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The IASP defines Pain as:
“An unpleasant sensory and emotional experience
associated with actual or potential tissue damage, or
described in terms of such damage“
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
The IASP defines Pain as:
"Pain is whatever the experiencing person says it is and
exists whenever he says it does."
Margo McCaffery
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
PAIN
▫ Motivates us to withdraw from damaging or
potentially damaging situations.
▫ Protect the damaged body part while it heals, and
avoid those situations in the future.
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Pain Pathway:
Children are at Risk of Inadequate Pain
Management
▫ Age-Related Factors
Neurobiological
Physiological
Psychological
▫ Misconceptions
Inadequate analgesia
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Developmental Neurobiology
• Sensory fibers are abundant by 20 weeks
• Functional spinal reflex is present by 19 weeks
• Connection to the thalamus are present by 20 weeks
Lee SJ, Ralston H, Drey EA, Partridge J, Rosen MA. Fetal Pain: A Systematic
Multidisciplinary Review of the Evidence.
JAMA. 2005;294(8):947-954
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Developmental Neurobiology
• Connection to the subplate neurons are present by 17
weeks e` intensive differentiation by 25 weeks
• Mature thalamocortical projections not present till
29-30 weeks
Lee SJ, Ralston H, Drey EA, Partridge J, Rosen MA. Fetal Pain: A Systematic
Multidisciplinary Review of the Evidence.
JAMA. 2005;294(8):947-954
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
NOW well accepted by Neuroscientists and Pain Specialists that..
The nervous system is sufficiently developed before birth.
Children experience pain from birth onward
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
NOW well accepted by Neuroscientists and Pain Specialists that..
Infants and young children may experience a greater
neural response more pain sensation and pain-related
distress
The impact of painful experience on the young
long-term effects can occur
i.e. lowered pain tolerance
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Physiological Changes
• CNS (BBB)
• Liver ( Hepatic blood flow Vs. Immaturity)
• Protein Bindings (Albumin Vs. AAG)
• Kidney (Protein load , Excretion Capability)
• Volume of distribution (water Vs. Fat compartments)
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Physiological Changes
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Cognitive Factors
• Understanding the pain source
• Ability to understand what happen
• Expectation regarding the quality or strength of pain
• Previous experience
• Knowledge of pain control strategies
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Behavioral Factors
• Distress responses (child and family)
▫ May initiate, maintain or exacerbate a child’s pain.
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Emotional Factors
• Vary widely & include:
▫ Neutral acceptance
▫ Anxiety
▫ Fear
▫ Anger
▫ Frustration
▫ sadness
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Developmental Stages
Neonateup to 1 mth
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Misconceptions
• The myth that infants and children do not feel pain, or
suffer less from it than adults.
• Lack of routine pain assessment in children.
• Lack of knowledge regarding newer modalities and
proper dosing strategies for the use of analgesics in
children.
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
The American Academy of Pediatrics and
the American Pain Society
• Fears of respiratory depression or other adverse effects
of analgesic medications.
• The belief that preventing pain in children takes too
much time and effort.
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
The American Academy of Pediatrics and
the American Pain Society
Misconceptions
Classification of Pain
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Sharp & well localized.
Reproduce by touching &
moving the affected area
Somatic1-Nociceptive
Noxious stimulation of
specific pain receptors
Thermal, Mechanical or
Chemical
Deep or Superficial
Stretch, Inflammation &
Ischemia
Poorly localized, cramping,
colicky in nature & may feel like
vague deep ache
2-Non-Nociceptive
within PNS / CNS
Nerve cell dysfunction.
No specific receptors for pain
Neuropathic
AKA: Pinched/ Trapped Nerve
Degeneration, Pressure,
Inflammation ..
it becomes electrically unstable,
firing off signals randomly
Sympathatic
Over-Activity of Sympathetic
Nervous System, and CNS/ PNS
More Commonly After Fractures or
Soft Tissue Injuries
may lead to Complex Regional
Pain Syndrome (CRPS).
Partially Sensitive to:
Paracetamol
NSAIDs
Opioids.
More Sensitive to:•Anti-Depressants
•Anti-Convulsants
•Anti-Arrhythmics
•NMDA Antagonists
•Topical Capsaicin may be helpful
Acute Pain:
• More common
• Begins suddenly
• Sharp in quality
• Serves as a warning of disease/threat
• Caused by ..▫ Procedures
▫ Surgery
▫ Broken bones
▫ Dental work
▫ Burns or cuts
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Chronic Pain:
• Longer than 3-6 months
• Despite the fact that an injury has healed
• Pain signals remain active in the nervous system for
weeks, months, or years.
