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Pain management in the Pediatric
Emergency Department
Itai Shavit, MD
Alberta Children’s Hospital
November 2001
Objectives

1. Pain in children: Perception, Myths, Attitudes and Ethics
 2. Pediatric pain assessment
 3. Pediatric Procedural Sedation and Analgesia (PSA)
 4. Narcotic analgesia in acute abdomen
 5. Topical analgesia
 6. Neonatal & Sucrose analgesia
 7. AAP, September 2001 guidelines
 8. Summary
Pain in children:
Perception, Myths, Attitudes and
Ethics
The definition of pain

An unpleasant sensory or emotional experience
associated with actual or potential tissue damage,
or described in terms of such damage (International
Association for the study of Pain: IASP,1979)

Does the human neonate capable of perceiving pain ????
The concept of pain perception

In the eighties, Premature infants who had major surgeries
were treated with minimal anesthesia during and after the
surgery (normal standard)

Pain and its effects in the human neonate and fetus.1987,
NEJM. Landmark seminar paper. Anand and Hickley Called
into question the widely held belief that neonates do not
have the Neurophysiologic apparatus required to
experience pain
AAP & APS policy statement, 09/2001

“The concepts of pain and suffering go well beyond that of
a simple sensory experience. It has emotional, cognitive,
and behavioral components as well as developmental,
environmental and sociocultural aspects”
(AAP and American Pain Society policy statement,
September, 2001)
Myths

Myth 1: “Babies don’t feel pain”

Myth 2: “Babies don’t remember”

Myth 3:
“My son doesn’t need pain killers”
“No pain no gain”,
“Pain is character building”
Myth 1: “Babies don’t feel pain...”
Babies do experience pain!

By 29 wks of gestation, pain pathways and cortical + subcortical centers involved in the perception of pain are well
developed, as are the Neurological systems for the
transmission and modulation of pain sensation

Pain sensitivity in neonates may be more profound that that of
older individuals; their nervous system may be less effective at
blocking painful stimuli than those of adults
Myth 2: “They don’t remember...”
Babies do remember pain!

Effect of neonatal circumcision on pain response during
subsequent routine vaccination. 1997, Lancet.
Taddio, Kats, Ilersich, Koren

Does neonatal circumcision alter pain response at 4-month
or 6-month vaccination compared with the response of
uncircumcised infants?

Prospective. cohort design. 87 patients.

3 groups: uncircumcised infants, circumcised infants who
had randomly pretreated with either EMLA cream or Placebo
for circumcision in a previous clinical trial

All infants were videotaped during vaccination in a primary
care clinic. Videotapes were “blindly” scored by a trained
research assistant. The score measured facial action, cry
duration and visual analogue scale

Results: Circumcised infants showed a stronger pain response
to subsequent routine vaccination than uncircumcised infants.
Among the circumcised group, preoperative treatment with
EMLA attenuated the pain response to vaccination

The pain itself may not be consciously remembered but the
painful experience does

Consequences of inadequate Analgesia during painful
procedures in childen. 1998, Arch Ped Adolesc Med.
Weisman, Bernstein, Schechter

How does inadequate Analgesia for painful procedures
(BMA, ST) effect pain response in subsequent procedures?

Cohort study, randomized, placebo control (Placebo vs Oral
Transmucosal Fentanyl), small sample

Young children (<8y) who received placebo in previous
procedure had consistently higher pain scores than children
who had proper analgesia
Myth 3: “Pain is character building…”
Pain is not character building,
it has a negative influence on children !

This statement is unfair. It legitimizes pain and takes
away the child’s right for pain relief

Children younger than 8 years are not able to understand
that short term pain may have long term benefit

Adolescents who had poorly managed pain procedures
show increased level of anxiety in subsequent pain
situations

Pain is a subjective experience and is incomparable.
There is no direct relationship between “pain
experience” and pain intensity or between physical
pathology and pain intensity
Our fear of Analgesia...
Masking of symptoms and signs
 Changes in the exam
 Side effects and complications

Ethics


The Ethics of pain control in Infants and children. Walco GA,
Cassidy RC, Schechter NL, NEJM, 1994;331(8):541-43
“…The assessment and treatment of pain in children are
important parts of Pediatric practice, and failure to
provide adequate control of pain amounts to substandard
and unethical medical practice
Short term effects of inadequate pain management

