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Assessment of Pain in Children

Dr Robin Dunn Medical Trustee Copii in Difficultate

Diagnosis of Pain
The Doctor?
Who is the person most likely to notice when a child is in pain? The Nurse? The Parents?

The Person Who Is With Him Most

The Person Who Knows Him Best The Person Who Is Trained to Assess Pain

At St Margarets/St Laurences /St Andrews Who is the pain expert for the children? The Nurse

The Doctor
The Parent

What Factors Affect How a Child Feels Pain?

Developmental stage of the child.

Affected by childs age. By co-morbidity i.e. brain damage either congenital or acquired . Childrens developmental level may regress when they are seriously ill.

Cause of the pain.

Visceral. Neuropathic. Bone Pain etc.

Psychological background.
Fear - previous experience of pain. Unfamiliar surroundings/people. Most children want company when in pain.

Evidence of Poor Pain Control in Children

Mathers and Mackie (1983). 75% of children were in pain on the day after surgery 40% were in severe pain. Royal College of Surgeons (U.K.). Many studies have shown that Doctors prescribe weaker painkillers and in relatively smaller doses in children compared to adults. McIlvane (1989). If painkillers are prescribed on an as necessary basis Nurses tend not to give strong painkillers. Cummings (1996). Many children in hospital still enduring unacceptable levels of pain.

What Influences How Nurse and Doctors Assess and Deal With Pain in Children ?

Factors Which Influence the Importance Carers Give to Pain Control

Having a child who has had a painful episode (Not as influenced by their own experience of pain). Type of care facility i.e. palliative care unit, ordinary paediatric bed, intensive care unit etc. Priority given to pain control if given high priority more pain killers. Level of training the more knowledge and experience the more pain relief. The diagnosis. Some diagnoses are seen to justify more analgesia than others i.e. cancer. Childs behaviour. A shouting crying child more likely to be given analgesia than a quiet child. Workload Very busy staff use less pain relief.

Pain Assessment
Determining the level of pain in a child is often difficult but is first step to managing the pain. Each child will feel pain of differing levels and degrees and react to this and cope in his or her own way. In order to cope with pain in children we should try to have a reliable reproducible measure of pain used on a regular basis. Yes but How ???

Physiological Consequences of Pain

Unrelieved pain causes :
Rapid breathing. Inadequate chest expansion -> Chest infections. Increased pulse rate / poor blood supply to tissues. Poor mobility. Psychological consequences i.e. anxiety, depression lack of co-operation with treatment, loss of trust in carers.

Facts & Fiction About Pain in Children

Infants cant feel pain because nerves not fully developed Children dont feel as much pain as adults Opiates i.e. Morphine etc.are dangerous in children and often cause poor breathing and addiction
Active children are not in pain Children who play cannot be in pain Sleeping children are not in pain Injections are not very painful for a child

True or False?

Facts & Fiction About Pain in Children

Infants cant feel pain because nerves not fully developed Children dont feel as much pain as adults Opiates i.e. Morphine etc.are dangerous and often cause poor breathing and addiction Active children are not in pain Children who play cannot be in pain Sleeping children are not in pain Injections are not painful
Pain felt despite incomplete development . Neonates show behavioural physiological and hormonal responses to pain Tolerance to pain increases with age
Same risk of Respiratory depression in adults and children Opiates rarely cause addiction when used as painkillers Increased activity is often a sign of pain Children are good at using play as distraction therapy for pain Sleep may be caused by exhaustion from pain 62% of children aged 4-10 said injection was the worst pain theyve ever had

All above are False

Assessing Pain in Children Who Can Both Understand and Communicate their Experiences
If possible try to find out.
The level of their understanding of their condition Where the pain is - frequency and duration? What causes the pain - is there anything which makes it better or worse? What significance does the pain have for the child? How do they cope with the pain ? What effect does it have on their life?

Use pain Rating Scales in order to:

Assess how bad the pain is and treat accordingly (give time for prescribed treatment for pain relief to work). Reassess the effectiveness of treatment.

How to Measure Pain

In Children who can talk. Self Report (Verbal scales).
Pain can be measured by what children say about their pain.

In All Children (talking or not able to talk). Pain can be measured by. Biological Markers.
How their bodies react.

What children do.

