Paediatric Handbook - (CHAPTER 3 Pain Management)

CHAPTER
3
Pain management
Jane Munro
George Chalkiadis
Numerous misconceptions contribute to under-treatment of paediatric pain, including

Neonates and children do not experience pain or remember painful events.
Children tolerate pain better than adults as their nervous systems are immature.
All children are ‘sensitive’ to analgesics.
Opioids are addictive or too dangerous to use in children.
These myths lead to poor pain prevention and management in neonates, children and
adolescents. If unrelieved or inadequately treated, pain has negative physiological,
psychological and emotional consequences.
Assessment of acute pain

Pain scores are important! They are the fifth vital sign on patients' observation charts. Pain
assessment includes a combination of the following:
History
Including site, onset, duration, quality, radiation, triggers and relievers, impact on
functioning (including sleep disturbance and other activities), treatments tried and their
effectiveness.
In developmentally normal children, ask the child directly about their pain using
appropriate tools.
Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved.
In neonates, pre-verbal children and cognitively impaired children, parents and regular
caregivers are often best equipped to interpret the child's pain reliably.
Examination
Behavioural observation (e.g. vocalisation, facial grimacing, posturing, movement).
Physiological parameters (e.g. heart rate, respiratory rate, blood pressure) and physical
signs (e.g. muscle spasm).
Functional effects: for example, the ability to move (e.g. sitting up after laparotomy) and
the tolerance of touch of the painful area usually signify adequate analgesia, whereas a
child lying still and withdrawn may be in severe pain.
Paediatric Handbook, edited by Amanda Gwee, et al., John Wiley & Sons, Incorporated, 2015. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/unimelb/detail.action?docID=4038605.
Created from unimelb on 2023-08-01 05:08:58.
Use of pain-rating scales
Observe trends of change in an individual's pain score or function (e.g. ability to turn in bed
comfortably, ability to walk to the toilet) rather than the ‘raw’ pain score.
Verbal children
FACES scales for children >4 years, for example, Wong–Baker FACES Pain Rating
Scale (Fig. 3.1) or Bieri revised
Visual analogue scale (e.g. 100-mm ruler)
Verbal numerical rating scale (e.g. ‘out of 10 where 0 is no pain and 10 is the worst
pain imaginable …’)
Non-verbal children including neonates and cognitively impaired are particularly
vulnerable (see Pain in children and adolescents with disabilities, p. 28)
FLACC: Face, Legs, Activity, Cry and Consolability
PATS (for neonates): Pain Assessment Tool Score
Figure 3.1 Wong–Baker FACES pain rating scale. Reproduced with permission from
Hockenberry MJ, Wilson D, Winkelstein ML. Wong's Essentials of Pediatric Nursing, 7th ed.,
St. Louis, 2005, p. 1259. © Mosby. (Hockenberry 2005. Reproduced with permission of
Elsevier.)
Analgesics for acute pain

