Chapter

Pain Management in Children

39
K E Y T E R M S Robin Harvey is a

• acute pain • pain threshold 3-year-old girl who

• conscious sedation • pain tolerance was admitted to your
• chronic pain • patient-controlled analgesia
• cutaneous pain • referred pain hospital unit and has
• distraction • somatic pain just returned from a bone marrow
• epidural analgesia • substitution of meaning
aspiration to rule out the possibility of
• gate control theory • thought stopping
• nociceptors • transcutaneous electrical nerve stimulation leukemia. Robin received intravenous
• pain • visceral pain
morphine sulfate during the procedure.
Her mother asks you if Robin could
O B J E C T I V E S
have some more. “I know she’s not
After mastering the contents of this chapter, you should be able to:
having pain yet,” her mother tells you,
1. Describe the major methods and techniques of pain management
for children. “but I want her to have something
2. Identify National Health Goals related to pain management in chil-
before the pain comes back.”
dren that nurses can help the nation achieve.
3. Use critical thinking to analyze ways nursing care for a child in pain Previous chapters described the
could be more family centered. growth and development of children
4. Assess a child regarding whether pain management is needed or
adequate. and general care of ill children. This
5. Formulate nursing diagnoses for a child in pain. chapter adds information about care of
6. Identify expected outcomes for a child in pain.
7. Plan nursing care for a child in pain. children when they need pain manage-
8. Implement nursing care related to a child in pain such as suggest- ment. Such information builds a base
ing an alternative therapy.
9. Evaluate outcomes for achievement and effectiveness of care of a for care and health teaching in a cru-
child in pain. cial area.
10. Identify areas related to care of children in pain that could benefit
from additional nursing research or application of evidence-based
practice. Is this mother’s assessment or Robin’s
11. Integrate knowledge of pain in children with nursing process to
assessment of her pain apt to be most
achieve quality maternal and child health nursing care.
accurate? Would anticipating pain in this
way be the best intervention for Robin?

1116

Pain is a difficult concept to define because it is experi-
enced uniquely. It is important to remember that it is sub-
jective (experienced by the person), not objective (able to be
determined by observation). McCaffery’s classic description
of pain (Pasero & McCaffery, 2004) is the one most useful
with children: “The sensation of pain is whatever the person
experiencing it says it is, and it exists whenever the person
says it does.”
For children, pain is not only a hurting sensation, but it
can also be a confusing one because a child did not anticipate
the pain, does not have words to explain how it feels, and
cannot always understand its cause. In addition, preschoolers
and younger children lack an understanding of time, which
makes it difficult to explain when the pain will go away.
Children may feel frustrated or angry because no one can
prevent their hurt or give them relief. Because children may
have difficulty describing pain in a manner adults can un-
derstand, it is difficult to assess the extent of their discom-
fort. Because pain is an individualized sensation, it may be
experienced and expressed differently by different children.
In some families, for example, pain may be expressed very
openly and freely. In others, children are expected to be stoic
about pain. Because the expression of pain is culturally de-
termined this way, two children who have the same degree of
pain may express it very differently (Eccleston et al., 2009).
Additionally, children’s perception of the situation in-
fluences their response to the situation, independent of the
BOX 39.1 ✽ Focus on National
Health Goals
Although National Health Goals do not speak directly to
alleviating pain in children, many of the goals speak to
reducing unintentional accidents, which are a major
source of pain in children. Some of these objectives are:
• Increase the rate of use for automobile safety belts
and infant safety seats to 100% for children under
age 4 from a baseline of 92%.
• Increase the rate of helmet use to at least 79% of mo-
torcyclists from a baseline of 67%.
• Increase the number of states with laws requiring bi-
cycle helmets for riders under the age of 15 from a
baseline of 10 states to all states.
• Increase the presence of functional smoke detectors
to 100% of all inhabited residential dwellings from a
baseline of 88%.
• Reduce the rate of hospital emergency department
visits for nonfatal dog bite injuries to 114 per 100,000
of the population from a baseline of 151 per 100,000
(http://www.nih.gov).
Nurses can be help the nation to reduce pain among
children by teaching about the importance of using
safety belts and bicycle helmets. As primary care
providers, they can lead the effort to be certain that chil-
dren and parents receive counseling on safety precau-
tions. Additional nursing research that is needed in the
area of pain relief concerns identifying the best way for
children to rate pain and the nonpharmacologic mea-
sures that work best with different age groups.
CHAPTER 39 Pain Management in Children 1117
intensity of the pain. This means that children experiencing
procedures that are less intrusive but who are feeling maxi-
mum anxiety may describe the degree of pain felt as more
intense than they otherwise might, because of the
accompanying anxiety.
Both helping children describe the type and extent of pain
they are feeling and performing active interventions to relieve
pain are important nursing roles. Assessing for pain is so im-
portant that pain can be considered the “fifth vital sign.”
National Health Goals do not address pain relief in chil-
dren directly, but they do address the reduction of accidental
injury, which is a major source of pain in children. These
goals are shown in Box 39.1.
Nursing Process Overview
For a Child in Pain
Assessment
Children, like adults, experience pain differently depend-
ing on the type and cause of the pain, their temperament,
their previous experience with pain, and their expectation
of relief. Infants and young children cannot verbalize
what they are feeling so have the most trouble communi-
cating how they feel.
Beginning with preschool age, children can indicate
where they feel pain and can learn to express the degree
of pain through a system such as comparing it to a num-
ber of poker chips or drawings of faces. Older school-age
children and adolescents can be asked to rate their pain
on a scale of 1 to 10. Be aware that children may be re-
luctant to admit pain because they are trying to be brave.
Some may be reluctant to say they have pain because
they are afraid they will receive a “shot” to relieve it, and
that will cause more pain. As a rule, including assess-
ment of pain level along with vital sign measurement is
an efficient way to ensure that pain is assessed. Be alert
that this is only the first step in pain management,
though. If children have pain, they need some interven-
tion as a second step to relieve it. Let children know that
admitting to having pain is necessary for them to obtain
adequate relief.
Parents often are unclear what role they should assume
in pain management. Frequently parents believe nurses
and doctors are the experts and so will automatically treat
their child’s pain. Nurses, on the other hand, may assume
that parents will speak up if their child is in pain. How
pain will be assessed, the parents’ role, and what is avail-
able for pain relief should be discussed clearly and openly
so these misunderstandings do not occur. Be certain that
you also reassess pain to be certain that interventions such
as administration of an analgesic or distraction or im-
proved positioning were effective.
Nursing Diagnosis
Nursing diagnoses for children with pain focus not only
on the pain but also on the stress, fear, or anxiety that pain
produces. Examples of nursing diagnoses are:
• Pain related to frequent invasive procedures
• Fear related to anticipation of painful procedures
1118 UNIT 6 The Nursing Role in Supporting the Health of Ill Children and Their Families
• Disturbed sleep pattern related to chronic pain
• Anxiety related to planned dressing changes that
cause pain
Outcome Identification and Planning
The mark of efficient pain control is to anticipate when
pain will occur and plan interventions to prevent it rather
than let it occur and then relieve it. Three common rea-
sons why nurses may not provide adequate pain relief to
children are a belief that infants and young children do
not experience pain, a fear that children will become ad-
dicted to pain relief medications, and a fear of causing res-
piratory depression from analgesics. Infants and young
children do experience pain, and there is no confirmation
that children receiving narcotics during a short hospital
stay will become addicted to pain medication or that opi-
ates cause greater respiratory depression in children than
in adults. Although the use of opiates can lead to depen-
dency, this is very different from addiction and can be ad-
dressed with a weaning regimen if needed. The American
Academy of Pediatrics’ pain management suggestions are
available at http://www.aap.org/.
Implementation
Implementation for pain relief includes choosing the spe-
cific method of pain relief best for each child. All persons
involved in a child’s care need to be aware of the signs and
symptoms an individual child uses to express pain and
specific ways that will help the child manage pain. If chil-
dren are reluctant to admit they have pain because of the
fear of receiving an injection, advocate for an oral form of
analgesia or an intermittent intravenous (IV) infusion de-
vice or patient-controlled analgesia (PCA) as appropriate
options. Many parents are unsure about the safety of
using strong analgesics for pain relief so often give less
than the prescribed dose. Therefore, educating parents
about the need for pain relief, proper doses, and taking ac-
tions to involve them in the assessment and evaluation
process are essential. Planning and assisting with comple-
mentary therapies is yet another area to consider.
Outcome Evaluation
Evaluation of expected outcomes is a key aspect of manag-
ing pain because no one pain relief measure is effective for
everyone. After a child is given an analgesic, look for non-
verbal clues, assess vital signs, and listen to the child’s state-
ments about pain to determine whether a drug was effective.
Based on these findings, it may become clear that the tech-
nique of pain management being used may need to be mod-
ified or increased. A new technique may need to be added to
the regimen so a child receives maximum pain relief.
Possible examples indicating achievement of expected
outcomes are:
• Child states pain is now at a tolerable level.
• Adolescent says she has managed her fear through
imagery.
• Child rates pain as no greater than 2 on a 1-to-10
scale.
• Child describes ways he will help reduce pain when it
returns.
• Child resumes age-appropriate behaviors following
analgesia administration. ❧ mission of pain and how pain can best be managed. Of these,
PHYSIOLOGY OF PAIN
As in adults, pain in children occurs for one of four reasons:
reduced oxygen in tissues from impaired circulation, pressure
on tissue, external injury, or overstretching of body cavities
with fluid or air. The stimuli causing pain are not always vis-
ible or measurable. In addition, anxiety can lead to increased
pain regardless of the physical stimuli.
Pain conduction consists of four major steps: transduction
(sensing the pain sensation), transmission (routing the pain
sensation to the spinal cord), perception (the brain interprets
the sensation as pain), and modulation (steps taken to relive
pain).
Transduction begins in the peripheral nerves when a me-
chanical, thermal, or chemical stimulus activates nociceptors,
a specialized group of sensory receptors. Several neurotrans-
mitters (e.g., substance P) are also stimulated and involved in
conducting pain. Sharp pain impulses are conducted by both
A-alpha and A-beta fibers (large fibers that are myelinated and
conduct the response at a rapid rate). Light pressure and vi-
bration are conducted by A-delta fibers, fibers that are smaller
and conduct at a slower rate. C fibers are smaller yet and con-
duct at an even slower rate.
Pain impulses join central nervous system (CNS) fibers in
the dorsal horn of the spinal cord. Here the impulses are
projected upward to the brain, where they will be perceived
as pain.
• Acute pain is sharp pain. It generally occurs abruptly after
an injury. Paper cuts are examples of lacerations that cause
acute pain.
• Chronic pain is pain that lasts for a prolonged period
(often defined as 6 months). Acute pain usually causes ex-
treme distress and anxiety; chronic pain can lead to de-
pression and less ability to achieve (Eccleston et al., 2009).
• Cutaneous pain is pain that arises from superficial struc-
tures such as the skin and mucous membrane. A paper cut
is an example.
• Somatic pain is pain that originates from deep body
structures such as muscles or blood vessels. The pain of a
sprained ankle is somatic pain.
• Visceral pain involves sensations that arise from internal
organs such as the intestines. The pain of appendicitis is
visceral pain.
• Referred pain is pain that is perceived at a site distant
from its point of origin. Right lower lobe pneumonia, for
example, is often first thought to be abdominal pain be-
cause the pain of this is referred to the abdomen.
A child’s pain threshold refers to the point at which the
child first feels pain. This varies greatly from person to person
and is probably most influenced by heredity. All people also
have a point above which they are not willing to bear any ad-
ditional pain. This is a person’s pain tolerance. Pain tolerance
levels are probably most affected by cultural influences.
When pain is felt the pituitary and hypothalamus glands
attempt to modify pain by releasing endorphins or polypep-
tide compounds that simulate opiates in their ability to pro-
duce analgesia and a sense of well-being. Children also mod-
ify pain by physical actions such as shifting position or
rubbing the body part.
Several theories have been proposed to explain the trans-
the gate control theory is the best known.

