Session 4: A case based exploration. Darko.. Question. Why is he still in pain? Pain Assessment and Management 9/1/17

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1 Session 4: Pain Assessment and Management Assessment - Learning outcomes By the end of the session participants should: Be able to describe what pain is and the holistic nature of pain Understand the different types of pain in children Be aware of the different myths that exist that prevent children s pain from being managed well By able to discuss the key elements of pain assessment in children Be able to utilise different pain assessment tools and the QUESTT assessment process. 2 A case based exploration Darko.. Darko is an 8 year old boy who was admitted to your hospital 2 days ago. He has a brain tumour. His father died in a road traffic accident eighteen months ago. He is looked after by his mother and grandmother. He is very close to his older sister Jovana who is 11 years old. 3 They live in Pilsen but have come to Prague for treatment. His grandmother is at home in Pilsen looking after his sister who is at school. Darko had a cycle of chemotherapy 10 days ago, and was very sick at the time of administration. He is now withdrawn, does not want to sit up and is reluctant to move his head. 4 Question Why is he still in pain? Do you think he is in pain? Why do you think Darko s pain may not have been adequately addressed? In groups discuss why you think pain in children may not be adequately managed 5 6 1

2 What is PAIN? Pain is an unpleasant sensory or emotional experience associated with actual or potential tissue damage (IASP) (International Association for the Study of Pain). Pain is: what the child says hurts Assess what is pain and what is fear The problem with the definition in children Relies on children telling us about their pain. Assessment may be difficult in pre-verbal children. We need to find ways to speak the language of children which means using other clues to help us assess and manage pain in children. 8 Some Possible Reasons Resources Understaffed Staff too busy Cost of medicines Availability of medicines Staff Poor understanding of pain Inexperienced with prescribing Pain not assessed Underlying cause not yet treated Language barriers Staff attitudes 9 Some Possible Reasons.(2) Child Refused medicines Refused to communicate Denies pain Language barrier Cultural beliefs Spiritual beliefs Family Language barrier Cultural beliefs Spiritual beliefs Adult may answer for a child 10 Myths and facts of pain(1) Myth: Children become accustomed to pain Fact: Increased anxiety and pain perception occurs with repeated painful procedures Myth: Children are unable to tell where it hurts Fact: Children can point to an area, can draw Myth: Children will tell you when they have pain Fact: May not - due to fear of treatment, inadequate communication skills, or not aware that they have chronic pain 11 Myths and facts of pain (2) Myth: Behaviour reflects intensity of the pain Fact: All have unique way of coping, behaviour is not a specific indicator of pain level. A lack of behavioural responses (including crying and movement) does not necessarily indicate a lack of pain. 12 2

3 Truths about children s pain Pain is not just physical: It is total PHYSICAL The child s pain is real and the child is the ultimate authority on this pain. Leora Kuttner, PhD A Child in Pain PSYCHOLOGICAL SOCIAL 13 CULTURAL SPIRITUAL 14 Classification of Pain Acute or Chronic Situational Pain Breakthrough End of dose Incidental Procedural Anticipatory pain Types (Sources) of pain Nociceptive pain or Physiological pain Neuropathic pain Sympathetic pain Psychogenic pain Nociceptive pain Stimulation of sensory receptors Damage or disease Superficial Skin and mucous membranes Deep somatic Muscles and joints Visceral Organs Treatment Non-opioids and opioids 17 Neuropathic pain Abnormal reaction to stimuli caused by damaged nerves Burning pain Poor response to analgesics Adjuvant therapy 3

4 Sympathetic pain Damage to sympathetic nerves Burning pain Vasomotor instability How would you assess Darko s pain? What are the barriers to pain assessment in children? Discuss in Pairs Regional sympathetic blocks Barriers to pain assessment Lack of age-appropriate and validated painmeasurement tools Lack of knowledge as to which tools to use for which age children Lack of training on the use and implementation of tools Lack of knowledge on how to interpret a pain score Uncertainty as to how to differentiate between anxiety and pain Lack of understanding of children s experience of pain 21 Embark on a QUESTT to evaluate the child s pain. (Wong 2001) 22 QUESTT principle to assess children s pain Question the child and parent/caregiver Use pain rating scales Evaluate behaviour and physiological changes uestioning a child, parent or caregiver on pain: Secure parent/caregiver s involvement Take cause of the pain into account Take action and evaluate results