Multimodal analgesia (MMA) involves the use of more than one drug and/or method of
controlling pain to obtain additive beneficial effects, reduce side effects, or both.
MMA use is ideal for acute pain management including pain due to surgery, trauma or cancer,
as it allows analgesia to be optimised and directed according to the multiple sources of pain
(somatic, visceral and/or neuropathic).
Drug options include paracetamol, NSAIDs, COX-2 inhibitors, muscle relaxants (e.g.
Buscopan for smooth and diazepam for skeletal muscle spasm), tramadol and neuropathic
analgesics (such as gabapentin, pregabalin, amitriptyline, clonidine and ketamine).
Drugs can be administered by various routes. Specialised infusions (e.g. local anaesthetics,
ketamine and opioids) can be via bolus and/or continuous infusion.
Use an analgesic ladder approach to manage acute pain (see Table 3.1). The progress up or
down the steps varies according to
the intensity of pain experienced;
its anticipated duration; and
the expected recovery period.
Table 3.1 Analgesic ladder approach
Degree of pain and Analgesic ‘steps’
setting
Severe pain
Inpatient Add specialised infusion, for example ketamine, epidural local
anaesthetic
Add parenteral opioid by infusion (nurse or patient controlled)
Outpatient or Add parenteral opioid by bolus or regular oral opioid (consider
emergency presentation controlled release when long duration)
Consider parenteral tramadol, NSAID, paracetamol
Address sleep impairment and anxiety if present
Moderate pain Add one (or combination) of:
Strong opioid, for example oral morphine, oxycodone
'Non-opioid': tramadol
Mild opioid: codeine
Address environmental/psychosocial contributors
Mild pain Begin with paracetamol and/or NSAIDs
Each step up employs all the analgesics listed in the steps below. Once pain is controlled,
wean back to the previous step. This varies with the speed of resolution of the painful
condition and the number of breakthrough or rescue agents that are required in the higher
category. If pain is poorly responsive to these measures, get consultant assistance. See Table
3.2 for dosing.
Table 3.2 Analgesic medication
Drug Dose Route(s) Indications
Special Side effects
notes/contraindica
Paracetamol Oral, rectal: Oral: syrup or Effective for Hepatotoxicity Hepatotoxicity has
15 mg/kg per tablets mild-to- Otherwise well reported in children
dose 4 hourly Oral is moderate pain tolerated Use with caution in
prn rounded to preferred to Also has patients with sever
appropriate rectal antipyretic liver disease, jaund
suppository administration effects but malnutrition, glutat
strength for as absorption physical depletion, dehydrat
rectal is more measures are and long-term inges
administration. reliable and better Significant opioid
Total daily has an earlier sparing effects
maximum 60 peak Adjust dosing to le
mg/kg/day concentration body mass in obese
IV: (oral 30–60 children
15 mg/kg qid minutes vs.
rectal 2–3
hours)
IV (onset 15
minutes)
Opioid
Oxycodone 0.1–0.2 mg/kg Oral tablet Stronger Nausea and Cost is only slightl
4 hourly (onset 30–60 opioid vomiting, greater than codein
minutes) constipation no metabolism issu
Also Less itch than Avoids morphine s
available in morphine or
slow release codeine
(SR) form
Morphine 0.25–0.5 Oral (onset Stronger As above Stigma
mg/kg 4 hourly 40–60 opioid
orally 0.1 minutes)
mg/kg 4 hourly Also
iv available in
controlled
release (CR)
form
Tramadol 1–2 mg/kg 6 Oral; 50 mg For moderate- Nausea and Off-license use in <
hourly or 100 mg to-severe pain vomiting, year olds requires
capsules, IR dizziness, anaesthetist-only
(onset 30– sedation prescription or Dru
60 minutes) Not as Usage Committee
Also constipating approval at RCH
available in: and less itch Avoid if history of
SR tablet and respiratory seizures
IV form depression than Mechanism of actio
(onset same opioids serotonin, noradren
as IV reuptake and opioid
morphine) receptors-dont
prescribe with
antidepressants (ris
serotonin syndrome
Opioid effect by
metabolite M1 (req
CYP2D6 for
conversion)
Fentanyl 1.5 mcg/kg Intranasal Short-term Initial emergency
(half into each (initial analgesia department studies
nostril) studies have used 300 mcg/mL
used a concentrations. Stu
specially validating the use o
designed mcg/2 mL are pend
atomiser)
NSAIDS
Ibuprofen 5–10 mg/kg Oral: For mild-to- Gastrointestinal Caution in low volu
t.i.d–q.i.d syrup 100 moderate pain Renal status, poor urine o
mg/5 mL Particularly for Platelet renal failure, bleed
200 mg muscular, bony inhibition and asthma
tablets (large) or visceral (bleeding) Avoid in severe ast
pain with nasal disease
(because of
NSAID/aspirin-
exacerbated respira
disease (ERD))
Can be used in mild
asthma
Generally NSAIDs
avoided in infants <
months in Australia
<12 months in USA
Diclofenac 1 mg/kg b.i.d– Oral and

