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Chapter 32: Pain Management & Pediatric Palliative & End-of-Life Care

Brian S. Greffe; Jeffrey L. Galinkin; Nancy A. King

INTRODUCTION

Children experience pain to at least the same level as adults. Multiple studies have shown that neonates and infants perceive pain and have memory of these painful experiences. Frequently, children are underprescribed and underdosed for opioid and nonopioid analgesics due to excessive concerns of respiratory depression and/or poor understanding of the need for pain medications in children. Few data are available to guide the dosing of many pain medications and the majority of pain medications available on the market today are unlabeled for use in pediatric patients.

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Taddio  A, Katz  J: The effects of early pain experience in neonates on pain responses in infancy and childhood. Pediatr Drugs 2005;7:245–257
[PubMed: 16118561] .
CrossRef

PAIN ASSESSMENT

Standardizing pain measurements require the use of appropriate pain scales. At most institutions, pain scales are stratified by age (Table 32–1) and are used throughout the institution from operating room to medical floor to clinic, creating a common language around a patient’s pain. Pain assessment by scales has become the “5th vital sign” in hospital settings and is documented at least as frequently as heart rate and blood pressure at many pediatric centers around the world. There are many pain scales available, all of which have advantages and disadvantages (eg, Figures 32–1 and 32–2, and Table 32–2). It is less important what type of scale is used, but that they are used on a consistent basis.

Table 32–1.Pain scales—description and age-appropriate use.
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Table 32–1. Pain scales—description and age-appropriate use.
Name of Scale Type Description Age Group
Numeric Self-report Verbal 0–10 scale; 0 = no pain, 10 = worst pain you could ever imagine Children who understand the concept of numbers, rank, and order; approximately > 8 y
Bieri and Wong-Baker scales Self-report Six faces that range from no pain to the worst pain you can imagine Younger children who have difficulty with numeric scale; cognitive age 3–7 y
FLACC Behavioral observer Five categories: face, legs, activity, cry, and consolability; range of total score is 0–10; score ≤ 7 is severe pain. Figures 32–1 and 32–2 and Table 32–2 Nonverbal children > 1 y
CRIES, NIPS, PIPP Behavioral observer Rates a set of standard criteria and gives a score Nonverbal infant < 1 y

CRIES, Crying Requires O2 saturation, Increased vital signs, Expression, and Sleeplessness; FLACC, Face, Legs, Activity, Crying, Consolability; NIPS, Neonatal Infant Pain Scale; PIPP, Premature Infant Pain Profile.

Reproduced with permission from Motoyama EK, Davis PJ: Smith’s Anesthesia for Infants and Children, 7th ed. St. Louis: Mosby/Elsevier; 2006.

Table 32–2.FLACC pain assessment tool.
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Table 32–2. FLACC pain assessment tool.
Categories Score 0 Score 1 Score ...

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