PAIN IN CHILDREN

Are we accomplishing the optimal pain treatment?

Dr. Roshana Mallawaarachchi

A little History
1970sonly half of children treated postoperatively

with analgesics.
1980s only half of the doses of analgesics compared

to adults with the same operation.

1990sdoing better with surgical but not medical pain

and certainly not chronic pain.

Even NowUp to 40% of providers believe newborns

dont experience pain.

A little History
Text book of Paediatrics (1968): Swafford and Allan

Pediatric patients seldom need medication for

the relief of pain. They tolerate discomfort well.
The child will say he does not feel well or that he is
uncomfortable or that he wants his parents but often
will not relate this unhappiness to pain

A little History
We no longer assume that neurological

immaturity limits an infant or childs perception

and experience of pain.

What is Pain?
The International Association of the Study of Pain:

An unpleasant sensory and emotional

experience associated with actual or
potential tissue damage, or described in
terms of such damage

What is Pain?
Pain is subjective. The response to pain is highly

variable:

Among different individuals.

Same person at different times.

Newborns, infants and disabled individuals can not

describe their pain.

But, from the gestational age of 20 weeks have a
functional pain system.
Anand and Craig extend the definition of Pain to
include behavioral responses caused by pain.

What is Pain?
1. Acute Pain: Due to nociception. (noci = Harm),

Neural responses to traumatic or noxious stimuli.

Somatic (Superficial / Deep)
Visceral
Nociceptive pain is the commonest source of pain.
in children. (Eg: Post Op pain)
2. Chronic Pain: May be due to nociception, major

role: Psychological & Behavioral factors.

Acute pain

Sudden in onset
Severe in nature
Intensity can vary from
mild to severe
Different magnitudes
Does not persist beyond
3 months.

Chronic pain

Lasts for more than 3

months.
A syndrome
Acute pain can become
chronic pain rapidly

Chronic pain serves no

The body's alarm system

purpose

Development of Pain Pathways

All neural pathways are present from birth.

(including premature neonates)

PNS:
C-fibres are mature in neonates although their
cortical connections at the level of the dorsal horn
are immature.
A-Beta fibres can produce nociceptive signaling
from lower intensity stimuli.
Less discrimination between the perception of
noxious and non-noxious stimuli.

Development of Pain Pathways

Inhibitory pathways are not fully developed in

the spinal cord during early life.

More pain in Paediatric patients because:

Widened receptive fields.

Lower sensory discrimination .
Reduced inhibitory pathways.

Pain Physiology

Pain Stimuli
Physical
Mechanical
Thermal

Chemical
Toxins,

tissue proteases
Hydrogen ions, Potassium ions, Prostaglandins,
Histamine, Bradykinin and Serotonin
Tissue injury stimulate nociceptors.
Tissue

damage release prostaglandins

Nociceptors
Special free nerve endings, at the end of sensory nerves.
Located next to mast cells and small blood vessels.
Found in the skin, muscles, joint capsules, visceral organs

and arterial walls.

Two types

High Threshold Mechanoceptor

Polymodal Nociceptor

Nociceptors
Mechanoceptor
Respond to intense mechanical stimulation.
Polymodal nociceptors

Respond to noxious mechanical, thermal and chemical

stimuli.

An initial pain stimulus stimulate nociceptors

depolarise the sensory nerve

Proportionate to the intensity of the stimulus

The frequency of the stimuli

Pain Physiology
With stimuli mast cells activate.

Pain Physiology
With activation histamine is released

Pain Physiology
Histamine stimulates nociceptor

Pain Physiology
Nociceptor release subs P & glutamate

Pain Physiology
That will stimulate mast cells further

Pain Physiology
.. & release more histamine

Pain Physiology
Depolarization of nociceptor occurs

Pain Physiology
Action potentials transmitted along pain fiber

Pain Physiology
Transmission of pain impulses to the spinal

cord
The afferent or sensory neurones
A

delta () fibers
C fibers
The cell bodies are located in the dorsal root
ganglions.
Sensory nerve fibers enter the dorsal roots.
Some afferents do enter the ventral roots.