t.i.d rectal
25 and 50 mg
tablet
Rectal
suppositories
available at
RCH
Piroxicam 0.2–0.4 mg/kg Oral tablet
(adult 10–20
mg) daily
Indomethacin 0.5–1.0 mg/kg Oral tablet
per dose
(adult 25–50
mg) 8 hourly
(max 6 hourly)
Ketorolac 0.2 mg/kg IV available Off-license use <16

IV (not IM) for years
anaesthetists
to use at RCH
COX-2 inhibitor
Celecoxib 2–4 mg/kg Oral capsule No platelet COX-2 s are OK in
b.i.d inhibition NSAID–ERD
class="grey"Off-lic
use <18 years
Local anaesthetics
Lignocaine Maximum Injectable Wound Neurological Do not inject adren
(lidocaine) doses: infiltration Cardiac into ‘end organs’ su
1–2% (1 mL of lignocaine Nerve as fingers, toes, pen
1% = 10 mg) (lidocaine) blocks/infusion nose or ears due to
with risk of ischaemia
adrenaline: 7
mg/kg
Without
adrenaline: 3
mg/kg
Bupivacaine Maximum
0.25–0.5% dose 2–2.5
mg/kg
e.g. <0.5
mL/kg of 0.5%
Levobupivacaine Maximum
0.25–0.5% dose 2–3
mg/kg, e.g.
0.4–0.6 ml/kg
of 0.5%
COX, cyclooxygenase; CR, controlled release; ERD, exacerbated respiratory disease; IR, immediate release; NSAIDs, non-
steroidal anti-inflammatory drugs; SR, slow release.
Examples of patients with severe pain and suggested management
Femoral fracture
Single-shot local anaesthetic femoral nerve block.
Diazepam.
Place in back slab or traction.
Give other agents according to need.
Bowel obstruction requiring laparotomy

The patient will be nil orally and will universally require parenteral analgesia for severe pain.
The following are suggested options. It is important that analgesia be commenced even if the
child is to be transferred to a larger centre.
Regular parenteral NSAID and paracetamol and
Postoperative epidural local anaesthetic infusion or
Opioid via patient-controlled analgesia (PCA) and ketamine infusion.
Metastatic cancer with bony metastases and large intra-abdominal mass

Will benefit from regular dosing with a long-acting opioid such as MSContin or fentanyl
patch (applied every 3 days).
Manage breakthrough pain with immediate release morphine, fentanyl lozenges, sufentanil
nasal/buccal spray or ketamine lozenges.
Procedural pain management

See Chapter 4, Procedures, p. 30.
Everyday events such as blood collection, cannula insertion, port cannulation, lumbar puncture
and suturing are often a source of fear and anxiety for children. The aims of treating procedure-
related pain are to prevent or minimise pain and distress.
Children with illnesses that require multiple painful procedures should be treated with care
and sensitivity from the outset to avoid the development unnecessary psychological trauma.
Anticipation by staff and preparation of patients and their parents are of key importance.
Consider
The patient: age, previous experiences, emotional and physical condition of the child.
The procedure: is it needed and how urgently, the level of expected pain and duration.
The proceduralist: availability of appropriately skilled staff.
Always combine pharmacological and non-pharmacological techniques.
Behavioural strategies (e.g. calico dolls, play therapy) can be used before all painful
procedures. Use of appropriate distraction and breathing techniques are very helpful.
Analgesic and sedative drugs are added when required.
Remember that sedatives alone are not analgesics.
It is difficult to assess pain and the effects of analgesia and sedation in neonates and
children with cognitive impairments.
Before the procedure

