Pediatric Pain: Making Needles Hurt Less Needles Hurt Less because First Impressions are Lasting

Mary Walters, RN, CPN

Learning Objectives

1. Describe at least one developmental characteristic of a child’s response to pain in each age group.

2. List at least 2 medications used to reduce anxiety and pain during painful procedures such as IV starts in children.procedures such as IV starts in children.

3. Identify the mechanism of action for the use of sucrose before painful procedures in neonates and young infants.

Developmental Characteristics of Children’s Response to Pain

Young InfantsYoung InfantsYoung InfantsYoung Infants•Generalized body response of rigidity or thrashing

•Loud crying

•Facial expression of pain•Facial expression of pain

•Demonstrates no association between approaching stimulus and subsequent pain

Facial Expression of physical distress in infants

( Hockenberry, Wilson, & Winkelstein, Wong’s Essentials of Pediatric Nursing 7th

Edition, Elsevier Mosby 2005, page 643.)

Developmental Characteristics of Children’s Response to Pain

Older InfantsOlder InfantsOlder InfantsOlder Infants•Localized body response with deliberate withdrawal of stimulated area

•Loud crying•Loud crying

•Facial expression of pain and/or anger

•Physical resistance, especially pushing the stimulus away after it is applied

Developmental Characteristics of Children’s Response to Pain

Toddler/Preschool ageToddler/Preschool ageToddler/Preschool ageToddler/Preschool age•Loud crying, screaming.

•Verbal expressions of “Ow,”

“Ouch,” or “It hurts”.

•Thrashing of arms and legs.

•Attempts to push stimulus

away before it is applied.

Developmental Characteristics Cont.

School ageSchool ageSchool ageSchool age•May display all behaviors

of young child, especially

during painful procedure,

but less anticipatory

period.period.

•Stalling behavior, such as

“Wait a minute” or “I’m not

ready.”

•Muscular rigidity, such as

clenched fists, white

knuckles, gritted teeth,

contracted limbs, body

stiffness, closed eyes,

wrinkled forehead.

Developmental Characteristics Cont.

AdolescentsAdolescentsAdolescentsAdolescents•Less vocal protest.

•Less motor activity.

•More verbal expressions, such•More verbal expressions, such

as “It hurts” or “You’re hurting

me.”

•Increased muscle tension and

body control.

The Challenges of Pain Management

Challenges

Barriers to the treatment of pain in Barriers to the treatment of pain in Barriers to the treatment of pain in Barriers to the treatment of pain in childrenchildrenchildrenchildren•Myth that children do not feel pain the

way adults do .

-No consequences if they do.

•Lack of assessment and reassessment •Lack of assessment and reassessment

for the presence of pain.

•Misunderstanding of how to conceptualize

and quantify a subjective experience.

•Lack of knowledge of pain treatment.

•The notion that addressing the pain in

children takes too much time and effort.

•Fears of adverse effects of analgesic medication.

*Based on: AAP/APS. Pediatrics. 2001;108 (3):793-797.

Embracing What We Can Change

•Minimize patient/family anxiety

•Allow child a sense of control

•Promote coping skills during painful procedures

•Encourage the presence of family membersfamily members

•Provide patient-friendly environment

•Use available interventions

*Based on: AAP/APS. Pediatrics. 2001;108 (3):793-

797.

Guidelines Support a Multi-Modal Approach

AAP Committee on Pediatric Emergency AAP Committee on Pediatric Emergency AAP Committee on Pediatric Emergency AAP Committee on Pediatric Emergency MedicineMedicineMedicineMedicine

•Create a favorable environment for patients in the pediatric ED

•Incorporate child life specialists and others trained in non-pharmacologic stress reduction •Incorporate child life specialists and others trained in non-pharmacologic stress reduction

•Family presence should be offered during painful procedures

•Painless administration of anesthetics and analgesics should be practiced when possible

AAP=American Academy of Pediatrics; APS=American Pain Society1 AAP/APS. Pediatrics. 2001;108 (3):793-797.

