Pediatric Pain Assessment and Nonpharmacological Therapy

Tracy Akitt

Sadie Bartram

Sheryl Christie

Karen Paling

Introduction

Many factors can contribute to how a child perceives pain and copes with anxiety-provoking situations.
The pain response for a particular patient is individual and learned through social learning and experience.
Unmanaged pain can lead to:
- Short-term consequences such as children displaying heightened sensitivity to subsequent medical procedures.
- Long-term consequences such as the development of hyperalgesia.
Pain endured as a child correlates with adult behaviors such as pain responses, fear, coping effectiveness, and willingness to seek medical attention.

Understanding Coping Mechanisms

Adequate interventions to assess and manage childhood pain are essential.
Use a multimodal and multisystem approach when treating a child in pain.
Involve skilled and specially trained professionals such as child life specialists to assist with pain assessments and interventions, and also to assist pediatric patients and their caregivers to cope.
Through appropriate assessment, coping behaviors can be identified as to how a child responds to anxiety and distress.
- According to Kuttner (1996), there are four types of coping behaviors:
  - Catastrophizers – view painful events in a very negative way. Although they ask many questions to gain information, the information is not comforting.
  - Sensitizers – find the information is comforting to them. They are able to gather lots of information to develop more coping strategies to handle painful events.
  - Minimizers – only process information given in small amounts. They are able to use the information to help themselves cope with situations and may require more time to develop coping strategies.
  - Deniers – prefer not to have any information. This can be difficult when it is time for the stressful event to occur (i.e., surgery).
- It is important to note that these coping behaviors are not static and can change over time depending on the situation and the supports provided.

Use of Child Life Specialists in the Emergency Department

Implementing child life programs in the emergency department (ED) have been shown to relieve the stress and anxiety associated with an ED visit.
Procedure teaching and support, guided imagery, distraction, and other techniques used during procedures have been shown to:
- Improve coping and decrease upset behavior (of patients and parents).
- Decrease medication required for sedation or analgesia.
- Improve staff efficiency.
- Improve parent satisfaction.

Pediatric Pain Assessment

Pain assessment in children should be an ongoing process.
Assessment tools should be used to understand the level of pain a patient is experiencing (see examples listed in Tables 13.1–13.5).
- Many hospitals have a variety of pain assessment tools readily available for their staff. Check with your local resources.
Pain in children is measured by:
- What the child says.
- What an observer sees.
- The child’s physiological responses to pain.
A child’s cognitive and language development play a large role in their ability to “self-report” pain, thereby making it necessary to rely more heavily on observational and biophysiological measures for infants, toddlers, and patients with neurocognitive impairments.
Self-reporting considerations:
- A child’s pain is measured simply by asking the child how much he or she hurts, where it hurts, and for how long it has hurt.
- The child is the best source of information, as he or she is truly the only person who knows the intensity of the pain.
- A child’s self-report, when possible, should be the primary measure of pain assessment.
Factors that will influence a child’s pain response include:
- Cognitive, emotional, and language development, as this will influence how children perceive and understand pain (see Tables 13.1–13.5).
- Developmental age and temperament.
- Previous pain experiences and a child’s memory in relation to these experiences.
- Caregiver involvement.

Table 13.1: Infant pain assessment and nonpharmacological pain management strategies

Infant (birth–18 mo)

Cognitive perceptions of pain

0–3 mo

No apparent understanding of pain; memory for pain likely but not conclusively demonstrated; responses appear mostly reflexive.

3–6 mo

Response to pain supplemented with sadness and anger.

6–18 mo

Developing fear of painful situations; early stages of being able to localize pain (through touching/pointing).
Understanding of common words for pain evolving such as “owie, ouchie, booboo.”
It is important to remember that words for pain vary with cultures and languages.
Ask parents the words they frequently use at home.

Pain assessment tools

Self-rating – Not possible.
Biophysiological – Heart rate, oxygen saturation, palm sweat.
Observations (behavioral):

Cry (length and type), facial expressions, body movement, parent ratings/perceptions.
Neonatal Facial Action Coding System (N-FACS).
Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS) – (1–7 yr).
Faces, legs, activity, cry, consolability (FLACC) – (0–7 yr).

Considerations for procedural preparation

Information to include:

Important to prepare the parents of infants. Their comfort to stay during the procedure should be assessed, and their presence should be encouraged.
Give parents information on the steps of the procedure, the responses their child could exhibit, and where to be positioned during the procedure.

Developmental considerations:

Infants are at a stage of building a secure attachment to a parent.
Including parents in all aspects of care and to be their source of comfort is highly important.

Without these interventions:

Infant’s stress levels can increase in absence of nurturing and comforting responses.
Failing to relieve the pain can cause mistrust and fear toward caregivers.
Immediate effects such as irritability, fear, and sleep disturbance may occur.
Effects include delayed healing, impaired emotional bonding, and altered response to subsequent painful experiences.

Environmental considerations

Caregiver involvement:

Encourage parental participation during the procedure to comfort their child.
Separation from parents can heighten the distress of infants.
If the parents are not comfortable or unable to stay, it is important for them to return as quickly as possible.

Health care worker behaviors:

Changes or missing their usual routine of sleeping, eating, and bathing can be distressing for the child.
This routine should be respected by the health care workers by planning procedures to be implemented to allow the child’s routine to continue as much as possible, and for the child’s routine care to be provided by their parents.

Health care setting:

Keep the room quiet and calm (voices low).
Minimize the number of people in the room.

Cognitive and behavioral distraction

Comfort suggestions:

Pacifier, blanket, favorite item
Swaddling position, massage, touch

Distraction play materials:

Rattles, pop-up toys, light-up toys, music, bubble blowing

Distraction conversation:

Singing, action rhymes, positive comforting words

Relaxation methods:

Massage, touching, blowing bubbles, blowing bubbles away

Developmental Age

Younger children (younger than 7 years):
- Rate their pain as higher than older children and display more distress during a painful event.
- Level of distress and pain ratings may be due to:
  - Their developmental level of not understanding the purpose of a painful procedure.
  - The fact that they do not grasp that often the procedural pain will be over quickly.
  - Their limited ability to use cognitive coping strategies.
Older children (older than 7 years):
- Are better able to distinguish the difference between “pain,” “unpleasantness,” and “fear.”
- May feel a need or may want to appear stoic, thus pain ratings (both self- and observer-reported) may be lower than younger children’s pain ratings.

Temperament

Temperament is a concept defined by Thomas and Chess that describes a person’s behavioral style.
Temperament theory looks at how children will respond to an external stimulus.
- Three temperament categories are as follows:
  - Difficult
  - Easy
  - Slow to warm up
- Children considered by parents to have “difficult” temperament were rated as having greater pain responses than children who were found to have “easy” temperaments when requiring immunizations.
Health care providers need to be flexible and adapt their interventions and modify the environment to better match the child’s temperament.
It is important to assess and collaborate with parents with regards to how they feel their children’s temperament may affect their ability to cope with their pain.

Table 13.2: Toddler pain assessment and nonpharmacological pain management strategies

Toddler (18 mo–3 yr)

Cognitive perceptions of pain

18–24 mo

Use the word “hurt” (language/culture specific) to describe pain and noncognitive coping strategies.

24–36 mo

Beginnings of pain description and attribute an external cause to pain.
Threat of immediate pain is overwhelming, particularly in situations where the child has a recent previous experience with that same or similar pain stimulus (i.e., IV start or blood work).
Future benefit of procedure not understood.