General principles – preparation is the key
Prepare yourself and the other staff involved.
Ensure parents and the child understand what the procedure involves. Ideally, prepare the
child <6 years immediately before the procedure and >6 years 1 week before.
Avoid medical jargon; explain what is going to happen and in what order.
Obtain consent from the parents (verbal or written as required).
Set up your equipment before the child enters the procedure room.
Encourage the parents to play an active role during the procedure by involving them in
distraction techniques and comfort strategies. Avoid asking them to restrain their child.
Children may be assisted to develop their own personal procedure routine, comfort or
distraction strategies.
An explanatory video may be helpful in preparing the child and their parent for the
procedure.
If considering procedural sedation, ensure adequate staffing and resources are available.
Pharmacological
Topical anaesthetics (e.g. AnGel, EMLA for intact skin; Laceraine for wounds).
Oral paracetamol, and/or NSAIDs and/or opioids, for example oxycodone.
During the procedure

General principles
Give the child some feeling of control (e.g. choice of hand for IV, sitting up or lying down).
Prompt the child to use the previously planned coping methods.
Monitor the pain and effectiveness of pain management techniques during a procedure.
If the child is not coping well, consider changing pain control measures or aborting the
procedure.
Consider sedation, depending on the procedure involved and the child's previous
experience.
Comfort techniques
Position for comfort (i.e. infants on parents' lap with physical/eye contact with parent).
Have parents comfort child with gentle massage/touch or holding hands.
Calm breathing.
Swaddling for infants (<6 months).
Distraction techniques
Choosing and playing an interactive iPad game, music CD or watching a favourite movie.
Playing with developmentally appropriate toys.
Counting objects in the room or looking at posters on the wall or ceiling.
Reading interactive storybooks.
Visual imagery (e.g. ask the child to imagine a place where they would like to be and to tell
you about it).
Pharmacological techniques
Sucrose: for infants (2 mL of 33% sucrose). Give 0.25 mL 2 minutes before the start of a
procedure onto the infant's tongue. Offer a dummy if it is part of the infant's care. Give the
remainder of the sucrose slowly during the procedure.
Topical local anaesthetic (e.g. EMLA or AnGel)
IV cannulation, lumbar punctures and blood sampling are all potentially distressing for
children.
Apply local anaesthetic cream 60–90 minutes before soft tissue needling procedures
(this ensures skin analgesia a few millimetres deep).
Creams remain effective for up to 4 hours after application.

