Up next is Caitlin Feeks and Christine Russo providing information on pediatric pain management from a physician and from a nursing perspective. Hello, everyone. I'm Caitlin Feeks. I'm a pediatric emergency medicine trained physician working in the Pediatric Emergency Department at Stony Brook Children's Hospital in Stony Brook, New York. And I'm Christine Russo, the Pediatric Trauma Program Manager at Stony Brook Children's Hospital as well. We're here today to discuss pain management and pediatric trauma. Today, we're going to discuss an overview of the pain management modalities that exist in the pediatric population, as well as their risks, benefits, and common scenarios of application. So let's get started. Pain in pediatric patients is often multifactorial and can be especially challenging to assess in preverbal children. The perception of pain in pediatric patients involves physiologic, behavioral, psychologic, and developmental factors. Children often do not exhibit the typical signs and symptoms of pain that we would expect from an adult. They may even be reacting more to family emotions or other behavioral cues surrounding the event. Ideally, a holistic approach to the evaluation and management of pain is required to recognize and treat the pain successfully. This approach includes consideration of both the child's age and developmental stage. This can be obtained by observing how the child is interacting and reacting to his or her environment, consideration of the surrounding circumstances involved, and evaluation of family and caregiver dynamics. The guiding principles to pediatric pain management include the recognition of age-appropriate signs, symptoms, and pain scales when used working with pediatric patients, allowance for self-reporting when possible, especially involving caregivers when appropriate, prompt analgesic administration following pain recognition, and early and frequent pain reassessments. So what is pain? Pain is a dynamic entity characterized by physiologic and neurologic responses. This can be compounded by socioeconomic status, post-experiences with pain, cultural, and even personal beliefs. We all need to remember it's an experience unique to the individual encountering it. It can be accentuated by fear and anxiety, or even suppressed by the actual fear of seeking treatment. The best way to understand the pain is to ask the patient to describe and rate the pain in their own words. Showing your concern for the patient's pain is as important as providing the pain control itself. There are arguments against aggressive pain management, and these often stem from the feared side effects of the medications being given. These include the fear of causing depressed mental or respiratory status in the young patient, such as with the use of opioids. We often see of the case of even simple abdominal pain, limiting analgesia pending a surgical evaluation as if it's going to seriously alter the exam. We also know that pain can hinder the ability of the healthcare provider to perform a thorough physical exam in order to help identify the underlying pain source. All of these added precautions due to fear of side effects could account for what we call oligoanalgesia, meaning the undertreatment of pain, which we'll get into more on the next slide. So the undertreatment of pain. Unfortunately, plenty of research has shown that pediatric pain is frequently undertreated. This is especially true in younger populations and those with cognitive impairments. Common causes include the inability to recognize pain using visual and behavioral cues, a decreased perception of pain in children, a lack of awareness of analgesic modalities available, incorrect medication dosing, and as I mentioned, the fear of medication side effects or toxicities. Now that we've addressed some principles of pain, let's go on to discuss the proper recognition and assessment of pediatric pain using age-specific pain scales. Because pain in our pediatric population is so challenging to assess, there are several age-specific pain management tools available to assist in quantifying the level of pain a patient may be experiencing. While it's important to familiarize yourselves with the pain scale, the more important take-home is to identify when our patients are signaling to us they are in pain. As we go through each of the scales listed on the slide, our focus will be on what the clinical picture of the pediatric patient in pain may look like in comparison to a child who is more comfortable and later appropriate actions to take. Having these strong assessment skills is particularly crucial for our pre-verbal younger patients and any non-verbal children we may encounter in our practice such as those with autism spectrum disorder. As our patients can become more verbal, we can incorporate their self-reported pain into your assessment, which ultimately becomes the gold standard. Let's start with what is traditionally considered one of our most intimidating pediatric populations, NEONATES. Recognizing pain in NEONATES represents a unique challenge for all providers as they may not demonstrate the typical pain behaviors that immediately come to mind. In order to determine an accurate picture of the patient's pain level, we need to provide physiologic clues and behavioral changes that can be observed. Use such as furrowed brows, eyes squinting shut, abnormal movement of the arms and legs, inability to be consoled, disturbed sleep patterns, and vital sign changes such as tachycardia can provide us with insight to our