Gate Control Theory of Pain
The gate control theory of pain (Melzack & Wall, 1965) at-
tempts to explain how pain impulses travel from a site of in-
jury to the brain, where the impulse is actually registered as
pain. This theory envisions gating mechanisms in the sub-
stantia gelatinosa of the dorsal horn of the spinal cord that,
when activated, can halt an impulse at that level of the cord.
This prevents the pain impulse from being received at the
brain level and interpreted as pain. Gating mechanisms can
be stimulated by three techniques: cutaneous stimulation,
distraction, and anxiety reduction.
Cutaneous stimulation has an effect because when the
peripheral nerves next to an injury site are stimulated, the
ability of the A-delta or C-fiber nerves at the injury site to
transmit pain impulses appears to decrease. Rubbing an
injured part such as a stubbed toe and applying heat or cold
to the site are effective maneuvers to suppress pain because
they activate these nearby fibers. This technique is especially
effective with children because the rubbing is not only com-
forting from a physical standpoint but also conveys psycho-
logical warmth.
Distraction allows the cells of the brainstem that register
an impulse as pain to be preoccupied with other stimuli so a
pain impulse cannot register. Having a child focus on an ac-
tion or a thought is a common form of distraction. Telling a
child to say “ouch” while an injection is administered is the
simplest use of this technique.
Pain impulses are perceived more quickly by the brain if
anxiety is also present. Therefore, attempts to reduce a child’s
anxiety as much as possible can help reduce the feeling of
pain. Teaching a school-age child about what to expect with
a procedure is the kind of technique that does this. As well as
knowing when something is going to happen, children also
should know when nothing is going to happen. Being told
that a clinic visit will not involve painful procedures allows a
child to relax and feel less anxiety.
The effectiveness of gate control theory techniques varies
with a child’s age, ability to cooperate, degree of pain, and
time allowed for learning and applying the techniques.
Because memory may influence the sensation of pain (ex-
pecting to have pain produces anxiety, which increases pain),
these techniques are best taught to children before they begin
to have pain. In all instances, children should know to use
them just before or at the moment they first feel the pain. If
they wait until pain is intense, the pain may be so distracting
they cannot concentrate on using a technique. Children who
were able to use a distraction technique in the past but can
no longer do so need to be evaluated for what is changing. Is
it their ability to cope with the pain, or is the pain increasing
in intensity? Contrary to common belief, familiarity with di-
agnostic or therapeutic procedures does not necessarily lessen
either the fear or the pain experienced.
ASSESSING TYPE AND DEGREE OF PAIN
Pain assessment is difficult with children, not only because
children have difficulty describing pain but also because
some children will suffer with pain rather than report it, un-
aware that someone could make it go away. Other children
may distract themselves by methods such as concentrating on
play. Some children may sleep, not from comfort but from
CHAPTER 39 Pain Management in Children 1119
Box 39.2 Assessment
Assessing a Child With Pain
Restless, irritable
Crying
Grimacing
Gritting of teeth
Screaming
Verbal expression of hurt
Touching or grabbing
painful part of body
Clenched fists
Kicking, thrashing
Attempting to push
away stimulus
the exhaustion caused by pain. Cultural differences also in-
fluence how pain is expressed (Box 39.2). All of these things
can make using only subjective measures, such as observa-
tion, to assess pain misleading.
Pain assessment in children is also difficult because tech-
niques vary widely from assessment of a nonverbal infant to
an older adolescent. Keep in mind a child’s developmental
level as well as chronological age when assessing for pain.
The Infant
In the past, it was believed that infants do not feel pain be-
cause of incomplete myelinization of peripheral nerves. This
is no longer believed to be true, because myelinization is not
necessary for pain perception.
A second argument against needing to provide pain relief
to infants was that they have no memory. It can be shown,
however, that physiologic changes occur with pain even in
premature infants, so even with a lack of memory, it is clear
pain is experienced. In all ages, pain has been shown to have
the potential for serious physical harm. Because they are pre-
verbal, observing for cues such as diffuse body movement;
tears; a high-pitched, sharp, harsh cry; stiff posture; lack of
play; and fisting are all cues to reveal discomfort (American
Academy of Pediatrics [AAP], 2007). Even newborns in-
stinctively guard a body part by holding an extremity still or
tensing the abdomen. Perhaps the chief mark of pain in in-
fants is that when pain is present, they cannot be comforted
completely. Preterm neonates may have a particularly
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1120 UNIT 6 The Nursing Role in Supporting the Health of Ill Children and Their Families
difficult time organizing a distress response to cue a health care
provider to the presence of pain. When working with infants
of this age, be sensitive to situations that could cause pain and
reduce them to the maximum extent possible. Be alert for sub-
tle alterations in facial expression, such as eyes squeezed shut or
a quivering chin, that might be a signal of pain.
The Toddler and Preschooler
Determining when and how much pain is present continues
to be difficult with toddlers and preschoolers because they
may not have a word in their limited vocabularies to describe
the sensation they feel (Box 39.3). Parents may have encour-
aged children this age to refer to pain as “my boo-boo” or
some other word instead of “pain.” They may have difficulty
comparing the pain they feel now to past pain (is it better or
worse?) because they have had little experience with past
pain. Words such as “sharp,” “nagging,” or “aching” have no
meaning in relation to pain until a child has experienced each
type. To assess such a child’s pain accurately, use the child’s
term or teach the child that “pain” is the same as “boo-boo.”
For some toddlers, pain is such a strange sensation that, aside
from crying in response to it, they may react aggressively
(pounding and rocking) as if to fight it off. They also may
avoid being touched or held.
BOX 39.3 ✽ Focus on Communication
Robin, 3 years old, has just returned from surgery. You
want to assess her level of pain.
Less Effective Communication
Nurse: Robin? How are you feeling?
Mrs. Harvey: I don’t think she hurts yet.
Nurse: I’m going to show you some faces, Robin. Just
point to the one that looks the way you feel. If you
point to a sad one, I’ll get you a shot to take away
your pain.
Robin: (Points to the first face—the “no pain” face.)
Nurse: No pain? Good. That’s probably because your
anesthetic is still working.
More Effective Communication
Nurse: Robin? How are you feeling?
Mrs. Harvey: I don’t think she hurts yet.
Nurse: Robin? Remember the faces we looked at this
morning before surgery? I want you to use them to
tell me how you feel. This one means “no hurt.” This
one means “the most hurt you could have.” Point to
the one that shows how much hurt you have.
Robin: (Points to the middle face—the “hurts even
more” face.)
It is important when using pain rating scales to intro-
duce them to children before surgery or before they
have pain from procedures, so that both the pain and
the rating tool are not new to the child all at once. It is
important also to give the correct instructions for stan-
dardized assessment tools, or the results will not be ac-
curate. Mentioning a “shot for pain” can cause children
not to report pain because they imagine the injection will
cause even more pain, rather than relieve it.
Preschool children can describe they have pain but con-
tinue to have difficulty describing its intensity. They begin to
use comforting mechanisms, such as gritting teeth, pressing a
hand against a forehead, pulling on their ear, holding their
throat, rubbing an arm, or grimacing, to control or express
pain. Some preschoolers do not think to mention they have
pain because they believe it is something to be expected or, be-
cause of their egocentric thinking, they assume adults are al-
ready aware of their pain. They may think pain is punishment
for some act, so this is what they deserve. It is sometimes diffi-
cult to comfort children this age during painful procedures be-
cause they do not yet have a perception of time. Soothing
statements such as, “It’s only for a minute” are not comforting
to the preschooler who does not know how long that is.
For all young children who cannot fully verbalize their
pain state, carefully examine their behavior. In addition to
behaviors already discussed, young children may regress or
become very withdrawn when in pain. Ask yourself, “What
would this child normally be doing (for example, playing,
eating, sleeping)?” Deviations from usual behavior may, in
the absence of any other verbal description, be signs a child
is in pain. Input from parents on how their child usually be-
haves can be valuable in evaluation. Keep in mind that any
procedure or condition that would normally cause pain in an
adult will cause pain in a child. In a nonverbal child, a trial
dose of analgesia may be used. You can then evaluate behav-
ior changes after the dose is given. Children who resume
their usual behavior after analgesia were probably in pain be-
fore the analgesia took effect.
The School-Age Child and Adolescent
Children who think concretely (preadolescents) can have dif-
ficulty envisioning that a word like “sharp” applies both to
knives and to the feeling in their abdomen. Because of this,
they continue to have difficulty describing pain. They may
also assume that you, as an authority figure, already know
they have pain (Schiavenato, 2008).
Some children of school age will regress with pain such as
baby-talk or lying in a fetal position. Children this age can
understand that if pain will last only an instant, such as with
an injection, it can be controlled through nonpharmacologic
activities such as distraction techniques.
Children may be in middle school before they can under-
stand how to use a numerical pain rating scale or that the
scale intensifies from left to right. Doing some preassessment
work with them, such as giving them 10 different-sized tri-
angles and asking them to arrange them from smallest to
largest, is a good way to evaluate if they understand incre-
mental measurements. The child who can arrange triangles
this way understands the concept of least to most. Once chil-
dren have grasped this concept, they can describe pain inten-
sity in a very measurable way. A scale of 1 to 5 can be used
in younger children if 1 to 10 seems overwhelming. Yet an-
other technique is to turn the scale vertically so it measures
bottom (little pain) to top (a lot of pain).
Adolescents commonly use adult mechanisms for control-
ling pain. Some are even more stoic in the face of pain than
adults, trying to avoid stereotypes of “crybaby” or “chicken.”
This tendency makes assessment for body motions that could
indicate pain, such as clenched hands, clenched teeth, rapid
breathing, and guarding of body parts, not as helpful as it
may be in adults.

