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PEDIATRICS Vol. 108 No. 3 September 2001, pp. 793-797
AMERICAN ACADEMY OF PEDIATRICS:
The Assessment and Management of Acute Pain in Infants,
Children, and Adolescents
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. Numerous myths,
insufficient knowledge among caregivers, and inadequate application of
knowledge contribute to the lack of effective management. The pediatric
acute pain experience involves the interaction of physiologic,
psychologic, behavioral, developmental, and situational factors. Pain
is an inherently subjective multifactorial experience and should be
assessed and treated as such. Pediatricians are responsible for
eliminating or assuaging pain and suffering in children when possible.
To accomplish this, pediatricians need to expand their knowledge, use
appropriate assessment tools and techniques, anticipate painful
experiences and intervene accordingly, use a multimodal approach to
pain management, use a multidisciplinary approach when possible,
involve families, and advocate for the use of effective pain management
in children.
ABSTRACT
Top
Abstract
Introduction
Conclusion
Recommendation
References
An important responsibility of physicians who care for
children is eliminating or assuaging pain and suffering when possible. It has been well documented, however, that in this regard a substantial percentage of children have been undertreated.1 The most common type of pain experienced by children is acute pain resulting from injury, illness, or, in many cases, necessary medical procedures. There is extensive literature that describes how to evaluate and treat
acute pain in children using low-cost, widely available, convenient,
and safe methods; this information, however, has not been readily
applied.
Although this statement focuses on acute pain, it is the obligation of
primary care physicians, general pediatricians, pediatric surgeons, and
pediatric subspecialists to recognize and address all types of pain,
including acute pain, chronic pain, recurring pain, procedure-related
pain, and pain associated with terminal illness. The American Academy
of Pediatrics (AAP) and the American Pain Society (APS) jointly issue
this statement to underscore the responsibility of pediatricians to
take a leadership and advocacy role to ensure humane and competent
treatment of pain and suffering in all infants, children, and
adolescents.
A major aim of pain treatment is to eliminate pain-associated
suffering. Pain is an inherently subjective experience and should be
assessed and treated as such. Pain has sensory, emotional, cognitive,
and behavioral components that are interrelated with environmental,
developmental, sociocultural, and contextual factors. Suffering occurs
when the pain leads the person to feel out of control, when the pain is
overwhelming, when the source of the pain is unknown, when the meaning
of the pain is perceived to be dire, and when the pain is
chronic.2 The concepts of pain and suffering go well
beyond that of a simple sensory experience.
Barriers to the treatment of pain in children include the following: 1)
the myth that children, especially infants, do not feel pain the way
adults do, or if they do, there is no untoward consequence; 2) lack of
assessment and reassessment for the presence of pain; 3)
misunderstanding of how to conceptualize and quantify a subjective
experience; 4) lack of knowledge of pain treatment; 5) the notion that
addressing pain in children takes too much time and effort; and 6)
fears of adverse effects of analgesic medications, including
respiratory depression and addiction. Personal values and beliefs of
health care professionals about the meaning and value of pain in the
development of the child (eg, the belief that pain builds character)
and about the treatment of pain cannot stand in the way of the optimal
recognition and treatment of pain for all children.3
Although the AAP and the APS support the ethical mandate to treat
appropriately all pediatric pain and suffering, this policy statement
focuses on common acute pain experiences. Most acute pain experienced
in medical settings can be prevented or substantially relieved.
Comprehensive pediatric care considers all aspects of distress and also
should address these aspects in a compassionate, effective, timely, and
multidimensional manner. Anxieties that are experienced by children and
other symptoms that contribute to suffering need to be considered in
the treatment plan for pain. Effective pain management thus generally
involves an interdisciplinary therapeutic approach with a combination
of pharmacologic, cognitive-behavioral, psychologic, and physical
treatments.
Health care professionals should anticipate predictable painful
experiences and monitor the condition of patients accordingly. To treat
pain adequately, ongoing assessment of the presence and severity of
pain and the child's response to treatment is essential. Reliable,
valid, and clinically sensitive assessment tools are available for
neonates through adolescents.4 In a hospital setting, pain
and response to treatment, including adverse effects, should be
monitored routinely and documented clearly and in a visible place, such
as on the vital sign sheet, to facilitate treatment and communication
among health care professionals.
