Easing Children’s Pain

by Marlene Busko
Children’s pain is often ignored or undertreated. “Some people still believe that pain in young children doesn’t really matter because children won’t remember it, or they think it’s too dangerous to treat, or they feel they should treat it but don’t know how,” says G. Allen Finley, MD, FRCPC, Director of the Centre for Pediatric Pain Research at the IWK Health Centre, and Professor of Anesthesia and Psychology at Dalhousie University, in Halifax, Nova Scotia.
The result can be a lifelong fear of needles or the development of chronic pain from under-managed acute pain, cautions Alan Kaplan, MD, a family and emergency department physician in Richmond Hill, Ont.
More research is being done to increase awareness of pain in children and to guide clinical practice. In a recent study, Bonnie Stevens, RN, PhD, at the Hospital for Sick Children in Toronto, and her colleagues found that hospitalized children undergo an average of six painful procedures, but only one or two such procedures are accompanied by pain relief strategies. Anna Taddio, BScPharm, PhD, Associate Professor at the Leslie Dan Faculty of Pharmacy at the University of Toronto, and her colleagues developed an evidence-based practice guideline for reducing pain from childhood vaccinations, which was recently published.

Common types of pain
Pain from ear and throat infections or minor scrapes and cuts is a normal part of growing up. Vaccinations are the most common source of medically induced childhood pain. “Pain was not recognized as a side effect of vaccination, but now people are aware that it’s not so benign, especially as we keep increasing the number of vaccines that kids are getting,” says Dr. Taddio. Current Ontario immunization schedules call for 16 vaccination shots — 12 shots for infants aged two to 18 months, and four shots for children aged four to 14 years. Approximately 10% of children develop a phobia towards needles. Her group identified simple, low-cost strategies — including distractions and application of a topical anesthetic — that can be used to mitigate pain from vaccinations.
Other types of childhood pain include severe pain from an injury such as a broken leg or from disease such as cancer. A recent Statistics Canada study reported that 2% of boys and 6% of girls between 12 and 17 years had chronic pain, typically from rheumatoid arthritis or headaches.

Assessing the pain
Children are much more likely to hide their pain than to exaggerate it, says Dr. Finley. “If a child thinks that admitting to having pain means he’s going to get a needle, he’s going to have to stay in hospital, his parents are frightened or upset, or that you’re going to manipulate his broken arm to make it hurt more, then he’s not going to tell you,” he adds. Therefore, it is important to directly ask about pain.
To assess pain intensity, teenagers can be asked to rate their pain on a scale from “0” (no pain) to “10” (the worst possible pain). Young children can be shown the Faces Pain Scale-Revised (available at http://www.usask.ca/childpain/fpsr/pps92.pdf) and asked to select a face from “no pain” to “very much pain” to indicate how they feel inside.

3 Ps of treatment
Effective pain treatment generally incorporates the “3 Ps:” psychological intervention, physical therapy, and pharmacotherapy.
Psychological interventions such as slow rhythmic breathing, distraction, or the use of imagery can be very effective.
Common physical therapy strategies include applying heat or cold to reduce pain or swelling from bruises or insect stings, massaging a stubbed toe, or giving an infant a sweet solution to suck during a needle poke.
Children are treated with four main types of pharmacotherapy: nonopioids, opioids, topical anesthetics, and adjuvant therapies.
OTC non-opioids such as acetaminophen or a non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen are commonly used to treat headache, toothache, and earache. Ibuprofen, which has an anti-inflammatory effect, is used for musculoskeletal pain such as arthritis and sports injuries. “For earache, most children do fine with acetaminophen or ibuprofen,” says Dr. Kaplan. These drugs are safe for occasional use in children, notes Dr. Taddio, adding that they may be used to treat a fever or sore arm that occurs after a vaccination shot, but they are not effective for pain at the time of the injection.
The opioid morphine may be prescribed after tonsillectomy, hernia repair, or treatment of a fracture. Morphine can be used safely when given in appropriate doses with monitoring for respiratory depression, says Dr. Finley. Prescribing acetaminophen or ibuprofen along with morphine can improve pain relief and lessen the amount of morphine that is needed. Addiction is extremely rare in children under 12, Dr. Kaplan notes, although teenagers may be prone to experiment with drugs, and some physicians advise against codeine use in children due to fluctuating serum levels and the potential for unintentional overdose.
Three topical OTC anesthetics are available in Canada: lidocaine/prilocaine (EMLA), amethocaine (Ametop), and liposomal lidocaine (Maxilene). These drugs are effective for pain associated with injections, catheter insertions, or drawing blood, and are especially helpful for hospitalized children who undergo multiple procedures. However, the use of these creams has not yet become widespread outside the hospital setting, observes Dr. Taddio.

Differences in treating children
Children are not small adults. As they grow and develop, they undergo substantial changes that influence the efficacy, toxicity, and dosing regimens of medicines, says Jessika Truong, BScPharm, a pharmacist in hematology-oncology at The Montreal Children’s Hospital. It is important to consider a child’s age, medical problems, pain intensity, and previous pain experience, and choose the analgesic and route of administration that provides rapid, effective relief, while being aware of potential side effects. The dose may have to be adjusted, depending on the initial response to a drug.
Pharmacists may have to prepare special drug formulations when young children require smaller doses than are commercially available. Pharmacists can also advise parents how to mask the bad taste of a medicine. A liquid medicine can be combined with a small amount of juice or milk, or a pill can be crushed and combined with a small amount of jam or banana. For older children, tablets may be dipped into food. A child may be given tasty food before or after the medicine.

Resources for parents

1. Jacobson S. Common Medical Pains. Pediatr Child Health 2007;12(2):105-109
2. Ramag-Morin PL and Gilmour H. Chronic pain at ages 12 to 44. Statistics Canada,Catalogue No. 82-003-XPE, Health Reports, Vol. 21, No. 4, December 2010 Available
3. Stevens BJ et al. Epidemiology and management of painful procedures in children in Canadian hospitals. CMAJ 2011;183:E403-E410 Available at: http://www.cmaj.ca/cgi/reprint/183/7/E403 Accessed April 22, 2011.
4. Taddio A et al. Reducing the pain of childhood vaccination: and evidence-based clinical practice guideline (summary). CMAJ 2010;182(18):1989-1995. Available at: http://www.cmaj.ca/cgi/reprint/182/18/1989 Accessed April 22, 2011.

This article first appeared in Talking Points: Pain Management and is reprinted with permission from Rogers Healthcare Group and CanadianHealthcareNetwork.ca.