PAIN ASSESSMENT
Common fallacies about pain in children are shown in Table
39.1. The techniques to assess pain must vary depending on
the age of the child and the type and extent of pain. Although
monitoring for physiologic findings such as a change in pulse
or blood pressure may give some indication that a child is
under stress, these are not the most dependable indicators of
pain. Because pain is a subjective finding, once children can
speak, asking them to tell you about their pain (self-report-
ing on a pain rating scale) is the most accurate method for
assessment.
A variety of pain rating scales have been devised for use
with children. None has been proven to be consistently bet-
ter than the others, mainly because both children and the
type of pain they can be experiencing vary so much. As a rule,
pick a well-documented effective scale and use that consis-
tently for a child rather than asking a child to adapt to dif-
ferent assessment techniques. Be sure to follow the specific
instructions for that scale.
Pain Experience Inventory
The Pain Experience Inventory is a tool consisting of eight
questions for children and eight questions for the child’s par-
ents. It is designed to elicit the terms a child uses to denote
pain and what actions a child thinks will best alleviate the
pain. Such a form can be used when a child is admitted to an
acute care facility or on an initial home care visit (Box 39.4).
If possible, it should be used before the child has pain.
CRIES Neonatal Postoperative Pain
Measurement Scale
The CRIES inventory is a 10-point scale on which five phys-
iologic and behavioral variables frequently associated with
neonatal pain can be assessed and rated (Krechel & Bildner,
1995):
• Amount and type of crying
• Need for oxygen administration
• Increased vital signs
TABLE 39.1 ✽ Common Fallacies About Pain in Children
Fallacy
Nurses can accurately estimate children’s pain from
physical appearance or activity.
Young children, particularly newborns, do not feel pain.
A child who resumes usual activity or sleeps cannot be
in pain.
Because of the possible adverse effects, narcotic.
analgesics are too dangerous for young children.
Experiencing pain will not harm an infant or young child.
If children deny they are feeling pain, you should believe
them.
CHAPTER 39 Pain Management in Children 1121
BOX 39.4 ✽ Pain Experience Inventory
Questions for Child
Tell me what pain is.
Tell me about the hurt you have had before.
What do you do when you hurt?
Do you tell others when you hurt?
What do you want others to do for you when you
hurt?
What do you not want others to do for you when
you hurt?
What helps the most to take away your hurt?
Is there anything special that you would like me to
know about you when you hurt? (If yes, have
child describe.)
Questions for Parents
Describe any pain your child has had before.
How does your child usually react to pain?
Does your child tell you or others when pain is ex-
perienced?
How do you know when your child is in pain?
What do you do for your child when your child is
hurting?
What does your child do to help relieve pain?
Which of these actions work best to decrease or
take away your child’s pain?
Is there anything special that you would like me to
know about your child and pain? (If yes, have
parents describe.) (Hester & Barcus, 1986.)
• Facial expression
• Sleeplessness
Each area is scored from 0 to 2, and then a total score is
obtained (Table 39.2). On the scale, infants with a score of 4
or more are most likely to be in pain and need interventions
to reduce discomfort. The scale cannot be used with infants
Fact
Nurses commonly underestimate children’s pain when
they do not rely on children’s self-reports.
Newborns and children do feel pain.
Some children distract themselves with play or music
while in pain. They may sleep from exhaustion from
the pain.
Narcotics can be used safely with children, including low-
birth-weight infants.
Newborns with pain can become cyanotic and
bradycardic; no one knows the psychological stress of
pain at this age.
Children may deny pain to avoid a procedure, such as an
injection, which they view as more painful. They may
be afraid, fearing that they are being punished, or
believe others know how they feel.
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1122 UNIT 6 The Nursing Role in Supporting the Health of Ill Children and Their Families

TABLE 39.2 ✽ CRIES Neonatal Postoperative Pain Measurement Scale

Infant’s Score
Assessment 0 1 2
Crying No High-pitched Inconsolable
Oxygen required for saturation No ⬎30% ⬎30%
above 95%
Increased vital signs Heart rate and blood Heart rate or blood pressure Heart rate or blood
pressure within 10% of 11–20% higher than pressure 21% or
preoperative values preoperative value more above
preoperative value

Expression None Grimace Grimace/grunt

Sleepless No Waking at frequent intervals Constantly awake
Total infant score

Source: Krechel, S. W., & Bildner, J. (1995). CRIES: A new neonatal postoperative pain management score. Pediatric
Anesthesia, 5(1), 53.