Pain can be assessed using self-report, behavioral observation, or
physiologic measures, depending on the age of the child and his or her
communication capabilities. Specific measures vary in their validity
and usefulness. Accurate acute pain assessment requires consideration
of the plasticity and complexity of children's pain perception, the
influence of psychologic and developmental factors, and the
appreciation of the potential severity and specific types of pain
experienced.5 Because pain is a subjective experience,
individual self-report is often favored; however, it is important to be
sure that children, particularly those between 3 and 7 years of age,
are competent to provide information before their report of location,
quality, intensity, and tolerability are accepted. Observation of
behavior should be used to complement self-report and can be an
acceptable alternative when valid self-report is not available.
When communication is difficult, personal assumption by health care
professionals on the meaning of the behavior should be examined
carefully. Pain expression reflects the physical and emotional state,
coping style, and family and cultural expectations and can be
misinterpreted by the health care professional. For example, stoic or
depressed children with severe pain may not report or show expected
behavioral evidence of the severity of the pain. Pain experienced by
children with special health care needs or developmental disabilities
may be particularly difficult to assess accurately. Careful and
thorough assessments are necessary when communication with the patient
may be problematic, as may be the case with children who are
cognitively impaired, severely emotionally disturbed, or impaired in
sensory or motor modalities. Cultural and language differences between
the child and health care professional also require additional care in
assessment. When such patients are unable to report pain, credible
assessment usually can be obtained from the parent or another person
who knows the child well. However, there is a relatively pervasive and
systematic tendency for proxy judgments to underestimate the pain
experience of others. Physiologic measures should be recognized as
usually reflecting stress reactions during acute pain and usually are
only tenuously correlated with self-report of pain.
The key to managing procedure-related pain and distress is
anticipation. The approach to procedural pain varies according to the
anticipated intensity and duration of expected pain, the context and
meaning as seen by the child and family, the coping style and
temperament of the child, the type of procedure, the child's history
of pain, and the family support system. Procedures should be performed
by persons with sufficient technical expertise or who are directly
supervised by individuals with technical expertise so that pain is
minimized to the greatest extent possible. Children and parents should
receive appropriate information about what to expect and appropriate
preparation about how to minimize distress. It is advisable in
appropriate situations to have parents present and prepared with
specific ways of comforting their children.6,7
The treatment approach should be multimodal and meet the child's
needs. Depending on the nature of the procedure and characteristics of
the child, optimal pain control may be obtained with interventions ranging from deep sedation and anesthesia to strategies aimed at
facilitating competent coping with the procedure in ways that enhance
self-esteem with little or no pharmacologic support.8 Cognitive behavioral strategies that involve the use of imagery, relaxation, and self-regulation can provide pain relief independently or in conjunction with other pain management
modalities.1,8 Other complementary approaches, such as
massage or use of heat compresses, may be beneficial. Strategies that
reduce distress and worry for parents and children have been associated
with reductions in children's report of pain sensation and
observations of their pain behavior. For each of these approaches, a
quiet environment, calm adults, and clear, confident instructions
increase the likelihood that the specific pain management strategy
selected will be effective.
Local anesthetics and strategies to soothe and minimize distress should
be considered even for simple procedures, such as venipuncture. Some
common painful minor procedures, such as circumcision, do not always
receive the warranted attention to comfort issues. Available research
indicates that newborn circumcisions are a significant source of pain
during the procedure and are associated with irritability and feeding
disturbances during the days afterward.9-11 Opportunities
for alleviating pain exist before, during, and after the procedure, and
many interventions are effective.12-17
For procedural pain that is predictably severe and for which local
measures give inadequate relief, such as for bone marrow aspirations,
the use of systemic agents is required to bring pain to acceptable
levels. The use of anxiolytics or sedatives alone for painful
procedures does not provide analgesia but makes a child less able to
communicate distress. The child still experiences pain during the
procedure, and there are no data on the short- or long-term sequelae of
this strategy. When it is necessary to use sedation and analgesia for
painful procedures, the guidelines issued by the AAP18,19
should be followed. These guidelines recommend that sedation be
conducted in a monitored setting with resuscitative drugs and equipment
available and that agents be administered by a competent person. The
guidelines stipulate that one person is assigned to monitor the
child's condition and another qualified person is present to respond
to medical emergencies.
The study of operative and postoperative pain has contributed
enormously to the understanding of effective assessment and treatment
of pain, and this knowledge can be applied to many other areas of
pediatric pain management.7 Data support the concept that
morbidity and mortality can be reduced by good pain treatment.20 Although there have been sophisticated technologic advances in postoperative pain treatment, such as epidural
anesthesia21-23 and patient-controlled analgesia,24,25 most postoperative pain in children also
can be treated effectively in a simple, cost-effective manner by the
pediatrician and other health care professionals without advanced
techniques.
