PAIN IN CHILDREN : ADVANCES & ONGOING CHALLENGES

DR.DEEPAK SOLANKI M.D. ANAESTHESIOLOGY dr.dsolanki@gmail.com

INTRODUCTION
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Pain is an unpleasant physical and psychological experience which if not managed appropriately in children can lead to distress, clinical deterioration and severe functional limitations. Pain can be associated with numerous pediatric diseases and conditions and is an important consideration in children undergoing procedures and surgery. Cancers in children in particular are associated with ongoing pain that requires treatment Control of Pain in Children (Pediatric Pain Management) can be quite difficult as it is hard to determine the exact level of pain present. In addition, many of the medications used to treat pain have not been appropriately tested in children so doctors may not be entirely sure of their effects and be reluctant to use them. Failure to recognise the extent of pain in children and inadequate

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INTRODUCTION
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However, pediatric pain management has made several advances in recent decades through improved understanding of effects of ongoing pain, greater insight into the benefits and risks of aggressive management, and greater knowledge of the clinical aspects of the analgesic (pain reducing) drugs in children. Pain management now focuses on a combination of pharmacological agents (drugs) including simple analgesics and opioids, along with proven non-pharmacological techniques such as hypnosis and Cognitive-Behavioral Therapy .

WHAT IS PAIN ?
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Pain is described as an unpleasant and unique physical and psychological experience. In general terms it can be divided into acute pain, which is often a natural response and acts to protect the body, and chronic pain which lasts for several months. Pain in children has several unique features which make appropriate management challenging. In the past, pain has been poorly managed in pediatric patients due to the false belief that neonates and children do not experience pain or require pain relief, as commonly as adults.

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PAIN IN CHILDREN
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It was thought that neonates did not experience or remember pain due to their immature nervous systems. Subsequent studies showed these responses develop much earlier than thought previously. Furthermore, several studies have highlighted that many health professionals underestimate the level of pain experienced by young children. More recent studies have confirmed the benefits of appropriate pain relief in young patients and that neonates, infants, and children can receive analgesia and anesthesia safely if the necessary dosing and administration adjustments are made. Inadequate management of pain, particularly chronic forms can have substantial impacts on children.

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EFFECTS OF PAIN IN CHILDREN

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A recent study proved that chronic pain in children and adolescents can cause considerable functional limitations, particularly school absenteeism, sleep disturbance and inability to perform sporting activities. Ongoing absences from school due to pain can lead to poor school performance and long-term complications Pain in the acute setting can lead to deterioration in the patient's clinical condition.

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HOW PAIN IS EXPRESSED ?

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All children experience pain differently and it can be quite difficult as a parent to guess that behavioral changes and other signs may be due to pain. Some children in severe pain may become quiet and withdrawn whilst others may display aggressive tendencies. In young children especially, it can be hard to tell as they simply can't verbalize that something is painful or sore. On the contrary, adolescents tend to minimse or deny pain in the presence of their peers thus they require specific and private questioning about their pain. The varying outward expressions of pain also make it hard for medical staff to diagnose and manage pain in children

HOW PAIN IS EXPRESSED IN CHILDREN ?

As an overview, pain may present in various forms including changes in: n Behaviour n Appearance n Activity level n Vital signs- These include heart rate, respiratory rate, blood pressure and other signs which are often monitored in hospital.

HOW PAIN IS ASSESSED IN CHILDREN ?

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Perhaps the greatest challenge of pain management in children, is gaining an objective assessment of the level of pain. Infants and young children cannot verbalize their pain levels so rely on adult's and health professional's interpretations of external manifestations of the pain. Older children may still be unable to conceptualize and communicate their pain. Difficulties assessing pain have lead to the development of numerous pain assessment scales that health professionals use to grade patient's pain. These look at behavior pattern and what the child reports as their level of pain. There are different tools for different age groups. Children older than eight years of age can usually describe their pain similar to adults by rating it according to the intensity of pain on a horizontal ruler. For younger children, doctors use series of faces and pictures (progressively becoming more distressed) which

HOW PAIN IS ASSESSED IN NEONATES , INFANTS

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Neonates, infants and children under four years are assessed based on observation of behaviour and physiologic changes such as facial expressions, motor expressions, verbal responses and vital signs (such as pulse, blood pressure etc). The assessment tools are not entirely reliable but usually give the medical staff a sufficient idea of whether pain is present and how severe so they can treat it appropriately.