What Changes in Behaviour Have you noticed in Children in Pain?

General behaviour

Non Verbal Assessment of Pain

Specific Behaviour
Banging head Pulling ears Curling up on side foetal position Refusal to move specific limb or limbs Constantly rubbing specific region

Changed behaviour Mood -Irritability or depression Unusual posture Screaming Reluctance to move Lying scared stiff Aggressiveness Increased clinginess Unusually quiet Poor appetite Restlessness Whimpering/sobbing Lethargy Disturbed sleep pattern

Biological Markers
Markers i.e. Pulse , Blood pressure, Respiratory rate. Use in Conjunction with other data about pain assessment. Body may adapt i.e. biological markers may erroneously suggest reduction in longstanding pain especially Change is more important than the actual reading. Dont use as sole method of assessment.

Pain Assessment Tools

Visual Analogue Scale Verbal Graphic rating scale Numerical rating scale Pain thermometer Poker Chip tool Eland Colour Scale PATCh Diaries McGill Pain Questionnaire Varni-Thompson Questionnaire Faces Scale
None of them are perfect. Many unsuitable for non verbal children. PATCh has elements from several rating scales and can be used for wider range of ages. McGill and Varni- Thompson are chronic pain scales developed for older children mainly. Different scales for different ages. Child is taught to rate their own pain using the various scales. Most scales can only be used in children over three.

Faces Scales

Wong and Bakers Faces

Bieris faces pain scale

The Oucher

PATCh Scale

REMEMBER No scale is perfect use together with other evidence

Pain Assessment in Children Who Cant Speak

These include: Children who are either too young or with too severe a learning difficulty to understand instructions or communicate verbally. Some physically handicapped children especially those who are blind or deaf. Children who are intubated. Children whose consciousness is impaired i.e. after a head injury.

Is pain better or worse for a child who cant communicate than one who can?

Is Pain Better or Worse for a Child Who Cant Communicate Than One Who Can?

Not Known for certain but:

Verbal Children can communicate pain to others better so carers can take action to relieve the pain Older children have experience of pain so can place the new pain in context Know from previous experience that the pain will eventually get better

Pain Assessment in the Pre-verbal /Handicapped Child

Not much research on pain assessment tools for child with learning difficulties. Sick Children especially those with learning difficulties are known to have different pain responses from healthy children. However what is painful to an adult must be assumed to be painful to a small child.

Pain Assessment Tools for Non Verbal Children

Need to be:
Able to discriminate pain from other causes of distress Able to give a guide to severity of pain so that treatment effectiveness can be assessed Simple to use Appropriate for the childs level of understanding (Cognitive Development) There are few validated scales for children with learning difficulties

Pain Assessment in Children With Learning Difficulty

Vital Role of Carer/Parent in reporting behaviour of child. INRS Individualised Numerical rating Scale. Based on each childs individual behaviour in response to pain. Evidence based pain assessment tool from Boston Childrens Hospital. Soloduik,Martha and Curley 2003.

INRS Questionnaire
Think about childs behaviour in the past when child has been in mild pain, moderate pain or severe pain. Fill in on the diagram typical pain behaviours where 0 is no pain and 10 is the worst possible pain. Produces a check list of behaviours. Is reproducible and especially useful for carers who dont know the child as well. Based on FLACC Face Legs Activity, Cry and Consolability.

Facial expression.

Checklist for INRS

i.e. squinting eyes, frowning, distorted face, grinds teeth thrusts tongue etc.

Leg or general body movements.

i.e. tense, gestures or touches part of body which hurts.

i.e. Uncooperative, irritable, unhappy, not moving, less active quiet or more active/fidgety.

Cry or vocalisation.
moaning, whimpering, crying, yelling.

less interaction, seeks comfort or physical closeness, difficult to distract/satisfy.

Other changes.
tears, sweating, breath holding, gasping.

Visual Scale for INRS

Case example: Timmy 5 year old with cerebral palsy and severe learning disability. Initially scale completed by mother but nursing staff wrote in additional observations

Nurses/carers are the most important member of the team in assessing childrens pain especially in non-verbal children Pain assessment tools help to quantify pain and evaluate effectiveness of treatment Observation and interpretation of individual childs response to pain is essential in assessing pain especially in non-verbal child