Paediatric Pain Management

A Multi-Disciplinary Approach

Alison Twycross, Anthony Moriaty, Tracey Betts

• Publisher: CRC Press
• Year: 2018
• Print ISBN:
  9781857752465
• eBook ISBN:
  9781315348681
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Children are still enduring unnecessary pain. This unique book is for all health care professionals who care for children, both in hospitals and in the community, and has contributions from nurses, doctors and clinical psychologists. It provides the theoretical knowledge required to manage acute and chronic paediatric pain, and discusses both drug and non-drug methods of pain relief. The information is presented in an accessible manner to enable readers to apply it in their daily clinical practice.

1 Perceptions about paediatric pain

Introduction

‘Pain is whatever the experiencing person says it is, existing wherever they say it does.’¹

‘An unpleasant sensory and emotional experience 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.’²

These two well-known definitions of pain illustrate that the experience of pain is both subjective and an individual phenomenon. It is, therefore, not surprising that health care professionals encounter difficulties in the assessment and management of pain. The perceptions of health care professionals about pain are also influenced by their personal beliefs, attitudes and values.³ The situation is exacerbated by the continuing belief in the misconceptions about paediatric pain that persist despite compelling evidence which proves them to be myths.^4,5 This chapter will demonstrate that children’s pain is not managed appropriately in practice and will then explore the evidence that demonstrates the mythological status of the misconceptions about paediatric pain. The factors that influence health care professionals in their assessment of pain will then be discussed and finally consideration will be given to changing practice.

How well is children’s pain managed in practice?

Seventy-five per cent of children were in pain on the day of surgery, and 40% in severe pain. Only slightly fewer patients reported moderate to severe pain on the first post-operative day. Children were not receiving sufficient analgesics post-operatively.⁶

The Royal College of Surgeons and College of Anaesthetists’ report on Pain After Surgery states that several studies have shown that weaker oral analgesics were relied upon more frequently in children and fewer and relatively smaller doses of opioids were given compared with those for adults.⁷

Mcllvaine indicates that nursing staff will not give opioid analgesia on a fixed schedule if the analgesics are ordered on an ‘as necessary’ (p.r.n.) basis. He suggests that the child must demonstrate a need for the analgesia and then suffer through the period between the request and relief.⁸

Mather and Mackie felt that this situation was due to several factors:⁶

• medical prescriptions were often inadequate
• nurses interpreted the p.r.n. prescriptions as meaning ‘as little as possible’
• nurses were reluctant to give opiate analgesics, substituting non-opiates soon after surgery.

Other studies also found that pain in children was not managed effectively:

• Eland and Anderson compared the post-operative pain management of 18 adults with 25 children. Twelve of the children received a total of 24 doses of analgesics (13 non-opiates and 11 opiates), whereas the remaining 13 children were not given any analgesics. In contrast the adults received 372 doses of opiate and 299 doses of non-opiate analgesics⁹
• Schechter et al. reviewed the charts of 90 children and 90 adults with identical diagnoses and found that, in general, adults received twice as many doses of opioids as the children per hospital day. The longer the hospital stay the greater became the difference between adults and children¹⁰
• Beyer et al. compared the administration of analgesics to 50 children and 50 adults who had undergone cardiac surgery. Six children were prescribed no post-operative analgesics; adults received 70% of the analgesics administered; children received 30%¹¹
• Eland reported that 66% of hospitalized children (n = 2000) aged four to 10 years received no analgesics for the relief of pain¹²
• Cummings et al. found, in 1996, that many children were still enduring unacceptable levels of pain during hospitalization.¹³

Analysis of these findings indicates that children’s pain is still not being managed effectively. This has serious implications – not only are children suffering unnecessary pain but unrelieved pain has many undesirable consequences. The consequences of unrelieved pain are shown in Box 1.1.

Box 1.1 Consequences of unrelieved pain¹⁴

• Rapid shallow breathing that can lead to alkalosis
• Inadequate expansion of lungs that can lead to bronchiectasis and atelectasis
• Inadequate cough that can lead to retention of secretions
• Increased heart rate and tissue ischaemia; the patient will not move spontaneously and will not ambulate
• Fluid and electrolyte losses are increased resulting in rapid respiration and increased perspiration and an increased metabolic rate
• Psychological consequences resulting in nightmares about pain and surgery – the patient will be less co-operative in the future and will have increased anxiety

Initially, at least part of the problem with the management of children’s pain was an inadequate research base. Research on paediatric pain, however, has proliferated in the last 15 years but health care professionals are still not managing pain appropriately.^{15,16, and 17} It is difficult to establish exactly why this should be. It would appear to be partly a problem of implementing evidence-based practice. Significant contributions to the problem are the attitudes and beliefs about children in pain that are held by many health care professionals. These erroneous attitudes will now be discussed.

Misconceptions about paediatric pain

Nurses continue to have misconceptions about paediatric pain in spite of the compelling evidence that demonstrates that they are myths.^4,5

It is clear that children’s pain is not being managed adequately a...

Table of contents

• Cover
• Title Page
• Copyright Page
• Contents
• Foreword
• Foreword
• Preface
• List of contributors
• Acknowledgements
• 1 Perceptions about Paediatric Pain
• 2 Children’s Cognitive Level and their Perception of Pain
• 3 Pain Pathways
• 4 Quality and Pain Management
• 5 Pain Assessment in Children
• 6 Pain Assessment in the Pre-verbal Child
• 7 Non-drug Methods of Pain Control
• 8 The Role of the Clinical Psychologist in Paediatric Pain Management
• 9 The Pharmacological Management of Acute Pain
• 10 The Management of Chronic Pain
• 11 The Future of Paediatric Pain Management
• Index