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62 Pain Management

Inflammatory mediators, such as prostaglandins and bradykinins, activity and behaviour are often especially insightful. In particular,
have been found to be responsible for stimulating nerve receptors in the the child’s ability to partake in usual activities or interest in pleasur-
periphery. Neurotransmitters, such as endorphins and encephalins, are able activities should be queried. Enquiry should be made into school
thought to be at least partly responsible for the central modulation of the absences, sleep disturbance, and reduced interest in feeding, which are
pain response. As a result, both the initial inflammatory response and often also particularly significant.
central pathways involved in pain perception are targets for analgesics. In taking the history, the clinician should also attempt to elicit
The Importance of Pain Control family beliefs and expectations about pain and disease. Previous
experiences of the child or other family members may well affect how
Everyone involved in the care of a child is distressed when the child
the child (and parents) responds to pain. Culture also affects how pain
is in pain. It is increasingly being recognised, however, that the del-
is described or even acknowledged.
eterious effects of pain are more far-reaching than the immediate
The signs from the physical examination that can be used to make
psychological dimension. The experience of pain leads to activation
an assessment of pain largely fall into two categories: physiological
of the sympathetic nervous system. This has various potentially harm-
and behavioural.
ful effects, including increased myocardial stress and hypertension.
In neonates, pain can precipitate apnoeas, and infants may experience Physiological
syncopal episodes. Pain also leads to activation of the stress axis, First, the cause of pain may be identified, for example, by seeing a vis-
which causes increased blood cortisol levels that could impair wound ible wound or from palpating abdominal guarding, suggestive of perito-
healing. In addition, patients in pain are less likely to mobilise in the neal irritation. Second, increased heart rate, respiratory rate, and blood
postoperative period, putting them at increased risk of atelectasis and pressure are indicative of sympathetic stimulation in response to pain.
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chest infections. An increased risk of deep venous thrombosis is also a Such signs are objective and do not require the child’s cooperation.
concern in the adolescent age group. The culmination of these adverse They are therefore particularly important in preverbal children, those
consequences is an increased length of hospital stay and associated with physical or mental disability, those with impaired consciousness,
increased costs. In addition, longer-term consequences to consider with and the apparently “stoic” child. However, they are also nonspecific
a child who has suffered a distressing experience include the likelihood indicators of physiological stress, so these indicators should not be used
that the child will be more distressed and less cooperative in the future. in isolation. Traditional healer’s markings are other good indicators of
the site of pain and disease.
The Assessment of Pain
The first step towards appropriate pain management is being able to Behavioural
assess how much pain a child is experiencing and why. Naturally, the Behavioural signs may be generalised responses to pain, such as facial
source of pain should be identified by using investigations appropri- expression, irritability, crying, or lethargy, or may be more specific
ate to the differential diagnosis. The accurate assessment of pain in reactions to certain types of pain, such as ear pulling, assuming cer-
children, however, requires separate consideration of the history of the tain postures, or refusing to move a certain limb. Although useful,
pain, observation and examination of the child, and the use of validated one should not be misled by such signs. There is well-established
scoring tools, in addition to knowledge of the underlying cause of dis- cultural and even gender-related variation in the degree to which pain
comfort. No single method should be used in isolation. The child and is externalised—particularly in the social acceptability of crying. The
parent should both be consulted; in addition, a range of appropriately degree of illness can also influence the extent to which a child is able to
trained and experienced health care professionals should be assembled. express his or her pain. One should always beware of underestimating
the degree of pain being experienced in a critically ill child. In some
History cultures, pain is acknowledged as a sign of weakness, and this taboo
A good history of pain can aid the clinician in diagnosing the underly- needs to be eradicated.
ing condition as well as in gaining insight into the degree of discomfort.
Where possible, the clinician should seek the child’s description of the Assessment Tools
pain. Parental report is also useful. The “SOCRATES” mnemonic is Various pain scales have been developed to help measure the degree of
helpful to use whenever taking a pain history—enquiry should be made pain being experienced by a child. Using such tools has been shown to
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to the Site, Onset, Character, Radiation, Associated features, Temporal improve pain management and aid nursing care.
features, Exacerbating/relieving factors, and the Severity of the pain. The choice of scale should reflect the nature of pain (for example,
Questions pertaining to the effect of the pain on the child’s level of acute versus chronic pain), the ethnicity of the child, and—crucially—

Source: Wong-Baker Faces Pain Scale 1981.
Figure 11.2: Example of pain scale using facial expression of pain severity.