Pain Physiology
A & C fibers

The pain pathway

Transmits pain from the periphery to the cerebral

cortex:
Consists of 3 neurones.
The primary or first order neurone

Bipolar
Cell body in the dorsal root ganglion
The axon which projects to the dorsal horn of the spinal
cord.

The pain pathway

A second order neurone:
Synapses with the primary neurone in the dorsal horn.
The axon crosses over and ascends.
There are two types of 2nd order neurones

Wide -dynamic range (WDR) neurones

-Respond to non-noxious stimuli and noxious stimuli

Nociceptive -specific (NS) neurones

-Respond exclusively to noxious stimuli

The pain pathway

Ascending tracts

Carry pain information to the brain:

Spinothalamic

tract
Spinoreticular tract
Spinal mesencephalic tract
Postsynaptic dorsal column pathway
The 3rd order neurone projects from the thalamus,

reticular formation or mesencephalon to the cerebral

cortex.

The pain pathway

Spinothalamic Tract
Originate in laminae I and V.

Cross over to the other side of the cord.

Ascend in the anterolateral quadrant of the spinal

cord.
Reach thalamus

Lateral nuclei and Medial nuclei.

In the thalamus synapse with 3rd order neurones,

3rd order neurone project to
Frontal cortex
Somatosensory cortex

The pain pathway

Spinoreticular Tract
Fibres of the spinoreticular tract ascend from the dorsal

horn to the reticular formation in the brain stem.

The reticular formation plays a crucial role in processing

pain information.
Activity in the spinothalamic and spinoreticular tracts are

responsible for determining the quality and intensity of the

pain.

The pain pathway

The brain structures

Thalamus
The reticular formation
The limbic system
Periaqueductal gray in the brain stem
Lentiform nucleus in the basal ganglia
Parts of the cerebral cortex
The

anterior cingulate cortex

Insula
Somatosensory cortex

The pain pathway

Thalamus and hypothalamus
A lot of pain information is relayed through the thalamus

(spinothalamic tract)
Fibers from the thalamus project to
Brain

stem

- Sensory, arousal and autonomic components

Sensory

cortex and the frontal lobes

- Behavioural or affective component

The pain pathway

Limbic system

Is a collection of components.
It is sometimes called the emotional brain.
Receives many fibers from the thalamus.
Responsible for emotional aspects of pain and its

responses (anxiety and fear)

The amygdala

Important for affective, emotional, behavioral and

autonomic responses to pain.

The pain pathway

Cerebral cortex
Anterior Cingulate Cortex
Integrate information about pain perception.
Involved in the perception of suffering and emotional

response.
Opioid receptors are abundant in this area.
May be influential in modulating the pain experience.

The pain pathway

Somatosensory cortex

Located in the parietal lobes

Responsible for the conscious perception of pain
Location
Quality

of the pain
Magnitude of the stimulus

Knowing-doing gap
Reluctance of using new knowledge in real practice.

Due to:

Lack of interest
Fear of using strong analgesics
Misconceptions

Why Analgesics?
Untreated pain may have long-term negative effects on

Pain sensitivity
Immune functioning
Neurophysiology
Attitudes
Health care behaviour

Pain assessment
Pain is a complex experience:

So assessment scores have to be judged together with

other clinical factors
Behavioral observation
Physical exam
Origin of pain

Tools are based on

Self-report - gold standard , Preferred method

Observation of behaviour

Pain assessment
Self-report tools

Visual analogue scale (VAS)

Wong-Baker Faces Pain Rating Scale
Faces Pain Scale - Revised
Poker chip tool

Pain assessment
Visual analogue scale (VAS)
For ages 3- adult
Horizontal line with no pain at one end to worst

possible pain at the other.

Pain assessment
Wong-Baker Faces Pain Rating Scale

For acute pain. Age group 3-18 years.

Six line-drawn faces range from no pain to worst

pain.

Pain assessment
Faces Pain Scale-Revised
For acute pain. Age group 4- 16 years.
Six cartoon faces range from neutral to high pain

expression.

Pain assessment
Poker chip tool
Child chooses which chips represent the pain.
One chip indicating a little hurt and all four chips

indicating the most hurt.

