Pain assessment in children

Acute pain in children can occur following trauma and injury or secondary to medical and surgical intervention. Before acute pain can be effectively treated, it must be accurately assessed. In spite of many years of research to enhance our understanding of pain, the assessment of pain in children continues to be a challenge and is often inconsistent and suboptimal in many organizations. Pain and its perception are multi-factorial, hence an approach to pain assessment and treatment must also be multi-faceted and multidisciplinary. Painful experiences are dynamic, with huge inter- and intra-individual variation; therefore pain assessment tools must be adaptable, reproducible and accurate to accommodate such variation. This article outlines the different tools available for pain assessment in infants and children (excluding neonates).     

Pain assessment in children

Acute pain in children can occur following trauma and injury or secondary to medical and surgical intervention. Before acute pain can be effectively treated, it must be accurately assessed. In spite of many years of research to enhance our understanding of pain, the assessment of pain in children continues to be a challenge and is often inconsistent and suboptimal in many organizations. Pain and its perception are multifactorial, hence an approach to pain assessment and treatment must also be multifaceted and multidisciplinary. Painful experiences are dynamic, with huge inter- and intra-individual variation; therefore pain assessment tools must be adaptable, reproducible and accurate to accommodate such variation. This article outlines the different tools available for pain assessment in infants and children (excluding neonates).     

Pain assessment in children

Acute pain in children can occur following trauma and injury or secondary to medical and surgical intervention. Before acute pain can be effectively treated, it must be accurately assessed. In spite of many years of research to enhance our understanding of pain, the assessment of pain in children continues to be inconsistent and suboptimal in many organizations. Pain and its perception are multi-factorial, hence an approach to pain assessment and treatment must also be multi-faceted and multidisciplinary. Painful experiences are dynamic, with huge inter- and intra-individual variability, therefore pain assessment tools must be adaptable, reproducible and accurate to accommodate such variability. This article outlines the different tools available for pain assessment in infants and children (excluding neonates).     

Acute pain management in the neonate

Acute pain management in the neonatal period remains a challenge for the clinician. Responses to pain and analgesic intervention are developmentally influenced and cannot be directly extrapolated from the older child. Successful and safe intervention will minimize acute physiological and behavioural distress, reduce pain scores and potentially improve short- and long-term outcomes. This requires an understanding of the physiology and pharmacology in this age group alongside a multi-modal approach to treatment using both pharmacological and non-pharmacological interventions.     

Acute pain management in the neonate

Acute pain management in the neonatal period remains a challenge for the clinician. Responses to pain and analgesic intervention are developmentally influenced and cannot be not directly extrapolated from the older child. Successful and safe intervention will minimize acute physiological and behavioural distress, reduce pain scores and potentially improve short- and long-term outcomes. This requires an understanding of the physiology and pharmacology in this age group alongside a multi-modal approach to treatment using both pharmacological and non-pharmacological interventions.     

Preoperative assessment and preparation for safe paediatric anaesthesia

The delivery of anaesthesia to children and young people provides unique challenges. A careful, systematic approach to assessment and preparation can deliver a positive experience for the child, carers and staff while mitigating potential complications. Preparation for anaesthesia should encompass information gathering, assessment and planning for anatomical, physiological, social and behavioural elements specific to the child and the surgery. Delivery of appropriate information, consent and fasting are also key elements of ensuring positive perioperative outcomes. We consider the common components of preparation for the delivery of safe paediatric anaesthesia.     

Preoperative assessment and preparation for safe paediatric anaesthesia

The delivery of anaesthesia to children and young people provides unique challenges. A careful, systematic approach to assessment and preparation can deliver a positive experience for the child, carers and staff while mitigating potential complications. Preparation for anaesthesia should encompass information gathering, assessment and planning for anatomical, physiological, social and behavioural elements specific to the child and the surgery. Delivery of appropriate information, consent and fasting are also key elements of ensuring positive perioperative outcomes. We consider the common components of preparation for the delivery of safe paediatric anaesthesia.     

Can computer-based assessment help us understand children's pain?

Good measures for self-report of pain in children are important, particularly as other informants tend to underestimate children's pain. This paper describes the development of a new computer-assisted approach to assessment of pain in children. The child can represent a range of different types of pains on body maps, and use two scales to indicate the size of the pain and the 'throb' or intensity. Facial expressions of associated emotions can also be incorporated into the figure. A series of 'pain pages' is included in the program. The pages allow changes in pain to be tracked over time, building up a cumulative record. The child can also report on different experiences and give retrospective accounts. Potential applications are suggested, for example in facilitating communication with children who find it difficult to give a clear verbal account of their pain, due to emotional difficulties, language or disability. Research directions are outlined.     