who are intubated or paralyzed for ventilatory assistance be-
cause they would have no score for cry, and because their faces
are obscured, it is difficult to rate them for facial expression.
The COMFORT Behavior Scale
The COMFORT behavior scale is a pain rating scale devised
by nurses to rate pain in very young infants (van Dijk et al.,
2005). On the first part of the scale, six different categories
(alertness, calmness/agitation, crying, physical movement,
muscle tone, and facial expression) are rated from 1 to 5. Six is
the lowest score (no pain), and 30 is the highest (a great deal
of pain). In addition to rating physical parameters, the infant
is then observed for 2 minutes and the evaluation of the baby’s
pain is documented on an analogue (1-to-10) visual scale.
FLACC Pain Assessment Tool
The FLACC Pain Assessment Tool (Merkel et al., 1997) is a
scale by which health care providers can rate a child’s pain
when a child cannot give input, such as during circumcision
(Brady-Fryer, Wiebe, & Lander, 2009). It incorporates five
types of behaviors that can be used to rate pain: facial ex-
pression, leg movement, activity, cry, and consolability. Data
indicate the scale is reliable and valid. Because a child does
not provide active input, an older child may experience a loss
of the self-control that can come from active participation by
using this scale.
pieces of hurt do you have right now?” Children without
pain will reply they don’t hurt; others will point to one of the
poker chips. To gain more understanding of how much pain
the child is feeling, clarify the child’s answer by a follow-up
question such as, “Oh, you have a little hurt? Tell me about
the hurt.” This is an effective tool for young children because
the poker chips are concrete items and children are concrete
thinkers (Fig. 39.1).
FACES Pain Rating Scale
This scale consists of six cartoon-like faces ranging from smil-
ing to tearful (Fig. 39.2). Explain to the child that each face
from left to right corresponds to a person who has no hurt up
to a lot of hurt (Wong & Baker, 1996). Use the words under
each face to describe the amount of pain the face represents.
Next, ask the child to choose the face that best describes the
child’s pain and record the number under the face the child
chooses. Children as young as 3 years can effectively use this
scale. The scale appeals to health care providers because it is
cute; however, because it is not as concrete a measure as the

Poker Chip Tool

The Poker Chip Tool (Hester & Barcus, 1986) uses four red
poker chips placed in a horizontal line in front of the child.
The technique can be used with children as young as 4 years
of age, provided the child can count or has some concept of
numbers. To use the tool, tell the child, “These are pieces of
hurt.” Beginning at the chip nearest the child’s left hand and
ending at the one nearest the child’s right hand, point to the
chips and say, “This is a little bit of hurt, this is a little more FIGURE 39.1 Use a pain rating tool to assess children’s pain.
hurt, this is more hurt, and this [the fourth chip] is the most Here, a child points to the poker chip indicating the degree of
hurt you could ever have.” Then ask the child, “How many pain she is experiencing.
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CHAPTER 39 Pain Management in Children 1123

FIGURE 39.2 The FACES pain rat-

ing scale. (From Whaley and Wong’s
essentials of pediatric nursing [5th
0 1 2 3 4 5 ed., p. 1216] [1997]. Copyright by
No Hurt Hurts Hurts Hurts Hurts Hurts Mosby–Year Book, Inc. Reprinted by
Little Bit Little More Even More Whole Lot Worst permission.)

Poker Chip Tool, it, therefore, may not be as effective with activity, tell children to point to or circle as many words as
all children. possible on the form that describe their pain (words such as
horrible, pounding, cutting, and stinging). The scale is
Oucher Pain Rating Scale suggested for use in children 8 through 17 years. As many
children below this level need so much help reading and in-
The Oucher (Beyer, Denyes, & Villarruel, 1992) scale con- terpreting the multitude of words that describe pain it makes
sists of six photographs of children’s faces representing “no the form impractical below this age. This is a useful tool for
hurt” to “biggest hurt you could ever have.” Also included is involving parents to talk with their child about pain. Reading
a vertical scale with numbers from 0 to 100. To use the pho- the words together helps children examine the type, location,
tograph portion, point to each photograph and explain what and level of pain they are experiencing. It also helps parents
each photo represents. Ask the child to point to the photo to better understand what their child is experiencing.
that best represents the child’s degree of hurt.
To use the numbered scale portion, point to each section of Logs and Diaries
the scale and explain 0 means “no hurt”; 1 to 29 means “a lit-
tle hurt”; 30 to 69 means “middle hurt”; 70 to 99 means “big Having children keep logs or diaries in which they note when
hurt”; and 100 means “the biggest hurt you could ever have.” pain occurs and then rate the pain each time it occurs is use-
Ask the child to point to the section of the scale that represents ful for assessing children with chronic but intermittent pain.
the present level of hurt. Children as young as 3 can use the Examining such a diary can not only reveal when pain occurs
tool by pointing to the photograph that best describes their but also provide direction for pain management. For exam-
level of pain. If the child can count to 100 by ones and under- ple, if the diary shows the child always awakens with pain in
stands the concept of increasing value, the numbered scale can the morning, the child may need a longer-acting analgesic to
be used. The Oucher scale has white, African American, and take at bedtime; if pain is worse during weekends spent at a
Hispanic American photograph versions. Allow children to se-
lect the version they want to use or present the version that
most closely matches the cultural characteristics of the child.
Simple Descriptive Pain Intensity Scale*
Numerical or Visual Analog Scale
A numerical or visual analog scale (Fig. 39.3) uses a line with
end points marked “0 ⫽ no pain” on the left and “10 ⫽
No Mild Moderate Severe Very Worst
worst pain” on the right. Divisions along the line are marked
pain pain pain pain severe possible
in units from 1 to 9. Explain to children that the left end of pain pain
the line (the 0) means a person feels no pain. At the other end
is a 10, which means a person feels the worst pain possible. 0 – 10 Numeric Pain Intensity Scale*
The numbers 1 to 9 in the middle are for “a little pain” to “a
lot of pain.” Ask children to choose a number that best
describes their pain. As soon as they can count and have a
concept of numbers, children can use a numerical scale. Be
0 1 2 3 4 5 6 7 8 9 10
certain to show school-age children the scale; do not just say
No Moderate Worst
score your pain from 0 to 10. Until children reach late ado- pain pain possible
lescence, they use concrete thought processes so need the pain
help of seeing the line to rate their pain accurately.
Visual Analog Scale (VAS)**

Adolescent Pediatric Pain Tool

The Adolescent Pediatric Pain Tool (APPT) combines a vi- No Pain as bad
sual activity and a numerical scale (Savedra et al., 1992). On pain as it could
one half of the form (Fig. 39.4) is an outline figure showing possibly be
the anterior and posterior view of a child. To use the tool, tell
a child to color in the figure drawing where pain is felt. In ad- * If used as a graphic rating scale, a 10-cm baseline
dition, on the right side of the form, tell the child to rate is recommended.
present pain in reference to “no pain,” “little pain,” “medium ** A 10-cm baseline is recommended for VAS scales.
pain,” “large pain,” and “worst possible pain.” For a third FIGURE 39.3 Numerical and visual analog scales.
1124 UNIT 6 The Nursing Role in Supporting the Health of Ill Children and Their Families

2. Place a straight, up and down mark on this line to show

how much pain you have.
CODE

DATE No Little Medium Large Worst

pain pain pain pain possible
pain

3. Point to or circle as many of these words that describe

Adolescent and Pediatric Pain Tool (APPT) your pain
1 5 10 15
1. INSTRUCTIONS off and on
annoying blistering awful
Color in the areas on these drawings to show where you bad burning deadly once in a while
have pain. Make the marks as big or as small as the place horrible hot dying sneaks up
where the pain is. miserable 6 killing sometimes
terrible cramping 11 steady
uncomfortable crushing crying
2 like a pinch frightening If you like
Right Left Left Right aching pinching screaming you may add
hurting pressure terrifying other words:
like an ache 7 12
like a hurt itching dizzy
sore like a scratch sickening
3 like a sting suffocating
beating scratching 13
hitting stinging never goes away
pounding 8 uncontrollable
punching shocking 14
throbbing shooting always For office use only
4 splitting comes and goes
biting 9 comes on all of BSA:
cutting numb a sudden IS:
like a pin stiff constant
continuous
#S (2-9) /37= %
like a sharp knife swollen
pin like tight forever #A (10-12) /11= %
sharp
#E (1,13) /8= %
stabbing
#T (14,15) /11= %

Total /67= %

FIGURE 39.4 Adolescent Pediatric Pain Tool (APPT). (From Savedra, M. C., Tesler, M. D., Holzemer, W. L., et al. [1992].
Adolescent pediatric pain tool: user’s manual. San Francisco: University of California–San Francisco.)

