pain in children · there are mounting data to show that untreated or poorly treated pain in...

PAIN IN CHILDREN: EVIDENCE-BASED ASSESSMENT AND PREVENTION

Lisa M. Peters, MN, RN-BC

Clinical Nurse Specialist

Seattle Children’s

Regional Pediatric Nursing Grand Rounds

February 4, 2016

Disclosure Statement

• I do not have any conflict of interest or will be discussing any off-label product use.

• This class has no commercial support or sponsorship, nor is it co-sponsored.

objectives

1. Define evidence based rationale and approach to pediatric pain assessment, intervention and reassessment.

2. Apply the principle of preventable harm in terms of unnecessary pain and our call to action.

3. Identify communication strategies to help ensure effective teamwork for patient safety.

Pediatric pain: an evolving understanding of preventable harm

An evolution of understanding

Undertreatment of pain in children. – Limited clinical information

– Persistence of misinformation

– Attitudes about pain in children

Pre 1970s— Pediatric pain literature almost non-existent

1980s— Pain management in the newborn

1990s— Guideline development with multidisciplinary teams

2001— JCAHO standards and ‘fifth vital sign’

APS and AAP Policy statement

Definition

Pain is an unpleasant sensory and emotional experience, associated with actual or potential tissue damage, or described in terms of such damage.

The inability to communicate in no way negates the possibility that an individual is experiencing pain and is in need of appropriate pain relieving treatment

International Association for the Study of Pain

Pain… so what?

SYSTEM CONSEQUENCE OF UNTREATED PAIN

Pulmonary ↓ flow & ↓ volume → retained secretions and atelectasis

Cardiovascular ↑ HR, ↑ CO, ↑ SVR→ ↑ BP & ↑ myocardial O2 consumption

Endocrine ↑ stress hormone, ↑ metabolic rate, ↑ HR, ↑ water retention

Immune depression of immune functions

Coagulation platelet adhesion, fibrinolysis, activation of coagulation cascade

Gastrointestinal delayed return of gastric and bowl function

Musculoskeletal ↓ muscle function, fatigue & immobility

There are mounting data to show that untreated or poorly treated pain in children has lasting negative effects

Changes in pain processing, especially during critical periods of development

Sensitization

Memories for pain – amount of distress experienced in early event shapes response in future events

Distress

Specific or generalized (e.g. needles to white coats)

Higher risks for morbidity and mortality with avoidance of preventative or maintenance care

Avoidance

Increased analgesic and anxiolytic requirements in future procedures

Analgesic use

Why Treat Pain in Children?

• During critical periods of development, recurring pain induces

excessive sprouting of peripheral nerves, leading to hyperalgesia

(excessive pain response) for months to years thereafter

• Ongoing or recurrent pain induces a phenomenon known as “wind

up,” and amplification of pain signals in the central nervous

system

Fitzgerald et al. (1988 and 1989)

Heel lancing in neonates—tactile threshold is significantly lower at lower gestational ages;

And may be significantly lowered by repeated tactile stimulation.

Taddio et al. (1995 and1997)

4-6mo males during routine vaccinations, those previously circumcised had higher pain

scores and duration of cry than those uncircumcised

Changes in pain processing, especially during critical periods of development

Sensitization

Notice how many

elements make

pain signals

louder in

newborns:

Much more A-δ

pain in infants

than adults

More A-δ

stimulation of

excitatory

interneurons

Fitzgerald M. The development of nociceptive circuits. Nature Reviews Neuroscience 2005; 6:507-520

Sensitization

Myth: Infants do not feel pain!

Notice how many

elements make

pain signals

louder in

newborns:

No C-fiber

stimulation of

inhibitory

interneurons


Sensitization

Myth: Infants do not feel pain!