patient's pain status. Here listed on the slide, you can see the CRY scale, which is frequently used for NEONATES. The CRY scale evaluates the patient for crying, oxygen requirements, changes in heart rate and blood pressure, expression, sleeplessness. As I mentioned earlier, my goal is not to focus on what a high score of each of these scales would be, but instead to recognize when a patient is in pain, what they would look like, even if this clinical tool isn't in front of you. Keeping this in mind, let's for example, consider a two month old who's quietly resting in their infant carrier on arrival to triage. The vital signs including heart rate and oxygen, saturation on room air are normal and the patient's face is relaxed and appears at rest. The child may be vocalizing soft cooing noises or may not be making any noises at all. This patient would be demonstrating a low CRY score and would not likely require any pain management at that time. In contrast, let's think of another two month old. Even when the primary caregiver attempts to hold the child in a position of comfort, they're difficult to console. The patient's heart rate is elevated and their scrunched faces and inability to nap tells that this baby is uncomfortable. The patient is a prime candidate for your intervention. Here, we have the NIPS or Neonatal Infant Pain Scale, which is another assessment tool available for our youngest age group. This was designed to evaluate infants less than one year old. As you can see, the scale looks pretty similar to some of the variables in the CRY scale. Facial expression, CRY, respiratory assessment and the weak sleep patterns are considered in bulk. The NIPS scale has added the patient's arms and legs into the assessment. Extremities that may be relaxed or flexed but able to be moved freely would be a reassuring sign of our patient's comfort level. A patient with all extremities restrained, on the other hand, in combination with a grimace, whimper or cry or vigorous cry, fussiness would all raise our concerns for this patient's pain score. A lower score of three or four would indicate mild to moderate pain, which could benefit from non-pharmalogic intervention and a higher score of five or more indicates severe pain, which typically requires pharmacologic intervention. The FLAC score stands for FACES, LEGS, ACTIVITY, CRY, CONSOLABILITY and this is used in children greater than one year old. Again, you'll notice the variables of FACE, EXTREMITIES, in this case the LEGS, CRY and CONSOLABILITY are evaluated. In the FLAC scale, activity has been added and more descriptive factors are available. A patient whose body is squirming, shifting, tense or even more significantly arched, rigid or jerking shows activity that would point towards acute pain. This is the FACES scale, the pediatric pain scale many of us are most familiar with using. As children get older and become school-aged, their language skills allow for more direct communication throughout assessment. In the meantime, this is a great option to utilize. The caveat here with young children is to avoid leading questions as we've all probably experienced a preschooler who answers yes to all questions and is easily instructable. Another source of helpful information that you can utilize towards your assessment is the parent or caregiver. Inquire about behavioral changes they have noticed such as changes in normal activity, favoring extremity, limping, et cetera. In our adolescent population, we can utilize a common adult rating scale called the NRS and the VAS. This does require some insight into the maturity level and intellectual development of the patient. It is also important to note that pain expressions and numerical reporting can vary from child to child. Regardless of the pain scale used, the original score should serve as your guidance and assessment and efficacy of continuing analgesic management for frequent reassessments. Now that we've reviewed some of the various scales to assess pain, let's discuss interventions. Not all pain needs chronologic management, particularly as the first step. The beauty of non-pharmalogic approaches listed above is that any team member can initiate them. While some facilities have child life specialists available to help with these, a fundamental understanding of developmental stages can assist any staff member to choose the most appropriate distraction techniques and soothing measures. If you have trouble discerning what would be an effective intervention for your patient, asking the caregiver what they think might help suit their child is a good option. Even if their efforts feel unsuccessful, caregiver involvement often contributes to alleviating their own fears surrounding the experience. Now let's talk about some age-specific approaches to non-pharmalogic management of pain. When neonates and infants less than 12 months old, engage and comfort the parent. Encourage them to hold the patient when possible, empower them to comfort their child. Utilize soothing sensory measures such as gentle touch, speaking softly, rocking, and singing. Other techniques such as pacifiers and swaddles can come in handy. As we move to toddlers and preschool children, engaging comfort and empowering parents still continues to be essential. Similar sensory measures such as gentle touch and a soft voice are still encouraged and communicating in simple direct language is helpful. Give calm, firm directions as this is important in this age group. Demonstrating a new experience such as taking a blood pressure on a doll or toy