5 Questioning a child/ parent on pain: Precipitating/palliating/provoking factors Quality/quantity Use pain rating scales if appropriate Region/radiation/related factors Site, severity Time course Pain measurement Pain rating scales Pain is a subjective phenomenon and objective measurement is not possible Pain rating scales are useful as they: Guide treatment Help monitor response to interventions 27 There is no ideal rating scale Use one that is appropriate to the child s culture and developmental level May also have to consider ease and time taken to administer the scale Find one or two that you are comfortable to use Remember children may deny pain for fear of consequences 28 FLACC SCALE <3 yrs, not communicating Wong Baker FACES scale > 3 yrs Wong-Baker FACES Pain Rating Scale Although the Wong-Baker Faces Scale has been validated it is not always a practical tool to use. Find a tool you are happy using!

6 Revised faces pain scale Hand Rating Scale Although not validated, this can be very useful Eland Body tool Drawing pain Behavioural changes Evaluate behaviour and physiological changes Newborn Young children School aged child Adolescent

7 Behaviour and physiological changes Crying Muscle rigidity Guarding Loss of appetite Change in sleeping patterns Increased pulse rate and BP Sweating, pallor, dilated pupils Secure parent/ caregiver involvement Parent/ caregiver involvement: Listen to mothers, fathers and caregivers: they know the child best Include them in decision making They are more tuned to subtle changes in behaviour They know what works best to comfort the child Take the cause of pain into account Consider the cause Consider the pathophysiology of the underlying problem into account: i.e. the cause of the pain. Descriptions of the type of pain help to determine its cause and management. Take action and evaluate results

8 Take action and evaluate results: Management of pain Assess pain Revise treatment Develop treatment plan Re-assess Treat 43 Pain pathways Causes of pain in Children Start from head to toes Clinical Examination Causes of Misery -1 Mouth Eyes Ears Lymph nodes Nutritional Deficiencies: Vitamin C Vitamin D Iron Zinc Salt depletion Skin

9 Causes of Misery -2 Underlying illness - spasms Immobility - intestinal stasis - osteoporosis - dislocated hip Gut related - gastro-oesophageal reflux - constipation - leaking gastrostomy Bone related Infection - fracture/micro-fracture - Glandular fever - Brucellosis What happens when pain goes untreated? Untreated acute pain can lead to a metabolic cascade that adversely affects morbidity and even mortality Untreated acute pain can result in chronic pain Exposure to painful procedures in paediatrics (especially in the neonatal period) resets pain threshold for the rest of the child s life Oncology - Neuroblastoma 2 50 Renal stones or Gall stones Generic Approach to Pain What are the principles of pain management in children? Brainstorm 51 1) Reverse the reversible 2) Use Non-drug measures 3) Use Drug measures a) specific to the cause b) general 4) Address associated psychosocial distress e.g. Child with oral thrush 1) improve mouth hygiene 2) soft foods 3) a) topical soothing gel, antifungal b) analgesic 4) explanation and reassurance to mother Reverse the Reversible Seek underlying cause Treat what can be treated Stop offending drugs if possible 2. How do non-drug measures work? Largely by distraction Stimulate descending inhibitory pathway Decreases afferent stimulation COCHRANE Review - Can help significantly with symptom control

10 3. Drug Measures Non-pharmacological measures Swaddling Positioning Handling Massage Warmth Distraction Music Therapy Environment Aromatherapy Reflexology Hypnotherapy 55 What are some of the principles of pharmacological pain management? 56 Drug measures: Analgesics By the clock Correct use of analgesic drugs will relieve pain in most children! 4 KEY CONCEPTS (WHO): 1. By the clock 2. By the appropriate route 3. By the child 4. By the ladder 2 Minor Concepts 1. Attention to detail 2. Consider adjuvant therapy 57 No PRN prescribing in chronic pain On a prn basis, children must experience pain first before they can get medication fear that pain cannot be controlled worsens pain and anxiety Dosage intervals based on duration of action of drugs: 4HRLY for opioids Lower dosages of opioids ultimately used and smaller dose needed to prevent a recurrence of a controlled pain than to treat a new pain episode Rescue dosages for breakthrough pain 58 By the appropriate route. PO Use simplest, most effective route Intramuscular painful, avoid Intravenous may be used to titrate strong opioids Subcutaneous easier than IV Rectal may be unpleasant Topical EMLA Spinal/ epidural