Notice how many

elements make

pain signals

louder in

newborns:

Little or no

descending

modulation,

especially

inhibitory

responses


Sensitization

Children with negative pain memories:

– higher levels of anxiety (state/trait anxiety and anxiety sensitivity)

– expected to experience more pain in the future

– experienced greater increases in pain reporting over time

Memories for pain – amount of distress experienced in early event shapes response in future events

Distress

Adherence to vaccine schedules • up to 25% of children not fully vaccinated per routine schedule

• < 45% of children vaccinated for seasonal flu

CDC: 105 children died during flu season in US Published March 22, 2013 Associated Press

Specific or generalized (e.g. needles to white coats)

Higher risks for morbidity and mortality with avoidance of preventative or maintenance care

Avoidance

Weisman et al (1998) Archives of Pediatrics & Adolescent Medicine,152(2), 147-149

Increased analgesic and anxiolytic requirements in future procedures

Analgesic use

Evidence-based assessment

Pain assessment

• The cornerstone of effective pain management is regular measurement and assessment of an individual’s pain experience.

• APS and AAP 2001 Policy statement by Committee on

Psychosocial Aspects of Child and Family Health, Task Force on Pain in Infants Children and Adolescents

• ‘Fifth vital sign’

• National Database for Nursing Quality Indicators (NDNQI)

Pain assessment

• Measurement specifically applies a metric to define a dimension of pain and therefore is an aspect of assessment.

• Level of intensity • Location • Frequency • Duration • Aggravating and relieving factors • Disability

• Pain is a multidimensional phenomenon.

• Sensory dimension—strength and character of pain sensation • Affective dimension—emotional impact of pain

“Measuring pain means assigning a number to express its intensity.

This is obviously an oversimplification, like describing music only in terms of its loudness.” Carl von Baeyer

Pain assessment

• Assessment accounts for context.

• Unique plasticity in pain neurophysiology • Maturational status of structure and function at an early age; • Subsequent effects of each pain experience may result in

anatomic and functional changes; • Perception and meaning of pain is individualized based upon

individual and contextual factors.

Contextual Factors

Child

Development

- cognitive

- socio-emotional

- spiritual

Pain threshold, tolerance,

responsiveness

Healthcare providers

Premorbid functioning

Disease severity

Sociocultural &

family factors

Genetics

- physiologic maturation

- gender

- temperament

Pain measurement and assessment

• Developmental sequence of a child’s understanding of pain:

0-3 months No apparent understanding of pain, but prototypical sensory and emotional perceptual awareness, memory for pain available shortly after birth

3-6 months Immediate pain response of infancy supplemented by increased emotional differentiation

6-18 months Children develop clear fear of pain situations. Words to describe pain more reflexive (“ouch”, “owie”) and available at 14mos. Somatic localization becomes evident.

Up to 6 yrs

Prelogical thinking characterized by concrete understanding, egocentrism, and transductive logic. Meaningful description of pain and pain language (“hurt”, “pain”)

7-10 yrs

Concrete operational thinking characterized by child being able to distinguish self from environment. Beginning capacity for behavioral coping strategies (use of hypnosis, relaxation, imagery)

11+ yrs

Formal logical thinking, characterized by abstract thinking and introspection. Increased use of cognitive coping skills.

Craig & Korol 2008

Pain intensity tools

Question: Considering now the multidimensional nature of pain… name the primary source of data to measure pain intensity?

Answer: Individual’s self-report

Question: What about preverbal, nonverbal, or cognitively impaired children?

Answer: Observation of behavioral, physiological indicators, and parental report

Pain intensity tools

• Evidence based, developmental age appropriate, multidimensional, pain intensity tools

• Validity = strength

• Reliability = consistency

• Sensitivity = presence, degree, and changes of pain

• Specificity = target one aspect, r/o other factors

Pain intensity tools at SCH

Neonatal Pain, Agitation & Sedation Scale (N-PASS) <1yr

• A validated tool which uses behavioral states and physiological parameters to measure sedation & pain

• 2 scores may be recorded: 1 for pain & 1 for sedation • The pain score is 0 to 10

• The sedation score is 0 to -10

• Pain score is always recorded

• Sedation is scored by assessing response to stimulation in an infant

Pat Hummel A, APN, NNP, PNP

Premature Infant Pain Assessment: add 1 point to pain score +1 if <30 weeks gestation / corrected age.

