Children: Introduction

An eighteen month old girl splits her lip badly while climbing on an icy jungle gym at her daycare center. Her parents are contacted, and they rush her to the local emergency room. The attending physician confirms that her lip will need 3-4 stitches. He explains that he can use a local anesthetic to numb the area, but advises the parents that this too will be painful for their daughter. He suggests that they get the procedure over as quickly as possible, without local anesthesia. The father agrees to restrain his daughter while her lip is stitched.

The above story (based on an actual event)⁶ is not meant to imply that children are being cruelly subjected to torturous medical procedures. Its purpose is to invite questions about commonly held attitudes or beliefs about pediatric pain.

Is a child’s experience of pain different from an adult's experience of pain? Would the ER physician have dismissed the use of a local anesthetic with an adult?

The tendency toward under medication is far more pronounced in children than in adults. Studies reveal that children receive much less post-operative analgesia than adults who have the same diagnoses and have undergone the same procedures. Children younger than two years of age are less likely to be treated than are older children.

Reasons for these disparities are rooted in:

• Myths about a child’s experience of pain
• Fears held by patients, parents and health care providers about opioid addiction and adverse side effects of pain medication
• Inadequate knowledge of pain assessment and state-of-the-art treatment options

Examples of widely-held myths:

Myth: Young infants do not feel pain; children tolerate pain better than adults because their nervous systems are immature.

Fact: Neuroanatomical studies⁷ show that cortical and subcortical centers responsible for perceiving pain as well as the neurologic pain transmission pathways are well-developed by 29 weeks of gestation. Moreover, current research indicates that infants and children most likely experience more pain than adults as a result of a vigorous inflammatory response to pain combined with reduced central inhibitory influence.

Myth: Children have no memory of their early years, and as such, there are no long-term effects of pain.

Fact: It is now known that pain and distress do indeed endure in memory⁸ , and may exaggerate behavioral and affective responses during subsequent painful events. Preliminary research data suggest that early painful experiences may actually change the function and structure of nociceptive neural pathways, causing increased sensitivity to pain.⁹ Nociceptive pain results from the activation of nociceptors by noxious stimuli. Causes of nociceptive pain include bone fractures, inflammation, burns, and sprains, among others.

Myth: Children easily become addicted to narcotics.

Fact: Less than 1% of children treated with opioids develop addiction. Opioids are no more dangerous for children than they are for adults when appropriately administered (Foley, 1996).¹⁰

Myth: What physicians fear is that the use of opioids will result in respiratory depression.

Fact: While respiratory depression is a serious and well-known side effect of opioids, it rarely occurs in children. Safe and effective use of opioids in children has been documented, without increased risk of respiratory depression (Kart, Christrup and Rasmussen, 1997; Sabatino et al. 1997; Hertzka et al. 1989). With adequate monitoring and adherence to appropriate guidelines for dosages, respiratory depression should be a rare event in children. In addition, because agents are available to reverse the effects of opioids, the condition can be treated if it occurs.¹¹

Myths, fears, and poor application of available pediatric pain research have left many children suffering needlessly. Health care providers who have attitudinal biases toward pediatric pain relief, inadequate pain assessment skills, and limited knowledge of treatment options are at risk for claims of unnecessary physical and emotional distress. Fortunately, medical specialty organizations like the American Academy of Pediatrics and the American Pain Society are working hard to transform pediatric pain research into clinical practice, and excellent resources and guidelines exist for delivering safe, compassionate, quality pain care to children.

Common Causes of Pain in Children
There are two types of pain suffered by children:

• Acute
• Chronic

Acute pain follows injury to the body (i.e., a specific nociceptive event) and generally disappears when the bodily injury heals. The most common type of acute pain experienced by children results from injury, illness, or in many cases, necessary medical procedures. Invasive procedures are documented as the most painful and traumatic events experienced by children. An estimated 1.5 million children have surgery each year in the United States, and the majority of these children are inadequately treated for pain.¹²

Chronic pain may begin as acute pain, but it continues beyond the normal time expected for resolution of the problem, or persists or recurs for other reasons. According to the American Pain Society, chronic pain is estimated to affect 15 to 20% of children. Children with a chronic medical disease (e.g., cancer, arthritis, cystic fibrosis, sickle cell anemia) often experience moderate to extreme levels of pain, not only from the disease itself, but from procedures used in treating it.

