Numerous studies have shown that despite traditonal beliefs, practically everyone has the ability to feel pain3 and other studies have disproven the myth that “masking” pain with analgesia may cause diagnostic uncertainty, which was once a barrier leading to the under-treatment of pain.3
This issue of pain management in the pediatric population is often unsatisfactorily addressed.4
Nonetheless, inadequacies in pediatric pain management continue to be seen across the scope of emergency department care, despite an increasing recognition of the associated long-term psychosocial risk to the child that could result from improperly managed pain.5
Currently, there is a campaign in pediatric pain management that recognizes a large area for improvement that exists in the care of our youngest patients.6
Optimizing the Environment
There is a clear relationship between anxiety and perceived pain in children; additionally, the hospital can carry a stigma formed from prior encounters, acquaintances and the media. To combat anxiety, the physical environment should be bright. One study showed that sunlight, windows, odor, and seating arrangements when well-executed most consistently generated positive review.8 Age-appropriate themes should be utilized to bring familiarity to the new situation.8
This can be achieved when optimizing a dedicated pediatric space in a general emergency department.
Adequate pain assessment in the emergency department is the first step in addressing pain. Furthermore, this step is a requirement of The Joint Commission.9 Because pain is intrinsically a subjective concept that is affected by society, experience and psychological factors, one of the most convenient and practical methods that is used by providers is a self-report of pain. Converting subjective reports to objective measurement is currently the clinical standard, and this is accomplished by using a variety of pain scales.
There are several validated pain scales for children to use to self-report. Some of the most popular and best validated scales include the Wong-Baker FACES® pain rating scale, the FACES and FACES-revised pain scales, and the OUCHER™ pain scale.10 If a child is unable to self-report pain, there are behavioral pain scales such as the Faces, Legs, Activity, Cry and Consolability (FLACC) Scale, which utilizes a child’s presenting history and physical exam to assess pain.11
However, regardless of which pain scale is chosen, the most valuable information is gathered from the changes in the pain score upon reassessment using the same scale. In this way, the provider may determine the efficacy of interventions.
Noninvasive Pain Management
Origins of pain are both somatic and psychological. Acute pain is frequently associated with anxiety and hyperactivity of the sympathetic nervous system (e.g., tachycardia, tachypnea, elevated BP, diaphoresis). Chronic pain tends to manifest in more subtle signs and less sympathetic activity (e.g., fatigue, loss of appetite, depressed mood). As the cause of pain is multi-factorial, the approach to pain management should be multidisciplinary.
Studies have demonstrated that using a multidisciplinary approach to pain management in pediatrics can increase patient satisfaction and decrease reported pain scores.13 Complementary methods of pain management include bio-feedback, guided imagery, relaxation therapy, massage, acupuncture, art therapy, music therapy, meditation and others. Many of these adjunctive measures are now being used in the emergency department setting.
One noteworthy method of pain and anxiety management is the use of everyday technology in the art of distraction. Distraction is a practical and inexpensive method of pain and anxiety management that has been found to be successful in multiple forms (e.g., games, toys, music, videos). One publication reports success using our now ubiquitous smartphones for successful induction of anesthesia.13
Another novel publication by McQueen et al. (2012) documents a successful distraction technique using an iPad in the emergency department, thereby decreasing or eliminating the need for restraint or sedation in several typically painful situations.14
At other times, avoidance of the painful procedure may be the best approach. Thus, medical professionals should always consider alternatives to any potentially painful procedure for children, as the most commonly indicated procedure is not always necessary for a favorable outcome.
For example, tissue adhesive and Steri-Strips™ in the right context are painless alternatives to suture repair.15 Also, oral rehydration is shown to be an effective alternative in many children.16
If a painful procedure is absolutely necessary, topical anesthetics should be considered as a prelude to the procedure.
There are several options in topical anesthesia and all have been shown to be safe and effective. Cryotherapeutics (e.g., ice, vapo-coolant spray) have short onset times and short durations, which make these agents ideal for brief procedures.17
Additionally, commercial creams are an option when needing a longer-acting topical anesthetic. If anticipating a painful procedure, these creams are best administered as early as possible in the patient’s presentation because of these agents the prolonged time to onset.
A newer technique being applied in the emergency department is needle-free (jet) injection. This technique utilizes a gas cartridge under high pressure to provide local anesthesia with lidocaine with similar efficacy to the classical approach of using a needle.18
Topical anesthetics range in cost and time to onset (Table 1) but have overall been shown to decrease pain, improve procedural success rates and increase cooperation.19
Local and Regional Anesthesia
Local anesthesia can be applied independently or after the application of topical anesthesia. Classically, local anesthesia is achieved with needle infiltration of a local anesthetic (e.g., lidocaine, bupivacaine, prilocaine, etc.). However, there are certain techniques that can reduce the pain associated with the infiltration of local anesthetic. Stimulating the skin proximal to the site of injection, using a 25-gauge or smaller needle, infiltrating slowly20 and using warmed (room temperature) lidocaine21 will improve pain associated with injection of local anesthetics. Additionally, using lidocaine buffered with bicarbonate (9:1 parts) decreases the pH of lidocaine, reducing the burning sensation that local infiltration causes.22 For added convenience, the buffered solution can be made in advance and it may remain stable for up to 30 days.23
Regional anesthesia can be used to block pain and sensation in a specific nerve distribution. This targeted anesthesia is especially useful for painful procedures such as joint dislocations, fractures and lacerations.
