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Emerging Therapies in

Pediatric Pain Management

Wendy Mosiman, DNP, APRNPNP-BC, CNS, RN-BC

Clinical Nurse Specialist

Pediatrics/PICU

Via Christi Hospitals

Wichita, Kansas

Barriers

• Belief children, especially infants, don’t feel pain

• Belief unable to assess pediatric patient painBelief unable to assess pediatric patient pain

• Belief it is just a stick w/ no long term effect

• Belief managing pain takes too much time

• Belief pain treatment for kids doesn’t exist

Professional Perception

1968

“Pediatric patients seldom need medications for relief of pain. They tolerate pain well.”

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We know now!

Substantial evidence shows that even the smallest of preterm infants not only perceives but remembers pain and demonstrates recognizable pain behaviors.

Age Perception of Pain

Pre-termBy mid/late gestation has anatomical/functional ability to process pain; sensitivity to pain >term infants or children

Age/Perception of Pain

NewbornResponse to pain is inborn; newborns respond to pain with behaviors such as grimacing, crying, moving body

Infants older than one month

Metabolize analgesics/anesthesia effectively; Caregiver recognized as comforter

Age Perception of Pain

Toddlers andPreschoolers

Pain description of location/intensity possible; anger, crying, sadness response; may think pain punishment; may hold someone accountable for pain and remember

Age/Perception of Pain

y pexperiences, i.e. IV RN!

School-age children

When facing painful procedure may try to be brave; developmental regression to earlier stage common; seeks to understand reasons for pain

AdolescentsMay try to avoid acknowledging pain; showing signs of pain may be considered weak; regression to earlier stages of development common with persistent pain

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Pain doesn’t just hurt!

• Stress hormones released– Systemic changes

• Increased heart rate, BP, ICP, ,

• Increased oxygen consumption and hypoxemia

• Reduced tidal volume/abnormal respirations

• Weakened immune function → delayed healing

– Lengthened hospital stay

Pain doesn’t just hurt!

• Maladaptive response development to future painful procedures

– ↑ pain intensities + fear/non compliance↑ p p

– Procedural conditioned anxiety

– Significant anticipatory stress/anxiety

– Analgesic effectiveness diminished

– Needed medical care avoided or postponed

– Chronic pain more likely as an adult

Needle Pain

• It isn’t JUST A STICK!

• Two most common sources of pain in hospitalized childrenhospitalized children– Venipuncture

– Intravenous (IV) cannula insertion• 2nd most common cause of worst pain in hospital

• 1st is underlying disease!

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… Just because the patient is unable to scream the words ‘That HURTS’ doesn’t mean there is no way to tell they are

ff i d ’t d ’t t l tsuffering and can’t mean we don’t at least try treatment!…

FLACCFace

0 = No particular expression or smile

1 = Occasional grimace/frown; withdrawn or disinterested; appears sad or worried

2 = Consistent grimace or frown; frequent/constant quivering chin, clenched jaw; distressed-looking face;

expression of fright or panic

Individualized behavior:___________

Legs

0 = Normal position or relaxed; usual tone & motion to limbs

1 = Uneasy, restless, tense; occasional tremors

2 = Kicking, or legs drawn up; marked increase in spasticity, constant tremors or jerking

Individualized behavior:________

Activity

0 = Lying quietly, normal position, moves easily; Regular, rhythmic respirations

1 = Squirming, shifting back and forth, tense or guarded movements; mildly agitated (e.g. head back and forth, aggression); shallow,1 Squirming, shifting back and forth, tense or guarded movements; mildly agitated (e.g. head back and forth, aggression); shallow, splinting respirations, intermittent sighs.

2 = Arched, rigid or jerking; severe agitation; head banging; shivering (not rigors); breath holding, gasping or sharp intake of breaths, severe splinting

Individualized behavior:__________

Cry

0 = No cry/verbalization

1 = Moans or whimpers; occasional complaint; occasional verbal outburst or grunt

2 = Crying steadily, screams or sobs, frequent complaints; repeated outbursts, constant grunting

Individualized behavior:_________

Consolability

0 = Content and relaxed

1 = Reassured by occasional touching, hugging or being talked to. Distractible.

2 = Difficult to console or comfort; pushing away caregiver, resisting care or comfort measures

Individualized behavior:___________

©2002, The Regents of the University of Michigan—Permission granted

Wong-Baker FACES Pain Rating Scale

Brief word instructions: Point to each face using the words to describe the pain intensity. Ask the child to choose face that best describes own pain and record the appropriate number.

From Hockenberry MJ, Wilson D: Wong’s essentials of pediatric nursing, ed. 8, St. Louis, 2009, Mosby. Used with permission. Copyright Mosby.

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Presumed Pain

• Knowing what you know now, ask yourself, if this was happening to me, would I think it hurt?– If the answer is yes or even maybe, you

need to make sure the child is adequately treated.