Assessment

Criteria

Sedation

Sedation/Pain

Pain / Agitation

-2 -1 0 / 0 1 2

Crying

Irritability

No cry with

painful stimuli

Moans or cries

minimally with

painful stimuli

No sedation/

No pain signs

Irritable or crying at

intervals

Consolable

High-pitched or

silent-continuous cry

Inconsolable

Behavior

State

No arousal to

any stimuli

No spontaneous

movement

Arouses minimally

to stimuli

Little spontaneous

movement

No sedation/

No pain signs

Restless, squirming

Awakens frequently

Arching, kicking

Constantly awake or

Arouses minimally /

no movement (not

sedated)

Facial

Expression

Mouth is lax

No expression

Minimal

expression with

stimuli

No sedation/

No pain signs

Any pain

expression

intermittent

Any pain expression

continual

Extremities

Tone

No grasp reflex

Flaccid tone

Weak grasp reflex

muscle tone

No sedation/

No pain signs

Intermittent

clenched toes, fists

or finger splay

Body is not tense

Continual clenched

toes, fists, or finger

splay

Body is tense

Vital Signs

HR, RR,

BP,

SaO2

No variability with

stimuli

Hypoventilation

or apnea

< 10% variability

from baseline with

stimuli

No sedation/

No pain signs

10-20% from

baseline

SaO2 76-85% with

stimulation – quick

> 20% from

baseline

SaO2 75% with

stimulation – slow

Out of sync/fighting

vent

N-PASS

Faces, Legs, Activity, Cry and Consolability (FLACC) 1-3 yr

• FLACC is a behavior pain assessment scale for use in non-verbal patients unable to provide reports of pain.

• Instruction: Rate patient 0-2 in each of the 5 measurement categories, add together, and document total pain score (0 – 10).

0 1 2

FACE No particular expression or smile

Occasional grimace or frown, withdrawn, disinterested

Frequent to constant frown, clenched jaw, quivering chin

LEGS Lying quietly, normal position, moves easily

Squirming, shifting back and forth, tense

Arches, rigid, or jerking

ACTIVITY Normal position or relaxed

Uneasy, restless, tense Kicking, or legs drawn up

CRY No cry (awake or asleep)

Moans or whimpers, occasional complaint

Crying steadily, screams or sobs, frequent complaints

CONSOLABILITY Content, relaxed Reassured by occasional touching, hugging, or "talking to"; distractible

Difficult to console or comfort

Merkel SI, et al. (1997).Practice applications of research.The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatric Nursing, 23(3):293-297.

FACES Pain Scale Revised (FPS-R) 3-7 yr • These faces show how much something can hurt. This face [point to left-most face]

shows no pain. The faces show more and more pain [point to each from left to right] up to this one [point to right-most face] – it shows very much pain. Point to the face that shows how much you hurt [right now]."

• Score the chosen face 0, 2, 4, 6, 8, or 10, counting left to right, so '0' = 'no pain' and '10' = 'very much pain.' Do not use words like 'happy' and 'sad'. This scale is intended to measure how children feel inside, not how their face looks.

0 2 4 6 8 10

International Association for the Study of Pain (IASP) © 2001.

Wong Baker FACES

• Evidence for change to FACES Pain Scale Revised –literature review, national and international benchmarking

• Psychometrics

• Important features of the Wong Baker Faces • contains smiles and tears, which some people interpret as confounding

affect with pain intensity

• the lowest face showing any painful expression is scored 6/10

• anchor is smiling vs neutral

Self-report numeric 0-10 scale >7 yr

Ask the patient describe their pain according to intensity or severity

“0 is no pain and 10 is the worst pain you could ever imagine.

Tell me about your experience of pain intensity right now.”

Children with developmental disability unable to self-report

Pain assessment

Future directions in the field

• Highlighting culture • Current tools are not sensitive to detect racial and ethnic differences

(to the extent they may exist)

• Impact of pain on functioning • Prospective monitoring of children with recurrent and chronic pain

(e.g. electronic pain diaries)

• Positive outcomes (e.g. sense of self-efficacy or enhanced pain coping in the setting of chronic pain)

Synthesis: a case of prevention

Why needle pain?

• Prevalence

• Prospective study of procedural pain in neonates

admitted to NICU in Paris

• N=430, average painful procedures per day = 16, of which 79%

without specific analgesia

• Carbajal R, et al. JAMA 2008;300(1):60-70

• Vaccination schedule per CDC

• Number of injections by entry into kindergarten >20

• May receive up to 5 injections in a single office visit

Why needle pain?