Cancer
According to the one source, over 12,000 children in the United States are diagnosed with cancer annually.¹³ Pain results from tissue distention or infiltration caused by cancer, and/or resulting inflammation due to infection, necrosis or obstruction. Leukemia accounts for 30% of cancer cases in children ages 0-14. Malignant proliferation of white blood cells irritates and stretches the nerve cells of the bone's periosteum, producing severe pain. Cancer treatments— chemotherapy, radiation therapy and surgery—cause pain as well.

Juvenile Rheumatoid Arthritis
Juvenile Rheumatoid Arthritis (JRA) is one of the most prevalent chronic pediatric diseases in the United States. For many children with JRA, the pain can be intense and disabling, and affects their ability to fully participate in school or social activities. An autoimmune disorder, the most common features of JRA are:

• joint inflammation
• joint stiffness
• joint damage and/or alteration
• change in joint growth
• weakness in muscles and other soft tissues around involved joints

JRA commonly affects knees and the joints in hands or feet. Typically, inflammation and pain are more acute first thing in the morning or after a nap. While extensive research has been conducted on adult arthritis pain, a greater focus needs to be placed on pain in children with JRA.

Cystic Fibrosis
Cystic fibrosis (CF) is a chronic, progressive, inherited genetic disease affecting the body's mucous glands. There are about 30,000 people in the United States with CF; approximately one in every 2,500 babies born is affected with the disease. CF is predominantly seen in whites with a northern European heritage. In children and young adults, CF largely affects the respiratory and digestive systems. Pain resulting from abdominal and pulmonary obstructions is common; occasionally, the gut becomes completely blocked, resulting in extreme stomach pain.

Sickle Cell Anemia
In the United States, sickle cell anemia affects mostly African Americans and some Hispanics. According to the National Heart, Lung and Blood Institute, the disease occurs in about one in every 500 African-American births and one in every 1,000 to 1,400 Hispanic-American births. Sickle cell anemia is a notoriously painful disease that destroys red blood cells by causing them to take on a rigid “sickle” shape. When sickled red cells cannot squeeze through small blood vessels, they stack up and cause blockages that deprive organs and tissues of oxygen-carrying blood. This process produces periodic episodes of pain (often hideously painful) and ultimately, can damage tissues and vital organs and lead to other serious medical problems.

Other chronic conditions commonly seen in pediatric clinics include episodic headaches, stomach aches and chest pain.

Unrelieved pain causes sustained physical discomfort, can lead to emotional and other health problems, and delays recovery. On-going, persistent pain makes it difficult for children to participate in family, school and social events. Their quality of life is impaired. Children do not “get used to” pain. In fact, children often experience anxiety, depression, and/or insomnia as a result of chronic pain or in anticipation of a painful medical procedure. While complete absence of pain may not be possible in all situations, the goal of pediatric pain care should be to reduce a child's pain and distress to the greatest extent possible.

Assessing Pain
Pain assessment in the pediatric population presents several challenges. A child’s age, communication ability, emotional and psychological state, cognitive development, coping style, and family/cultural expectations mix together in ways that complicate accurate pain assessment.

There are several questions regarding pediatric pain assessment that must be considered:

1. If a child is unable to express pain, can credible assessment be obtained from a parent?
2. With older children, how much weight is given to the child's self-report of pain versus the parents' view?
3. Are the parents minimizing their child's pain intensity because they think the child is looking for attention?
4. Is the child simply being stoic and not reporting pain?
5. Is the child reluctant to talk about pain because he/she fears a painful injection?
6. Is the child inured to chronic pain?
7. How might the child's family support system/cultural beliefs impact pain reporting?
8. Is there a language barrier?
9. Given the child's language/culture, what words are commonly used to describe pain?
10. What special assessments are necessary for children who are cognitively impaired, severely emotionally disturbed, or impaired in sensory or motor modalities?

Because pain is a sensory, emotional and cognitive experience, several different assessment strategies are needed to discover the qualitative and quantitative information about pain, and identify an effective treatment strategy.