Plans for postoperative pain management should be discussed with the
family and generated before surgery.7 Basic elements of
pharmacologic treatment include type of analgesic, dose, timing, and
routes of delivery. Postoperative pain management encompasses the use
of different classes of drugs, including opioids and nonopioid
analgesics. Opioids, such as fentanyl citrate, morphine sulfate, and
hydromorphone hydrochloride, are indicated to manage moderate to severe
postoperative pain. Meperidine hydrochloride, because of metabolic
products and adverse effects, is not an opioid of choice for the
management of pain.7,26 The use of other analgesics, such
as acetaminophen and nonsteroidal anti-inflammatory agents
in combination with opioids, can reduce the amount of opioid required.
Starting doses of analgesics for children are provided in the Agency
for Health Care Policy and Research7 guidelines on acute pain management. Analgesic treatment should include proper dosing according to body weight, physiologic development, and the
medical situation. The goal is to control the pain as rapidly as
possible, and thus, the starting dose should be optimal and further
doses should be titrated depending on patient response. Administration
of multiple, small, ineffective doses of analgesic may result in the
prolongation of pain, exacerbation of anxiety, and even severe adverse
effects of the analgesic, such as respiratory depression.
Early effective treatment is safer and more efficacious than delayed
treatment and results in improved patient comfort and possibly less
total analgesic administered. Except in extenuating circumstances, medication should not be given intramuscularly, because
it is painful and absorption can be variable. Oral administration is
preferred for mild to moderate pain. When the child needs immediate pain relief, intravenous administration is indicated when regional routes are not appropriate or readily available. For moderate to severe
pain expected to persist, continuous dosing or around-the-clock dosing
at fixed intervals is recommended; there are few indications for an
as-needed regimen used alone. Dosages and the interval between doses
should be adjusted on the basis of assessment of the patient's
response.
Addressing the adverse effects of opioid use, such as nausea, vomiting,
and pruritus, is important to minimize distress and to ensure that
adequate pain management is not compromised. Anticipated common adverse
effects associated with prolonged opioid use (eg, constipation) should
be prevented or promptly treated. The potential synergistic sedative
effects of analgesics, anxiolytics, antiemetics, and antihistamines
require ongoing assessment of sedation and analgesia. As the child
recovers from painful surgery, the analgesic regimen is changed
according to need but generally should not be stopped abruptly.
Although there is an increasing trend toward same-day surgery or rapid
discharge after surgery, quality research on the effects of these
changes from surgical and pain management standpoints is lacking.
Formal provisions, including communication with the family, must be
made for adequate analgesia at home.
As part of the comprehensive assessment and management of trauma
necessitating emergency treatment, pain should be addressed in the
emergency department with provisions made for pain management at home.
Severe trauma may lead to hospitalization in an intensive care unit,
and the management of pain may risk being compromised because of the
primary emphasis on life-supporting critical care interventions. In
severe trauma, the psychologic effect of the injury and the intensive
care unit experience necessitate the optimal treatment of pain to
reduce the total burden of suffering. Pain may be attributable to a
variety of causes, including the trauma, surgical procedures,
restricted movement, underlying disease, and the presence of lines,
tubes, and drains.27 Because of the diversity and
complexity of the clinical issues present, pain treatment, including
choice of drug, dosage, route, and mode (continuous vs intermittent) of
administration, must be tailored to the individual patient and
analgesics given in the overall context of what is best for the
patient. Communication among caregivers and an interdisciplinary
approach are helpful. Attention should be paid to optimizing sleep-wake
cycles, because sufficient sleep will enable the child to cope better
when awake. Prolonged pain may require use of opioids for an extended
duration.28 Dosages should be adjusted to compensate for
the development of physical tolerance, and weaning strategies should be
used to minimize or obviate withdrawal symptoms.29
Pain associated with acute illness, such as otitis media,
pharyngitis, meningitis (headaches), and pelvic inflammatory disease (pelvic pain), also should be addressed. Types of treatment are determined by the severity of the pain and by the particular illness and situation. Pharmacologic intervention may include the use of
acetaminophen, nonsteroidal anti-inflammatory drugs,
opioids, and locally applied medications. As with other situations that involve pain, nonpharmacologic treatment, such as distraction, relaxation, and physical therapies, also can be used effectively in
conjunction with medications.
Ample knowledge about pediatric pain exists to treat children
humanely and effectively, but it is not universally applied. Multiple
sources of information are available, and it is important that
pediatricians expand their knowledge base and advocate for the
appropriate treatment of pain in children. This may include the
institution of and adherence to educational requirements and quality
improvement guidelines for the treatment of pediatric pain.