can help alleviate the fear of the unknown and provide choices when possible. For example, left or right, red or blue sticker, different bandages, et cetera. And lastly, distraction and child life services such as storytelling, bubbles, pinwheels, and brighter flashy toys can make all the difference. As we enter the school age group, we can start to have more of a conversation with both the patient and the family regarding what to anticipate. Communication should remain straightforward with simple direct language. Avoid medical jargon or slang and allow patients time to ask questions so that they can process the experience at their own developmental level. Involve patients in their own care when the opportunity presents. For example, ask the child to apply a heat or cold pack, reposition themselves when they can do so independently, and even assist in the final stages of dressing application when possible. Lastly, distraction measures such as electronic games, tablets, or music can be helpful. Our last age group to discuss is adolescents. This group can vary depending on maturity level. In order to assess this, start by asking simple questions such as name, age, what school they attend, activities they enjoy, and employing an age-appropriate pain scale. Evaluate their responses and see if they're using simple or complex language. Continue to communicate using simple direct language and encourage questions to ease anxiety. Maintaining flexibility with this population is essential and can contribute to better cooperation overall. Employing distraction techniques such as technology, guided imagery, and allowing them to zone out may be helpful depending on the patient's preference. And lastly, as with all age groups, offer comfort measures such as repositioning, ice and heat packs, warm blankets, et cetera. Although non-pharmacologic options are considered first line among the pediatric population, patients with moderate and severe pain often require pharmacologic treatment options for adequate pain control. It's essential to start with the least invasive routes and safest medications. Options include topical, oral, rectal, intranasal, inhaled or nebulized, intravenous, and subcutaneous medication interventions. Be sure to speak with the child's parents about drug indication, treatment goals, and anticipation of improvement. Here's a commonly encountered scenario that can employ both non-pharmacologic as well as pharmacologic interventions. Considering the information we've already talked about, here would be my approach to this patient. She appears school-aged, therefore the faceless pain scale can be utilized. She clearly has an open wound, unclear if there could be an underlying fracture, potential dislocation. She appears upset, crying. Her caretaker is at her side. At this point, reassuring the patient and the caretaker about the measures that will be provided to care for the child is crucial. She's a good candidate for non-pharmacologic interventions such as distraction, comfort measures, such as a position of comfort and ice pack, allowing the caretaker to provide these comfort measures as well. In further addressing her pain, she's likely experiencing mild to moderate pain and therefore a pharmacologic intervention is required. So let's keep this patient in mind while we discuss the variety of pharmacologic interventions that we could offer her. For mild pain, oral formulations such as acetaminophen, non-steroidal anti-inflammatory agents, such as ibuprofen are considered our first line. Acetaminophen is an oral agent that's administered at a dose of 10 to 15 mgs per kg every four hours, and rectally can be given 10 to 20 mgs per kg. Commonly used NSAIDs includes ibuprofen dosed at 10 mgs per kg every six hours, and this is for patients six months of age or greater. Topical analgesics provide a wide range of benefits but require forward thinking for them to be effective. Most have their peak effects within 20 to 40 minutes, so planning ahead is crucial. LMX and Emla are lidocaine-based creams that are very effective when used on closed skin for the eventual placement of IVs or injections. Letgel includes epinephrine and tetracaine and is easily absorbed into open wounds such as lacerations and skin abrasions. I find Let to be one of the most valuable topical medications in the care of injured children from scraped knees to facial lacerations to road rash. Let provides effective topical analgesia in a short amount of time, making procedural tasks more tolerable for patients and providers. Aerosolized sprays provide immediate analgesia although they're short-lasting. They can be ideal for procedures that need to be performed quickly, such as IVs and nerve blocks. For patients with moderate to severe pain, such as motor vehicle collisions, multi-trauma, long bone fractures, consider intranasal inhaled and intravenous methods of pain control. This is not to discount oral therapies as they tend to provide more long-lasting effects and actually can help bridge the pain when shorter acting agents are wearing off. The goal here is to start low and slow. Most pediatric patients are opiate naive, therefore a lower dose is often sufficient to start with. The purpose is not to undertreat the pain, but to avoid those potential side effects, such as depressed mental status and respiratory drive that we spoke of earlier. You can always go up, but it's a little more challenging to take away. Frequently assessing your patient's pain will help to achieve adequate pain control. For moderate to severe pain, I