11 By the child The OLD 3- step Ladder Need to adjust medication and dosages according to response and side effects No one dose will be appropriate for every child Remember: strong opioids have no ceiling dose titrate to response and side effects Classification of Analgesics Type Non-opioid Weak opioid Strong opioid Example Paracetemol NSAID s Codeine Tilidine (Valoron) Tramadol Morphine 63 The 2-Step Approach New WHO Guidelines 2011 Replaces the WHO ladder for children s pain Weak opioids not recommended in children Codeine not well metabolised in some children (?10%) Tramadol not licensed for use in children and insufficient evidence Exception is Valeron (Tilidine). This is only used in 3 countries in the world (RSA is one) and is higher potency than other weak opioids. Used for procedures. 64 The WHO 2 step analgesic ladder Dosing Non-opioid +/- co-analgesics STEP 1 Mild pain strong opioid +/-non-opioid +/- co-analgesics STEP 2 Moderate/Seve re pain 65 Type Example Dose Non-opioid Paracetamol Ibuprofen mg/kg 4-6hrly 5-10mg/kg 6-8hrly (max 30mg/kg/day) Strong opioid Morphine PO: 0.2 mg/kg 4hrly IVI bolus: 0.1 mg/kg IVI infusion: mg/kg/h 66 11

12 The adjuvant analgesics Important in the management of pain Offer a multi-pronged approach to pain Enhance the effects of opioids Treat concurrent symptoms that exacerbate pain Provide independent analgesia The adjuvant analgesics Antidepressants Anticonvulsants Antispasmodics Muscle relaxants Anxiolytics Corticosteroids Peripheral neuropathy Pain usually in legs/ feet Due to disease or medication e.g. Post herpetic neuralgia TB treatment/chemotherapy Treatment Change drugs Amitriptyline usually first line Carbamazepine/Gabapentin/Sodium Valproate 69 Pain in Oncology Headache Prednisone 2 4 mg/kg/day (single daily dose) Bone pain NSAID s, Steroids, Radiation Neuropathic Opioids, Amitryptiline, Carbamazepine, Regional Anaesthetic Blocks Visceral Antispasmodics, Opioids 70 Muscle spasm Case 1 - Sam Paracetamol NSAID s Baclofen Benzodiazepine Rivotril (Clonazepam) or Valium (Diazepam) 71 Sam, 7 years old 12 kg Confirmed diagnosis of lymphoma Severe abdominal pain, due to abdominal disease. How will you manage his pain? 72 12

13 Case 1: Sam Paracetamol 15mg x 12kg = 180mg 120mg/5ml = 7.5ml 6 hourly orally What do people say about morphine? Hyoscine butylbromide 5 to 10mg 3 x daily 5mg/5ml Morphine sulphate Opiophobia, a reality Morphine myths 75 Myth: It will shorten the child s life. Truth: Pain control does not shorten a child s life, it only improves the child s quality of life and brings comfort to a child s death. It can even extend a child s life because they are not exhausted from fighting pain. Myth: It will suppress a child s breathing. Truth: Respiratory depression can be avoided by steady increases of dose. Myth: It will make the child nauseous. Truth: Nausea may occur in 25% of cases but will normally settle in 5-7 days. 76 Morphine myths Myth: It will make the child even more constipated. Truth: Constipation must be prevented by the early use of prophylactic laxatives. Myth: They will develop addiction to it. Truth: Addiction is not a problem encountered in paediatric palliative care. Myth: Sedation will affect the quality of the child s life in the final days. Truth: Sedation will normally improve within a few days of taking morphine. 77 Morphine facts Morphine uses (4 A s) ü nalgesic ü nti-diarrhoeal (use stimulant laxative) ü nti-tussive ü naesthesia adjunct 78 13

