Pediatric pain management An individualized, multimodal, and interprofessional approach is key for success. By Sharon Wrona, DNP, PMGT-BC, CPNP, PMHS, AP-PMN, FAAN, and Michelle L. Czarnecki, MSN, PMGT-BC, CPNP, AP-PMN ACCORDING to the Healthcare Cost and Uti- lization Project, more than 5,000,000 children in the United States had a hospital stay in 2017. Many of them experienced some type of pain. Pain has an immense impact on the mind and body. In addition to the physical sensation of pain, effects include emotion- al suffering, pulmonary complications, de- creased mobility, poor sleep, immune impair- ment, reduced quality of life, economic costs, and a potential for developing persistent (chronic) pain syndromes. Despite advances in care, many children continue to experience significant pain because of undertreatment and inadequate pain management after surgery. Sparing children the short- and long-term ef- fects of pain requires early recognition and CNE 1.4 contact treatment. hours Nurses are critical to pain prevention, recog- nition, and treatment in children. They’re with LEARNING O BJECTIVES patients more than any other healthcare pro- 1. Identify strategies for assessing pain in children. fessionals and have the opportunity to assess 2. Discuss nonpharmacologic pain interventions for children. pain throughout their shift. When pain is diag- 3. Describe pharmacologic pain interventions for children. nosed, the nurse can start planning which in- The authors and planners of this CNE activity have disclosed no relevant terventions are most appropriate for individual financial relationships with any commercial companies pertaining to this patients. After interventions are implemented, activity. See the last page of the article to learn how to earn CNE credit. the nurse should reassess the patient’s pain Expiration: 3/1/24 and response to treatment to evaluate interven- tion effectiveness. Nurses have identified barriers (many out- 6 American Nurse Journal Volume 16, Number 3 MyAmericanNurse.com Choosing the right pain scale Pain scales have been developed for Ontario Pain Scale, Riley Infant Pain highly sensitive indicators of postpro- various pediatric populations. Nurses Scale, and Children and Infants cedure and postoperative pain. Several should select scales that are valid, reli- Postoperative Pain Scale. scales exist, each with varying levels of able, user friendly, and easy to incor- reliability and validity. Toddlers porate into practice. No matter which The revised FLACC (r-FLACC) has When possible, self-report scales are • scale is used, re-assessment after inter- been validated in children from age preferred over behavioral or observa- ventions is a necessary component of 4 to 19 years. Using the original tional scales in this patient population. the pain management plan. FLACC scale as a base, additional in- When children communicate pain with dicators (such as head banging and Neonates and infants words (usually by age 3 to 4 years), breath holding) were added, along Premature infants, starting around 20 many can self-report using faces with space for parents to document weeks gestation, can perceive and re- scales. spond to pain. To conserve energy, any features unique to their child. Several self-report faces scales exist, they frequently show a less-robust • Another helpful tool is the Individu- each with varying levels of validity • physical response compared to full- alized Numeric Rating Scale. Care- and reliability. These scales require term infants (for example, they are givers are asked to assign a number the child to point to the face that more likely to close their eyes instead to typical pain behavior seen in best depicts their pain level. Exam- of grimacing and often have lower their child. The scale must be peri- ples include Faces Pain Scale-Re- oxygen saturation levels). This unique odically updated because pain signs vised (FPS-R) and Wong-Baker response requires a scale specific to may change as the child ages. FACES pain rating scale. Nurses premature infants. should use the same scale with a Intubated and mechanically The Premature Infant Pain Profile • child rather than alternating be- ventilated children (PIPP), although less commonly tween scales. The FPS-R has been Very few validated scales exist for this used now because it’s valid only in used with smartphone technology patient population. premature infants ≤ 37 weeks ges- with some success. tation, is well equipped to measure • The COMFORT scale, which Van Dijk pain in this patient population. The School age and adolescents and colleagues demonstrated to be Neonatal Pain, Agitation and Seda- Many older children (8 years and older) reliable and valid, is one of the tion Scale (N-PASS) includes a seda- can self-report