encourage you to consider intranasal options. This tends to be my go-to solution for immediate pain control in the emergency department caring for children. It's quick, it's easy to use, it's very well-tolerated by patients, and with its fast onset, we get great results quickly. No peripheral access is needed, no site sterilization is required. This is a great option for musculoskeletal pain, such as fractures and dislocations. So let's talk a little bit more about the administration of intranasal medications. So the method of delivery is using an atomizer, which allows for maximum absorption, reduced runoff, increased patient comfort, and its use is independent of head position. The contraindications here for intranasal delivery is that it should not be used in patients with any concern for abnormal neurologic exams, facial trauma, epistaxis, or nasal obstructions. The adverse effects are fairly mild, and they include vocal irritation, bad tastes in the mouth, occasionally increased lacrimation, and occasionally a transient burning sensation. Strategies for good intranasal administration is to concentrate the medication, so ideally volumes of less than one milliliter per nostril should be used to reduce runoff of the medication. By nasal delivery, so dividing the doses between both nostrils to help optimize absorption. Instructing the patient not to inhale, but actually to encourage a sniffing position when applying the medication, and encouraging them to not blow their nose post-administration to help optimize absorption. So let's discuss medications that can be delivered intranasally. Fentanyl is one of my go-to options. I think that's probably the most commonly used in the ED for children. It is more potent than morphine, but it does have a short half-life, but it's very fast in onset. So you get your good effects quickly, and then you can reassess for their effectiveness. It has less cardiovascular side effects, including less hypotension, and it can easily be reversed by naloxone if for any reason you are getting depressed mental status or respiratory drive. The dosing would be 0.5 to 1.5 per kilo per dose. Ketamine is an option, which does carry the side effects of nausea, emesis, dizziness, and sleepiness, but you do not get any respiratory depression with ketamine, making it a very safe option, and that would be around one mg per kg per dose. And the last one would be Dilaudid or hydromorphone. Quick onset, pain reduction within about five to 15 minutes of administration, and duration of effect is about greater than one hour in 90% of patients. This medication I'd encourage you to reassess at about 15 to 30 minutes, and again, start low and slow, and escalate doses as needed in small aliquots. So moving from intranasal to IV. The most commonly used IV meds in pediatric patients or trauma patients are most likely to be morphine, fentanyl, and more recently, ketamine. Morphine's effect is observed in about 15 to 30 minutes after IV administration, and about 30 to 60 minutes after IM administration. Fentanyl, again, has a very quick onset, lasts about one to two hours. Ketamine is becoming more commonly used, in which you can get a different effect based on the dose that you're giving. You can get a dissociative amnesia, which can give you a bit of an anxiolysis effect, which is great for procedures such as dislocation reductions, or just getting imaging completed. So the lower dose, somewhere around 0.1 to 0.5 mg per kg. If you're looking for full sedation, that's going to give you more analgesia and amnesia. That's going to be around one mg per kg per dose, going higher if you're going intramuscular at four mg per kg per dose. So in case you give too much naloxone to the rescue, given the opioid epidemic that we're all very familiar with, many providers have become more familiar with using naloxone in the pre-hospital setting, but it's also a great adjunct to have at the bedside in case for any reason you do experience over-sedation that requires reversal. In kids less than five or around 20 kilos, the dose would be 0.1 mg per kg, and it can be given intravenous, IM, subacute, or actually endotracheally should you need to do that. Children greater than five or more than 20 kilos, you can go with the two mg dose. Your response time should be around two to three minutes after giving it, and the half-life is around one to two hours. You can get some rebound sedation and apnea, so be on the lookout for that. Regional anesthesia is a great method of pain control for pediatric patients. Peripheral nerve locks are a great modality for both hand and foot injuries as they provide pain control over a large area. Knowing the correct anatomy is key to their application. These are best used for laceration repairs or potential joint reductions. Common anesthetics include lidocaine, bupivacaine, and prilocaine. Inhaled analgesics are a good modality in the school age and adolescent population as one of the main requirements of their use is the child needs to be able to hold the mask on their face without any assistance. Medications that can be inhaled include opioids and nitrous oxide, which are good for treatment of moderate to severe pain as they are quick on onset and short lasting. Good uses for inhaled analgesics include quick procedures, such as fracture reductions, laceration repairs, wound exploration, and joint aspiration. Okay, so now that we've covered the ways in which to evaluate and treat pain, let's run through some common scenarios. Now that we've covered the ways in which to evaluate