The QUEST principles of pain assessment¹⁴ promote use of multiple sources of information, and can be used to comply with the Joint Commission for Accreditation of Healthcare Organization’s new pain management standards.

QUEST Approach for Pain Assessment in Children

Question the child.
Use pain-rating scales.
Evaluate behavior and physiological changes.
Secure parents’ involvement.
Take cause of pain into account.
Take action and evaluate results.

Where feasible, self-report measures are generally the most useful and reliable. Children should be encouraged to talk about their pain. Clinicians should involve parents in obtaining the child’s pain history, and in understanding the specific words used by the child to express pain (e.g., hurt, “owie” or “boo-boo”).

A variety of self-report tools (pain scales) have been developed to help quantify the intensity of a child’s pain. Children ages 8 and above can generally quantify their pain using a verbal analog scale. For children ages 3-8, there are three types of pain scoring tools:

• selection from drawings of facial expressions
• selection of a certain number of items to indicate pain (e.g., poker chips)
• selection of a color using a color intensity analog scale, where more intense red color is scored as more pain

Examples of these scales and other valuable assessment tools can be found on the Texas Children’s Cancer Center’s Website, www.childcancerpain.org. In addition, Appendixes C-E are excellent pain assessment tools to use with older children.

For newborns and very young children, pain is generally assessed using observational scales which combine behavioral indicators (facial expression, crying, body movements) and physiologic measures such as heart rate and oxygen saturation. The Face, Legs, Activity, Cry and Consolability (FLACC) scale uses descriptions of behavior to assess post-operative pain in children between the ages of 2 months and 7 years.

Clinicians using pain scales should keep in mind that a child’s previous experience (or lack of experience) with pain can affect his or her perception of intensity. Younger children may use the upper end of a pain scale simply because the injury or procedure is the strongest pain they have experienced to date.

While pain scales have been validated as effective assessment tools, there is no one ideal scale for every child and every situation. Combining both qualitative and quantitative information, the QUEST approach to pain assessment is an excellent model for obtaining the information needed to make informed decisions about pediatric pain treatment strategies.

Pain Experience History
Establishing a reliable pain history for a child can be difficult. In infants and nonverbal children the history must be obtained from the parent or guardian. Beginning at age 3 some children are able to provide reliable answers to questions regarding pain, but it is important to remember that up until age seven, children often lack the necessary skills to properly evaluate questions and provide accurate information. Again, the parent or guardian must be consulted for confirmation of the child’s responses.

On the following page is a recommended approach to obtaining a pediatric pain history:

This information was gleaned from www.childcancerpain.org. This site contains a variety of tools that will help the health care professional determine a child's pain in order to treat it successfully.

Treatment
All types of pain medication-and opioid analgesics-are available for children, regardless of their age or size. Today, pharmacologic and non-pharmacologic choices make it possible to successfully prevent and manage pain in children. Treatment strategies should be based on pain assessment findings, and should address both the underlying pain mechanisms and emotional and/or behavioral symptoms (sleep disturbance, anxiety, depressive feelings, etc.). For example, a multi-modal treatment approach for a child who is plagued with persistent shoulder pain, particularly at night while trying to sleep, might also include a sleep aid, massage, biofeedback, and transcutaneous electrical nerve stimulation (TENS). In every pain management situation, health care providers should consider the benefits of a multi-modal, multi-disciplinary treatment plan.

For the prescription of analgesics, the World Health Organization advocates a multi-step approach to treating pain referred to as the “WHO Analgesic Stepladder.” ¹⁵ It is a step-by-step guide for initiating analgesic drugs and dosages that correspond to the patient’s pain intensity:

• Step one reflects mild to moderate pain and involves the use of non-steroidal anti-inflammatory drugs (NSAIDs) and other non-opioid analgesics
• Step two reflects moderate pain and involves the use of opioid drugs (e.g., codeine, hydrocone, and meperidine) for moderate pain
• Step three reflects severe and/or intractable pain that is treated with progressively stronger opioids and if needed, invasive therapies (e.g., epidural)

Again, the potency of the prescribed analgesia should match the child’s reported pain intensity. For example, children reporting severe pain (Step 3) should be started on a potent opioid, not an NSAID. Pediatric emergency room studies show that inadequate analgesia not only impacts the child during the ER visit, but also diminishes the effect of adequate analgesia in subsequent procedures.