How many pieces of hurt do you have right

now?

Pain assessment
Observational Tools

FLACC Pain Assessment Tool

Procedure Behavior Checklist
Children's Hospital of Eastern Ontario Pain Scale
COMFORT Scale
Premature Infant Pain Profile

Pain assessment
FLACC Pain Assessment Tool
A simple framework for quantifying pain; who may not be

able to verbalize.
5 categories of pain behaviours.

Facial expression
Leg movement
Activity
Cry
Consolability

Total possible range of 0 to 10.

Pain assessment
Procedure Behavior Checklist
Age group 3-18 years.
8 behaviours rated on occurrence and intensity.

Muscle tension
Screaming
Crying
Restraint used
Pain verbalized
Anxiety verbalized
Verbal stalling
Physical resistance

Pain assessment
Children's Hospital of Eastern Ontario Pain Scale
Age group 112 years.
Assesses 6 behaviours.

Cry
Facial
Child verbal
Torso
Touch
Legs

Pain assessment
COMFORT Scale
Age group 018 years.
8 domains.

Alertness
Calmness/agitation
Respiratory response
Physical movement
Mean arterial blood pressure
Heart rate
Muscle tone
Facial tension

Pain assessment
Premature Infant Pain Profile

7 indicators of pain.
Physiological

Heart rate, Oxygen saturation

Behavioural dimensions

Facial expression, eye squeeze, brow bulge, nasolabial furrow,

and crying

Pain assessment
Recommended measures for procedural and
postoperative pain assessment:
Newborn3 yr
4 yr old
57 yr old
7 yr old +

COMFORT or FLACC
FPS-R + COMFORT or FLACC
FPS-R
VAS or NRS or FPS-R

Aetilogy of Paediatric Pain

Main causes of Acute pain in children:

Procedures
Surgery
Trauma
Acute medical illness

Successful pain management in Children:

Education of staff
Pain assessment
Anticipation of pain
Provision of a calm environment
Inclusion of parents

Procedure related pain

Multiple procedures are frequently required.
Aim:

Minimize pain
Minimize physical discomfort
Minimize psychological distress

Pharmacological and non-pharmacological

methods.

Procedure related pain

Non-pharmacological strategies:
Both child and parent should be adequately prepared.
Gaining parents confidence.
Age and developmentally appropriate information.

Chance to ask any questions.

Younger children: act out the procedure with a toy medical kit.

Comfortable, calm and friendly environment.

Equipment for distraction should be available.
(Eg: Toys, interactive books, puppets, bubbles and

electronic games)

Procedure related pain

Pharmacological methods
Analgesia with or without sedation.

Topical anaesthesia
Local infiltration
Peripheral nerve blockade
Biers block
Nitrous oxide
Ketamine
Intra-nasal fentanyl

Midazolam? : No analgesic effect / creates amnesia,

increased excitation for each procedure.

Procedure related pain

Combination of Analgesics:
LA, PCM, COX inhibitor
Buffered anaesthetic solutions in wounds and infiltration.
Short acting drugs are preferred.

Alfentanyl/Fentanyl
Alpha 2 agonists (Clonidine/Dexmedetomidine)

Atomizing devices:

Smaller dose, fast onset Eg: intranasal fentanyl, Sufentanyl,

Dexmedetomidine

Procedural pain in the neonate:

Blood Sampling:
Sucrose or other sweet solutions can be used
Topical local anesthetics
Nonpharmacological measures
Tactile stimulation
Breast-feeding
Massage of the heel

Procedural pain in the neonate:

Lumbar puncture
Topical

local anesthesia
Urine sampling
Local anesthetic gel
Nasogastric tube placement
Sucrose can reduce the pain response
Immunization and intramuscular injection
Swaddling, breast-feeding or pacifier, and
sucrose, least painful first, 25-gauge needle.
IM should be avoided.

Procedural pain in older children

Chest drain (tube) insertion and removal
General anesthesia or sedation combined with SC

infiltration of buffered lidocaine.

