Pain Management Children
Paediatric Analgesia Section
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.
How to treat pain
- 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 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 inifiltration [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 katamine sedation)
Unfortunately Intranasal Diamorphine (an extremely safe, effective and useful analgesic agent in paediatric practice is banned in paranoid Éire)
Contra-indications
Ibuprofen / diclofenac: avoid if previous reactions
to NSAID's or in moderate or severe asthmatics
Intravenous morphine: use with caution if risk of depression
of airway, breathing or circulation.
Assessment of acute pain in children in the Emergency Department
| |
No Pain |
Mild Pain |
Moderate Pain |
Severe Pain |
Faces pain score |
|
|
|
|
| |
0 | 1 - 3 | 4 - 6 | 7 - 10 |
Behaviour |
Normal activity No reduced movement Happy |
Rubbing affected area Decreased movement Neutral expression Able to play / talk normally |
Protective of affected area Decreased 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 Appendicitis Sickle crisis |
- 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
References
Bier's Block Regional Analgesia
1. Clinical Effectiveness Committee. January 2002.2. Emergency Triage. BMJ Publishing Group, 1997.
3. McGrath PJ et al, CHEOPS: A behavioural scale for rating postoperative pain in children. Advances in Pain Research and Therapy, vol 9, Ed. Fields, Raven Press, 1985.
4. Wong-Baker Faces Pain Scale. Adapted from Whaley L, Wong DL. Nursing care of infants and children. 3rd ed. St Louis: The CV Mosby Company, 1987.
5. Advanced Paediatric Life Support, 3rd ed. BMJ Publishing Group, 2001.
Links
BAEM Clinical Effectiveness Committee Publication on Management of pain in Adults Here. Local Version
BAEM Clinical Effectiveness Committee Publication on Management of pain in Children Here. Local Version.
British Association for Emergency Medicine. Royal College Surgeons England. 35-43 Lincoln's Inn Fields. London WC2A 3PE, UK