• Perspective

• Children

• In multiple studies, needle sticks are named one of the most

frightening and painful events, right behind post-op pain

• “When the doctors give the shots, they don’t know how it feels.

They say its not gonna hurt….only because it doesn’t hurt them”

• Parents

• Rated levels of distress and concern for their child’s suffering

with needle procedures second only to waiting for their child

during surgery

• Ellis et al. Pain Manag Nurs 2004;5,144-152

Preventing distress and pain

Self-assessment

You are about to undergo phlebotomy in the antecubital

space of your arm.

• Do you watch the technician as they place the tourniquet, wipe

with alcohol and place the needle?

• Do you look away and think pleasant thoughts elsewhere?


Coping style Attenders or sensitizers

- attempts at mastery

- participate in procedure

Distraction or blunting

- disassociation from event

Positioning - Supine position is threatening and uncomfortable

- Sitting upright or supportive holding are preferable

- Use the treatment room

Pharmacological - Topical local anesthetics

(LMX-4 or J-tip)

EVIDENCE BASED BUNDLE

Developmental sequence of a child’s understanding of pain:

0-3 months No apparent understanding of pain, but prototypical sensory and emotional perceptual awareness, memory for pain available shortly after birth

3-6 months Immediate pain response of infancy supplemented by increased emotional differentiation

6-18 months Children develop clear fear of pain situations. Words to describe pain more reflexive (“ouch”, “owie”) and available at 14mos. Somatic localization becomes evident.

Up to 6 yrs

Prelogical thinking characterized by concrete understanding, egocentrism, and transductive logic. Meaningful description of pain and pain language (“hurt”, “pain”)

7-10 yrs

Concrete operational thinking characterized by child being able to distinguish self from environment. Beginning capacity for behavioral coping strategies (use of hypnosis, relaxation, imagery)

11+ yrs

Formal logical thinking, characterized by abstract thinking and introspection. Increased use of cognitive coping skills.

Craig KD, Korol CT, In Walco GA, Goldschneider KD, Pain In Children: A Practical Guide for Primary Care. Humana Press, 2008

Preparation

Preparation

• Developmentally appropriate explanations and choices

• Tell the truth

• Do not minimize the experience, including with subtle, “more polite” expressions

• A needle penetrating the skin is not a “poke” or a “pinch” and labeling it that for a child is deceptive, confusing, and erodes trust.

• Chest tube removal or lumbar punctures, for example, are acutely painful. Stating otherwise reflects more about you, the provider, than the patient or the situation.

• Help the child understand and process the situation, tapping into their coping methods

Attenders

Distractors

Parental Coping

Effective partnerships

From the AAP – family-centered care in pediatrics generally results in: Decreased anxiety for the child and family

Less medication needed when parents present and assist in pain assessment and management

Earlier discharges from hospitals

Fewer re-hospitalizations

Improved family and staff satisfaction

Increased parent confidence and problem-solving capacity

Fewer lawsuits

Consider Language

Words to Avoid

You have to…

I want you to…

I’ll try, but…

But…

All we can do is…

It’s our policy to…

You can’t

It’s necessary

We expect your child to be

in pain right now

Words to Use Tell me what I’m not seeing,

describe what is different

What tells you that your child is in pain?

What has worked in the past?

That option is not safe, but this is what we can do instead…

It works well when…

We can’t promise no pain. We’ll do our best to work with you to keep your child comfortable











(LMX-4 or J-tip)


Positioning

Do NOT place children in a supine position

Goals of positioning for comfort : A secure, comforting, hugging hold.

Close physical contact with the parent or

caregiver.

Caregiver participates in positive

assistance, not negative restraining.

Sitting position promotes a sense of

control.

Immobility of extremity is successful.

Table does not move when the child moves.

Fewer people are needed to complete procedure.

Side Sitting Position

• Use when patient cannot straddle parents/health care giver

• More mobility to kick and move than chest-to-chest position

• Older children feel secure and less confined.

One Person Hold for IV Placement

• One arm across back—hand holds upper arm. • Other hand holds patient’s hand. • Hug patient to body to secure hold.