EMLA is a mixture of prilocaine 2.5% and lignocaine (lidocaine) 2.5%, and often
vasoconstricts the area under application (onset 60–90 minutes).
AnGel (amethocaine 1%) has a faster onset than EMLA (60 minutes). If amethocaine is
left on for >1 hour, erythema and itch can occur.
For specific procedures: a peripheral nerve block or IV regional anaesthesia (e.g. Bier's
block).
Local anaesthetic infiltration (lignocaine (lidocaine), ropivacaine, bupivacaine or
levobupivacaine)
The skin and subcutaneous tissues can be effectively infiltrated with local anaesthetic
solutions.
Lignocaine (lidocaine) stings as it is injected. Stinging may be reduced by adding 1 mL
of 8.4% sodium bicarbonate to 9 mL of lignocaine (lidocaine) solution.
The addition of adrenaline 1:200,000 or 1:400,000 (or 5–10 mcg/mL) may increase the
duration of action, slows systemic absorption by up to 50% and reduces bleeding, but
adrenaline should not be used in ‘end organs’ such as fingers, toes, penis, nose or
ears because of the risk of ischaemia.
Nitrous oxide
Useful inhalational analgesic agent which provides potent short-term analgesia for
painful procedures such as wound dressings and the removal of catheters.
Rapid onset and offset.
Side effects may include sedation, nausea and vomiting. Bone marrow depression can
occur with prolonged exposure (>12 hours) – consider in the child requiring daily
repeat procedures.
Do not use in patients with head injuries, pneumothorax, cardiac disease and those who
are obtunded.
The person administering nitrous oxide should have adequate airway management
skills.
Fast patient before administration (2 hours for solids and liquids, or longer as
clinically appropriate for more complex patients).
Methods of delivery include
Entonox (a mixture of 50% nitrous oxide and 50% oxygen).
Quantiflex (variable demand delivery system of nitrous oxide and oxygen).
Intranasal fentanyl
Has been used in Australian emergency departments in the initial pain management of
long-bone fractures.
A more concentrated solution of 300 mcg/mL was initially used, administered via an
atomiser at a dose of 1.5 mcg/kg, given into one nostril only (where the child is >50 kg
or if the less-concentrated solution is used, give half the dose into each nostril).
This has been administered prior to cannulation for subsequent opioid analgesia to be
given intravenously.
Note: The role of this agent via this route as the neat standardly available solution (100
mcg/2 mL) in procedural sedation requires further delineation.
Anxiolytics and sedatives
Procedural sedation should only be undertaken by accredited staff members, with appropriate
monitoring and equipment and line-of-sight nursing until return to baseline sedation score. Oral
midazolam 0.5 mg/kg (usual max 15 mg) 20-30 minutes before treatment is routinely
recommended. Intranasal delivery stings and is now avoided at RCH.
Sedation is not analgesia! Sedation alone is useful for non-painful procedures, for example
diagnostic ultrasound. For painful procedures, analgesia is also necessary.
Cautions
Observe the child in department or ward (line-of-sight nursing) until return to baseline
sedation score.
Usually recovery occurs by 60 minutes after oral/intranasal administration and 30 minutes
after IV administration.
Midazolam potentiates the sedative effects of other drugs, for example, opioids.
Be prepared for a paradoxical reaction (agitation secondary to benzodiazepines).
Midazolam should not be given to children with pre-existing respiratory insufficiency or
neuromuscular disease (such as muscular dystrophy).
After the procedure

Encourage the parent to remain with their child.
Provide ongoing analgesia as needed.
Document pain management techniques used and perceived success in minimising pain.
Depending on the procedure, the child may need the opportunity to debrief. For example,
staff and parents should focus on the helpful things the child did during the procedure. Staff
may also like to suggest alternative techniques for any further procedures that may be
planned.
Chronic or persistent pain management

Acute and chronic pain are distinct entities that require vastly different diagnostic and
management skills; see Table 3.3.
Table 3.3 Comparison of the qualities and clinical course of acute versus chronic or persistent
pain
Acute pain Chronic or persistent pain
Tangible and understandable by the patient, family, friends and Often nothing to see and
the treating doctor minimal evidence of tissue
damage
Usually brief, evoked by a recognised noxious stimulus and Often present for prolonged
associated with an adaptive biological significance (e.g. duration
protection of injured part to encourage healing)
Usually improves rapidly and is associated with functional May be evoked by minor
improvement and pain score reduction on a daily basis trauma
Usually related to the nature and extent of tissue damage Generally improves slowly
over time with an undulating
course
Responds to pharmacological intervention Improvement and
deterioration may be linked
to life stresses
Not necessarily related
directly to the nature and
extent of tissue damage
Does not always respond to
pharmacological intervention
Often associated with
secondary gains (e.g. school,
sport or chore avoidance)
Assessment
General principles
Integrated multidisciplinary assessment and management is ideal.