Such as:• Cancer pain
• Arthritis pain
• Neurogenic pain (pain resulting from damage to nerves)
• Psychogenic pain (pain not due to past disease or injury or any visible sign
of damage inside)
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Breakthrough pain:
A sudden Flare-up of pain that “break through” the
around the clock medication used for persistent pain.
Up to 86% of the patients
3 – 30 min & require different Tx.
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Overtreatment
Increased around the clock
medication
Increased side Effects
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
BTP Medications may not act
quickly enough
Patient suffer pain up to 30 min
or more
Undertreatment
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Quick onset BTP medication
Last as long as the BTP (30min)
Easily used
Has manageable Side Effects
Preferred Treatment
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Why Should we Treat Pain?
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Pain Assessment:
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
When ..?
• On admission
• After any known pain- producing event
• With each new report of pain
• Routinely at regular intervals
• After intervention
▫ at appropriate time (e.g. 15-30 min P` IV , 1 hr P` PO);
Follow-up assessment is crucial
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
• To assess pain adequately we must consider..
▫ The developmental stage
▫ Age
▫ Experience
▫ Family Culture/Belief
▫ Language
▫ Severity of Illness
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Neonates and Infants
▫ They communicate distress by crying
▫ Should involve the parents
Notice changes in the infant not obvious to the health care
provider
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Neonates and Infants
Observational pain scales (unable to verbalize)
These scales, though essential, also respond to distress
from causes other than pain, such as hunger, fear or
anxiety
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Preschool and School Age Children
Simple self-report scales using facial expressions or
small objects
To allow more accurately description of their pain
intensity.
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Pain Scales:
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Observational Pain Scales
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
NIPS0 – 1 Y
Observational Pain Scales
CRIESKing Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
0 – 1 Y
Observational Pain Scales
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
FLACC2M – 3 Y
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
2- Poker Chip Scale “pieces of hurt,”
1- Oucher Scale (ethnic versions) well accepted in children over 6 years of age
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
3- Wong-Baker
Faces Scale (free to
use)
(available in 30 languages) 4-
5- VAS , NRS 8 years and older
without difficulty
Pain Assessment in Pediatrics
Adult Pediatrics
Pain
Fear
Pain receptors are the same in the pediatric patient compared to the adult.
But Children do have increased fear and anxiety.
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Pain control must be based on scientific fact, not on
personal beliefs or opinions
Optimal pain management is the right of all patients
and the responsibility of all health professionals
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Treatment should include
▫ Pharmacological - Appropriate Multi-Modal
▫ Non-Pharmacological
▫ Sympathetic Nerve Blocks – as needed
▫ Intensive Rehabilitation
Occupational and Physiotherapy.
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Pharmacologic Pain Management
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
• Special Considerations in Treating Infants and
Children.
• Although most of the major organ systems in infants
are well developed at birth, their functional maturity
is often delayed.
• In the first months:
▫ These systems rapidly mature similar to adults before 3
months of age.
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Multi-Modal Medications
• Inhibition of peripheral inflammatory response to tissue injury (NSAIDs)
• Blocking the pain receptors (Opioids)
• Neural blockade of transmission of pain impulses (Regional Tech./Neuraxial blocks)
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Multi-Modal Medications
• Prevention of “Central Sensitization” before tissue injury (Preemptive analgesia)
• Prevention & treatment of anxiety accompanying acute pain.
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Preemptive analgesia
• Treatment that ..
▫ Starts before surgery
▫ Prevent the establishment of Central Sensitization caused by Injury/Inflammatory responses.
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Drugs used for pain management
• Non-Steroidal Anti-Inflammatory Drugs (NSAIDS)
• Acetaminophen
• Opioids
• Adjuvant
• Others
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Analgesics (Opioids/L.A)
Most are conjugated in the liver.
Newborns, and especially premature infants, have
delayed maturation of the enzyme systems involved
in drug conjugation
▫ Several of these hepatic enzyme systems mature at varying
rates over the first 6 months of life.
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Analgesics (Opioids/L.A)
Glomerular filtration rates :
▫ Diminished in the first week of life, especially in premature
infants
▫ but sufficiently mature to clear medications and metabolites
by 2 weeks of age.