Significant fluctuations in HR, BP, ICP, Oxygen level, and
stress hormones level

Sleep disturbances, agitation, crying
Long term effects of inadequate pain management

Inadequate surgical pain management has more
clinical complications, prolonged hospitalization time
and higher mortality rates

Behavioral and Psychological sequaela
Pediatric pain assessment

We’ve all experienced pain

Anxiety decreases pain threshold
Pediatric pain assessment scales

Inability to verbalize pain appropriately under 2 years of
age. At age 3-7 most children are competent to provide
accurate information (using assessment tools)

Pain is a subjective experience therefore individual self
report is favored (AAP recommendation)

Behavioral pain measures are more useful than
physiological parameters. Physiologic parameters are
unreliable
Pediatric pain assessment scales
Pain Assessment tools



0-2 Years: Neonatal Infant Pain Scale, Premature Infant Pain
Profile, Neonatal Infant Pain Scale, DAN score
3-7 years old: FACES pain rating scale, OUCHER Scale
7< years old: Verbal Report Scale, Visual Analog Scale
Neonatal pain assessment
Facial expression
Eyes squeeze
Brow bulge
Nasolabial furrow
Vocal expression
Circumcision
DAN score: Acute pain rating scale in neonates
(Douleur Aigue du Nouuveau-ne, 1997)
Facial expression: Calm (0), Snivels and alternates gentle eye openining and
closing (1), Determine intensity of one or or more of eyes squeeze, brow
bulge, nasolabial furrow: Mild, intermittent with return to calm (2),
Moderate (3), Very pronounced, continuous (4)
Limb movements: Calm or gentle movements (0), Determine intensity of one
or more of the following signs:pedals, toes spread, legs tensed and pulled up,
agitation of arms, withdrawal reaction: Mild, intermittent with return to calm
(2), Moderate (3), Very pronounced, continuous (4)
Vocal expression: No complaints (0), Moans briefly: for intubated child, looks
anxious or uneasy (1), Intermittent crying: for intubated child, gesticulations of
intermittent crying (2), Long lasting crying, continuous howl, for intubated
child, gesticulations of continuous crying
FACES pain rating scale (3-7 years)
The Wong Baker Scale
OUCHER scale (3-7 years)
Categorical
Available in versions for males and females and in
multicultural forms. The child is asked to point to
the picture that best shows how he or she feels
Verbal Report Scale (>7 years)
Categorical
“On a scale of 0 to 10, with 0 being ‘no pain’ and
10 being ‘the worst pain ever’, how would you
rate your pain?”
Visual Analog Scale (>7 years)
Non categorical
A straight line. The left end of the line representing
no pain and the right end of the line representing
the worst pain. Patients are asked to mark on the
line where they think their pain is
Visual Analog Scale (>7 years)
Non categorical
“The greatest pain imaginable”
“No pain”
Pediatric procedural analgesia
Guidelines for Pediatric procedural sedation and analgesia

Sedation and Analgesia for procedures in children
2001,NEJM. Krauss, Green

Management of acute pain and anxiety in children
undergoing procedures in the Emergency Department.
2001, Pediatric Emergency Care. Krauss

Pharmacological Management of pain and anxiety during
Emergency procedures in children. 2001, Paediatric
Drugs. Kennedy, Luhmann
Terminology

12 different definitions for state of sedation. Most of them are
based on the degree of sedation induced rather than the
specific indication for sedation

Only 4 are applicable for children
Conscious Sedation, AAP, 1992

A medically controlled state of depressed consciousness that:
1. Allows protective reflexes to be maintained.
2. Retains the patient ability to maintain a patient airway
independently and continuously
3. Permits appropriate response by the patient to physical
stimulation or verbal command, e.g., “open your eyes”.
Deep Sedation, AAP, 1992

A medically controlled state of depressed consciousness or
unconsciousness from which the patient is not easily aroused.
It may be accompanied by a partial or complete loss of
protective reflexes, and includes the inability to maintain a
patent airway independently and respond purposefully to
physical stimulation or verbal command.
General Anesthesia, AAP, 1992