Positioning











(LMX-4 or J-tip)


Topical local anesthetic

+/- Considerations

Invasiveness

Effectiveness

Side effects

Toxicity

Pragmatics Ease of application

Time to onset

Duration of effect

Cost Does the ‘perfect’ topical anesthetic exist?

Perhaps not, but data show they work…

so we will use them.

EMLA® vs LMX-4 ®

Eutectic mixture of local anesthetics

Lidocaine 2.5% and prilocaine 2.5%

Prescription only

Occlusive dressing needed

Onset of analgesia 60 to 120 minutes

Risk of methemoglobinemia in infants < 3

months (prilocaine)

Lidocaine

Liposomal lidocaine cream 4%

Over the counter

No occlusive dressing needed

Onset time of 20 minutes

No prilocaine-related risk of

methemoglobinenia

J-tip®, National Medical Products

Carbon dioxide propulsion Onset time within 3 minutes Depth is 3 to 8 mm Difficulties with device (10.5%) Increased cannulation failure (17.6% with vs. 10.1%

without) Bleeding from jet-injection (16.9%) Pain from injection (19.5%) Startle Need pediatric data Cost is about $2.40 per use

Placement matters! http://www.seattlechildrens.org/clinics-programs/pain-medicine/resources/

http://www.seattlechildrens.org/clinics-programs/pain-medicine/resources/






summary

• The mechanisms of pain processing and developmental context confirm the experience of pain in even the youngest children.

• The regular use of evidence based, developmental age appropriate, multidimensional, pain intensity tools capture the expression of pain.

• Un- and under-treated pain is harmful with short and longer term sequelae. Therefore, prevention and treatment of pain is our fundamental, humanitarian responsibility.

CALL TO ACTION:

We I will partner with you and your child

to prevent and relieve pain

as completely as possible.

Questions, comments, concerns? [email protected] or 206-987-4297

THANK YOU

mailto:[email protected]

PAIN IN CHILDREN: EVIDENCED-BASED ASSESSMENT AND PREVENTION

Regional Pediatric Nursing Grand Rounds, February 4, 2016

Lisa M. Peters, MN, RN-BC [email protected] Clinical Nurse Specialist, Seattle Children’s

Key Learnings

I. Long term effects of pain in children

II. Evidence-based assessment of pain intensity in children

III. Application to practice: prevent and relieve pain associated with needle procedures

mailto:[email protected]

REFERENCES

American Academy of Pediatrics. (2001) The assessment and management of acute pain in infants, children, and

adolescents. Policy statement by Committee on Psychosocial Aspects of Child and Family Health, Task Force on Pain

in Infants Children and Adolescents., 793-797.

Brighton Collaboration, global vaccine safety effort http://brightoncollaboration.org

Fitzgerald, M, Millard, C, & McIntosh, N. (1989). Cutaneous hypersensitivity following peripheral tissue damage in

newborn infants and its reversal with topical anaesthesia. Pain, 39: 31-36.

Fitzgerald M. The development of nociceptive circuits. Nature Reviews Neuroscience 2005; 6: 507-520

International Association for the Study of Pain Special Interest Group on Pain in Childhood: http://childpain.org

McGrath, P., Stevens, B., Walker, S., & Zempsky, W. (2014) Oxford Textbook of Paediatric Pain. Oxford, United

Kingdom: Oxford University Press.

Noel, M et al (2012) The influence of children’s pain memories on subsequent pain experience. Pain, 153: 1563-

1572.

Poehling, K et al (2013) The burden of influenza in young children, 2004-2009. Pediatrics, 131(2): 1-10.

Taddio, A, Katz, J, Ilersich, AL, Koren G. (1997) Effect of neonatal circumcision on pain response during subsequent

routine vaccination. Lancet 349: 599-603.

Taddio, A. et al (2010) Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline.

CMAJ 182(18): E843-E855.

Walco, GA, & Goldschneider, KR. (2008). Pain in children: a practical guide for primary care. Totowa, NJ: Humana

Press.

Weisman, et al (1998) Consequences of inadequate analgesia during painful procedures in children. Arch Pediatr

Adolesc Med, 152: 147-149.

http://brightoncollaboration.org/

http://childpain.org/

pain in children · there are mounting data to show that untreated or poorly treated pain in...

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