Managing pain in children

▸ In a recent policy statement, the American Academy of Pediatrics recognized the need to improve management of pain in children. “Acute pain is one of the most common adverse stimuli experienced by children, occurring as a result of injury, illness, and necessary medical procedures. It is associated with increased anxiety, avoidance, somatic symptoms, and increased parent distress. Despite the magnitude of effects that acute pain can have on a child, it is often inadequately assessed and treated. ... Pediatricians are responsible for eliminating or assuaging pain and suffering in children when possible.”¹

Primary care pediatricians occasionally care for children in extreme pain from acute burns, orthopedic injuries, sickle cell crises, and some cancers. Without adequate pain relief, these children are at risk for post-traumatic stress syndrome and avoidance of people and places that remind them of the trauma. More often, pediatricians care for children who experience mild-to-moderate pain while undergoing common medical procedures, such as injections, heel sticks, IV placement, venipuncture, bladder catheterization, and lumbar puncture.

Historical myths about pain in children—e.g., infants do not feel pain or infants and young children do not remember pain—have been discredited by neuroanatomic and behavioral studies. A striking example is the demonstration that newborns circumcised without anesthesia exhibit greater pain responses to immunization at 4 months of age compared with uncircumcised infants.² Pain in children is a complex experience that involves the interaction of physiologic, psychological, behavioral, developmental, and situational factors.

The November 2003 issue of Archives of Pediatric and Adolescent Medicine focused on recognition and treatment of pain in children.³ We have selected four studies that illustrate creative approaches to the relief of pain caused by common procedures in pediatric practice.

Martin T. Stein, MD

Published in Journal Watch Pediatrics and Adolescent Medicine January 16, 2004

Sucrose-based pain reduction during multiple immunizations

▸ Children now receive up to 20 immunization injections by their second birthdays; a convenient, quick-acting, inexpensive, and effective method to reduce pain during these injections is desirable. These researchers evaluated the analgesic effect of combining sucrose, oral stimulation, and parental holding on infants’ response to immunization at age 2 months, when 4 injections are administered.

A total of 116 infants (mean age, 9.5 weeks) were studied. Those in the intervention group were held across a parent’s lap throughout the procedure and received oral sucrose (10 mL of 25% sucrose, prepared by mixing one standard packet of table sugar with 10 mL of tap water) 2 minutes before the injections, followed by provision of a pacifier or bottle. The control group received the 4 injections on an exam table without specific comforting measures.

The median duration of the first cry was shorter in the intervention group than in the control group (19 vs. 58 seconds; P = 0.002). Infants in the intervention group also had shorter median total crying times (92 vs. 115 seconds; P = 0.05). Compared with parents in the control group, those in the intervention group reported a stronger preference for using the same injection procedure in the future (P<0.001). Nurses rated the ease of vaccine administration to be equivalent with either method.

Comment

▸ Previous studies substantiated the use of oral sugar solutions as effective analgesia in newborn infants; for example, newborns given oral glucose experienced less pain during venipuncture than did those given a topical anesthetic (JW Pediatrics and Adolescent Medicine Jan 13 2003). Oral sucrose, used in the current study, has a peak onset of action of 2 minutes and a duration of action of 5 to 10 minutes. This study demonstrates that the analgesic effect of oral sucrose is enhanced when combined with nonnutritive sucking and parental holding. This combined approach will dramatically reduce postimmunization crying and lessen parental stress.

Martin T. Stein, MD

Published in Journal Watch Pediatrics and Adolescent Medicine January 16, 2004

Procedural conscious sedation and analgesia in the ED

▸ Diagnostic and therapeutic procedures in the emergency department (ED) can evoke pain and anxiety in pediatric patients. Reassurance and local analgesia, though helpful, are often insufficient to prevent the need for physical restraint, which could cause further psychological trauma. Therefore, procedural conscious sedation and analgesia (PSA), which produces “a pharmacologically induced state that allows patients to tolerate painful procedures while maintaining protective reflexes (e.g., gag, cough) and adequate airway control,” is used in EDs and is usually provided by nonanesthesiologists. Prior study of PSA has primarily concerned the effects of specific pharmacologic agents. These investigators analyzed rates of success and complications of PSA administered by nonanesthesiologists to pediatric patients in the ED.

PSA was administered on 1244 occasions to 1215 patients from May 1, 1997, through April 30, 1999, in the ED of a large, urban tertiary care children’s hospital. Median patient age was 5.9 years (range, 2 months to 19.4 years), and 65% of patients were boys. PSA was given for fracture reduction in 53% of cases and for laceration repair in 33%; 59% of patients received intravenous fentanyl and midazolam; 24% received IV ketamine, midazolam, and atropine; and 7% received intramuscular ketamine, midazolam, and atropine. Delivery was successful (defined as completion of the procedure in a minimally responsive subject) in 99% of uses. Complications, including hypoxia, vomiting, and dizziness, occurred in 18% of uses. No patient required intubation. Complications were not related to the type of PSA agents employed.

Comment

▸ These results speak for themselves. PSA is used safely by nonanesthesiologists in the ED, with high rates of success and few complications. Hospitals should consider these data in formulating sedation policies, particularly at a time when pediatric anesthesiologists are in short supply.

Harlan R. Gephart, MD

Published in Journal Watch Pediatrics and Adolescent Medicine January 16, 2004

EMLA reduces pain in neonatal lumbar puncture

▸ Operating on the incorrect premise that neonates do not feel pain, clinicians have performed lumbar punctures without analgesia in newborns for many years, and the practice remains standard in many NICUs. These researchers prospectively compared the topical anesthetic cream EMLA, a mixture of lidocaine and prilocaine hydrochloride, with placebo for pain reduction in 60 newborns undergoing diagnostic lumbar puncture in a NICU. All infants had an estimated gestational age of at least 34 weeks (mean, 37 weeks). Physiologic measures of heart rate and oxygen saturation were taken, and behavioral responses were measured using the Facial Coding Scale (indicated by brow bulge, eye squeeze, nasolabial furrow, and open mouth).

Physiologic and behavioral measurements taken during the procedure showed a painful stress response that increased from baseline in both groups. The EMLA group had a significantly lower absolute increase in heart rate and a lower mean total behavioral score at both insertion and removal of the lumbar needle. No adverse events were associated with EMLA or placebo. No infants required more than two attempts at needle placement.

Comment

▸ These findings reconfirm that newborns feel pain during lumbar puncture and demonstrate that this pain can be ameliorated but not eliminated with local anesthetics. Because newborn pain may have developmental consequences (JW Pediatrics and Adolescent Medicine Sep 9 2002), use of local anesthetics prior to lumbar puncture should be standard practice.

Janey P. McGee, MD, and F. Bruder Stapleton, MD

Dr. McGee is a senior resident in the Department of Pediatrics, University of Washington, Seattle, with a special interest in pediatric pain management. Published in Journal Watch Pediatrics and Adolescent Medicine January 16, 2004