Managing Pediatric Pain: One plan does not fit all

Suzan Miller-Hoover DNP, RN, CCNS, CCRN-

Managing Pediatric PainAs a healthcare provider, can you decipher the numerous definitions that refer to pain such as somatic, visceral, nociceptive or neuropathic? Did you answer yes, no, or somewhat? Now, consider these same questions from the perspective of a child.

The foundation of pediatric pain assessment is the use of pain assessment tools that are based on cognitive ability and not the age of the child (Hauer & Jones, 2018). The age of the child is important, if the child is not developmentally delayed. When working with pediatric patients it is important to determine the patient’s baseline cognitive abilities to select the correct assessment tool.

In assessing pain, self-report is always the gold standard; however, in the younger or cognitively impaired child, using observational scales are appropriate (Gaglani & Gross, 2017). There are numerous validated, pediatric pain scales available for use. Pediatric pain scales are available for patients who are verbal and awake, or sedated and chemically paralyzed.

Another segment of pediatric pain assessment requires that the practitioner explore the past history of the child. Understanding the child’s past experience with painful situations will assist the RN in appropriately assessing and treating his or her pain.
  •   What kind of experience has the child had with pain in the past?
  •   What behaviors does the patient exhibit when he/she is in pain?
  •   Does the child have chronic pain due to an underlying disease process such as cancer or is the patient
  being subjected to multiple surgical procedures?
  •   Is there an effective pain management plan already in place?
  •   What does the patient/family do for pain relief at home?
  •   Utilizing this information can help ensure that the plan meets the needs of the patient.

Managing pediatric pain is achieved using pharmacological and nonpharmacological methods. Child life Specialists, parents, and play therapists may help reduce pain and anxiety by providing distraction and a calming presence. Keep in mind that when the child’s parents or caregivers exhibit anxiety, the child may pick up on this. This in turn leads to increased anxiety in the patient (Gaglani & Gross, 2017).

When utilizing pharmacological methods, it is important to follow the World Health Organization (WHO) guidelines. These guidelines outline a 2-part process to managing pediatric pain.
Step one: Nonopioid analgesics for mild pain
  •   Acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDS)
  •   Aspirin should be used with caution in children due to the risk of Reye’s Syndrome
Step two: Opioids and concurrent analgesics for moderate to severe pain
  •   Acetaminophen has been shown to reduce the amount of opioid required when used concurrently
  •   Titrating opioid dosing to pain relief is imperative to treating pain and avoiding adverse effects
  •   Codeine and Tramadol should be used with caution in children as there are genetic variabilities
  in metabolism that may lead to increased respiratory depression
  (Gaglani & Gross, 2017; Hauer & Jones, 2018)

The last thing to consider when implementing a pain management plan, is the assessment of pain relief. Reassessing the patient’s pain level after administration of pain medications is essential to successful pain management. It is important to note that pain medication administration, especially opioid administration may lead to sedation. Therefore, it is important to add a sedation assessment tool. Using a sedation tool when reassessing pain levels after opioid administration will help the practitioner identify over-sedation and reduce the risk of respiratory depression (Miller-Hoover, 2017).

Using a variety of assessment skills will help the healthcare provider reach the goals of pediatric pain management: to reduce, control, or prevent pain in children. To meet this goal, it is imperative the practitioner understands that pain management depends on accurate assessment based on the patient’s cognitive level and varies depending upon the type, source, severity, and duration of pain. Use your puzzle solving skills to design an appropriate pain management plan for your specific patient.

For more information regarding pain, review RN.com: Management of Acute Pain.

Gaglani, A. & Gross, T. (2017). Pediatric Pain Management. Emerg Med Clin N Am 36 (2018) 323–334 https://doi.org/10.1016/j.emc.2017.12.002

Hauer, J. & Jones, B.L. (2018). Evaluation and management of pain in children. Retrieved from: https://www.uptodate.com/contents/evaluation-and-management-of-pain-in-children/print?search=evaluation%20and%20management%20of%20pain/

Miller-Hoover, S. (2017). Pediatric Sedation Scales: Using the Right One When It Counts. Retrieved from: https://www.rn.com/clinical-insights/using-the-right-pediatric-sedation-scales/

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