grandparent’s house, investigate whether something different
is happening in that setting than at home that is causing
increased pain.
What if... Robin completely colored in the figure on an
Adolescent Pediatric Pain Tool to show where she has
pain? Would you assess she has pain all over?
PAIN MANAGEMENT
Pain management techniques, like assessment techniques,
vary greatly depending on the age of a child and the degree
and type of pain a child is experiencing. Many health care
agencies employ nurses specially prepared in pain manage-
ment to serve on an interdisciplinary team of health care
providers, including physicians, anesthesiologists, patient ad-
vocates, and wound therapy nurses, to plan individual pain
management programs for children (Box 39.5).
Children with chronic pain or pain not relieved with stan-
dard approaches may benefit from a referral to a pain man-
agement specialist or team. Relief of frequent pain episodes
or prolonged pain may require intense, consistent assessment
and intervention, which is difficult to achieve in an acute care
setting or during infrequent office visits. Whatever assess-
ment tools or methods of pain relief are used, staff should be-
come familiar and comfortable with their use. It is important
that pain be assessed in an organized and consistent manner
so relief and interventions do not vary based on the health
care provider.
In the past, children frequently were not prescribed po-
tent analgesics because of the fear that the drugs commonly
used, such as morphine, would decrease their respiratory
rate to an unsafe level. Children who had adequate analge-
sia prescribed may not have received it because a nurse was
overly concerned about causing respiratory distress. Today,
it is recognized that if the dosage of an opiate such as mor-
phine is based on the child’s size, there is no more danger
of respiratory depression in children than in adults.
Therefore, after checking that the correct dosage has been

BOX 39.5 ✽ Focus on Evidence-
Based Practice
Can nurses be instrumental in teaching other health
care providers about pain management?
Pain management programs work best if all health care
providers are aware of both assessment and manage-
ment aspects of the program. To see if pain manage-
ment on a hospital unit could be improved, researchers
asked five senior house officers to take a 1-hour educa-
tion program on pain management provided by the hos-
pital play specialist. Following care by the newly edu-
cated house officers, nurses reported on the clinicians’
adherence to best practice, and 21 children who had
undergone painful procedures were interviewed with
their parents to assess their levels of pain, distress, sat-
isfaction, and coping style. Results of the study showed
that house officers had increased their knowledge of
how to work with children undergoing painful proce-
dures. The main changes in knowledge were involving
nurses and the play specialist, preparing the equipment
out of sight of the child, and using distraction tech-
niques. Parents and children reported low levels of dis-
tress during painful procedures and high levels of satis-
faction with procedures and listed several coping
strategies such as distraction that helped the child, and
the parent, to cope during the procedure.
Based on the above study, would you try to change the
attitude of health care providers toward pain manage-
ment or rate that as too difficult to attempt?
Source: Lawes, C., et al. (2008). Impact of an education pro-
gramme for staff working with children undergoing painful pro-
cedures. Paediatric Nursing, 20(2), 33–37.
prescribed, opiates can be given with confidence to decrease
pain without untoward effects. To give nurses more leeway
in pain management, it is helpful if a range is given for a
dose, rather than a set number so the dose can be adjusted
based on the degree of pain (Pasero, Manworren, &
McCaffery, 2007).
A good rule for determining whether children need pain
relief for a procedure is to remember that if the procedure
would cause pain in an adult, it will also cause pain in a child.
Often a combination of nonpharmacologic and pharmaco-
logic methods is most effective for pain relief (see Focus on
Nursing Care Planning Box 39.6). Many health care profes-
sionals such as laboratory technicians, physicians, and x-ray
or endoscopic assistants are called on to perform procedures
with a child that could cause pain. Health care is a collabo-
rative enterprise. Assist these individuals to schedule
procedures at times when a child can be administered opti-
mal pain relief. Help them institute nonpharmacologic mea-
sures of pain management such as distraction (Gatlin &
Schulmeister, 2007).
General measures to alleviate pain that are helpful to
parents as well as health care providers are summarized in
Box 39.7. These guidelines are based primarily on the gate
control theory.
CHAPTER 39 Pain Management in Children 1125
NONPHARMACOLOGIC
PAIN MANAGEMENT
Nonpharmacologic pain relief measures can be used inde-
pendently or as complements to pharmacologic pain relief.
They fit under the umbrella of alternative and complemen-
tary therapies.
Distraction
Distraction techniques aim at shifting a child’s focus from
pain to another activity or interest (Fig. 39.5). Blowing soap
bubbles, for example, could be used during an injection to
accomplish this. If oral glucose is offered to infants during
painful procedures, the pain they experience appears to be
significantly less (Hatfield et al., 2008). It is hypothesized
that drinking glucose not only serves as a distraction tech-
nique but also activates endorphins and produces a central
analgesic effect (Stevens, Yamada, & Ohlsson, 2009).
Breastfeeding may also be used in this way but is not advised
to avoid the infant making an association between breast-
feeding and pain. When helping parents teach a distraction
technique such as blowing soap bubbles to their child, be cer-
tain they do not interpret “distraction” as just talking to the
child or suggesting a video game to divert attention.
Although these are distractions, simple distraction like this
can allow pain to break through.
Substitution of Meaning or Imagery
Substitution of meaning or guided imagery is a distraction
technique to help a child place another meaning (a non-
painful one) on a painful procedure (Russell & Smart, 2007).
Children are often more adept at imagery than adults because
their imagination is less inhibited. Success with this tech-
nique requires practice, so it has limited application in an
acute care setting. This technique works well with quick,
simple procedures such as venipunctures or chronic pain. A
venipuncture, for example, could be viewed as a silver rocket
probing the moon to transport specimens back to earth or a
submarine diving under the water to escape torpedoes just in
time. Be certain a child thinks of a specific image. Help the
child elaborate on the image to make it more concrete each
time it is used so the child’s mind stays on the image (what
color is the rocket ship? Are there stripes on the sides? What
does the pilot look like?).
Thought Stopping
Thought stopping is a technique in which children are
taught to stop anxious thoughts by substituting a positive or
relaxing thought. As with imagery, this technique requires a
great deal of practice before it is used in a painful situation.
Anticipatory anxiety is a negative force because it increases
the pain experience during a procedure and makes the time
before it full of anxiety as well. For this technique, help chil-
dren to think of a set of positive things about the approach-
ing feared procedure. For a bone marrow aspiration, for
example, this might include, “It doesn’t take long; the doctor
and nurse who do it are helping me; it’s important to help
me get better.” Whenever children start to think about the
impending procedure, they should stop whatever they are
doing and recite the list of positive thoughts to themselves if
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1126 UNIT 6 The Nursing Role in Supporting the Health of Ill Children and Their Families

BOX 39.6 ✽ Focus on Nursing Care Planning

A Multidisciplinary Care Map for a Child Requiring Pain Management

Robin Harvey, a 3-year-old girl admitted to your hospital morphine sulfate during the procedure. Unfortunately,
unit, has just returned from a bone marrow aspiration to the bone marrow obtained for analysis is not adequate,
rule out the possibility of leukemia. Robin received IV so a repeat procedure is scheduled for 3 hours from now.

Family Assessment ✽ Child is only daughter of two Nursing Diagnoses ✽ Anxiety related to fear of the un-
parents. Father works as a welder in a local steel mill; known and anticipation of painful procedure
mother works part time at a local convenience store.
Outcome Criteria ✽ Child identifies pain as no higher
Family rates finances, “Doing good.”
than 1 with Oucher Pain Rating Scale; exhibits few to no
Client Assessment ✽ A 3-year-old girl with a history of nonverbal indicators of pain; exhibits age-appropriate
frequent nosebleeds, petechiae, and bruising admitted coping behaviors, including one nonpharmacologic pain
for diagnostic testing. First experience with hospitaliza- relief technique.
tion. Screams at the sight of a syringe and needle. Both
parents at bedside talking with child. Child upset and
crying, “Don’t let them hurt me!”

Team Member
Responsible Assessment Intervention Rationale Expected Outcome
Activities of Daily Living

Nurse Assess if IV morphine Review with parents
provided adequate the necessity for the
pain relief for last repeat procedure
procedure. and possible meth-
ods to help child
with pain.
Nurse Assess vital signs and Engage the child in
child’s present pain quiet activities for
rating. the first hour post-
procedure.
Being prepared for Parents state they un-
coming procedure derstand why repeat
can reduce anxiety procedure must be
in both parents and done; are satisfied
child. with pain relief mea-
sures to be used.
The child is at risk for Vital signs remain sta-
bleeding from the ble; pain rating is
puncture site. Quiet not over 1 on child
activities reduce the rating scale. Child
risk for bleeding and colors quietly.
also provide
distraction.

Consultations

Nurse/ Assess if pain manage- Consult with pain man- Well-planned pain relief Pain management
physician ment team member agement team can best meet the team member
is available for member for best needs of an anxious meets with parents
consultation. pain relief for fright- child. and child; deter-
ened preschool mines best method
child. of pain relief.