Pediatricians are encouraged to advocate for and facilitate the use of
services offered through child life programs that can have a dramatic
effect in improving psychologic and physical comfort. In many treatment
centers, pain is a continuous quality improvement measure and included
as a fifth vital sign.
There is need for more research to elucidate further the strategies for
optimal pain management and the effect of the pain experience. It is
unacceptable that almost no potent analgesics have received approval
from the Food and Drug Administration for use in children. Children
deserve the benefit of systematic research on the clinical efficacy and
adverse effects of such medications.
Treatment of children will improve as pain management education expands
and as the issue of pediatric pain is brought into greater public
awareness. Education of parents and others in the community who deal
with children in pain is an important pediatric issue. When
pediatricians consistently make comfort a priority for their patients
and help others to treat pain more effectively, the treatment of pain
in children will improve.
Opportunities exist for improving pediatric pain management.
Pediatricians can facilitate the comfort of their patients by using the
following strategies:
INTRODUCTION
Top
Abstract
Introduction
Conclusion
Recommendation
References
PAIN ASSESSMENT
PROCEDURE-RELATED PAIN
OPERATIVE PAIN AND TRAUMA-ASSOCIATED PAIN
ACUTE ILLNESS
CONCLUSION
Top
Abstract
Introduction
Conclusion
Recommendation
References
RECOMMENDATIONS
Top
Abstract
Introduction
Conclusion
Recommendation
References
Committee on Psychosocial Aspects of Child and Family Health, 2000-2001
Joseph F. Hagan, Jr, MD, Chairperson
William L. Coleman, MD
Jane M. Foy, MD
Edward Goldson, MD
Barbara J. Howard, MD
Ana Navarro, MD
J. Lane Tanner, MD
Hyman C. Tolmas, MD
Liaisons
F. Daniel Armstrong, PhD
Society of Pediatric Psychology
David R. DeMaso, MD
American Academy of Child and Adolescent Psychiatry
Peggy Gilbertson, RN, MPH, CPMP
National Association of Pediatric Nurse Practitioners
Sally E. A. Longstaffe, MD
Canadian Paediatric Society
Consultants
George J. Cohen, MD
Anthony J. Richtsmeier, MD
American Pain Society, Task Force on Pain in Infants, Children, and Adolescents
Gary A. Walco, PhD, Chairperson
Marion E. Broome, RN, PhD
Neil L. Schechter, MD
Barbara S. Shapiro, MD
Maureen Strafford, MD
Lonnie K. Zeltzer, MD
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FOOTNOTES |
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The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
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ABBREVIATIONS |
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AAP, American Academy of Pediatrics; APS, American Pain Society.
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REFERENCES |
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Abstract
Introduction
Conclusion
Recommendation
References
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Pediatrics (ISSN 0031 4005). Copyright ©2001 by the American Academy of Pediatrics
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L. A. Hatfield, M. E. Gusic, A.-M. Dyer, and R. C. Polomano Analgesic Properties of Oral Sucrose During Routine Immunizations at 2 and 4 Months of Age Pediatrics, February 1, 2008; 121(2): e327 - e334. [Abstract] [Full Text] [PDF]
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R. R. Pillai Riddell and K. D. Craig Judgments of Infant Pain: The Impact of Caregiver Identity and Infant Age J. Pediatr. Psychol., June 1, 2007; 32(5): 501 - 511. [Abstract] [Full Text] [PDF]
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 R. Y. Zisk, M. Grey, J. E. MacLaren, and Z. N. Kain Exploring Sociodemographic and Personality Characteristic Predictors of Parental Pain Perceptions Anesth. Analg., April 1, 2007; 104(4): 790 - 798. [Abstract] [Full Text] [PDF]
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 A. J Harvey and N. S Morton Management of procedural pain in children Arch. Dis. Child. Ed. Pract., February 1, 2007; 92(1): ep20 - ep26. [Full Text] [PDF]
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J. Simons and L. M. MacDonald Changing practice: implementing validated paediatric pain assessment tools J Child Health Care, June 1, 2006; 10(2): 160 - 176. [Abstract] [PDF]
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A. L. Drendel, D. C. Brousseau, and M. H. Gorelick Pain Assessment for Pediatric Patients in the Emergency Department Pediatrics, May 1, 2006; 117(5): 1511 - 1518. [Abstract] [Full Text] [PDF]
