Managing Pain in Children

A Clinical Guide for Nurses and Healthcare Professionals

Alison Twycross, Stephanie Dowden, Jennifer Stinson, Alison Twycross, Stephanie Dowden, Jennifer Stinson

• Publisher: Wiley-Blackwell
• Year: 2013
• ISBN:
  9781118514566
• Edition: 2
• Topic: Medicine
• Subtopic: Pedriatic Nursing

Providing an evidence-based, practical guide to care in all areas of children's pain management, Managing Pain in Children offers nurses and other healthcare professionals an introduction to the skills and expertise to manage children's pain effectively.

This fully-updated second edition first explores the relevant anatomy and physiology of children, the latest policy guidelines surrounding pain management and ethical issues involved in managing children's pain. Various pain assessment tools available for children and non-drug methods of pain relief are then explored and applied to practice in relation to acute pain, chronic pain, palliative care and the management of procedural pain. The evidence base, assessment techniques, pain-relieving interventions, and guidance for best practice in both hospital and community settings are covered throughout, making this title an ideal resource for all nurses and healthcare professionals working with children.

CHAPTER 1

Why Managing Pain in Children Matters

Alison Twycross

Department for Children's Nursing and Children's Pain Management, London South Bank University, United Kingdom

Anna Williams

Faculty of Health, Social Care and Education, Kingston University and St George's University of London, United Kingdom

Introduction

Despite the evidence to guide clinical practice being readily available, the management of pain in children is often suboptimal. This chapter will start by providing a definition of pain and pain management and will highlight the consequences of unrelieved pain. Children's views about the effectiveness of their pain management will be discussed, and commonly held misconceptions about pain in children detailed. The factors thought to influence pain management practices will be outlined. Information about pain management standards published in several countries will be discussed. How well children's pain is currently managed will be considered alongside the issue of professional accountability. Finally, the ethical imperative for managing children's pain effectively will be examined.

What is Pain?

---

‘Pain is whatever the experiencing person says it is, existing wherever they say it does’ (McCaffery 1972).

‘Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Pain is always subjective. Each individual learns the application of the word through experiences related to injury in early life’ (International Association for the Study of Pain [IASP] 1979, p. 249).

---

These two definitions of pain illustrate that the experience of pain is both a subjective and an individual phenomenon. This is particularly clear in the IASP definition, which explains how the many facets of pain interrelate and affect pain perception. Although supporting the concept of pain as a subjective phenomenon, the original IASP definition fell short in relation to those unable to communicate verbally, including neonates and young children and cognitively impaired children. This was addressed in 2001 when the following amendment was made:

‘The inability to communicate in no way negates the possibility that an individual is experiencing pain and is in need of appropriate pain-relieving treatment’

(IASP 2001, p. 2).

---

Pain management means applying the stages of the nursing process – assessment, planning, implementation and evaluation – to the treatment of pain.

---

The cyclical basis of these stages is illustrated in Figure 1.1.

Figure 1.1 The stages of pain management.

Consequences of Unrelieved Pain

Pain has an important purpose, serving as a warning or protective mechanism, and people with congenital analgesia, who are unable to feel pain, often suffer extensive tissue damage (Melzack and Wall 1996). However, unrelieved pain has a number of undesirable physical and psychological consequences (Box 1.1). When these are considered, the need to manage children's pain effectively is clear. The results of studies demonstrating this are outlined in Box 1.2.

---

BOX 1.1
Consequences of unrelieved pain

Physical effects

• Rapid, shallow, splinted breathing, which can lead to hypoxaemia and alkalosis
• Inadequate expansion of lungs and poor cough, which can lead to secretion retention and atelectasis
• Increased heart rate, blood pressure and myocardial oxygen requirements, which can lead to cardiac morbidity and ischaemia
• Increased stress hormones (e.g. cortiosol, adrenaline, catecholamines), which in turn increase the metabolic rate, impede healing and decrease immune function
• Slowing or stasis of gut and urinary systems, which leads to nausea, vomiting, ileus and urinary retention
• Muscle tension, spasm and fatigue, which leads to reluctance to move spontaneously and refusal to ambulate, further delaying recovery

Psychological effects

• Anxiety, fear, distress, feelings of helplessness or hopelessness
• Avoidance of activity, avoidance of future medical procedures
• Sleep disturbances
• Loss of appetite

Other effects

• Prolonged hospital stays
• Increased rates of re-admission to hospital
• Increased outpatient visits

Source: WHO (1997)

---

---

BOX 1.2
Examples of research demonstrating the effects of poor management of acute pain

Taddio et al. (1997)

• Data from a clinical trial studying the use of EMLA® during routine vaccinations at 4 or 6 months was used to ascertain whether having had a circumcision impacted on boys' (n = 87) pain response.
• Boys who had been circumcised without anaesthesia as neonates were observed to react significantly more intensely to vaccinations than uncircumcised boys (p < 0.001).
• Supported findings from a previous study (Taddio et al. 1995).

Grunau et al. (1998)

• Examined the pain-related attitudes in two groups of children, aged 8–10 years: extremely low birthweight children (n = 47); full birthweight children (n = 37).
• The very low birthweight group of children had been exposed to painful procedures as neonates, the other group had not.
• Children were shown the Pediatric Pain Inventory, which comprises 24 line drawings, each depicting a potentially painful event (Lollar et al. 1982).
• The two groups of children did not differ in their overall perceptions of pain intensity. However, the very low birthweight children rated medical pain intensity significantly higher (p < 0.004) than psychosocial pain, suggesting that their early experiences affected their later perceptions of pain.

Saxe et al. (2001)

• Investigated the relationship between the dose of morphine administered during a child's hospitalisation for an acute burn and the course of post-traumatic stress disorder (PTSD) symptoms over the 6-month period following discharge.
• Children (n = 24) admitted to the hospital for an acute burn were assessed twice with the Child PTSD Reaction Index: while in the hospital and 6 months after discharge.
• The Colored Analogue Pain Scale was also administered during the hospitalisation. All patients received morphine while in the hospital. The mean dose of morphine (mg/kg/day) was calculated for each subject.
• There was a significant association between the dose of morphine received while in the hospital and a 6-month reduction in PTSD symptoms.
• Children receiving higher doses of morphine had a greater reduction in PTSD symptoms.

Rennick et al. (2002)

• A prospective cohort study of patients (n = 120) in paediatric intensive care units and medical-surgical wards.
• There were no differences between wards in terms of negative outcomes; however, children in the intensive care units received more analgesics and sedation.
• 17.5% of patients expressed significant medical fears 6 weeks after discharge.
• 14% continue to express these fears 6 months later.
• Children who underwent more invasive procedures had more medical fears, felt less in control of their own health, and exhibited more signs of post-traumatic stress for 6 months after discharge.

Taddio et al. (2002)

• A prospective cohort study of babies (n = 21) born to mothers with diabetes and babies (n = 21) born to mothers with an uneventful pregnancy.
• Infants of diabetic mothers had repeated heel-sticks in the first 24–36 hours of life.
• Babies of diabetic mothers demonstrated significantly greater pain behaviours at venepuncture for newborn blood screening (p = 0.04).

Grunau et al. (2009)

• Infants (n = 137 born preterm at 32 weeks gestation; n = 74 full-term controls) were followed prospectively.
• Infants with significant brain injury or major sensorineural impairments were exclude...