Procedures/Medications

Nurse Assess if bone aspira- Apply anesthetic cream
tion site is free of to aspiration site
inflammation. and cover with an
occlusive dressing 1
hour before sched-
uled procedure per
MD order.
Nurse Assess reddened or Just prior to the proce-
blanched skin at site dure, remove the
of anesthetic cream occlusive dressing
just prior to proce- and wipe away the
dure. EMLA cream.
An anesthetic cream Child cooperates with
anesthetizes skin. application proce-
An occlusive dress- dure. Occlusive
ing enhances ab- dressing remains in
sorption and tissue place preprocedure.
penetration.
Removal prior to the Child cooperates with
procedure is neces- removal of occlusive
sary to cleanse skin. dressing and anes-
Reddened or thetic cream. Skin
blanched skin indi- appears as if anes-
cates that the drug thetic effect has
has been effective. been achieved.
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CHAPTER 39 Pain Management in Children 1127

Nurse Assess if child or par-
ents have prefer-
ence for where IV
line should be
inserted.
IV analgesia or con- A bone marrow aspira- IV line is safely in-
scious sedation is tion is painful, so a serted; child
administered by IV route for pain relief chooses site that
route. is necessary. will best allow her to
Allowing choice of color quietly follow-
IV site offers a ing the procedure.
sense of control.

Nutrition

Nurse Assess when child Keep NPO for 30 min- Heavy analgesia can Parents state they un-
last ate. utes preprocedure. lead to aspiration if derstand temporary
stomach is full. restriction for fluid.

Patient/Family Education

Nurse Assess what child and Review with child feel-
parents believe was
most traumatic as-
pect of previous
bone marrow
aspiration.
Nurse Assess if pain assess- Introduce the child to
ment tool was used
with child during
prior procedure.
Nurse Assess the child’s un-
derstanding about
the reason for the
bone marrow
aspiration.
Anticipatory knowledge Child and parents state
ing of pressure with of events and feel- they feel prepared
needle insertion. ings helps to pre- for new procedure.
pare the child and
aids in coping.
Introducing the child to Child rates her pain
Oucher Pain Rating the tool prior to the preprocedure as 0
Scale. onset of pain mini- to 10 to demon-
mizes anxiety asso- strate she under-
ciated with a new stands how to use
experience and in- scale. Sets a base-
creases the tool’s line for comparison.
usefulness and ac-
curacy in determin-
ing the child’s pain
level.
Review procedure with Assessment and re- Child and parents voice
child and parents. view reveal informa- accurate under-
tion about the child, standing of the
her knowledge procedure of bone
base, and possible marrow aspiration
clues to her anxiety, and importance for
providing a founda- diagnosis.
tion on which to
build future strate-
gies and teaching.

Psychosocial/Spiritual/Emotional Needs

Nurse Assess if child has had
experience with
therapeutic play.
Provide opportunities Therapeutic play helps Child plays with doll
for therapeutic play the child express and syringe under
with a doll and sy- her feelings about nurse supervision.
ringe before and painful procedures Does not demon-
after procedure. and possibly reduces strate behavior sug-
anxiety. gestive of extreme
anxiety or fright.

Discharge Planning

Nurse Assess if child is free of Ask child to rate pain Postprocedure evalua- Child rates pain as 1 or
pain postprocedure; on Oucher scale; tion helps to meet below on pain rating
if parents received ask parents if they further needs of scale. Parents state
adequate informa- have received pro- child and parents they have results of
tion on outcome of cedure report and and improve skills of procedure and un-
procedure. understand results. health care derstand the next
providers. step needed for
diagnosis and
treatment.
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1128 UNIT 6 The Nursing Role in Supporting the Health of Ill Children and Their Families

BOX 39.7 ✽ Focus on

Family Teaching
Pain Management With Children
Q. Mrs. Harvey asks you, “How can I be sure I can keep
my daughter free from pain after she returns home
from the hospital?”
A. Here are some ways to offer pain relief in addition to
just giving medicine:
• Let the child know it is important to you to try to take
the pain away, and you will work with her to relieve it.
Use a positive approach: “This medicine will take
away your pain,” not “Take this and let’s hope it
works.”
• Administer pain medication before pain becomes in-
tense to help prevent pain rather than just relieve it. If
a child is in the hospital, inform the staff if a particu- FIGURE 39.5 A child using distraction as a pain management
technique.
lar approach works or does not work.
• Never just give an analgesic. Make the child com-
fortable in ways such as straightening the sheets or
offering a backrub.
so at the time of the pain, the child can produce a trance-like
• Ask your child about measures she thinks will be
state to avoid sensing pain (Shakibaei et al., 2008).
helpful, such as an additional pillow, the television
turned on, a favorite toy nearby.
• Help your child talk about and describe the pain she Aromatherapy and Essential Oils
is experiencing. This can help make it more concrete Aromatherapy is based on the principle that the sense of smell
and not as psychologically frightening. plays a significant role in overall health. When an essential oil
• Relieve anxiety about other phases of life, if possible. is inhaled, its molecules are transported via the olfactory sys-
Relaxation reduces muscle strain and tension that tem to the limbic system in the brain. The brain responds to
add to pain. particular aromas with emotional responses. When applied
• Offer emotional support to your child. Pain never externally, the oils are absorbed by the skin and then carried
seems as bad when a support person is present. throughout the body. Essential oils may be able to penetrate
Reassuring your child that she is loved and that you cell walls and transport nutrients or oxygen to the inside of
will be there for her can be very comforting. cells. Jasmine and lavender are oils thought to be responsible
• Try not to use such statements as, “Be a big girl” or for relieving pain. When a drop of lavender oil is placed on
“Stop crying” when a child is in pain from a proce- the skin, a child should be able to taste it within 15 seconds.
dure such as an injection. Say instead, “It’s all right
to cry. I know it hurts,” to avoid shaming a child who Magnet Therapy
cannot stop crying.
Magnet therapy is based on the belief that magnets can con-
trol or shift body energy lines to restore health or relieve pain.
Magnets can be applied as jewelry or sewn into clothing or
shoes. Although many people find relief from magnet ther-
others are present or out loud if they are alone or only im- apy, the relief may be more of a placebo effect than an actual
portant support people are present. Children can then return change in pain level (Pope & McNally, 2007). Copper also
to a usual activity. Every time the anxious thoughts appear, is believed to have pain-relieving ability and is often incor-
however, a child should stop and recite the list. porated into rings and bracelets for this reason.
Thought stopping is an effective technique because it al-
lows children to feel in control of their thoughts, which is Music Therapy
different from merely saying, “Don’t think about it.” This
technique does not suppress thoughts; rather, it changes Music therapy is the use of music for calming or improving
them into positive ones. The secret for success is for the child well-being and can be effective even for premature infants. It
to use the technique every time the disturbing, anxious can help to relieve pain both because it can be relaxing and is
thought appears even if, at first, such thoughts crowd in as a distraction (Windich-Biermeir et al., 2007). Children may
frequently as every few minutes. “blast” music not because they enjoy hearing it that loud but
because they are feeling great pain and need that level of dis-
Hypnosis traction to feel free of pain.
Hypnosis is not a common pain management technique with Yoga and Meditation
children but can be very effective when a child is properly
trained in the technique (Robertson, 2007). For best results, Yoga, a term derived from the Sanskrit word for union, in-
a child needs to train with a therapist before anticipated pain, volves a series of exercises that were originally designed to