and treat pain, let's run through some common scenarios. Here's our friend from earlier with her leg injury. Here's how I would approach her care. You would provide reassurance and comfort measures to an age-appropriate basis pain scale, apply LET to the wound, position of comfort to the lower extremity, place LMX to the potential peripheral site if she's going to need IV insertion, employ some distraction techniques. We can go with oral acetaminophen or ibuprofen. And once pain control is achieved, proceed to wound exploration, potential x-rays, sutures, et cetera. In this next image, we can see a school-aged child with an obviously deformed upper extremity. For this patient, we're going to employ the basis pain scale. We're going to put him in a position of comfort, utilizing splint and towel roll. We can use distraction techniques, such as a tablet, video, music. We're going to place LMX to a potential peripheral IV site on the other extremity, and we can utilize intranasal fentanyl. We can supplement with oral acetaminophen, and once pain control is achieved, we can proceed to x-rays with orthopedic evaluation. We can escalate with repeat doses of intranasal fentanyl if needed, and IV if necessary. Our next patient is coming in with what looks like a distal amputation of the finger. It's probably school-aged or toddler-aged child. So in this case, we would start using the plaque pain scale, given their age, to assess their pain. We're going to provide a nerve block for immediate pain relief, as this is a very painful injury. Utilizing ethyl chloride spray in the region of the nerve block would be essential. Placing LMX to a potential peripheral IV site in case further pain medication is needed or potentially sedation for a repair. Supplementing with oral acetaminophen and ibuprofen to give that bridge of pain relief. Escalating to intranasal fentanyl as needed. And once pain control is achieved, proceed to x-rays and potential orthopedic intervention. Our next patient is what appears to be an adolescent. So at the NRS, VAS pain scale would be appropriate given his age. Placing him in a position of comfort, whether it's a sling or just adjusting the bed. Placing LMX to a potential peripheral IV site if an IV is not already obtained. This is a good age group to employ distraction techniques like we talked about earlier, technology, just letting them kind of zone out. Intranasal fentanyl or IV morphine would be a great start for pain medication in this patient with adjunct of oral acetaminophen or ibuprofen. Once the pain is controlled, achieving proceeding to x-rays and reduction measures as needed. During a reduction, you can give as needed doses of both morphine and fentanyl, either intranasal or IV, depending on access points. This is a great patient to consider anxiolysis. So even low dose ketamine or oral Versed would be great to help you in your reduction. Now, our last patient scenario here is what appears to be multi-trauma. So this is a case where there's a lot of moving parts. So reassuring the patient, telling the patient what to expect using simple language, making them aware of the surroundings that there's going to be a lot of people involved. There may be a lot of noise and kind of help guiding them through the next steps of what's going on. This patient based on his age would be appropriate to use the FACES pain scale if he was interactive with you, otherwise assess and assume severe pain. Immediate IV access would be essential given this is potentially multi-trauma, considering ethyl chloride spray for that IV access would be wonderful. Placing topical solutions to any sites of injury if they're warranted. So if you see lacerations or abrasions, this is a good time to start treating them because they may not be addressed for maybe an hour or so, but at least you're starting that pain relief right now. If there are any evidence of deformed extremities or painful extremities, you should immobilize them and place in a position of comfort. This is a great case to consider intranasal versus IV intervention, depending on how severe the injuries seem or what kind of access can be achieved. Once pain control is achieved through either intervention, then I would proceed to imaging and further reassessing your pain control through your interventions. Escalating doses of intranasal or IV medications such as fentanyl and morphine would be very appropriate. So in summary, we know that children react to pain differently depending on their age and developmental stage. Pain in children is often undertreated due to the fear of side effects. Obtaining a baseline pain score using an age appropriate pain scale is truly essential. Treating pain promptly and reassessing frequently for assessment of analgesic efficacy is essential as well. Non-pharmacologic intervention should be combined with pharmacologic interventions as well as a multimodal approach to address pediatric pain. Always consider a stepwise approach when using oral, topical, nebulized, intranasal and intravenous routes depending on the severity of pain patients are presenting with. Younger infants and those with cognitive impairments may express pain in a unique and unexpected way. So consider physiologic variables in nonverbal patients, but when possible, allow the child to speak for themselves. Thanks so much for joining us today. We'll be available for questions.

pediatric pain management

multifactorial pain assessment

holistic approach

age-specific pain scales

non-pharmacologic interventions

pharmacologic treatment options