Paediatrics: Pain management

Pain management

Assessment

Always consider the possibility of a child being in pain, either as a result of their disease or the interventions that are required. Accurate assessment requires an age-appropriate validated pain assessment scale. Self-reporting is the ideal, but the child needs to be 3yrs old to be able to do this. Do not use pain scales validated for acute pain to assess chronic pain.

•   Self-report scales: usually involves the child pointing to a photograph of a child in pain (the Oucher) or a diagram of a child in pain (Bieri Faces Pain Scale or Wong–Baker Faces Pain Scale). The Oucher has been validated in children as young as 3yrs of age, whereas the Bieri Faces Pain Scale has only been validated in children aged 6yrs. The Wong–Baker Faces Pain Scale is more reliable in children aged 8–12yrs than in the 3–7-yr age group. The Adolescent Paediatric Pain Tool is for children between the ages of 8 and 17yrs.

•   Behavioural pain scales: rely on assessment of the child’s behaviour. Validated for children aged 1–5yrs. Examples include the Toddler— Preschooler Postoperative Pain Scale (TPPPS) and the CHEOPS. The FLACC has been validated for children aged 2 months–7 years.

•   Neonatal pain scales: examples include CRIES, NFCS, NIPS, and PIPP. These rely on behavioural observation and, in some, measurements of pulse, BP, and O₂ saturation. It is important to use one that has been validated for the gestation of the infant, e.g. is it valid only in full-term neonates?

Management

It is best to consider pain as being mild, moderate, or severe.

•   Mild pain: paracetamol is the safest analgesic available and is the first-line drug to be used for mild pain in all ages.

•   Moderate pain: children who are unresponsive (or unlikely to respond) to paracetamol should receive either a NSAID, such as ibuprofen or diclofenac. Alternatively, codeine or dihydrocodeine can be administered orally.

•   Severe pain: morphine is the drug of choice. It can be given IV (including patient-controlled analgesia (PCA)), intranasally, or orally.

Procedural pain: for certain painful procedures, e.g. dressing change in burns patients, it may be better to use inhaled entonox. This is an effective and safe analgesic with a short duration of action, which the child can control themselves