Postoperative pain management—practice guidelines

Establishment of an acute pain management programme is considered essential to reduce the incidence and severity of postoperative pain experiences of surgical patients in surgical wards. Several quality assurance standards and practice guidelines on pain management for professionals involved in the treatment of pain have been presented. Assessment of pain, using accepted approaches, should be undertaken at regular intervals at rest, during movements and at an appropriate interval after any intervention. It is essential to document pain scores and also to include assessment of patient satisfaction with the postoperative pain management provided so that pain and its treatment is made clearly visible in the clinical setting. A program for acute pain management should also include assessment of the adherence to the accepted postoperative pain management standards over time within the organization.     

Comment je prends en charge un enfant qui souffre d’une hémoglobinopathie

Perioperative management of a child with sickle-cell disease requires close collaboration between hematologist, surgeon and anesthetist. The level of preoperative preparation must consider both the surgical risk and the impact of the disease. Preoperative hydration and blood transfusion are the most important part of preoperative management. Anesthetic technique is not as important as preoperative preparation, management of stress and anxiety, and optimization of intraoperative physiological parameters (oxygenation, acid-base balance, tissue perfusion, normothermia). Pain management must be optimal for these children with increased needs of analgesic. Preoperative assessment of a child with thalassemia must include evaluation of the impact of chronic hemolytic anemia and iron overload induced by repeated transfusions. The most important factor in the management of a child with glucose-6-phosphate dehydrogenase deficiency is to avoid exposure to oxidative stressors. Outpatients should be informed of the risk of hemolytic crisis, and free hemoglobin in the urine should lead to discontinuation of drugs associated with hemolysis and to maintenance of urine output to prevent acute renal failure.     

Acute pain management in paediatrics and geriatrics - pain assessment: which scale for which patient?

In the perioperative period acute pain is measured by one-dimensional scales concentrating on pain intensity. As part of a quality assurance procedure pain assessment is to be exercised during periods of rest and activity. Pain is a subjective experience. That is why self-report is the golden standard of pain assessment. Only in case self-report is not available due to mental development or to cognitive restraints, it has to be replaced by behavioural observation. Established scales are the visual analogue scale (VAS), the verbal rating scale (VRS), and the numerical rating scale (NRS) with a preference for the NRS. Scales that measure pain in children are the Faces-Pain-Scale and behavioural observation scales. The assessment of non verbal adults also has to rely on behavioural observation.     

Postoperative pain assessment in preverbal children and children with cognitive impairment

Postoperative pain assessment and management in preverbal children and children with cognitive impairment poses major challenges to pediatric anesthesiologists. An accurate diagnosis of extent of pain is the keystone for the successful management of pain. This article reviews the neurobiology of pain at birth, long-term consequences of early pain and different pediatric pain assessment tools used for postoperative assessment in infants, young children, and children with cognitive disabilities.     

Polytrauma in children

Polytrauma in children is rare; however, trauma is a leading cause of death in children. Clinicians with responsibility for management of the child suffering major trauma must recognize the conflict between these facts. Simulation and preparation can help to improve the quality of care at both individual and institutional levels. Children are not small adults, and their anatomical and physiological differences manifest themselves in different responses to major trauma than those seen in adults. This reality should be met with a tailored approach to assessment, investigation and management that accommodates the changes occurring from infancy, through childhood and adolescence to adulthood. This approach minimizes the risk of harm from inappropriate irradiation or intervention. Children have remarkable resilience and can make dramatic recoveries from seemingly irrecoverable situations. The comprehensive treatment of musculoskeletal injuries should therefore not be compromised in the setting of polytrauma, and attention must be given to the optimal time for treatment. Damage control resuscitation and early appropriate care facilitate an individualized response. Outcomes for paediatric polytrauma are improved by management in a specialist centre, with early aggressive management of injuries that require surgical treatment by an experienced multidisciplinary team.     

Pain management in children with and without cognitive impairment following spine fusion surgery

BACKGROUND: We compared pain assessment and management practices in children with and without cognitive impairment (CI) undergoing spine fusion surgery. METHODS: The medical records of 42 children (19 with CI and 23 without) were reviewed and data related to demographics, surgery, pain assessment and management, and side-effects were recorded. RESULTS: Fewer children with CI were assessed for pain on postoperative days (POD) 0-4 compared to those without CI (P < 0.002). Self-report was used for 81% of pain assessments in children without CI, while a behavioural tool was used for 75% of assessments in cognitively impaired children. Children with CI received smaller total opioid doses on POD 1-3 compared to those without CI (P < or = 0.02). Furthermore, children without CI received patient/nurse-controlled analgesia for more postoperative days than children with CI (P=0.02). CONCLUSION: Our data demonstrate a discrepancy in pain management practices in children with and without CI following spine fusion.     