Painful procedure in Neonates

• >10,000 infants in NICU across USAuthors # Painful Procedure in NICU

Johnston et al, 1997 2-10 per day

• Pre-emptive analgesia <35%

• Nearly 40% had NO analgesia

Benis & Suresh, 2001 6 per day

Simons et al, 2003 14 per day

Carbajal et al, 2008 16 per day

Painful procedures in older children

• Kids undergo many painful procedures

*14-20 separate immunization injections by age 2

*Venipuncture, IV start, laceration repair

• Children interviewed 7 years after pediatric cancer stated procedural pain (lab draws, IV start) worse than cancer pain

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Procedural Pain

So we are all

convinced they hurt.

What should we do?

Ethically? Morally?

• Nurses obligated to relieve children's pain– ANA code of ethics

• Right behavior, right knowledge, compassion

– Immanuel Kant duty based perspective• When the knowledge/tools exist, poor

management is wrong

– Relational ethics• Nurses “are the healthcare system”

• Child depends on nurses to protect from pain

Procedural Pain

• Plan ahead—we almost always have time to provide pain management before sticks

• TJC considering 2 new standards• Involving parents in identifying signs of pain

• Intervening before the procedure• Pharmacologically

• Non pharmacologically

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Intramuscular - IM

• Painful administration and for days

• Sterile abscesses

• Fibrosis of muscle and soft tissue

Just plain mean!!

• Absorption erratic

• Titration not possible

• Respiratory depression more likely

• ↑↑ expense over oral meds

• Needle stick risk to care providerAmerican Pain Society, Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain, 6th ed., American Pain Society, Skokie, IL, 2008. AAP 2001

DO NOT USE

DEMEROLDEMEROLDevil Drug

PLAN AHEAD• Develop standard protocols

• Develop standard orders

Develop staff expectations• Develop staff expectations

• Develop education for parents

• Organize needed equipment

• Make it easy to do the right thing

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Environment– Child friendly

– May or may not be the child's room

Comfort HoldSaint Joseph's Children's Hospital, Marshfield, Wi

• Comfort positioning purpose is to increase the comfort of infants and children as well as parents and medical staff.– Invites the presence of the parent/caregiver

– Prepares the child/parent for procedure and their role

– Gives the option of the treatment room

– Positions child in a that allows control and comfort

– Maintain a calm, positive atmosphere

• Youtube video from Dell Children’s Medical Center

Comfort HoldSaint Joseph's Children's Hospital, Marshfield, Wi

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Side Sitting PositionSaint Joseph's Children's Hospital, Marshfield, Wi

IV Start Sitting PositionSaint Joseph's Children's Hospital, Marshfield, Wi

Distraction– Child Life Specialist

• Trained professional not causing pain

– Distraction• Infant: pacifier, bubbles, toys

• Toddler: bubbles, songs, pop-up books, party blower, kaleidoscope, toys

• School-age: videos, video games, search for objects in pictures, stories, jokes, counting, nonprocedural conversation

• Adolescent: music by headphones, video games, nonprocedural conversation, focusing on objects

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Non Pharm with some effect but incomplete

• Pre term Infants– Skin to skin contact

– Sucking related i t ti

• Neonates– Sucking related

interventions

R ki /h ldiinterventions

– Swaddling/facilitated tucking

– Rocking/holding

Older infants – the latest Cochrane review did not find sufficient evidence for any of the above (sucrose, breast feeding and music were excluded from the review)

Sucrose solution 24%Neonates >28 days Infants>4kg up to 6 months of age

•0.1 mL of solution at a time on anterior section of infant’s tongue PRN painsection of infant s tongue PRN pain, irritability, or prior to a procedure.

•For optimal effect, begin 2 minutes before procedure.

•Maximum volume of 24% sucrose is 0.5mL per procedure or 2 mL in 24 hours

NON-NUTRITIVE SUCKING

NNS shown to reduce pain behavior.

Offer dummy (pacifier) at least 2Offer dummy (pacifier) at least 2 minutes before minor procedure.

May be dipped in sucrose solution or offered after sucrose.

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L·M·X·4

• Topical 4% liposomal Lidocaine cream

• Intact skin needed, cover with clear occlusive dressing

• Available over the counter

• May be applied by parent

• Effective from 30 minutes– Longer is better, up to 5 hours is safe

LIDOCAINE/PRILOCAINE CREAM EMLA

Age up to 3 months or weight < 5 kg:

Apply a maximum of 1 gram to affected area x 1, 60 mins prior to procedure. Maximum application area = 10 cm2, p p pp ,Maximum application time = 1 hour, Cover with clear occlusive dressing