A medically controlled state of depressed consciousness
accompanied by a loss of reflexes including the inability to
maintain a patent airway independently and respond
purposefully to physical stimulation or verbal command
Procedural Sedation and Analgesia (PSA),
ACEP, 1998


A Technique of administering sedatives or dissociative agents
with or without analgesics to induce a state that allows the
patient to tolerate unpleasant procedures while maintaining
cardiorespiratory function. Procedural sedation and analgesia is
intended to result in a depressed level of consciousness but one
that allows the patient to maintain airway control independently
and continuously. Specifically, the drugs, doses, and techniques
used are not likely to produce a loss of protective airway reflexes.
Significant improvement over the traditional AAP terminology
Precautions




Midazolam
Reduce dose when used in combination with Opioids
Ketamine
Higher risk for hallucinations > 15y, may be blunted with
Midazolam . Adding Midazolam to Ketamine in children
younger than 15y appears to be unnecessary (Sherwin et al,
Ann Em Med, 2000)
Hypersalivation can be minimized with Atropine (poor
evidence)
Fentanyl
Reduce dose when combined with Midazolam
Ultra-Short acting medications


Propofol
Currently not (yet) recommended for PSA in children. High
risk for apnea and loss of airway reflexes. No analgesic
effect. Insufficient data (only one study in children)
Etomidate, Methohexital
Insufficient data in children for safety and reliability
Oral/Intranasal medications for PSA

Oral Transmucosal Fentanyl (lozengens)
High rate of emesis (>30%)
 Intranasal Sufentanyl
Insufficient data on safety and efficacy in children. 7 times more
potent than Fentanyl. With Midazolam for lacerations. The nasal
delivery is painless, no vomiting . Mean time to sedation 20 min,
discharge time 54 min. Expensive.
 Oral Ketamine
Insufficient data. Optimum oral dose for safe and reliable
sedation for PSA has to be determined.
Long discharge time (100 min)
Antagonists

Naloxon
Introduced in 1960, proven to be safe in children.
Opioid antagonist of choice for PSA
 Flumazenil
Introduced in 1987, proven to be safe in children
 Nalmefen
New Opioid antagonist, Introduced in 1995, proven to be useful in
adults. Long acting (3.5h).
 Only one study in children (Nov 2001, Ann Em Med): Patients who
had PSA with Fentanyl/Midazolam received Nalmefen after the
procedure. Sedation reversal parameters were improved, no side
effects, no cardiorespiratory changes, no resedation phenomena.
Nalmefen seems to be effective in children. (small sample)
Narcotic analgesia in the pediatric
acute abdomen
Narcotic analgesia in acute abdomen

The Ethical dilemma of withholding analgesia while
awaiting surgical evaluation

4 prospective randomized controlled double blind studies
in adults, no studies in children

All 4 studies use Morphine sulfate or Morphine derivatives
Narcotic analgesia in acute abdomen

In all studies, opiates didn’t change management and were
not found to be associated with increased morbidity or
mortality. None of the trials was able to identify even one
patient in which analgesia led to a poor outcome

In adults the use of narcotic analgesia doesn’t mask
symptoms or change the physical exam findings

In children there is no data
Topical analgesia
Needlephobia

Topical anesthetics do not reduce needlephobia

Coping strategies used by parents proved to significantly
reduce stress (e.g. favorite toy, books, singing songs)

Both child and parents have to be fully aware of what is
going to occur and the reasons why
EMLA

For IV cannulation and lumbar puncture. Not recommended
for IM injection or heel prick in neonates

Mixture of 2.5% lidocaine and 2.5% prilocaine in a cream
base. The specific concentration gradient promote
penetration of intact skin

Application under an occlusive dressing. Depth of
anesthesia ranges from 3mm after 60 min (onset to pick
effect), to 5 mm after 90
EMLA

Should be placed on skin for at list 60 min. Changing
Triage protocols?

Safe. Recently been approve to for use in newborns.