Paediatric chronic pain

Chronic pain in childhood is common and if untreated may lead to significant pain-related disability, emotional disturbance and poor school attendance. Many children and adolescents are successfully managed outside of specialist paediatric pain management clinics in a wide range of clinical settings. However, some children require the expertise of a multidisciplinary pain management team in a dedicated paediatric centre. Following multidisciplinary assessment an individualized pain management plan is agreed with the family. Treatment options can be classified into pharmacological, physical and psychological therapies. The aim of treatment is to facilitate a restoration of function for the child, working with the family as a whole.     

Algorithmus zum Vorgehen bei häufigen respiratorischen Notfällen im Kindesalter

Dyspnea is the most common pediatric emergency and represents a dangerous life threatening situation. Rapid diagnostic assessment and initiation of efficient therapy are a prerequisite for a favorable prognosis in dyspneic children. Children are more susceptible to the development of respiratory distress than adults due to the anatomy and the small diameter of the airway, frequent respiratory infections and high oxygen demand. Correct diagnosis and preclinical therapy are therefore needed to avoid life threatening situations, as most resuscitation attempts in children are of respiratory origin. In preclinical emergency management the presence of either inspiratory or expiratory air flow limitation (with a concomitant stridor or wheeze) and the age of the child are the most important diagnostic tools for the correct diagnostic and therapeutic measures. The conscious child with acute dyspnea has to be handled with extreme caution, because agitation can lead to dramatic deterioration. The most important respiratory diseases, their symptoms and therapeutic initial management are discussed following an algorithm.     

Experiences and needs of parents of critically injured children during the acute hospital phase: A qualitative investigation

IntroductionPhysical injury is a leading cause of death and disability among children worldwide and the largest cause of paediatric hospital admission. Parents of critically injured children are at increased risk of developing mental and emotional distress in the aftermath of child injury. In the Australian context, there is limited evidence on parent experiences of child injury and hospitalisation, and minimal understanding of their support needs. The aim of this investigation was to explore parents’ experiences of having a critically injured child during the acute hospitalisation phase of injury, and to determine their support needs during this time.MethodsThis multi-centre study forms part of a larger longitudinal mixed methods study investigating the experiences, unmet needs and well-being of parents of critically injured children over the two-year period following injury. This paper describes parents’ experiences of having a child 0–13 years hospitalised with critical injury in one of four Australian paediatric hospitals. Semi-structured interviews were conducted with forty parents and transcribed verbatim. The data were managed using NVIVO 10 software and thematically analysed.FindingsForty parents (26 mothers and 14 fathers) of 30 children (14 girls and 16 boys aged 1–13 years) from three Australian States participated. The majority of children were Australian born. Three main themes with sub-themes were identified: navigating the crisis of child injury; coming to terms with the complexity of child injury; and finding ways to meet the family’s needs.ConclusionsThere is a need for targeted psychological care provision for parents of critically injured children in the acute hospital phase, including psychological first aid and addressing parental blame attribution. Parents and children would benefit from the implementation of anticipatory guidance frameworks informed by a family-centred social ecological approach to prepare them for the trauma journey and for discharge. This approach could inform care delivery throughout the child injury recovery trajectory. The development and implementation of a major trauma family support coordinator in paediatric trauma centres would make a tangible difference to the care of critically injured children and their families.     

Pediatric pain management

Regional anesthesia has become an integral part of adult anesthesia. Although not routinely used in children because of the need for general anesthesia that is necessary to keep the patients from moving and cooperating with the operator, regional anesthesia has been gaining immense popularity in the last decade. Although there is not much objective evidence, large prospective databases and expert opinion have favored administering regional anesthesia in the asleep child safely because major neural damage has not been reported in children. This review discusses a comprehensive approach to acute pain management in infants, children, and adolescents using regional anesthesia.     

Perioperative management of the child on long-term opioids

The strategies used to manage children exposed to long-term opioids are extrapolated from adult literature. Opioid consumption during the perioperative period is more than three times that observed in patients not taking chronic opioids. A sparing use of opioids in the perioperative period results in both poor pain management and withdrawal phenomena. The child's pre-existing opioid requirement should be maintained, and acute pain associated with operative procedures should be managed with additional analgesia. This usually comprises short-acting opioids, regional or local anesthesia, and adjuvant therapies. Long-acting opioids, transdermal opioid patches, and implantable pumps can be used to maintain the regular opioid requirement. Intravenous infusion, nurse controlled analgesia, patient-controlled analgesia, or oral formulations are invaluable for supplemental requirements postoperatively. Effective management requires more than simply increasing opioid dose during this time. Collaboration of the child, family, and all teams involved is necessary. While chronic pain or palliative care teams and other staff experienced with the care of children suffering chronic pain may have helpful input, many pediatric hospitals do not have chronic pain teams, and many patients receiving long-term opioids are not palliative. Acute pain services are appropriate to deal with those on long-term opioids in the perioperative setting and do so successfully in many centers. Staff caring for such children in the perioperative period should be aware of the challenges these children face and be educated before surgery about strategies for postoperative management and discharge planning.