bring people who practice it closer to God. It offers a signif-
icant variety of proven health benefits, such as increasing the
efficiency of the heart, slowing the respiratory rate, improv-
ing fitness, lowering blood pressure, promoting relaxation,
reducing stress, and allaying anxiety. Exercises consist of
deep-breathing exercises, body postures to stretch and
strengthen muscles, and meditation to focus the mind and
relax the body. Yoga may be helpful in reducing pain
through its ability to relax the body and possibly through the
release of endorphins (Galantino, Galbavy, & Quinn, 2008).
Acupuncture
Acupuncture involves the insertion of needles into critical
positions (meridian lines) in the body to achieve pain relief
(Vas et al., 2007). Although acupuncture is almost painless,
children can be very afraid of it at first because of the sight of
the needles. This level of stress can make it an unattractive
option for pain management for children. Children who
consent to having it done, however, particularly those with
chronic pain, report that the overall process is pleasant and
the method offers good pain relief.
Crystal or Gemstone Therapy
Some people believe that gemstones or crystals have healing
powers, which are magnified when they are positioned
around the body. If these are being used, be careful when
changing bedding or rearranging equipment in a child’s
room that you do not tip them over. A child may feel they
may lose their pain-relieving powers if placed in a different
position (Vantol, 2008).
Herbal Therapies
Parents may believe that specific herbs are helpful in reliev-
ing pain for their child and in general improving their child’s
health. Some examples include chamomile tea (inflammation
reduction), garlic (anti-inflammatory, anticancer), ginger
(nausea or vomiting reduction), goldenrod (urinary tract in-
flammation reduction), or peppermint (abdominal pain re-
lief ) (DerMarderosian & Beutler, 2007). Always ask when
taking health histories if a child is being given any herbs,
both to be informed about common herbs and to be certain
that what the child is receiving will complement, not inter-
fere with, the effects of a pain medication.
Biofeedback
Biofeedback is based on the belief that people can regulate in-
ternal events such as heart rate and pain response (Tsai et al.,
2007). A biofeedback apparatus is used to measure muscle
tone or the child’s ability to relax. Biofeedback can be effec-
tive with adolescents but is less effective with school-age and
younger children because they tend to resist the biofeedback
information or cannot concentrate for long enough for train-
ing to be effective. Children who want to use biofeedback
need to attend several sessions to condition themselves to reg-
ulate their pain response.
Therapeutic Touch and Massage
Therapeutic touch is the use of touch to provide comfort and
relieve pain (Dowd et al., 2007). It is based on the concept that
CHAPTER 39 Pain Management in Children 1129
the body contains energy fields. When these are plentiful, they
lead to health, but when they are in lesser supply, ill health re-
sults. Proponents believe it is possible to redirect energy fields
to increase the release of endorphins. Therapeutic touch may
also be effective as it serves as a form of distraction.
Transcutaneous Electrical Nerve Stimulation
Transcutaneous electrical nerve stimulation (TENS) in-
volves applying small electrodes to the dermatomes that sup-
ply the body portion where pain is experienced (Poole,
2007). When children sense pain, they push a button on a
control box, which then delivers a small electrical current to
the skin. The principle underlying this technique is the same
as rubbing an injured part: the current interferes with the
transmission of the pain impulse across small nerve fibers.
TENS can be used to manage either acute or chronic
pain. Some children (and parents) dislike TENS therapy be-
cause they are afraid or nervous about the electric current.
Assure them the current is a very mild one and will not harm
their child. TENS is not recommended if the child is incon-
tinent or has a wound that is likely to cause the electrodes to
get wet.
Heat or Cold Application
Cold reduces pain by constricting capillaries and therefore re-
ducing vessel permeability and edema and pressure at an in-
jured site. After the first 24 hours of an injury, applying heat
may be more helpful because this dilates capillaries, increases
blood flow to the area, and again helps reduce edema.
✔Checkpoint Question 39.1
You teach Robin imaging to help reduce pain. Why does a
technique such as imagery work well for children?
a. Children’s pain is not as acute as is adults’ pain.
b. Intravenous pain relief is not effective in children.
c. Children’s imaginations are at their peak.
d. Children’s muscles are less tense than adults’ muscles.
PHARMACOLOGIC PAIN RELIEF
Pharmacologic pain relief refers to the administration of a
wide variety of analgesic medications (D’Arcy, 2007). Many
children need analgesic agents in addition to nonpharmaco-
logic techniques for pain relief, especially for acute pain.
Medications can be applied topically or given orally, intra-
muscularly, intravenously, or by epidural injection. As a rule,
intramuscularly administered analgesia should be avoided in
children because children dislike injections. Be certain chil-
dren understand it is acceptable to ask for medication for
pain; they may not know they can unless this is stressed by
health care providers.
Topical Anesthetic Cream
To reduce the pain of procedures such as venipuncture, lum-
bar puncture, and bone marrow aspiration, a local anesthetic
cream or a solution of lidocaine and epinephrine can be used
(Subramanian et al., 2008).
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1130 UNIT 6 The Nursing Role in Supporting the Health of Ill Children and Their Families