14 Morphine facts Opioid side effects Morphine is a versatile drug with no ceiling effect and no danger of accumulation (except with renal failure) Transient Nausea Sedation The dose The correct dose of morphine for an individual patient is that dose which is effective. Possible routes po, pr, sc, nasal, buccal, iv (im- not for ppc) Remember to wean children off morphine if stopping especially if it has been used for >2 weeks 79 Ongoing Rare Constipation Hyperactivity Dysphoria Myoclonus Pruritis Urinary Retention 80 Morphine sulphate Morphine sulphate Dosage = 0.2 mg/kg 4 hourly Liquid preparations = 10 mg/5ml or 5mg/5ml or 50mg/5ml (10mg/ml) Weight of child is 12 kg Calculate the dosage of this child using a strength of 10 mg/5ml NB there are different preparations available e.g. tablets. And slow release tablets 81 Dosage = 0.2 mg/kg 4 hourly Strength = 10 mg/5ml Weight of child is 12 kg Calculate the dosage of this child Sam 12kg 0.2mg x 12 kg = 2.4 mg = 1.2 ml 4 hourly PO 82 Morphine sulphate prescription Morphine sulphate 2.4 mg - 10mg/5ml = 1.2 ml 4 hourly PO x 5 days. For Breakthrough Pain (30% to) 50% of dosage Morphine sulphate 1.2 mg 10mg/5ml = (0.4ml to) 0.6ml 4 hourly PO PRN (as required) Think about Laxative e.g. Lactulose 5 ml nocte, Sennokot 7.5mg nocte Anti-emetic - Metoclopramide or Haloperidol 83 How would you increase this? Increase regular dose by 30 50% of previous dose 2.4mg 2.4mg + 1.2mg = 3.6mg 3.6mg 3.6mg + 1.8mg = 5.4mg 8.1mg 5.4mg + 2.7mg = 8.1mg Until pain is controlled for full 4 hours. After 24 hours add up all doses (regular and breakthrough). Prescribed dose is one sixth (1/6) this total amount of morphine (taken in previous 24 hours) given regularly every 4 hours. Calculate a breakthrough dose of 50% of new regular 4 hourly dose NB. If breakthrough dose is required < 1 hour after regular dose then the regular dose needs to be increased 84 14

15 Sustained release morphine Given as 12 hourly dose orally Add total daily mg of morphine used if pain is controlled and divide by 2 e.g: 2.4 mg x 6 dosages (14.4mg) mg x 3 breakthrough doses (3.6mg) = 18 mg total daily dose Only 10, 30, 60 and 100 mg tabs Therefore give 10 mg 12 hourly PO (rounding up) Morphine sustained release granules (easily go down a naso-gastric or gastrostomy tube) (?minimum dose 3mg from a 20mg sachet). 85 Alternatives to morphine Hydromorphone: 7x potency of morphine Fentanyl: available as patches (72 h) takes up to hours to peak Diamorphine More soluble than morphine Methadone: Possibly more effective for neuropathic pain 86 Forms of Opiates Group discussion: What is wrong with this scene? Opiate Liquid Tab Buccal Supps Slow release IV/SC Codeine Y Y Y IM Dihydrocodeine Y Y Y Morphine Y Y? Y Y (Liquid/Tab) Y Diamorphine Y Y Oxycodone Y Y (Tablet) Y Hydromorphone Y Y Fentanyl Y(Patch) Y Alfentanyl Y Y Buprenorphine Y Y(Patch) Methadone Y Y Procedural pain How to deal with procedural pain Goal: children to be happy and secure before and after the procedure Needle phobia : 20% of Adults have moderate-intense fear of needles, blood Fear triggers anxiety, fainting, shock Avoidance of further treatment 89 Preparing the environment: Safe, friendly Preparing the adult: Help to calm and distract child, age appropriate info. Preparing the child: Topical anaesthetic Allow age appropriate choices Be honest about pain Cognitive e.g. explanation closing gates Distraction e.g. sing song, tell story, blow bubbles Relaxation 90 15

16 9/1/17 How to relieve fear Consider the following What will you give : Give control Explain what is happening Discuss options Seek and answer questions A 1-month old baby before an injection? A 3-year old with gastro-enteritis and abdominal pain? A 6-year old that injured his leg? An 8-year old with terminal cancer and severe pain? A 10-year old with headache? Non-pharmacological Blowing bubbles, progressive relaxation, aromatherapy/ massage, play/distraction Conclusion Any questions? In managing pain it is important to reverse the reversible and treat the underlying course. Non-pharmacological methods are important in managing pain in children. The majority of pain in children can be managed using the four main principles by the clock, by the mouth, by the child and by the ladder. Adjuvant analgesics have an important role to play in the management of pain in children. Morphine and other opioids can be used safely to manage pain in children. Thank you Pain is inevitable but suffering is optional

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