The main modes of transmission in the WHO prescribing method are:

• BY THE MOUTH - Whenever possible, use the least invasive route. A child’s resistance to taking medication is a common challenge. Age, level of cooperation and temperament must be considered. If taking medication becomes a struggle, children and parents will often under-report pain to avoid the discomfort of taking or giving medicine. If other administration routes are required (injections, IVs, etc.), physicians should use anesthetic creams or gels to minimize the pain associated with skin puncturing.
• BY THE CLOCK - Pain medications should be given around the clock; children should not have to wait for pain to develop before medicine is given. A prn or “as needed” dosing schedule commonly results in under medication of the child, where brief periods of pain relief are followed by long periods of pain. Administering analgesics “by the clock” on a scheduled basis ensures a steady state of pain relief and allows for tolerance to side effects to develop.
• FOR THE INDIVIDUAL - The individual child’s response to analgesics must be considered and appropriate adjustments made. There is no standard pain medication dose that works for all children. The goal is to determine the dose that effectively prevents recurrence of pain prior to the next dose.
• WITH ATTENTION TO DETAIL - All aspects of a child’s pain treatment program should be monitored carefully, adjusted as needed, and documented fully.

Patient Education/Communication
In the area of pediatric pain management, patient education is primarily directed toward parents or guardians. They are the ones who are the constant observers of the child's behavior. They are the ones who will have to provide informed consent. Unfortunately, they are also the ones who might become litigious if they feel their child has not been treated properly. An example of this is Oswald versus Legrand,¹⁶ in which a married couple sued health care providers for mental injury due to “severe emotional distress and mental anguish” due to witnessing the negligent treatment of their newborn infant. The infant had been presumed stillborn, but was in fact alive.

In its decision for the plaintiff, the court stated in part:

“...Where the nature of the relationship between the parties is such that there arises a duty to exercise ordinary care to avoid causing emotional harm...[we] think liability for emotional injury should attach to the delivery of medical services.”

In other words, parents who suffer emotionally because their child’s pain is/was not treated, or not treated correctly, might very well have a basis for a lawsuit.

Appendix F is a copy of “Four Pain Commandments for Parents.” It is perforated for easy removal and reproduction. A copy of the Commandments should be given to all parents and guardians to help them provide the correct information, and ask the questions that will provide the information they want from their physician.

Effective communication is essential in pediatric pain assessment and management. Clinicians should be particularly sensitive during high-risk interactions when the patient or parents are emotionally vulnerable. Physicians should believe the patient and/or family reports of pain and involve them in the decision making for pain control. Through education, health professionals can dismiss unfounded fears and possible barriers to effective pain treatment. Providing children and their parents easy-to-understand information on pain (what it is, safe use of analgesics, non-pharmacological pain relief options, importance of pain management compliance and monitoring, possible side effects, consequences of inadequate pain management, etc.) will help avert potential misunderstandings and possible legal action. When use of opioid analgesics is included in the treatment plan, physicians should diligently address patient and/or family concerns about addiction and review potential risks, no matter how small.

Summary
Myths, fears and lack of adequate knowledge explain, but do not excuse, the suffering children experience as a result of under medication. Availability of safe, low-cost pediatric pain management technology now begs an important question: Is the apparent under treatment of pain in children ethically justifiable? If the fundamental principle of responsible medical care is “first do not harm,” pediatric clinicians must consider the potential “harm” of pain and decide whether failure to use all possible means of relieving pain is ethical. As seen in recent lawsuit decisions, physicians are increasingly being held accountable for failure to adequately treat pain. Pressure from parents is also playing a part in the evolution of new pediatric treatment protocols. In examining current practices and identifying needed changes, pediatric physicians are encouraged to utilize new pain management standards and guidelines, online resources, research data, and risk managers.

In the policy statement from the American Academy of Pediatrics’ report on “The Assessment and Management of Acute Pain in Infants, Children, and Adolescents” recommendations are made for improving pediatric pain management. These recommendations are included as Appendix G.

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