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Analgesics (Opioids/L.A)
Newborns
have a higher percentage of body weight as water and
less as fat
Water soluble drugs often have larger volumes of
distribution.
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Analgesics (Opioids/L.A)
Newborns
• Have reduced plasma concentrations of both albumin
and alpha-1 acid glycoprotein may lead to higher concentrations of unbound drug (active), and
thereby greater drug effect or drug toxicity.
• Have diminished ventilatory responses to hypoxemia
and hypercarbia - especially premature infants
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Acetaminophen
• Excellent safe profile and lack of significant side
effects
• commonly used
• mild to moderate pain,
• often combined with opioid (for more severe pain)
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Acetaminophen
• Can results in Hepatotoxicity
• Infants and children produce high levels of GSH as a
part of hepatic growth may provide some
protection
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Acetaminophen
• Still acetaminophen toxicity are highest in pediatric
patients.
▫ Analysis of Poison Control Center data, FDA adverse
event reports, and clinical trial reports indicate that
therapeutic doses of <75 mg/kg daily are safe with
respect to hepatotoxicity.
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
NSAIDs
• Pharmacodynamics and pharmacokinetics are not
much different than in adults.
• Potential for GI, renal and other toxicities exist
but less than in adults.
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
NSAIDs
• Ibuprofen
▫ frequently chosen
▫ mild to moderate pain
▫ liquid form easy administration
▫ fever reduction
▫ pain relief
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Patient Controlled Analgesia
• Widely used for postoperative pain relief
• Appropriate preoperative teaching and
encouragement
• As young as 6 to 7 years of age can independently
use the PCA
• 4 and 6, however, require encouragement from their
parents and nurses
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Local Anesthetics and Regional Anesthesia
• Topical Anesthetics (EMLA)
• provide pain relief prior to needle-stick procedures
• requires 30 to 60 minutes to become fully effective after application.
• must be applied in a thick layer
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
EMLA
• Clinical trials have shown effectiveness of EMLA in
reducing the pain or distress of a number of common
pediatric procedures including:
▫ venous cannulation
▫ Venipuncture
▫ lumbar puncture,
▫ Circumcision
▫ urethral meatotomy
▫ Immunizations
▫ dermatologic procedures … etc.
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Nonpharmacologic Pain Management
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Comfort Methods:
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
RepositioningSinging
or soft music
Gentle stroking
Rocking with the child
in a rocking chair
Swaddling
Comfort Methods:
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Watching a movie
Reading a book
Other methods used at home
to comfort the child
Psychological strategies:
For children undergoing repeated painful procedures,
cognitive-behavioral therapy
▫ decrease anxiety and distress
▫ help children master a distressing situation.
▫ take time to learn and master
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Psychological strategies:
• Distraction techniques ▫ divert attention away from painful stimuli
• positive incentive techniques
▫ provide a small reward (e.g., stickers or prizes)
Decrease anxiety but not adequate as the sole means of
pain relief.
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Persistent Pain in Children
• Children with chronic medical disease can
experience:
▫ a significant amount of pain associated with both their
underlying disease and the procedures that are performed to
treat it.
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
Persistent Pain in Children
• Children with chronic medical disease can
experience:
▫ They deserve not only access to adequate pain medication,
but also psychological support to help them continue to
learn and grow as they should.
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
SUMMARY
• The pediatric nervous system is fully developed and
able to respond to Nociceptive stimuli even in pre-
term neonates
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
SUMMARY
• Pain can have lasting physiological and
developmental consequences if not appropriately
managed
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
SUMMARY
• Regular pain assessment is fundamental to good pain
management but is often poorly performed
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
SUMMARY
• A variety of pain assessment tools are available and
should be utilized according to a patient’s age and
developmental stage
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
SUMMARY
• Multi-modal therapy is appropriate for managing all
forms of pediatric pain and should utilize
combinations of local anesthetic, paracetamol,
NSAIDs and opioids as appropriate
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
SUMMARY
• Adequate monitoring, safety equipment and
resuscitation skills are needed to safely manage
patients requiring combinations of sedation and
analgesia for painful procedures
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
SUMMARY
• The pharmacokinetic and pharmacodynamic profile
of commonly used analgesics can be variable
depending on the age and development
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام
THANK YOU
Aola H. Al Duhaim RN, BScN
Pain Management CNC
King Fahad Specialist Hospital
Dammam
مــسـتــشـفى الـمـلـك فـهـد الـتخـصـصي
الــدمـام