PAIN & PHARMACOLOGICAL CONSIDERATIONS

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It is important to remember that children are not just small adults. They are actively growing and many of their systems are not yet fully developed. Thus, drugs affect children differently to adults and often the children's body absorbs, transports, distributes and excretes drugs slightly differently to an adult's body. Drugs must be given at lower doses per body weight compared to adults to avoid toxicity. It is also important for medical staff to closely monitor children taking pain medication because as fore mentioned the exact effects on young children are not always known due to the lack of research in this field. Child may have to be closely watched or have blood test to check the drug is at the right level and having an appropriate response.

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Drugs and techniques used to Control Pain in Children

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There are numerous options available for paediatric pain management outlined below. In general, a multidisciplinary approach (that is using several different agents such as drugs and other techniques in combination) has been proven to be the most beneficial. Acetaminophen, aspirin and NSAIDs: These are mild analgesics and are usually considered first in treating mild to moderate pain. Acetaminophen (paracetamol) is probably the most commonly used analgesic as it is very safe. Aspirin is an effective analgesic but it has some nasty side effects such as Reye's hepatic encephalopathy which damages the brain and liver. Non-steroidal anti-inflammatory drugs (such as ibuprofen, ketorolac, naproxen ) are also used in children but they have limited uses in childhood cancer and other conditions due to their inhibition of platelet function. In general, these agents are given orally which is the preferred route of administration for most patients.

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Opioids: Opioids are stronger drugs used for more severe pain such as that associated with surgery or chronic cancer. Morphine, fentanyl (Durogesic), codeine and merperidine (pethidine) may be administered by various routes. In some cases the drug can be given intravenously and may be connected to a special pump. The patient can press a button to get a dose of medication as required. This is called 'patient controlled analgesia' and is a good method of administering pain medications due to the highly varied doses needed to get appropriate pain relief. It has been used in children as young as six years. The machine has special cut off values so the patient is unable to overdose by pressing the button too much. In other cases the nurse or parent may control the doses. It should be recognized that infants less than 3 months old and neonates and infants with lung disease are at particular risk of respiratory depression from some of these drugs. This is because accumulation of the drug causes inhibition of the breathing centers in the brain.

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Tricyclic antidepressants and anti-epileptic medications can be used in the management of neuropathic pain. Numerous sedative drugs are also used in children undergoing surgery and other procedures. However, these drugs are more to treat anxiety than pain per se but they are worth a mention. Chloral hydrate, benzodiazepines (especially midazolam), ketamine, barbiturates and nitrous oxide are the main sedative agents used in pediatrics. The safety of sedation in children has greatly increased over the years particularly when agents were developed that could reverse some of the respiratory depressive actions of the above drugs

Pharmacologic considerations for pediatric patients

DRUG
Acetaminophen Ibuprofen Naproxen Codeine Oxycodone Meperidine Morphine

DOSE
5- 15 mg/kg 20 mg/kg 8 mg/kg .5-1mg/kg .005-.15mg/kg 1-1.5 mg/kg .1-.15 mg/kg .05-.06mg/kg

INTERVAL (hr)

ROUTE
po , rectal po po po po im iv epidural iv

4-6 4-6 8 -12 4-6 4-6 2-3 2 12- 24

Fentanyl

1- 1.5mg/kg

Regional anaesthesia
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As in the adult population, regional anesthetic techniques have been used instead of general anesthesia as an adjunct to general anesthesia for postoperative analgesia as well as to manage acute and chronic pain problems when parenteral opioids fail or result in adverse effects. Spinal anesthesia should now be considered as an equivalent alternative to general anesthesia for intraoperative anesthetic care in pediatric patients and not used only for those patients that are considered "too sick for general anesthesia." Spinal anesthesia has also been applied alone or combined with general anesthesia to surgical procedures previously unapproachable by regional anesthesia such as repair of meningomyelocele, ligation of patent ductus

