain

○ Strong pain needs a strong pain plan

○ Opioids are the best strong pharmacologic analgesic we

regularly use
 Principles of Pediatric Pain Management

Opioid Attitudes and Myths:

● Opioids will give the child too many side effects

● Giving the child opioids will mask signs and symptoms16

○ Review of adults and children showed no significant

increase in management errors when patient given opioid
prior to examination by surgeon17
 Principles of Pediatric Pain Management

Opioid Attitudes and Myths:

● Children (and/or babies) don’t feel pain anyway

○ Jeffrey Lawson, 1985

○ 1987: Lancet article “Randomized trial of fentanyl

anesthesia in preterm babies undergoing surgery: effects
on stress response” by Anand KJS
Principles of Pediatric Pain Management

ASSESSMENT
Principles of Pediatric Pain Management
 Principles of Pediatric Pain Management

How do we assess pain?

● Measuring pain intensity

○ “Measuring pain by its intensity alone is like describing music only in terms
of its loudness.” -Carl von Baeyer, MD

● Reasons for differences between stated pain rating and

observed behavior
○ Anchors, patient doesn’t understand scale, social influences
 Principles of Pediatric Pain Management

Anchors:

● Let’s go to the gym

● How do you describe the maximum amount of pain?

● Use of simple anchors (very much pain, hurts worst, most

pain) avoids child having to suppose how painful a given
scenario might be.
 Principles of Pediatric Pain Management

Patient doesn’t understand scale:

● Is the scale developmentally/age-appropriate?

○ Faces (4yo), VAS (6-7yo), NRS (8+yo)
○ For 3-5yo, limit their options to the same number as their age

● Was the child trained how to use the scale when they were
NOT in pain?

von Baeyer, 2003

 Principles of Pediatric Pain Management

Social Influences:

● What (good) reasons do kids have for not telling the truth?

● What effect does modeling have on reported pain score?

● Pain is experienced, expressed (encoded), interpreted by

another (decoded), all before it can be treated18
 Principles of Pediatric Pain Management

So, how did you do?

Principles of Pediatric Pain Management
Principles of Pediatric Pain Management

TREATMENT
 Principles of Pediatric Pain Management

2012 WHO Guidelines:

● By the clock

● By the child

● By the appropriate route

● By the ladder
 Principles of Pediatric Pain Management

By the clock:

● When a child is having persistent pain, pharmacologic

analgesia should be scheduled

● This allows drugs to reach stable levels in the blood

● PRN = Patient Receives Nothing

 Principles of Pediatric Pain Management

By the clock:

● PRN dosing may take longer amount of time to manage pain

○ Results in cycle of undermedication and pain alternating
with overmedication and side effects or toxicity19
○ 69% of hospitalized pediatric patients for whom
pharmacologic analgesia was ordered didn’t receive a
single dose20
 Principles of Pediatric Pain Management

By the child:

● Treatment should be tailored to the individual child

○ Different children may respond differently to same dose
○ Reassess frequently to look for signs of oversedation or
side effects
○ At analgesic opioid dosing, no or minimal sedation
expected
 Principles of Pediatric Pain Management

By the child:

● “Autonomic stress” response not correlated with pain

intensity in post-operative patients21
● Use of objective autonomic or respiratory data cannot
replace traditional thorough pain assessment22
● Absence of tachycardia, tachypnea, hypertension does not
mean that the child has no pain
 Principles of Pediatric Pain Management

By the route:

● PO, IV, PR, SQ, SL, IN, TD, IM

● Which route works best?

○ Whichever is LEAST noxious and MOST efficient

 Principles of Pediatric Pain Management

By the ladder:

● Step 1: Mild Pain

○ Acetaminophen and/or Ibuprofen
○ Possibly other NSAIDs?
○ Basic non-pharmacologic pain management
● Step 2: Moderate to Severe Pain
○ Incorporate Step 1
○ Add Opioid Medications
 Principles of Pediatric Pain Management

Acetaminophen:

● Great, safe option for mild acute pain

● FDA recommends no more than 3g/day

● Combination medications can lead to overdose!

 Principles of Pediatric Pain Management

Ibuprofen:

● Great, pretty safe option for mild to moderate acute pain

● No significant difference in incidence of post-operative

hemorrhage between acetaminophen or ibuprofen23

● Ibuprofen and Ketorolac appear to have equivalent analgesic

effect24
 Principles of Pediatric Pain Management

Ketorolac:

● Good short-term IV NSAID

● Mechanism - reversible inhibition of COX-1 and COX-2

● 30mg IV provides analgesia comparable to 12mg PO

morphine25
 Opioid Use in Pediatrics

Morphine:

● Gold Standard Opioid, Mu receptor agonist

● Peak analgesic effect

○ PO: ~60 min
○ IV: 10-20 min26

● Duration of analgesia ~4 hours, less in younger children

 Opioid Use in Pediatrics

Hydromorphone:

● No significant difference in analgesia or side effect profile

compared to morphine27

● Peak analgesic effect28

○ PO: ~60 min
○ IV: 10-20 min
 Opioid Use in Pediatrics

Oxycodone:

● Oral dosing, lasts longer than morphine

● Infants <6mo can’t metabolize as fast - adjust dosing29

● Recommended starting doses are NOT ceiling doses

 Opioid Use in Pediatrics

Conclusions:

● Primum Non Nocere

● PRN = Patient Receives Nothing

● Anchors Away

● Opioids: The sky is the limit

 Principles of Pediatric Pain Management

Sources Cited:
1. Wolfe, Joanne. Textbook of Interdisciplinary Pediatric Palliative Care. Elsevier, 2011.
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3. Weisman SJ, et al. “Consequences of inadequate analgesia during painful procedures in children.” Arch Pediatr Adolesc Med
1998. Feb;152(2): p.147-9
4. Stoddard FJ Jr, et al. “Preliminary evidence for the effects of morphine on posttraumatic stress in one- to four-year-olds
with burns. J Burn Care Res. 2009 Sep-Oct;30(5):836-43
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Lancet 1987 Jan 31; 1(8527):243-8
 Principles of Pediatric Pain Management

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246-51
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costs-of-illness study.” Pain. 2005 Dec 15;119(1-3): 183-90.
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three academic children’s hospitals. Pediatric Crit Care Med. May 2014; 15(4): 77
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18. Adapted from Craig KD 2002, 2010 by von Baeyer, CL
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20. Howard RF. Current status of pain management in children. JAMA 2003; 290:2464-69
 Principles of Pediatric Pain Management

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control. Pain. 2012 Apr; 153(4): 759-64
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tonsillectomy. Int J Ped Otorhinolaryngology. 2012 Jul; 76(7): 1027-29
24. Braaten KP. Intramuscular ketorolac versus oral ibuprofen for pain relief in first trimester surgical abortion: a randomized
clinical trial. Contraception. 2014 Feb;89(2):116-21
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