Change of dressings in children with burns
Potent opioid analgesia given by oral, transmucosal,

or nasal routes.
50% nitrous oxide/oxygen.

Procedural pain in older children

IV cannulation:

Topical LA (EMLA or AMETOP)

Buffered injected LA (lidocaine + bicarbonate 10:1) with a fine
30G needle SC prior to cannulation.
Nitrous oxide (5070%) inhalation.
Vapocoolant topical spray. (ethyl chloride)

Laceration repair

Tissue adhesives
Hair apposition technique (HAT) in scalp lacerations
Topical anesthetic preparations (LAT)

Post-operative pain
Discuss pre-operatively with the carers and with the

children.
Aim: Control pain as early as possible.
Regional anaesthetic techniques before starting surgery,

multi-modal analgesia are preferred.

Alpha-2-agonists as premedication: Limits post anaesthesia
agitation.
Major surgeries: Low dose S-Ketamine continuous
infusions for several days.
Dosages and the interval should be adjusted based on the
assessment.

ENT surgery
Myringotomy: Oral paracetamol or NSAIDS
Tonsillectomy: Intraoperative opioids,

dexamethasone, and mild analgesics (NSAIDS

and /or paracetamol)
Mastoid and middle ear surgery
Great auricular nerve block

Opthalmology
Strabismus surgery
Intraoperative LA blocks (subtenons or peribulbar)
Vitreoretinal surgery
NSAID, Peribulbar block

Dental procedures
NSAIDS with or without paracetamol.
Swabs soaked with bupivacaine on exposed tooth

sockets.

General surgery and urology

Sub-umbilical surgery

Wound infiltration, TAP block, ilio-inguinal nerve block

and caudal analgesia
Circumcision
Caudal epidural and dorsal nerve block
Topical application
Hypospadias repair
Caudal or dorsal nerve block
Open inguinal hernia repair
LA wound infiltration, ilio-inguinal nerve block,
paravertebral block or caudal analgesia

 Major intra-abdominal surgery:

Intravenous opioids either as continuous infusion, NCA,

or PCA, Epidural analgesia
Appendicectomy:
PCA combined with NSAID
Laparoscopic surgery:
Infiltration of port sites with LA is part of a multimodal
analgesic.
Orthopaedics, spinal and plastic surgery
Epidural analgesia using opioids
Short-term NSAID

Trauma

Morphine is still the most commonly used first line

analgesic for severe pain.

Incrementally up to a dose of 0.1mg/kg.
Other methods:

Topical anaesthesia, inhaled 50% N20/ 50% 02, IV regional

anesthesia and inhalational or transmucosal opioids.

Pharmacological Therapies
Paracetamol
COX Inhibitors
Opioids
Alpha 2 agonists
S- Ketamine
Local anaesthetics and Nerve block
Other Analgesics

Paracetamol (Acetaminophen)
Should be considered at all stages.
Inhibition of prostaglandin H2 and cyclo oxygenase

3 (COX-3) in CNS.
Both anti-pyretic as well as analgesic action.
Opioid sparing effect.
Side effects and adverse reactions are uncommon.
Complications: Hepatotoxicity
Variety of routes: Oral, Rectal, IV

Paracetamol (Acetaminophen)
Oral dose: 15 20 mg/kg given 4-6 hourly for pain relief

and anti-pyresis.
Rectal dose: 30-40 mg/kg or 20mg/kg for neonates.
IV: Greater dosing accuracy, rapid and predictable onset

of action (within 5 min), Better until GI motility regain,

Less toxicity, Reduce morphine dosage upto 50%.
Daily maximum dose is 90 mg/kg in children aged > 3

months. 60mg/kg: 3252 weeks PCA

COX Inhibitors
Inhibits the cyclooxygenase-2 isoenzyme.
Prevents the conversion of arachidonic acid to

prostaglandins and thromboxane.

Prostaglandins sensitize nociceptors to increase
afferent nociceptive signalling.
Considered as part of routine acute analgesic as
opioid sparing effects.
NSAID and paracetamol is recommended.
Eg: diclofenac, ibuprofen and ketoprofen.

