Page 24 - 59peadiatric-surgery-speciality8-14_opt

Pain Management 63

the child’s age and developmental level. Children older than 3 years of familiarise themselves with equipment by first playing with it in a
age are generally considered to have the cognitive ability to use self- nonpressured environment is also useful to reduce the shock associated
report scales. Commonly employed techniques involve the child being with procedures. Employing “play specialists”—specially trained
asked to point to a photograph or cartoon of a face in various degrees members of staff who are familiar in using a variety of such techniques
of pain, or the use of linear analogue scales reflecting the continuum of and able to identify when best to use these—has been shown to reduce
pain intensity. Examples of commonly used tools and the age group for hospital length of stay and increase compliance in some hospitals. 10
7
which they are validated include: Analgesia
• the Oucher Scale, from the age of 3 years; The prescription of analgesics should follow the World Health
• the Bieri Scale, from the age of 6 years; Organization (WHO) pain management ladder (Figure 11.3). A key
principle behind this is the cumulative effect of drugs and the step-
• the Wong-Baker Faces Pain Scale, 8–12 years of age; and wise addition of drugs to address pain requirements. Similarly, as
• the Adolescent Paediatric Pain Tool, validated in children from 8 to pain requirements reduce (for example, in the postoperative period),
17 years of age. analgesia should be reduced in a stepwise manner down the ladder. The
route of administration, dosage, and timing should be tailored to suit
Tools that use cartoon representation of children’s faces in various
of degrees of pain are likely to be more globally applicable and may the individual child. In particular, it is important to realise that the gas-
be especially useful where resources are limited. An example is shown trointestinal absorption of medications is affected after major surgery,
in Figure 11.2. meaning oral administration is often inappropriate in this setting. Age-
For children who are not considered able to verbalise their and weight-appropriate dosages for each analgesic should be calculated
pain adequately, behavioural scales can be employed. The Faces, for each child on an individual basis.
Legs, Activity, Crying, and Consolability (FLACC) scale, Toddler-
Preschooler Postoperative Pain Scale (TPPPS), and the Children’s Analgesic Ladder
Hospital of Eastern Ontario Pain Scale (CHEOPS) are generally Pharmacological Management of Acute Pain
thought to be suitable from around age 1 to 5 years. Specific scoring in Children (age ≥ 1year)
systems encompassing behaviour observation and physiological
variables should be used in neonates, with separate tools needed for
use in premature babies. Patient Controlled
Ideally, a variety of different pain scales should be available, with Morphine Continue to give regular
the choice of which scale to use determined on an individual basis. Severe Pain Nurse Controlled paracetamol ± NSAID
Morphine
Pain assessment using such tools should be approached with the same IV Morphine rescue
attention as that of vital signs: by staff trained in its assessment and Epidural infusion
who constantly re-evaluate the effectiveness of interventions. Pain Continue to give regular
flow sheets included in the hospital record may be useful in meeting Oromorph paracetamol ± NSAID
this goal. Parents should also be educated in the ongoing assessment
of their child’s pain. Codeine Continue to give regular
paracetamol ± NSAID
Management
It goes without saying that treatment of the underlying condition is Moderate Pain Paracetamol + Diclofenac
or
critical to managing a child’s pain. This, however, is often not imme- Paracetamol + Ibuprofen
diately possible and, crucially, many treatments themselves cause pain.
Adequate symptomatic relief is therefore essential. To control pain Diclofenac
effectively, consideration must be given to both pharmacological and or
nonpharmacological methods of management. The relative use of each Mild Pain Increasing Pain Ibuprofen
or
should be tailored to the individual child, and each intervention should Paracetamol
be modified according to assessments of effectiveness.
Nonpharmacological Techniques Source: Cross L, Bridge H, ORH & NHS Trusts, Version 1, July 2003.
Nondrug methods often do not alleviate pain completely but do help to Figure 11.3: The principles of the WHO analgesic ladder.
make it more tolerable by providing the child with coping mechanisms.
The hospital environment is often a source of distress in itself, which Paracetamol is an excellent first-line drug for children with pain. It
compounds the experience of pain in children. In recognition of this, exists in forms suitable for oral, rectal, and intravenous administration.
attempts should be made to keep to the child’s normal routine when Rectal absorption is often slow and unpredictable, so this route is less
in hospital; the number of “new” people tending the child should be commonly used. Paracetamol is generally well tolerated and low in
minimised and parents should be involved in care as much as possible. side effects.
Other nondrug methods can be employed in specific situations— Children who do not get sufficient analgesia from paracetamol
especially in relation to certain procedure-related pain. Distraction alone should also be prescribed a nonsteroidal anti-inflammatory drug
8
is especially useful for short procedures. Methods should be age (NSAID). Drugs such as ibuprofen and diclofenac work by inhibiting
specific and chosen to reflect the interests of the child. Commonly prostaglandin synthesis and reducing inflammation. They are therefore
used examples include videos, games, and books for older children, especially valuable in patients with surgical pain. Oral and rectal
and bubbles, lights, and music for younger children. Feeding an infant preparations are available, with rectal diclofenac being particularly
or using a pacifier are simple and inexpensive interventions that have well absorbed and of great use in acute pain relief. Caution should be
been shown to have analgesic effects. Relaxation techniques, such as exercised in patients with asthma or with renal or hepatic impairment.
9
gentle rocking and massage, have also been used with some success. These drugs should not be used in patients with known bleeding
Discussion of the procedure, what it involves, and why it is necessary tendency or those under 3 months of age. Due to the risks of gastric
is often useful with older children. Allowing younger children to
irritation, they should ideally be given with food or milk.