CLINICAL GUIDELINES ID TAG

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1 CLINICAL GUIDELINES ID TAG Title: Author: Speciality / Division: Directorate: Guideline for the management of pain in children Kieran O Connor Anaesthetics ATICS Date Uploaded: 1 September 2016 Review Date Sept 2019 Clinical Guideline ID CG0013[1]

2 Guideline for the management of pain in children This guideline aims to outline the key steps for managing peri-operative and procedural pain in children at the Southern Health & Social Care Trust (SHSCT). These principles also apply to pain preoperatively. 1 Background and context Managing pain in paediatric patients can be challenging, due to difficulties in pain assessment and limitations in pharmacological agents available, amongst other things. These challenges can result in the under-treatment of pain in children. This guideline sets out some key steps that can be taken to effectively manage pain in the paediatric context (see section 2 below). In addition to those steps, the key principles below should always be adhered to, to maximise efficacy of treatment and positive outcomes. Pre-operative analgesia should always be considered as part of the analgesia management plan. Postoperative analgesia should be planned and organised prior to surgery in consultation with patients and their families or carers, and other members of the perioperative team. Postoperative analgesia should be appropriate to developmental age, surgical procedure, and clinical setting to provide safe, sufficiently potent, and flexible pain relief with a low incidence of side effects. Pain after surgery is usually most severe in the first hours but may persist for several days or weeks. Analgesia can be given regularly in the early postoperative period and then as required according to assessed pain. 2 Guideline Overview The process of managing pain in children can be summarised in three key stages as follows: Stage 1: Assessment of pain in the child Stage 2: Pain management plan: Non-pharmalogical and pharmalogical interventions Stage 3: Reassessment and documentation These are discussed further below.

3 3 Assessment of the child There are a number of ways in which pain can be recognised in children. These include but are not limited to: - Verbal description from child or parent - Behavioural changes: crying, facial grimacing, etc. - Physiological changes: pallor, tachycardia, tachypnoea, etc. - Situational pain, e.g. trauma, post-surgical pain 3.1 Pain assessment tool Verbal description of pain may be limited in children of certain age groups. In these cases, pain assessment tools can facilitate the diagnosis and assessment of pain. An example of an assessment tool is the Wong and Baker FACES Pain Scale for use in children aged 3 18 years. The basis of the Wong-Baker approach is that the patient must choose the face that best describes how they are feeling, which is assigned a pain rating score between 0-10, as shown in Figure 1 below. Figure 1: Wong and baker Faces pain Scale 4 Pain Management Once the extent of pain has been ascertained, a management plan must then be implemented. In devising a pain management plan, a number of actions and interventions should be considered. In particular, both non-pharmacological and pharmacological interventions should be applied as outlined below. Non-pharmacological interventions - Managing expectations: The planned procedure as well as the pain relief plan should be explained to the child and parents. This has the benefit of reducing any anxiety that the patient may be feeling. - Supportive and distractive techniques: Use of distractive strategies such as toys, music, blowing bubbles, etc. should also be considered. Parents should remain present if possible, and may also be able to recommend useful distraction aids, such as the child s favourite toy.

4 Pharmacological interventions - Topical local anaesthetics: These should be applied on intact skin (in children >1month), and sufficient time should be given for analgesia to be achieved (i.e. 30mins for Ametop gel). These have most benefit for procedures such as IV cannula insertion. - Infiltrated local anaesthetics: 1% Lidocaine or other local anaesthetics should be used for all minor surgical procedures, such as suturing. Maximum dose of lidocaine is 3mg/kg. - Pharmacological analgesics: In all instances, pharmacological analgesics should be considered based on pain severity as described in Figure 2 below, which shows examples of managing mild, moderate and severe pain in a five year old child of weight 20 kg.** - Note that the below examples are for illustration purposes only. All drug calculations must be adjusted based on the child s weight. Please refer to trust prescribing policy for dose calculation guidance. Mild Pain Example: 5 year old child with facial laceration requiring suturing Moderate Pain Example: 5 year old child post tonsillectomy Severe Example: 5 year old child for Appendicectomy Note: Analgesia must be commenced in the preoperative period Figure 2: Pharmacological analgesics recommended by pain level

5 PCA (Patient Controlled Analgesia) This may be required for the control of severe pain following major surgery e.g. appendicectomy. This can be used if the child understands the concept of pressing the button and is physically able to do so. Usually this means 6 years and above. See Paediatric Patient Controlled Analgesia Guideline CG0167 **Recent guidance from MHRA (Medicines and Healthcare Products Regulatory Agency) and PRAC (European Medicines Agency s Pharmacovigilance Risk Assessment Committee) and advice sent out regionally by DHSSPSNI states that: Codeine containing medicines should only be used to treat acute (short lived) moderate pain in children above 12 years of age, and only if it cannot be relieved by other painkillers such as paracetamol or ibuprofen Codeine should not be used in - all children (aged below 18 yrs) who undergo surgery for tonsillectomy and/or adenoidectomy for obstructive sleep apnoea - all patients of any age known to be CYP2D6 ultra- rapid metabolisers (more commonly seen in the Afro-Caribbean population) Codeine should be used with extreme caution in children, especially those whose breathing might be compromised, including those with: - neuromuscular disorders - severe cardiac or respiratory conditions - upper respiratory or lung infections - multiple trauma To minimise risk to children and in view of recent guidance it has been agreed that codeine phosphate will no longer be routinely prescribed to any children under the age of 18. In exceptional circumstances after careful risk/benefit assessment it may be prescribed by the consultant involved in the care of the child. A potential area of concern is prescribing opioids for home use in paediatric patients. The responsibility remains with the surgical team looking after the child. Opioid home prescription after careful risk/benefit assessment may be considered by the consultant involved in the child s care or by a suitably senior trainee (ST4 or above) or staff grade of that team. 5 Reassessment and documentation A vital component of the management of pain in children is the reassessment and evaluation of pain to determine the effectiveness of interventions. Adequacy of pain management can be assessed by carrying out a further reassessment of the child, as described in Section 3 above. If pain persists, it must be acted upon, and further interventions as outlined in section 4 (above) should be implemented. All pain assessments should be clearly documented in the patient s notes.

6 6 Conclusion and summary Managing pain in paediatric patients can be challenging. However, with adequate planning, assessment, engagement of the parents/guardians, regular re-evaluation and customisation of the pain management approach to suit the patient, these challenges can be managed and opportunity for positive outcomes maximised. Authors: Dr Karen Goddard (Anaesthetic ST, CAH) Dr Kieran O Connor (Consultant Anaesthetics, Lead in Paediatrics, CAH) Richard Clements (Clinical Pharmacist, Paediatrics, CAH) CAH Acute Pain Team **revised August 2016 References Good Practice in Postoperative and Procedural Pain Management 2 nd Edition, A Guideline from the Association of Paediatric Anaesthetists of Great Britain and Ireland. Paediatric Anaesthesia. Volume 22 Supplement 1 July Wong-Baker FACES Pain Rating Scale. Paediatric analgesic guidelines. Craigavon Area Hospital

7 Appendix 1.