COX Inhibitors
Ibuprofen- oral suspension, infant drops, tablet and IV

formulations.
In children weighing > 7 kg
Licensed from age: 3 months
Dose is 30mg/kg in 3-4 divided doses.
Diclofenac- tablets, suppository and parenteral

formulations.
Licensed from age: 6 months
Dose orally and per rectum is 0.31 mg/kg (max. 50 mg) 3
times daily.

COX Inhibitors
Ketorolac
IM, IV or orally
Not licensed for use in children below 16 years of age.
Only for the short term management.
Higher risk of bleeding.
If post Op bleeding must be avoided (Neurosurgery)

more selective COX 2 inhibitors are recommended.

(Eg: Parecoxib)

COX Inhibitors
Side effects:
Hypersensitivity reactions.
Reduce platelet aggregation and prolong BT.

CI in coagulation disorders.

Inhibit prostaglandin-mediated renal function.

Gastric irritation and bleeding.
Excess leukotriene > exacerbate Asthma (1:1000)

COX Inhibitors
A standard Multimodal analgesic approach

important for fast recovery:

Eg of a combination (Sweeden):

IV Paracetamol
COX inhibitors
Alpha 2 agonists
Continuous opioid infusion

Opioids
Act through dedicated receptors:
Mu, Kappa, Delta and ORL-1 (orphanin like receptor)
CNS and at sites of peripheral inflammation.
Dose adjusted to age, clinical response and presence of

side effects.
What is Opioid rotation?

Alteration of opioids to achieve less side effect and better

analgesia

A combination of 2 opioids can be advantageous. Eg:

low dose of Methadone

Opioids
Codeine should No longer used in children. (2012)
Case reports of deaths in children with OSA

undergone tonsilectomy.

Opioids
MorphinePhenanthrene derivative.
2 main metabolites: M-3-G, M-6-G.
M-3-G : No analgesic effect / create excitation
M-6-G: Active/ Analgesic effect
Infants formation of M-3-G is more, causing:

Jitteriness, sleep disturbances, signs of discomfort.

Opioids
Morphine- cont
Oral, IV, IM, SC, rectal, intrathecal, epidural and

intranasal.
Guided by the age, weight and clinical response of
the child.
16 mn initially: 50150 micrograms/kg every 4 hrs
6mn12 yrs 100-300 micrograms/kg every 4 hrs
1218 yrs 520 mg every 4 hrs

Opioids
FentanylSynthetic phenylpyperidine derivative.
100 times more potent than morphine.
Inactive metabolites.
IV, transmucosal, transdermal, inhalational or intra-

nasal route.
Procedure related pain.
IV dose: titrate 0.51.0 mcg/kg (decrease in
neonates)

Opioids
Remifentanil
Synthetic phenylpyperidine derivative.
IV infusions.
Rapidly broken down by non-specific plasma and

tissue esterases.
Short elimination half-life (3-10 minutes).
Induces hyperalgesic effect post operatively.
Loading dose of 0.1 1 mcg/kg over 30 sec
Infusion between 0.1 2mcg/kg/h.

Opioids
Tramadol
Centrally acting.
Structurally related to morphine.
It is not licensed for children under 12 years.
Orally 50100 mg every 4 hours
Might be considered in neuropathic pain.

Patient Controlled Analgesia (PCA)

Can be used in children as young as 5 years.
Similar efficacy to opioid infusions.
Morphine is most commonly used in PCAs
Bolus dose of 20mcg/kg
Background infusions of 4 mcg/kg/hr to maximise

analgesia and minimise side-effects.

Nurse controlled analgesia is also an accepted and
effective variation in practice.

Alpha-2 Agonists
Eg: Clonidine, Dexmedetomidine
Can be used in both nociceptive and neuropathic

pain.
Sedative, anxiolytic, and analgesic properties.
Beneficial in Abdominal and ischaemic pain.
No respiratory depression.
Limited effect in GI motility. Less Nausea and
constipation.
Pain sensitization is reduced.
12 mcg/kg clonidine to caudal prolongs analgesia

Alpha-2 Agonists
Dose dependent sedation. Meta analysis confirmed

benefits of using compared to midazolam as

premedication. Lower incidence of postop agitation.
Adjuvants to Local anaesthetics in PNB and epidurals. (Eg:

Levobupivacaine and Clonidine)

Recommend for post operative pain after discharge.
Should not be given to children with AV block Type II, III.