pain by using a 0 to 10 more commonly used scales in this tion assessment so that only one scale. population. It uses six behavioral and two physiological metrics for a scale is needed for infants 23 weeks Numeric rating scales are easy to • total score from 8 to 40. gestation through 100 days of life. use and may be verbal (Verbal Nu- The N-PASS scores pain/agitation merical Rating Scale) or written (Vi- • An American Society of Pain Man- from 0 to 10 and sedation from -10 sual Analogue Scale). agement Nursing position state- to 0. ment recommends using self-report • Scales appropriate for full-term and Children with cognitive if possible, evaluating potential older infants include the Neonatal developmental delays sources of pain, assessing patient Infant Pain Scale, the FLACC (Face, These children are at increased risk for behaviors, incorporating physiolog- Legs, Activity, Cry, Consolability) poor pain assessment and manage- ic measures (keeping in mind that scale, Child Facial Coding System, ment. Although their pain response they may not be specific to pain), CRIES (Crying, Requires increased may be diminished, no studies have soliciting input from parents, and oxygen administration, Increased vi- demonstrated a decrease in pain sen- assuming pain is present if the child tal signs, Expression, Sleeplessness) sation. Voepel-Lewis found that when is undergoing a painful procedure score, Children’s Hospital of Eastern self-report isn’t possible, facial cues are or has known reasons for pain. side of their control) to pediatric pain man- ple, they can use the electronic health record agement. Czarnecki and colleagues’ 2019 mul- to develop order sets that include analgesic tisite study of barriers to pediatric pain man- options, reducing barriers to adequate and agement found commonalities across the timely orders. At a system level, nurses can United States. The most frequently identified collaborate with interprofessional teams on barriers included inadequate provider orders, quality improvement projects to remove barri- insufficient time to provide pain medication ers that are out of the nurse’s control but with- before a procedure, insufficient premedication in the area of other professionals’ work. In the orders before procedures, and low priority Czarnecki study, concerns about addiction, given to pain management by medical staff. limitations in nurses’ ability to assess pain, Regardless of role or setting, nurses can be and a low priority given to pain by nursing empowered to overcome these barriers and staff were rated among the least frequently provide optimal pain management. For exam- identified barriers. MyAmericanNurse.com March 2021 American Nurse Journal 7 sources of distress in pediatric patients. Pain intensity ratings are one piece of a pain assessment, but function is more impor- tant. Among adult patients, pain intensity ratings are being replaced with multidimen- sional pain assessments. For example, the Clinically Aligned Pain Assessment Tool guides the conversation between nurse and patient, focusing on general comfort, treat- ment effectiveness, whether pain is getting better or worse, activity level, and sleep quality. The tool can be adapted for use with children. Not all categories may apply to all pediatric patients, so the tool should be in- Age-appropriate options dividualized and include parental input. When used, pain intensity ratings should Nonpharmacologic pain management interventions should be be gathered with developmentally appropri- age-appropriate. ate, reliable, and validated tools. (See Choos- Infants ing the right pain scale.) • Breastfeeding Treating pain in children and adolescents • Oral sucrose Pain management should take an individu- Non-nutritive sucking • alized, multimodal (nonpharmacologic and • Swaying (rocking the infant back and forth) pharmacologic), and interprofessional ap- • Swaddling proach. The Pain Management Best Practices Toddlers Inter-Agency Task Force identified gaps where multimodal, nonopioid treatment options • Bubbles, toys, books, or other objects for distraction were underused, especially in acute care • Comfort holds (secure hugging by a parent or caregiver that helps settings. This report suggests the need for the child feel safe and secure, decreases movement, and allows the more guidelines, including a multimodal parent to appropriately participate in the procedure) approach. School-age children • Comfort holds during procedures Nonpharmacologic approaches • Video games, toys, books, bubbles, and other objects for distraction Nonpharmacologic approaches to pain treat- ment should be tailored to the developmental Adolescents level of the child and their individual needs. • Whenever possible, allow adolescents to use their independence,