BOX 39.8 ✽ Focus on

Pharmacology
EMLA Cream
Classification: EMLA (an eutectic mixture of local anes-
thetics) is a topical analgesic cream containing lido-
caine and prilocaine.
Action: Acts to anesthetize skin before potentially painful
procedures (Karch, 2009).
Pregnancy risk category: B
Dosage: Dollop of cream to intended skin site for at least
1 hour before procedure (2–3 hours before deeper
procedures such as lumbar puncture or bone mar-
row aspiration)
Possible adverse effects: Hypersensitivity
Nursing Implications
• Explain to the child that the cream will help prevent
pain during a procedure.
• Apply a dollop of cream to the intended site and
cover with a transparent occlusive dressing at least 1
hour before the procedure. Do not spread cream or
rub it in.
• If the cream is to be applied at home, instruct the
parents how to apply the cream and the occlusive FIGURE 39.6 A father applies an anesthetic cream at home
dressing. Suggest that the parents use plastic wrap, prior to a painful procedure.
such as Saran Wrap, for the occlusive dressing.
• Instruct the child not to touch the dressing while it is
in place. If necessary, cover the occlusive dressing
with an opaque material to prevent the child from (Subramanian et al., 2008). It can be purchased without a
touching or playing with the dressing. prescription.
• Just before the procedure, remove the dressing and
then wipe the skin to remove cream. What if... Robin is scheduled to have blood drawn at
• Observe the skin. Look for reddened or blanched 10 AM and, to prepare her for this, you apply an anes-
skin, which indicates that the drug has penetrated thetic cream that takes an hour to be effective at 9 AM,
the skin. but then the technician who will take the blood arrives
• Do not use the drug for a child with a known history early? Would you ask the technician to wait, or explain to
of sensitivity or allergy to local anesthetics such as li- Robin the cream is not going to work?
docaine.
• The drug is not approved for use in infants younger
than 1 month. Oral Analgesia
Oral analgesia is advantageous because it is cost-effective and
relatively easy to administer. Many analgesics can be prepared
as elixirs or suppositories for children unable to swallow pills.
The cream is applied to the skin, and the site is then cov- Analgesia can be adequately achieved if dosing is correct.
ered with an occlusive dressing or plastic wrap. To be most Over-the-counter analgesics, such as acetaminophen
effective, it must be applied at least 1 hour before an expected (Tylenol), are flavored to make them taste good. Caution
procedure (Box 39.8). Parents can apply anesthetic cream at parents that even though such drugs taste sweet, they should
home before bringing a child to a clinic visit for a procedure never refer to medicine as “candy.” Reinforce with them the
such as bone marrow aspiration (Fig. 39.6). Caution them need for proper storage (locked or out of the child’s reach).
not to allow their child to remove the dressing and eat the Otherwise, children may help themselves to more when the
cream (it could anesthetize the gag reflex). It also is poten- parent leaves the room. Toxicity from too-frequent or overly
tially dangerous if rubbed into the eyes. Anesthetic creams large doses of acetaminophen can lead to severe liver damage
have changed procedures such as obtaining blood from in children (Karch, 2009).
painful ones to painless ones. They also can be used effec- Nonsteroidal anti-inflammatory drugs (NSAIDs) are ex-
tively for pain relief with circumcision (Taddio, Ohlsson, & cellent for reducing the pain that accompanies inflammation
Ohlsson, 2009). A disadvantage of EMLA cream is that it in injuries such as sprained ankles or rheumatic conditions.
must be applied at least 1 hour before the procedure; how- Examples of NSAIDs include ibuprofen and naproxen.
ever, it can be applied up to 3 hours before a procedure and Long-term administration of any NSAID can lead to severe
still be effective. A newer compound, ELA-MAX (LMX), gastric irritation and may be associated with heart attacks, so
containing only lidocaine, takes effect in 30 minutes or less it should not be used longer than prescribed. Help parents
15610_Ch39.qxd 6/30/09 9:50 AM Page 1131
giving any analgesia around the clock for several days to
make out a medication sheet to hang on their refrigerator
door. This reminds them when the next dose is due and
alerts them not to give the drug doses too close together.
Children should not receive acetylsalicylic acid (aspirin)
for routine pain relief, especially in the presence of flulike
symptoms, because there is an association between aspirin
administration and the development of Reye syndrome (see
Chapter 49).
For managing severe or acute pain, such as postoperative
pain or the pain of a sickle-cell crisis, opioids, such as mor-
phine, codeine, and hydromorphone (Dilaudid), are the
usual drugs of choice. Codeine may be given in combination
with acetaminophen. Because this class of drugs is also re-
ferred to as narcotics, parents may be reluctant to give their
children these medications, concerned their child will be-
come addicted. Acknowledge their concern but reassure
them the risk for addiction during short-term use is remote.
Reinforce that the main concern is supplying adequate pain
relief for their child.
Intramuscular Injection
Opiates are available as intramuscular injections. Analgesia
for children is rarely given by this route, however, as injec-
tions are associated with pain on administration and also pro-
duce great fear in children. It is also associated with several
risks, including uneven absorption, unpredictable onset of
action, and nerve and tissue damage. Other routes should be
used whenever possible.
Intravenous Administration
IV administration of analgesia, the most rapid-acting route, is
the method of choice in emergency situations, in the child
with acute pain, and in a child requiring frequent doses of
analgesia but in whom the gastrointestinal tract cannot be
used. Common opioids given by this route include morphine,
fentanyl, and hydromorphone (Dilaudid). Hydromorphone is
8 to 10 times stronger than morphine but very similar to mor-
phine in action. Fentanyl has a shorter duration of action than
morphine. Side effects of pruritus and vasodilatation are less.
These features make it an ideal drug to use for short, painful
procedures, such as debriding a burn or inserting a chest tube
to relieve a pneumothorax.
These analgesics can be given by bolus injection or by
continuous infusion. If doses will be given periodically by an
IV line, advocate for the use of an intermittent infusion de-
vice to avoid repeated venipunctures with each dose or the
need for a confining IV line to be in place.
If a child’s pain is frequent or constant, continuous IV ad-
ministration may be necessary to reduce the level of pain. As
the child becomes able to take medications by mouth, oral
forms of analgesics are then administered. When switching
from IV to oral medications, it is important to use equianal-
gesic doses. As-needed (PRN) dosing should be avoided be-
cause it leads to inconsistent administration.
All opioids have the potential to decrease respiratory rate,
although this is not a worry with accurate dosing. Other side
effects include nausea, pruritus, vasodilatation, cough sup-
pression, and constipation. If toxicity with opioids should
occur, naloxone (Narcan) can be administered to counteract
the effects.
CHAPTER 39 Pain Management in Children 1131
✔Checkpoint Question 39.2
Robin was given analgesia intravenously. Why is the intra-
muscular route infrequently used to administer analgesia to
children?
a. The average child has a tremendous fear of injections.
b. IM doses must be larger in children than in adults.
c. IM medications must be administered cold or chilled.
d. IM solutions are readily confused with IV solutions.
Patient-Controlled Analgesia
Patient-controlled analgesia (PCA) is a form of IV admin-
istration that allows a child to self-administer boluses of med-
ication, usually opioids, with a medication pump (see also
Chapter 16). Children as young as 5 or 6 years may be able
to assess when they need a bolus of medicine and press the
button on the pump to deliver the new dose through an es-
tablished IV line. Parents or a nurse can administer a new
dose to children younger than this. Morphine is a common
analgesic used for PCA administration (Cho, Ha, & Rhee,
2007). The pump is set with a lock-out time so that after
each dose the pump will not release further medication even
if the button is pushed again; because of this, children can-
not overmedicate themselves. If pain is constant, a continu-
ous infusion should be used so that pain relief continues even
while the child sleeps. The pump can still be programmed for
bolus dosing to cover episodes of increased pain.
Conscious Sedation
Conscious sedation refers to a state of depressed conscious-
ness usually obtained through IV analgesia therapy (Hertzog
& Havidish, 2007). The technique allows a child to be both
pain-free and sedated for a procedure. Unlike with the use of
general anesthesia, protective reflexes are left intact and a
child can respond to instructions during the procedure. The
technique is used for procedures such as extensive wound
care; bone marrow aspiration, which is potentially very
painful; magnetic resonance imaging, which may require a
child to lie still for a long period of time; and endoscopy,
which is both potentially frightening and requires a child to
lie still for a period of time. In many health care settings, con-
scious sedation is administered and monitored by nurses spe-
cially prepared in the technique (Fig. 39.7). Drugs used for
conscious sedation can be something as common as chloral
hydrate or as involved as a sedative-hypnotic-analgesic com-
bination that relieves both anxiety and pain and depresses the
child’s memory of the event.
Intranasal Administration
Intranasal administration is becoming an attractive way to dis-
pense medicine for children. Influenza vaccine, for example, is
now available in an intranasal form (Carpenter et al., 2007).
Midazolam (Versed) is a short-acting adjuvant sedative that
can be administered intranasally by nasal drops or nasal spray
before surgery or procedures such as nuclear medicine scan-
ning (Karch, 2009). Because it has a very short duration of ac-
tion, it may require repeat administration. Because midazolam
has no analgesic action, analgesia, such as with morphine,
should also be used if the procedure will be painful.
1132 UNIT 6 The Nursing Role in Supporting the Health of Ill Children and Their Families
FIGURE 39.7 A nurse monitors the vital signs of a child who
has received conscious sedation.
Local Anesthesia Injection
Local anesthetics stop pain transmission by blocking nerve
conduction of the impulse at the site of pain. Children re-
ceive local anesthetic injections, such as lidocaine, before
procedures such as bone marrow aspiration and peritoneal
dialysis. For many children, the sight of the anesthetic needle
is so frightening that they cannot listen to the assurance that
the momentary needlestick will actually prevent further pain.
The use of an anesthetic cream before the injection relieves
the needlestick pain and allows the anesthetic to numb the
deeper tissues.
Epidural Analgesia
Epidural analgesia, injection of an analgesic agent into the
epidural space just outside the spinal canal, can be used to
provide analgesia to the lower body for 12 to 24 hours. An
opioid, often combined with a long-acting anesthetic, is in-
stilled continuously or administered intermittently. Opiate
receptors in the spinal cord are affected directly, providing
analgesia. Epidural anesthesia is commonly used for child-
birth (see Chapter 16). Children who have orthopedic or
chest surgery, for example, may have an epidural catheter in-
serted in the operating room and continue to receive analge-
sia by this method to relieve postsurgical pain (Schoen,
2007). This is a very effective route of analgesia in the post-
operative child in the first few days.
Some parents may be reluctant to allow this type of anal-
gesia because they equate it with spinal anesthesia, which can
be followed by severe headaches. You can assure them that an
epidural needle does not enter the cerebrospinal fluid, so
spinal headaches are rare.
ONGOING PAIN RELIEF
Be certain children who begin a pain management program
in a health care setting are provided with support and follow-
up pain management to the extent necessary when they
return home. Early discharge and the increased use of outpa-
tient surgery necessitate adequate pain management in the
home setting. Otherwise, lack of pain relief at home can be
overwhelming.
Either oral or IV analgesia may be needed in a home set-
ting. Be certain parents have instructions on dosing, admin-
istration, frequency, expected outcomes, and expected level
of relief. Provide them with the name and telephone number
of a health care professional whom they can call if they have
questions about pain management.
✔Checkpoint Question 39.3
Suppose Robin is scheduled for conscious sedation to have
her repeat bone marrow aspiration. Which would be the best
explanation to prepare her for this?
a. “You’ll be given a special medicine to put you to sleep for
surgery.”
b. “I’ll give you some medicine, but you’ll still be awake and
feel pain.”
c. “Conscious sedation is an analgesic, not anesthetic,
method of pain relief.”
d. “I’ll give you medicine so you’re very sleepy but can still talk
to me.”
Key Points for Review
● Many children and infants are undermedicated for pain
relief because of common misperceptions by health care
personnel, such as that infants do not feel or remember
pain.
● Inviting parents and the child, if preschool age or older, to
participate in assessment and pain management is an im-
portant aspect of pain therapy.
● Pain in children is best assessed by means of a standard-
ized self-report tool such as the Poker Chip or FACES
tool. Without self-report forms, both nurses and parents
may underestimate children’s pain.
● Many children benefit from a combination of nonpharma-
cologic and pharmacologic methods of pain management.
● Many nonpharmacologic pain relief measures such as im-
agery, distraction, and TENS are based on the gate con-
trol theory of pain management.
● Few analgesics are administered intramuscularly to chil-
dren. Instead, IV administration is the method of choice
for the child with acute pain. Patient-controlled analgesia,
commonly used to administer morphine, can be used ef-
fectively with children.
● Conscious sedation is useful for potentially frightening
procedures. Protective reflexes are left intact, and the child
can respond to instructions during the procedure.
CRITICAL THINKING EXERCISES
1. Robin is the 3-year-old girl you met at the beginning of
the chapter. She was given IV morphine in surgery 1
hour ago for a bone marrow aspiration. Her mother asks
15610_Ch39.qxd 6/30/09 9:50 AM Page 1133
you now if Robin can have some more, not because her
pain has returned, but because the mother wants it
given before any pain comes back. Is this mother’s as-
sessment or Robin’s assessment of her pain apt to be
most accurate? Would anticipating pain in this way be
the best intervention for Robin?
2. Robin is prescribed an intravascular antibiotic twice
daily. She always screams the second she sees the syringe
even though the addition of the medicine to her IV line
should cause minimal pain. What type of pain manage-
ment should be used? How should the child’s anxiety be
addressed?
3. A fellow nurse tells you that she does not use self-report
tools with children; she feels they take the place of her
nursing judgment. You like to use rating scales. How
would you justify your view? What are the pros and
cons of pain assessment tools?
4. Examine the National Health Goals related to pain as-
sessment and management in children. Most govern-
ment-sponsored funds for nursing research are allotted
based on these goals. What would be a possible research
topic to explore pertinent to these goals that would be
applicable to Robin’s family and also advance evidence-
based practice?
CRITICAL THINKING SCENARIO
Open the accompanying CD-ROM or visit http://
thePoint.lww.com and read the Patient Scenario in-
cluded for this chapter, then answer the questions to
further sharpen your skills and grow more familiar
with NCLEX style questions related to pain manage-
ment in children. Confirm your answers are correct by
reading the rationales.
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