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 R. M. Rosenfeld MD, MPH, L. Brown MD, MPH, C. R. Cannon MD, R. J. Dolor MD, MHS, T. G. Ganiats MD, M. Hannley PhD, P. Kokemueller MS, CAE, S. M. Marcy MD, P. S. Roland MD, R. N. Shiffman MD, MCIS, et al. Clinical practice guideline: Acute otitis externa Otolaryngology -- Head and Neck Surgery, April 1, 2006; 134(4_suppl): S4 - S23. [Abstract] [Full Text] [PDF]
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M. Sinha, N. C. Christopher, R. Fenn, and L. Reeves Evaluation of Nonpharmacologic Methods of Pain and Anxiety Management for Laceration Repair in the Pediatric Emergency Department Pediatrics, April 1, 2006; 117(4): 1162 - 1168. [Abstract] [Full Text] [PDF]
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 R. L. Blount, T. Piira, L. L. Cohen, and P. S. Cheng Pediatric Procedural Pain Behav Modif, January 1, 2006; 30(1): 24 - 49. [Abstract] [PDF]
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F. D. Armstrong Analgesia for Children With Acute Abdominal Pain: A Cautious Move to Improved Pain Management Pediatrics, October 1, 2005; 116(4): 1018 - 1019. [Full Text] [PDF]
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F. D. Armstrong and G. H. Reaman Psychological Research in Childhood Cancer: The Children's Oncology Group Perspective J. Pediatr. Psychol., January 1, 2005; 30(1): 89 - 97. [Abstract] [Full Text] [PDF]
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J. M. Simons and L. M. MacDonald Pain assessment tools: children's nurses' views J Child Health Care, December 1, 2004; 8(4): 264 - 278. [Abstract] [PDF]
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W. T. Zempsky, J. P. Cravero, and Committee on Pediatric Emergency Medicine, and Sec Relief of Pain and Anxiety in Pediatric Patients in Emergency Medical Systems Pediatrics, November 1, 2004; 114(5): 1348 - 1356. [Abstract] [Full Text] [PDF]
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 D. O'Rourke The Measurement of Pain in Infants, Children, and Adolescents: From Policy to Practice Physical Therapy, June 1, 2004; 84(6): 560 - 570. [Full Text] [PDF]
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Subcommittee on Management of Acute Otitis Media Diagnosis and Management of Acute Otitis Media Pediatrics, May 1, 2004; 113(5): 1451 - 1465. [Abstract] [Full Text] [PDF]
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Journal Watch Arch. Dis. Child., April 1, 2004; 89(4): 392 - 393. [Full Text] [PDF]
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 Managing Pain in Children Journal Watch Pediatrics and Adolescent Medicine, January 16, 2004; 2004(116): 2 - 2. [Full Text]
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 S. Kharasch, G. Saxe, and B. Zuckerman Pain Treatment: Opportunities and Challenges Arch Pediatr Adolesc Med, November 1, 2003; 157(11): 1054 - 1056. [Full Text] [PDF]
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E. C. Reis, E. K. Roth, J. L. Syphan, S. E. Tarbell, and R. Holubkov Effective Pain Reduction for Multiple Immunization Injections in Young Infants Arch Pediatr Adolesc Med, November 1, 2003; 157(11): 1115 - 1120. [Abstract] [Full Text] [PDF]
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 L. S. Franck Nursing management of children's pain: Current evidence and future directions for research Journal of Research in Nursing, September 1, 2003; 8(5): 330 - 353. [Abstract] [PDF]
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 P. C. Walker and D. S. Wagner Treatment of Pain in Pediatric Patients Journal of Pharmacy Practice, August 1, 2003; 16(4): 261 - 275. [Abstract] [PDF]
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 E. Goldson Pediatricians should not give up on children with life-limiting illnesses AAP News, December 1, 2002; 21(6): 286 - 288. [Full Text] [PDF]
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D. M. Gaughan, M. D. Hughes, G. R. Seage III, P. A. Selwyn, V. J. Carey, S. L. Gortmaker, and J. M. Oleske The Prevalence of Pain in Pediatric Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome as Reported by Participants in the Pediatric Late Outcomes Study (PACTG 219) Pediatrics, June 1, 2002; 109(6): 1144 - 1152. [Abstract] [Full Text] [PDF]
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 G. J. Boyle, R. Goldman, J. S. Svoboda, and E. Fernandez Male Circumcision: Pain, Trauma and Psychosexual Sequelae J Health Psychol, May 1, 2002; 7(3): 329 - 343. [Abstract] [PDF]
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