Assess the physical and psychosocial causes for the child's presentation.
The factors maintaining persistent pain will determine specific treatment.
An integrated approach with good communication between the involved healthcare
providers is ideal.
History
Is the pain
Nociceptive (arising from peripheral or visceral nociceptors)?
Neurogenic (arising at any point from the primary afferent neurone to higher centres in
the brain)?
Psychogenic (occurs in the absence of any identifiable noxious stimulus or injurious
process)?
Fixed factors (age, cognitive level, previous pain experience, witnessed examples of how
other family members react to pain).
Situational factors (social and academic functioning at schools, learned pain triggers,
independent pain-reducing strategies).
Suffering (fear, anxiety, anger, frustration, depression).
Pain behaviour (overt distress, secondary gain, consultation with multiple health
professionals factors, moaning, splinting, complaining of pain). Pain behaviour is
exacerbated where the following factors are present:
Pain is central to communication (e.g. to receive a diagnosis or treatment).
Similarly, there is an absence of reinforcement for non-pain communication.
The child is fearful of increased pain (e.g. with movement).
The meaning of pain is fear-inducing.
The child and their parents may hold unhelpful beliefs and inadvertently maintain
suffering, disability and dependency. The parents or child may obtain significant
secondary gain from the child's maintained pain.
Assess for
Unhelpful belief systems of child and/or family (e.g. if pain were cured the other
problems would not exist).
Unrealistic expectations (e.g. it is others' responsibility to fix the problem).
Functional disability (e.g. inability to play sport, socialise with peers, attend school).
Impaired sleep often occurs.

Examine the painful site
What is causing the pain?
Are there signs of complex regional pain syndrome (CRPS)? (see p. 27).
Is there secondary deconditioning (e.g. muscle wasting, joint stiffening, tendon shortening)?
These can occur rapidly, especially when fear of touch or movement exists.
Management
The goals are to eliminate pain, restore function and reduce pain behaviour. It is desirable to
identify the cause of pain, treat and eliminate it; however, this is not always possible.
Therefore management aims to achieve a more active and fulfilling lifestyle, less constrained
by pain with improved coping.
Coordinate outpatient appointments to facilitate achieving these goals and minimising school
absenteeism, time off work for parents and discouraging adoption of the sick role.
When to refer to a multidisciplinary pain clinic

A multidisciplinary team should ideally include a pain medicine specialist, physiotherapist,
clinical psychologist, occupational therapist and child psychiatrist. The team should have
access to an orthopaedic surgeon, neurosurgeon, paediatrician, paediatric rheumatologist and a
rehabilitation specialist.
Refer when
Pain is more intense or persists longer than anticipated (e.g. after an injury).
Character of pain is different to that expected.
Pain responds poorly to medication.
Loss of function results in secondary deconditioning (e.g. muscle wasting).
Pain interferes with sleep, socialising with peers, school attendance and leisure activities.
Pain behaviour manifests.
CRPS is present.
Pain is neuropathic.
Non-pharmacological techniques in chronic pain management

Pain education
Help the patient understand that stress, anxiety and anger may contribute to pain.
Identifying these stressors (often school or family) and managing these feelings more
effectively may reduce or eliminate pain.
Help the patient understand that pain does not always mean damage, and that pain is not
a hindrance to return to function.
Provide illness information (if one has been identified) outlining implications for the
future. This can minimise anxiety.
Cognitive behavioural techniques address the (often unhelpful) thoughts that maintain pain
and disability.
Thought stopping or challenging techniques.
Mindfulness
Behaviour modification techniques: based on modifying the consequences of the child's
pain experience and pain behaviour by rewarding positive behaviour.
Pain coping strategies include
Relaxation techniques: muscle relaxation via body awareness techniques, meditation,
self-hypnosis or biofeedback.
Distraction techniques: art, play or music therapy.
Physiotherapy reconditioning programs
Involve gradual return to function.
Utilise: muscle stretches, postural exercises, reconditioning programs and stress
loading (e.g. ‘scrub and carry’ techniques for the upper limbs, weight bearing for lower
limbs).
Ultrasound treatment.
Heat/cold treatment.
Transcutaneous electrical nerve stimulation (TENS): activates large, myelinated
primary afferent fibres (A fibres) that act through inhibitory circuits within the dorsal
horn to reduce nociceptive transmission through small unmyelinated fibres (C fibres).
TENS is more likely to be effective if pain responds to heat or cold.
Pacing activity with reasonable goals.
Management of setbacks.
Sleep management.
Family therapy
Addresses how family dynamics may maintain pain.
Addresses how pain affects the rest of the family (e.g. lack of attention for well
siblings).
Parental counselling
Parents may inadvertently support illness and ignore non-pain activities.