Single dose does not cause Methemoglobinemia
(Prilocaine side effect)
Tetracaine cream
Ametop Gel (Smith & Nephew 1997)

4% Tetracaine cream (Amethocaine)
 Applied under occlusive dressing
 Rapid onset of action (30 to 40 min)
 Provide anesthesia for up to 4 hours
 Should not be used in neonates (irritation, even blistering)
Lidocaine injection




Subcutaneously injected buffered lidocaine 1% (1/10 with
Bicarbonate solution of 1meq/ml) using 30-gauge needle,
reduces struggling during LPs in newborns
± EMLA or Ametop (>1mo) prior the procedure if possible
Buffering decreases onset time for analgesia without affecting
efficacy or duration
To reduce pain: Distract the patient, use buffered lidocaine,
use 30 (for infants) or 27 gauge needle, warm the anesthetic to
body temperature prior administration, avoid intradermal
injection
Neonatal analgesia
Analgesia for minor invasive procedures in neonates
(Neonates usually suffer more than one poke……)

Acetaminophen?
 Not effective in controlling neonatal procedural pain
 Ibuprofen?
 Its safety under 6 months of age hasn’t been established
 Codeine?
 Codeine requires the conversion to its active component,
Morphine. This enzymatic conversion activity is <10% of
that seen in adults
Sucrose analgesia

Since 1991, 14 RO,CO,BL studies were published

All studies found sucrose to be safe and effective in
reducing neonatal procedural pain (using various neonatal
pain rating scales)

most studies used 24% sucrose, 30% sucrose or 30%
glucose

Sucrose elicits analgesia in neonates when
administered prior to a painful procedure
The phenomenon of sucrose analgesia

Infant rats showed attenuated pain response when given
intraoral infusions of sugar (1987, Blass et al,Pharmacol
Biochem Behav)

1991, Blass & Hoffmeyer, Pediatrics. First report in
neonates. 24% Sucrose solution proved to attenuate pain,
especially when given with pacifier (Circumcision, small
sample, only % of crying time was measured)
Theoretical Mechanism

Endogenous Opioid release? The animals analgesia was
reversible with the administration of opiate antagonist

Perception of sweet taste signaling pain pathways ?

How does pacifier elicit analgesia? Pacifier may promotes
sucking and calming that increase pain threshold by reducing
stress/anxiety
DAN score during venepuncture in 150 newborns
Carbajal et al, BMJ, 1999
Practical considerations

Optimal sugar solution ? Optimal dose ?

The suggested solution for practical purposes is sucrose 25
gram dissolved in 100cc of sterile water, or D25W



Technique:
1. Two minutes prior procedure, put the pacifier soaked with
sugar solution in baby’s mouth. Coat the pacifier with the
solution repeatedly during the procedure Or
2. Two minutes prior procedure, Slowly (30 sec) administer
2cc of the solution to the tongue, then allow him to suck the
pacifier during the procedure
Practical considerations

Treatment of infants older than 1 month with sucrose solution?

Insufficient data. One study showed improved pain response
when given to children at 2-4 months prior immunization
AAP / APS policy statement
September 2001
The assessment and management of Acute
pain in Infants, Children, and Adolescent
Policy Statement, 09/2001
American Academy of Pediatrics
American Pain Society

The AAP and APS jointly issued this general statement to
emphasize the responsibility and the obligation of Physicians to
treat acute Pain in children

Discusses myths about pain in children, the importance of pain
assessment, procedure related pain and recommends using
guidelines for PSA
The assessment and management of Acute
pain in Infants, Children, and Adolescent
Policy Statement,
American Academy of Pediatrics
American Pain Society

“Because of the diversity and complexity of the
clinical issues present; pain treatment, including
choice of drug, dosage, and route, must be
tailored to the individual patient, and analgesic
given in the overall context of
what is best for the patient”
Summary

Pain has short and long term effects on children
 Assessment of pain should be part of the PE
 Pain is a subjective experience, Treat the individual !
 Use PSA guidelines
 Insufficient data to support narcotic analgesia in Pediatric
acute abdomen
 EMLA (60 min), Ametop (30 min), Buffered lidocaine
 2001, AAP policy statement
 “Just stick the sweetened soother in!”
[email protected]
Pediatric Emergency Medicine Discussion List
2001

“Would you give analgesia to a child
with a fracture, prior to obtaining
parental consent?”
[email protected]
Pediatric Emergency Medicine Discussion List
2001

“Pain is an emergency. It should
be treated regardless of parental
consent” Bill Zempsky, Connecticut