Because regional anesthesia often requires a smaller volume of anesthetic, this method has a lower risk for systemic toxicity and causes less tissue distortion. The advent of ultrasound in emergency care has helped greatly with the efficacy of this technique.24
Systemic Analgesia and Anxiolysis
For mild to moderate pain, oral medicines are often sufficient. Acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), and even some opiate formulations are available in liquid suspensions for easier administration to children. For more severe pain, intravenous agents may be administered. The intranasal route is a less intrusive route of medication administration in the pediatric population. This method is praised for its efficacy, ease and speed, and has been shown to be an effective route for analgesia (i.e., morphine, fentanyl) (Table 2) as well as anxiolysis (i.e., midazolam, ketamine)25 (Table 3).
Procedural sedation is an option for more lengthy, difficult or intrusive therapies. However, this procedure should be implemented with rigorous cardiovascular and respiratory monitoring by caretakers.
Neonatal Pain Management
There are some important physiologic differences in the neonatal population to be aware of when addressing pain and considering sedation. Most analgesics (including opiates and local anesthetics) are conjugated in the liver. Newborns are often still developing the necessary enzymes for drug metabolism for up to the first six months of life.26 Newborns also have a higher total percentage of water contributing to body weight (less fat) than older children and adults, therefore water soluble drugs will have a greater volume of distribution in the neonatal body. The ventilatory response to hypoxemia and hypercarbia in the newborn, particularly in the premature infant, is diminished27 so there is potential to blunt this response with benzodiazepine and opiates.
Topical anesthetics may be administered to the neonatal population. However, care should be taken not to allow prolonged exposure to the agents and to use appropriate dosing to prevent systemic toxicity.
In addition to showing efficacy of topical agents, literature has demonstrated that sucrose decreases the pain response in neonates in the following procedures: heel lance, venipuncture, ophthalmologic exam, bladder catheterization, nasogastric tube insertion, and subcutaneous injections.28
Sucrose solutions are most valuable about two minutes prior to the start of the painful procedure in neonates less than six months old. Oral sucrose is more efficacious in the younger neonate. Sucrose also may be more effective when administered with a pacifier.30
Encouraging maternal involvement is also helpful if a provider anticipates a painful procedure for a neonate.
One study has shown that breastfeeding or breast milk is better than placebo, positioning or no intervention, and may even have a similar effect compared to the use of sucrose solution.31
Child Life Specialists
Child life specialists are trained professionals who offer support for children and families, to help them cope with injuries and illness. There are currently 111 children’s hospitals within larger hospital systems that provide at least one full-time registered child life specialist in the emergency department. There are at least 40 children’s hospitals in systems that do not provide a full time registered child life specialist in the ED.32
Possessing a strong background in child development and family systems, child life specialists are an invaluable part of the emergency department team.
Child life specialists serve as a dedicated member of the health care team in helping the child feel more comfortable during the emergency visit.33
Examples of contributions by child life specialists can include:34
- Help decrease anxiety and pain perception using developmentally appropriate education and preparation to patients and families;
- Teach the child and staff simple distraction techniques, deep breathing, progressive relaxation or guided imagery;
- Help the child to develop and execute coping plans during difficult events in the ED;
- Educate the child about the ED environment and his or her diagnosis;
- Support family involvement in the child’s care.
Management of pain in the pediatric population during an emergency visit can often be over- looked by the care provider. However, first taking the time to assess pain will allow for appropriately addressing the pain. The roots of pain are psychological, somatic and social. There are many ways to address relieve pain in children provided that the caretaker thinks “outside the box.” Furthermore, a large portion of pediatric pain management requires anxiolytic supplementation to pharmacotherapy. Pediatric pain management continues to be an important area of research, as the emergency department can be a scary and painful place for any child. The astute emergency physician must be aware of pediatric pain and should be willing to try a multifactorial approach in order to mitigate pain for the emergency department’s youngest patients.
Dr. Ahn is the associate program director for the University of Chicago Emergency Medicine Program. He can be reached at firstname.lastname@example.org.
Dr. Kosoko is a postdoctoral fellow in pediatric emergency medicine and global health at Baylor College of Medicine/Texas Children’s Hospital.
She practices in Houston and can be reached at email@example.com.
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