Addresses parental feelings of helplessness and loss of control.
Equips parents with strategies to manage pain behaviour.
Assertiveness training.
School liaison
Address bullying.
Modifications to allow return to school despite disability.
Equip teachers with strategies to deal with pain behaviour.
Graded return-to-school programs with involvement and education of teachers.
Vocational counselling.
Hydrotherapy.
Acupuncture.
Pharmacological techniques in chronic pain management

Paracetamol
Limit the dose for long-term administration to 60 mg/kg per day.
Steroids
Triamcinolone used for joint injections, trigger point injections, tendon sheaths and
neuralgias.
Dexamethasone administered by iontophoresis for soft tissue injuries.
Epidural or root sleeve steroid administration for localised nerve root irritation due to disc
herniation without motor weakness.
Non-steroidal anti-inflammatory drugs

Topical gels (diclofenac, piroxicam, ibuprofen)
Oral and rectal preparations (described in Table 3.1)
Anti-neuropathic medications
Tricyclic antidepressants (TCADs)/newer noradrenergic and serotonergic reuptake
inhibitors (SSRIs)
Improve pain even if depression is not present by suppressing pathological neural discharges.
Provides more effective analgesia, usually within days, once appropriate dose reached.
Indications
Severe unremitting pain, especially if neuropathic

CRPS
Associated depression
Poor sleep
Amitriptyline is the most commonly used TCAD, starting at 0.2 mg/kg per day increasing over
2 weeks to 2 mg/kg per day. Administer as a single dose before bed to take advantage of
sedative properties. Increase dosage until the desired treatment goal is achieved or side effects
become unacceptable, for example dry mouth, morning somnolence.
Anticonvulsants (e.g. gabapentin, pregabalin or carbamazepine)
Indicated for neuropathic pain and CRPS
Dosage should be in the therapeutic anticonvulsant range, although there is no evidence of any
relationship between analgesic effect and the plasma level. Some recommend increasing the
dosage to the point of side effects or analgesia. Gabapentin is not licensed for use in pain and
incurs an out-of-pocket cost.
Opioids
Only partially modulate central sensitisation.
Usually ineffective in controlling neuropathic pain or pain secondary to CRPS.
Indicated in cancer pain and nociceptive pain.
Tramadol may be useful.
Other techniques can include ketamine, baclofen, clonidine, sympathetic and peripheral nerve
blocks. Surgical techniques are rarely used in paediatrics.
Complex regional pain syndrome (CRPS), types I and II

This condition is of unknown aetiology and is more common in paediatrics than is generally
realised. The diagnosis is clinical and treatment is easier when the condition is recognised
early.
Type I was formerly known as reflex sympathetic dystrophy (RSD). It often occurs after a
noxious stimulus to the affected limb (e.g. minor trauma or surgery). Symptoms are
disproportionate to the inciting event.
Type II was formerly referred to as causalgia. It differs from type I because it occurs after
peripheral nerve injury.
Clinical manifestations
The affected area, usually a limb, manifests autonomic, sensory and motor symptoms consisting
of
Pain
Regional non-dermatomal distribution
Hyperaesthesia (diffuse pain exacerbated by touch)
Allodynia (pain elicited by a stimulus that is not usually painful)
Temperature change (affected limb often colder)
Changes in skin blood flow – often red/purple colour change
Abnormal sweating
Oedema
Loss of function/reduced range of motion
Motor dysfunction – weakness, tremor, dystonia
Abnormal hair growth, skin and/or nail atrophy
Investigations
Acute phase markers – normal
Bone scan often abnormal – increased or decreased uptake
Plain radiograph – osteopenia in prolonged cases
MRI – diffuse marrow infiltration is sometimes present
Management
Management requires early identification, skilful physical therapy, avoidance of
immobilisation and multidisciplinary pain team input.
Consider psychiatric assessment, pharmacological and interventional techniques.
Neuropathic pain
Typified by continuous burning with an intermittent electric shock, stabbing or shooting-
type discomfort.
May be paroxysmal or spontaneous.
Pain in an area of sensory loss.
Pain in the absence of ongoing tissue damage.
Associated with dysaesthesia (unpleasant, abnormal sensation; e.g. ants crawling on skin),
allodynia and hyperalgesia (increased pain in response to noxious stimuli).