Regional anaesthesia
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We have also seen recent modifications and new insights into the cornerstone of pediatric regional anesthesia: the caudal epidural block. The time-honored criteria by which we had been taught to judge the possibility of intravascular injection during caudal block have been questioned. Because of the negative chronotropic effect of inhalational anesthetic agents, the positive response may need to be modified to an increase in heart rate of only 10 beats/minute and not 20 beats/minute as previously taught. More importantly, ones attention should also be directed toward other criteria such as an increase in systolic blood pressure and/or changes in the S-T segment or T waves on the electrocardiogram. Tsui et al. suggest the use of a nerve stimulator with the demonstration of an anal wink to document correct needle placement during caudal epidural block. Recent information demonstrates that effective analgesia can be achieved with lower concentrations and perhaps lower volumes of local anesthetic than previously used. For postoperative analgesia, 0.125 % bupivacaine appears to be as effective as 0.25 %, while adjuncts such as clonidine may provide effective analgesia with even lower total doses of the local anesthetic, thereby limiting the potential toxicity. The newer local anesthetics such as ropivacaine and levobupivacaine may provide an added margin of safety due

Regional anaesthesia
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The popularity of regional anesthesia has carried over into the postoperative arena. One of the greatest controversies that has arisen is the concern over placement of epidural catheters in heavily sedated or anesthetized children. Although this practice is not recommended in adults, younger children lack the ability to cooperate with the procedure, thereby making it hazardous, if not impossible. The practice and current "standard of care" concerning asleep epidurals is well-outlined in the consensus statement

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Local Anesthetics: Local Anesthetics such as lidocaine and bupivacaine, are widely used in children undergoing procedures. They have a narrow dose for which they are effective without causing side effects. Maximum doses of both drugs should not be exceeded or toxic side effects will occur. Administering epinephrine with the drug allows a slightly higher dose to be used. Epinephrine constricts surrounding blood vessels to keep the agent local so it cannot spread throughout the body and cause side-effects. Other analgesic techniques include blocking

Maximum local anesthetic doses in infants and children

DRUG Lidocaine (plain) Lidocaine (epinephrine) Mepivacaine Bupivacaine (plain) Bupivacaine (epinephrine) Chloroprocaine (plain) Chloroprocaine (epinephrine) Infant dose mg/kg age 5 birth on 7 4 2 2 4 5 birth on <6 mo <3 mo <3 mo <6 mo <6 mo Child dose mg/kg 5 7 5 3 4 8 10

Non-pharmacological therapy
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Non-pharmacological agents are often used in combination with the drug classes already mentioned in the management of chronic pain. Examples are listed below: Hypnosis has been proven beneficial in clinical studies. Cognitive Behavioral therapyevidence for this treatment. There is also good

Deep breathing and relaxation exercises. Distraction techniques- Focusing a child's attention away from something negative to something more positive such as music, toys or bubbles. Play therapy. Friendly hospital environment- This can reduce anxiety and fear in young patients which has been shown to exacerbate pain.

Non-pharmacological therapy
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Transcutaneous nerve electrical stimulation (TENS) refers to sending small electric currents through the skin. It is a possible treatment for neuropathic pain (in combination with opioids) but is not always effective. It has few side-effects so is often trialed initially in patients with moderate pain. Behaviour- Pain in neonates can be helped by breast feeding, sugars, pacifiers and multisensory stimulation of your baby (e.g. massage, voice, eye contact). Education- If child is adequately described the details and nature of a procedure (including being shown equipment and being allowed to ask questions) it can reduce their fear and help reduce pain. Only necessary procedures should be performed on child. Parent training programs- It can help child if parents are taught ways to identify and cope with pain so they are able to offer positive support.

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CONCLUSION
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As anesthesiologists, we possess the appropriate technical training and pharmacologic knowledge needed to provide analgesia in various settings, including the perioperative arena and the intensive care setting, as well as acute and chronic pain related to other etiologies. We will continue to debate several controversial issues such as the optimal means of providing postoperative analgesia, the role of parenteral NSAIDs in acute pain management, acetaminophen-dosing regimens, asleep epidurals, direct thoracic placement of epidural catheters, the best mix of local anesthetic agents and adjunctive medications for analgesia, and the criteria to identify inadvertent, intravascular injection. We will continue to seek new information and techniques for pain management with the applications of these techniques to difficult pain scenarios. Instead of the usual practice of taking what we have learned in adults and seeing if we can apply it to children, perhaps we will come up with innovative means of managing pain that will later be applied to the adult population. With all of the improvements, our goals will remain the same: to relieve pain and improve the quality of our patients lives.

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THANK YOU