• Example only, please develop your own procedures based on your population

EMLA CREAM For LP and implanted port access

Age and Body WeightRequirements

Max. TotalDose ofEMLA Cream

MaximumApplicationArea

MaximumApplication Time

0 up to 3 months or < 5 kg 1 g 10 cm2 1 hour

3 up to 12 months and > 5 2 g 20 cm2 4 hours

Please note: If a patient greater than 3 months old does not meet the minimum weight requirement, the maximum total dose of EMLA Cream should be restricted to that which corresponds to the patient’s weight. From AstraZenac package insert—Demonstration purposes only

3 up to 12 months and > 5 kg

2 g 20 cm2 4 hours

1 to 6 years and > 10 kg 10 g 100 cm2 4 hours

7 to 12 years and > 20 kg 20 g 200 cm2 4 hours

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Lidocaine/TetracaineSYNERA is a peel-and-stick procedural topical anesthetic patch with a novel heating technology designed to enhance the delivery of the anesthetic. The anesthetic formulation is a eutectic mixture of equal parts lidocaine and tetracaineequal parts lidocaine and tetracaine.

Iontophoresis

• 10-20 minutes

• Use in kids older than age 5

• Non Invasive• Non Invasive

• Small electrical charge– Tingling

• Unbroken skin needed

• Application to contoured skin difficult

J - TIP

• Needle free lidocaine by jet of compressed CO2

A th i i 1 3 i t• Anesthesia in 1-3 minutes

• Popping noise

• Can be prefilled or filled at facility

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J - TIP

http://www.jtip.com/injection_for_anesthesia.html

Injection Pain Management

• Warm Hands

• Warm Medication

• Buffer if needed• Buffer if needed

• Ask yourself if the medication

can be given any other way

Buzzy

• Decrease injection pain relief by use of vibration, cold and distraction

• See on YouTube and WebSee on YouTube and Web

• http://www.buzzy4shots.com/

• Data on effectiveness for IV starts >4

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Vapocoolant Pain Ease

• Ethyl vinyl chloride skin refrigerant

• Spray onto intact skin

• Lasts for up to one minute• Lasts for up to one minute

Opiates

• Mu Agonist (Morphine Like)– Morphine, Hydromorphone, Oxycodone, Fentanyl

N ili d (NSAIDS/APAP d !)No ceiling dose (NSAIDS/APAP do!)Do NOT cause end organ damage (NSAIDS/APAP do!)

Safe for childrenUtilize weight based dosingSmall frequent dosesPre printed orders for post op pain, sedation, PCA

Opiates

• Opiates safe for children

• Weight based dosing

• Utilize pre printed orders sedation PCA• Utilize pre printed orders sedation, PCA

• IV small frequent dose safest way

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Pediatric Morphine IVP Dose

• All <3 months .025 - 0.05 mg/kg

(start low 0.012 mg/kg titrate up)

• Infants/Children 0.1 - 0.2 mg/kg g g

(start low 0.05 mg/kg titrate up)

• You can always give more;

harder to suck it back out!

• IV peak 20 minutes, Duration 3-5 hoursPlease develop your own reference, recommendations vary

Morphine MaximumSingle Dose

–Neonate 0.1 mg/kg/dose

–Infants 2mg/dose

–Children 1-6 yr 4mg/doseChildren 1 6 yr 4mg/dose

–Children 7-12 yr 8mg/dose

–Adolescents 15mg/doseSTART LOW GO SLOW

YOU CAN ALWAYS GIVE MORE

HARD TO SUCK IT BACK OUT

Please develop your own reference, recommendations vary.

IV Acetaminophen

• Offirmev

• Mild to moderate pain or adjunct

• Generally post op• Generally post op

• > age 2

• 15 mg/kg over 15 minutes

• Don’t use if you wouldn’t use oral

• May mask fever

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May need sedation

• If you are giving a medication so you can do something (a procedure, a test, a treatment) to a child then thata treatment) to a child, then that medication is considered sedation and must be monitored as such.

Sedation for Procedures

Sedative hypnotic medication may be required to bring pain/stress levels under adequate control for many procedures.y p

Even those you may consider painless with the use of a topical or local anesthetic.

Sedation for Procedures

Current guidelines from AAP, ASA and ACEEP require structured evaluation of children’s risk before beginning sedation.

A critical component of any sedation protocol is a trained observer to be solely responsible for monitoring the patient while the procedure is being performed.

Physicians administering sedation and analgesia must have proven training and skills and ongoing training in the management of pediatric airways and resuscitation.

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Believe!

Infants and children feel at least as much pain as adults.

There are harmful effects, both physical and h l i l f li d ipsychological of unrelieved pain.

There are reasonable behavioral, non pharmacological and pharmacological solutions to pain management that every child deserves.

Be known for excellent pain management!

Questions?

Dedicated to Dr. Donna Wong (1948Dedicated to Dr. Donna Wong (1948--2008) 2008) for her devotion to assessment and for her devotion to assessment and Management of children's painManagement of children's painManagement of children s pain.Management of children s pain.

Contact me @Contact me @wmosiman@viawmosiman@via--christi.orgchristi.org

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