Increased sympathetic activity may be present.
Causes include CRPS type II, tumour, spinal cord injury, nerve damage (e.g. neuropraxia or
avulsion, neuroma).
Usually poor response to opioid medication.
Consider the use of anti-neuropathic medications and early referral to a pain specialist
and/or multidisciplinary pain management team if prolonged or refractory.
Pain in children and adolescents with disabilities
See also Chapter 23, Child development, p. 357.
Pain assessment in individuals with cerebral palsy, cognitive impairment and/or
communication difficulties can prove challenging.
No simple pain assessment tool exists.
Caregivers are best placed to distinguish pain from ‘normal’ behaviour in the individual.
Pain may manifest as crying, screaming, frequent waking, grimacing, arching, muscle spasm
or self-injurious behaviour, but some individuals with cerebral palsy or intellectual
disability may exhibit these behaviours without experiencing pain.
Differential diagnosis includes seizures, muscle spasm, anxiety, depression and anger.
A thorough search for the cause of pain will guide treatment options.
Sleep disturbance
Occurs frequently and has implications for the functioning of the whole family.
Address poor sleep hygeine.
Address underlying worries and concerns.
TCAD, via their analgesic and sedative effects, may be useful in reducing the frequency of
waking.
Melatonin may also be useful.
USEFUL RESOURCES
www.rch.org.au/anaes/pain_management/Acute_Pain_Management_CPMS/ – RCH
Acute Pain Management Service Clinical Practice Guidelines. Links to many topics
including: morphine by intermittent bolus guideline; opioid by infusion and patient
controlled analgesia (PCA).
www.rch.org.au/clinicalguide/guideline_index/Analgesia_and_Sedation/ [Analgesia
& Sedation] – RCH Clinical Practice Guidelines including links to Nitrous Oxide and
Ketamine Guidelines.
www.pediatric-pain.ca – Pediatric Pain Research Lab. Site created by a Canadian
research group, devoted to the topic. Contains useful downloadable pamphlets and
protocols.

Paediatric Handbook - (CHAPTER 3 Pain Management)

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Paediatric Handbook - (CHAPTER 3 Pain Management)

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CHAPTER

Numerous misconceptions contribute to under-treatment of paediatric pain, including

Assessment of acute pain

Analgesics for acute pain

Diclofenac 1 mg/kg b.i.d– Oral and

Ketorolac 0.2 mg/kg IV available Off-license use <16

Examples of patients with severe pain and suggested management

Bowel obstruction requiring laparotomy

Metastatic cancer with bony metastases and large intra-abdominal mass

Procedural pain management

Before the procedure

During the procedure

Creams remain effective for up to 4 hours after application.

Anxiolytics and sedatives

After the procedure

Chronic or persistent pain management

Integrated multidisciplinary assessment and management is ideal.

Impaired sleep often occurs.

When to refer to a multidisciplinary pain clinic

Non-pharmacological techniques in chronic pain management

Parents may inadvertently support illness and ignore non-pain activities.

Pharmacological techniques in chronic pain management

Non-steroidal anti-inflammatory drugs

Severe unremitting pain, especially if neuropathic

Complex regional pain syndrome (CRPS), types I and II

allodynia and hyperalgesia (increased pain in response to noxious stimuli).

Pain in children and adolescents with disabilities

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