(Reduce sympathetic outflow)

Ketamine
NMDA antagonist.
Blocks peripheral nociception and prevents central sensitization.
Procedural sedation.
Animal models: Developing brain demonstrated neuroapoptosis.
Dose is 1-2mg/kg IV and 4-13mg/kg IM
Lasting for 510 min.
Low dose infusions can be used for several days post op.
Adverse effects: laryngospasm, vomiting, salivation, increased

muscle tone, emergence hallucinations, drowsiness, rashes and

injection-site reactions.
S-isomer has approximately 2X the analgesic potency.

Nitrous oxide
50 % with oxygen for sedation and analgesia.
Side effects: nausea, vomiting and dizziness.
Prolonged periods may result in megaloblastic

anaemia.

Sucrose
Reduce many physiological and behavioral

indicators of stress and pain in neonates.

Related to the sweet taste.
24% solution 12 min before a painful stimulus.
Carefully to the tongue one drop at a time

Local anaesthetics and Nerve blocks

Block should be given before the surgical procedure.
Safe in all ages.
In conscious children pain on injection is due to acid

solution; Buffered solution minimize the pain and

faster onset.

Bupivacaine
Amide LA, racemic mixture.
0.0625%0.75%
Slow onset and a long duration.
Carbonated solution: faster onset
Complete sensory blockade.
Motor blockade depends.

0.0625%-0.125% less
0.25% incomplete motor block
0.5% extensive motor block
0.75% muscle relaxation

Neonates: reduced hepatic clearance > accumulation

Levobupivacaine: S-enantiomer, Less toxicity

Suggested maximum dosages of bupivacaine,

levobupivacaine and ropivacaine:
Single bolus injection (mg/kg)
Neonates

2
Children 2.5?
Continuous infusion mg/kg/hr
Neonates

0.2
Children 0.4
*A Guideline from the Association of Paediatric Anaesthetists of Great Britain and Ireland 2012

Lidocaine
Amide LA.
Rapid onset of action. intermediate duration.
Vasoconstrictor reduces systemic absorption,

increases both the speed of onset and duration.

Max dose 3 mg/kg.
Max Epinephrine should be 5 microgm/kg

EMLA
Lidocaine forms a mixture with prilocaine.
Melting point lower than that of either ingredient.
lidocaine 2.5% and prilocaine 2.5%.
Venepuncture, intravenous or arterial cannulation,

lumbar puncture, minor dermatological procedures.

Applied at least 60 min and a max of 5 h.
Should not be used on wounds or mucous
membranes or for atopic dermatitis, near eyes.

Ametop
4% Tetracaine gel.
Rapid and prolonged surface anesthesia.
Duration for 46 h
LET
4% lidocaine, 0.1% epinephrine, and 0.5% tetracaine
Combined in a gel.
Direct Surface anesthetic to lacerations. (<6 cm)

Caudal neuraxial analgesic

Additives:
S-ketamine, neostigmine, clonidine,

dexmedetomidine, midazolam, buprenorphine,

fentanyl, and morphine increased analgesic efficacy
and prolonged the duration of the block.
Morphine 0.05-o.1 mg/kg : 20 hrs
Ketamine 0.5 mg kg1 : 12 hrs

Summary
Multimodal approach is preferred.
The use of Non pharmacological therapies should

always be part of the mx.

5 Improvements in last decade:

Iv Paracetamol
COX inhibitors in bone pain
Low dose S-Ketamine infusion in major surgeries
Opioid combination with methadone in complex pain
Use of Alpha-2 agonists

Are we accomplishing the optimal pain

treatment in Sri Lanka?

THANK YOU!

1991 April (SAQ):

Discuss the provision of postoperative pain releif in

children under 5 years of age.

Q2:
What are the modalities of pain relief that you can

suggest to a 2 yr old child undergoing herniotomy?

Give advantageous and disadvantageous of each.