2 Zempsky W, et ak. Pediatrics. 2004;114(5):1348-1356.

American Pain Society & American Academy of Pediatrics

APS/AAPAPS/AAPAPS/AAPAPS/AAP

•Use a multimodal approach to pain management

•Approach should be multidisciplinary

•Involve families and tailor interventions to individual childindividual child

•Provide a calm environment to procedures to reduce stress-producing stimulation

•Advocate for effective use of pain medication for children to ensure compassionate and competent pain management

More Helpful Tools

•Tootsweet

•Versed

•L.M.X./Emla

•Buffered Lidocaine•Buffered Lidocaine

•J-tip

Toot Sweet or Sweet-ease

Sucrose can be used for:Sucrose can be used for:Sucrose can be used for:Sucrose can be used for:•ShortShortShortShort----term procedural painterm procedural painterm procedural painterm procedural pain

•For babies younger than 6 monthsFor babies younger than 6 monthsFor babies younger than 6 monthsFor babies younger than 6 months

•Must have proper dosing Must have proper dosing Must have proper dosing Must have proper dosing

•Must be given 2 minutes prior to Must be given 2 minutes prior to Must be given 2 minutes prior to Must be given 2 minutes prior to •Must be given 2 minutes prior to Must be given 2 minutes prior to Must be given 2 minutes prior to Must be given 2 minutes prior to procedureprocedureprocedureprocedure

•Do not use more then 2 doses Do not use more then 2 doses Do not use more then 2 doses Do not use more then 2 doses

•Dose range is 0.1Dose range is 0.1Dose range is 0.1Dose range is 0.1----0.7 0.7 0.7 0.7 mlsmlsmlsmls

Versed (Midazolam)

Sedative and used for amnesia prior Sedative and used for amnesia prior Sedative and used for amnesia prior Sedative and used for amnesia prior to proceduresto proceduresto proceduresto proceduresIntranasal:Intranasal:Intranasal:Intranasal: 0.2mg/kg

Oral for infants 6 months and olderOral for infants 6 months and olderOral for infants 6 months and olderOral for infants 6 months and older: 0.25-0.5mg mg/kg0.5mg mg/kg

IV for infants 6 months to 5 yearsIV for infants 6 months to 5 yearsIV for infants 6 months to 5 yearsIV for infants 6 months to 5 years: 0.05-0.1mg/kg titrate carefully to total dose of 0.6mg/kg may be required

6 years to 12 years: 6 years to 12 years: 6 years to 12 years: 6 years to 12 years: 0.025mg -0.05mg/kg titrate to total dose of 0.4mg/kg(Taketomo, Hodding,& Kraus, Pediatric Dosage Handbook 15th edition, Lexi-Comp 2008-2009,page 1178-1181.)

EMLA

Cream: 5% eutectic mixture of Cream: 5% eutectic mixture of Cream: 5% eutectic mixture of Cream: 5% eutectic mixture of lidocainelidocainelidocainelidocaineand and and and prilocaineprilocaineprilocaineprilocaine (prescription only)(prescription only)(prescription only)(prescription only)1 1 1 1

IndicationIndicationIndicationIndicationNormal intact skin for local analgesia or genital mucus membranes for superficial minor surgery and as pretreatment for infiltration anesthesiainfiltration anesthesia

ApplicationApplicationApplicationApplication• Amount used depends on size of child

•Apply in thick layer at site of procedure

•Must be covered with an occlusive dressing

•At least 60 min prior to procedure/needle stick

•Wipe off prior to procedure

L.M.X.4

LidocaineLidocaineLidocaineLidocaine (4%) in a liposomal (4%) in a liposomal (4%) in a liposomal (4%) in a liposomal delivery system delivery system delivery system delivery system

Indication:•Minor cuts and abrasions

Application:Application:

*Do not clean site prior to application*Works best begin by rubbing a small

amount into the site for 30 seconds

*Occlusive dressing not required but can be used especially for children

*30 to 60 minute application time

Buffered Lidocaine

Indication for usage:Indication for usage:Indication for usage:Indication for usage:•Use 31 gauge needle

•For intradermal injection

•Create “wheel” at insertion site

Wait 1-2 minutes before •Wait 1-2 minutes before starting IV

J-TIP

Combination Therapy

• Use of Sucrose and Emla for small infants

•Use of LMX and Buffered Lidocaine

•Use of Midazolam and Clonodine

Keys to becoming a believer

•Raise the barRaise the barRaise the barRaise the bar

-Promote awareness of the need to address

pain associated with venous access

and other painful procedures

•Increase knowledge of entire staff by Increase knowledge of entire staff by Increase knowledge of entire staff by Increase knowledge of entire staff by

-Sharing data

-Developing guidelines

-Internal practices

-Utilize patient and family experiences

•Support staff buySupport staff buySupport staff buySupport staff buy----in to process changein to process changein to process changein to process change

-Communicate successes

-Involve key players in decision making

Finally……

“Advocate for the effective use

of pain medication for children to children to

ensure compassionate and competent management of

their pain.”

---- AAP/APS Guidelines 2001