Assessment and Management of Acute Pain in Pediatric Patients: Best Practices and Challenges
Acute pain is a common and distressing experience for many children who are hospitalized or undergo surgery. Effective pain management is essential to ensure the well-being and recovery of pediatric patients, as well as to prevent the development of chronic pain and psychological complications. However, acute pain management in children poses several challenges, such as under-recognition, inadequate assessment, lack of evidence-based guidelines, and variability in practice. This article aims to provide a practical guide to the assessment and management of acute pain in pediatric inpatients, based on the current literature and expert recommendations.
Pain Assessment Tools
One of the key steps in pain management is to assess the intensity and quality of pain using valid and reliable tools. Pain assessment tools should be appropriate for the age, developmental stage, and cognitive ability of the child, as well as the type and context of pain. There are various types of pain assessment tools available, such as self-report scales, behavioral observation scales, physiological measures, and multidimensional tools. Some examples of commonly used pain assessment tools are:
– FLACC scale: A behavioral observation scale for children aged 2 months to 7 years, or older children who are unable to self-report. It consists of five indicators: face, legs, activity, cry, and consolability. Each indicator is scored from 0 to 2, giving a total score of 0 to 10. A higher score indicates more severe pain.
– Faces scale: A self-report scale for children aged 8 years and older, or younger children who can understand the concept of rating pain. It consists of six faces depicting different levels of pain, from no pain to very much pain. The child is asked to choose the face that best matches their pain level. The faces are scored from 0 to 5.
– Visual analog scale (VAS): A self-report scale for children aged 8 years and older, or younger children who can use numbers to rate pain. It consists of a 10-cm line with anchors at each end, such as “no pain” and “worst pain possible”. The child is asked to mark a point on the line that represents their pain intensity. The distance from the left end of the line to the mark is measured in millimeters and recorded as the pain score.
– Non-communicating Children’s Pain Checklist – Revised (NCCPC-R): A behavioral observation scale for children who are unable to communicate verbally due to developmental delay, cognitive impairment, or intubation. It consists of 30 behaviors grouped into seven categories: vocal, social, facial, activity, body and limbs, physiological, and eating/sleeping. Each behavior is rated as present or absent during a 10-minute observation period. The total number of behaviors observed is the pain score.
Pain assessment should be performed at regular intervals, depending on the severity and type of pain, as well as before and after any intervention. Pain assessment should also involve the child’s self-report whenever possible, as well as the input of parents and caregivers.
Pain Management Modalities
The main modalities for pain management are pharmacological and non-pharmacological interventions. Pharmacological interventions include analgesics (such as opioids, nonsteroidal anti-inflammatory drugs [NSAIDs], acetaminophen, and local anesthetics), adjuvants (such as ketamine, lidocaine, gabapentinoids, and antidepressants), and co-analgesics (such as sedatives, antihistamines, and antiemetics). Non-pharmacological interventions include psychological (such as distraction, relaxation, hypnosis, and cognitive-behavioral therapy), physical/sensory (such as massage, heat/cold therapy, acupuncture, and transcutaneous electrical nerve stimulation [TENS]), and environmental (such as music, aromatherapy,
and lighting) techniques.
The choice of pain management modality should be based on the individual needs and preferences of the child and their family, as well as the availability and feasibility of the intervention. The principles of multimodal analgesia should be followed whenever possible, which means combining different types of analgesics and non-pharmacological interventions to achieve synergistic effects and reduce side effects. The World Health Organization (WHO) analgesic ladder provides a useful framework for selecting analgesics based on the severity of pain (Fig. 1). According to this framework:
– For mild pain (FLACC score = 0-3 / Faces score = 0-1 / VAS score = 0-3), oral acetaminophen or NSAIDs should be given at regular intervals or as needed. Non-pharmacological interventions should also be considered.
– For moderate pain (FLACC score = 4-6 / Faces score = 2-3 / VAS score = 4-6), oral or intravenous opioids should be added to the previous regimen, with careful titration and monitoring. Non-pharmacological interventions should also be continued.
– For severe pain (FLACC score = 7-10 / Faces score = 4-5 / VAS score = 7-10), intravenous opioids should be given as boluses or infusions, with or without patient-controlled analgesia (PCA) or nurse-controlled analgesia (NCA) devices. Non-pharmacological interventions should also be maintained.
The dose and route of administration of analgesics should be tailored to the individual patient, taking into account their age, weight, medical history, allergies, renal and hepatic function, and potential drug interactions. The efficacy and safety of analgesics should be regularly evaluated and adjusted as needed. The common side effects of analgesics include nausea, vomiting, constipation, pruritus, respiratory depression, sedation, and addiction. These side effects can be prevented or managed by using appropriate doses, co-analgesics, and monitoring devices.
The Acute Pain Service
The acute pain service (APS) is a specialized, multidisciplinary team that provides consultation and support for the management of complex or refractory pain in pediatric inpatients. The APS typically consists of an anesthesiologist, a nurse specialist, a pharmacist, and a psychologist or psychiatrist. The APS works in collaboration with the primary care team, the bedside nurse, the child and their family, and other allied health professionals to provide a comprehensive and individualized pain plan. The APS can also provide education and training for health care providers on pain assessment and management.
The APS is usually consulted when the child’s pain is not adequately controlled by the standard analgesic regimen, or when there is a need for advanced pain management techniques, such as regional anesthesia, PCA/NCA devices, ketamine infusions, or intrathecal opioids. The APS can also assist in the management of pain-related complications, such as opioid-induced hyperalgesia, opioid tolerance or withdrawal, neuropathic pain, or chronic post-surgical pain.
Acute pain management in pediatric patients is a challenging but rewarding task that requires a multidisciplinary and patient-centered approach. By using valid and reliable pain assessment tools, multimodal analgesic regimens, non-pharmacological interventions, and specialized consultation services, health care providers can ensure optimal pain relief and improved outcomes for children with acute pain.
– Gai N., Naser B., Hanley J., Peliowski A., Hayes J., Aoyama K. A practical guide to acute pain management in children. Journal of Anesthesia. 2020;34(3):421-433.
– World Health Organization write my nursing thesis. WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses. Geneva: World Health Organization; 2012.
– Elsevier – Care Plans │Pain Acute (Pediatric Inpatient). https://elsevier.health/en-US/preview/pain-acute-pediatric-inpatient-cpg. Accessed November 14, 2023.