Pediatric Pain Management in the Emergency Department

Table of Contents

 

Untreated or inadequately treated pain causes significant harm to pediatric patients both in the short term and the long term. For a variety of reasons, adequate treatment of pain can be challenging. This issue offers guidance on assessing pain in pediatric patients and provides evidence-based recommendations for developing strategies to successfully manage pain in pediatric patients. You will learn:

Various factors that play a role in a patient’s perception of pain, and how painful stimuli that are experienced early in life can affect reactions to painful stimuli later in life

Which pain assessment scales are recommended for patient self-report (eg, the Faces Pain Scale-Revised [FPS-R] and the color analog scale [CAS]) and which can be used for assessing pain in preverbal children (eg, the Face, Legs, Activity, Cry, and Consolability [FLACC] scale)

The importance of reassessment using the same scale throughout the patient’s ED visit

Evidence-based strategies for management of pain in pediatric patients, including:

⚬ Nonpharmacologic techniques (eg, distraction, relaxation or visualization techniques)

⚬ Topical anesthesia (eg, EMLA®, LMX®, needle-free lidocaine, LET, vapocoolant)

⚬ Local anesthesia (eg, lidocaine, lidocaine with epinephrine, mepivacaine, bupivacaine, prilocaine)

⚬ Regional anesthesia (eg, lidocaine, bupivacaine, or ropivacaine for digital nerve blocks, femoral nerve blocks, or facial nerve blocks)

⚬ Systemic anesthesia, including nonopioid analgesics (eg, acetaminophen and NSAIDs) and opioid analgesics (eg, oxycodone, hydrocodone, morphine, hydromorphone, fentanyl)

The latest evidence regarding the use of analgesics in patients with acute abdominal pain

Which analgesics are recommended for patients with a fracture, based on the severity of pain

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal of the Literature
5. The History of Pain Treatment
6. Physiology of Pain
7. Prehospital Care
8. Emergency Department Evaluation
   1. Pain Scales
9. Treatment
   1. Nonpharmacologic Management
   2. Topical Anesthesia
      1. EMLA®
      2. LMX® and Topical Tetracaine
      3. Needle-Free Lidocaine
      4. LET
      5. Vapocoolant
   3. Local Anesthesia
   4. Regional Anesthesia
   5. Systemic Agents
      1. Nonopioid Analgesics
         • Acetaminophen
         • Nonsteroidal Anti-Inflammatory Drugs
           • Ibuprofen
           • Other NSAIDs
           • Side Effects of NSAIDs
      2. Opioid Analgesics
      • Codeine
      • Tramadol
      • Oxycodone
      • Hydrocodone
      • Morp hine
      • Hydromorphone
      • Fentanyl
      • Side Effects of Opioids
      • Management of Opioid Overdose
10. Special Circumstances
    1. Abdominal Pain
    2. Lumbar Puncture
    3. Fracture Management
11. Controversies and Cutting Edge
    1. Regional Anesthesia
       1. Epinephrine-Containing Anesthetics
       2. Femoral Nerve Blocks for Femoral Fractures
    2. Intranasal Ketamine
    3. Opioid Misuse
12. Summary
13. Time- and Cost-Effective Strategies
14. Risk Management Pitfalls for Pediatric Pain Management
15. Case Conclusions
16. Clinical Pathway for the Management of Pain in Pediatric Patients
17. Tables and Figures
    1. Table 1. Face, Legs, Activity, Cry, Consolability Scale
    2. Table 2. Summary of Recommended Pain Scales Used for Children
    3. Table 3. Onset and Duration of Action of Common Local Injectable Anesthetic Medications
    4. Table 4. Dosing of Nonopioid Analgesics
    5. Table 5. Dosing of Opioid Analgesics
    6. Figure 1. Faces Pain Scale - Revised
18. References

Abstract

Adequate analgesia is critical in the management of pediatric patients in the emergency department. Suboptimal treatment of pain can have deleterious effects in the short term, and it can also affect a patient’s development and reaction to future painful experiences. Tools exist to quantify a patient’s pain level regardless of age or developmental stage. Both pharmacologic and nonpharmacologic methods can be effective in the management of pediatric pain. Emergency clinicians must remain vigilant in the recognition, treatment, and reassessment of pediatric pain, as patients’ developmental level may limit their ability to independently express their pain experience without prompting or tools. This issue reviews pain scales that are suitable for pediatric patients and discusses pediatric pain management using nonpharmacologic methods, topical, local, and regional anesthesia as well as systemic agents.

Case Presentations

An 8-year-old boy presents to the ED after falling at a local playground. His mother, who was with him at the time of the injury, states that he was climbing out of a tree when he slipped and fell. He landed on his outstretched hands and is now complaining of right wrist pain. On examination, he has no open wounds, and he has a normal neurovascular examination, but he has an obvious deformity of his right forearm. The child describes his pain as 7/10. You ponder how best to treat the child’s severe pain as quickly as possible...

Your next patient is a 7-year-old boy who is brought in for 1 day of fever and right lower quadrant abdominal pain. His examination is significant for rebound and guarding of his right lower quadrant. The boy rates his pain as 9/10. You order initial laboratory studies. The patient’s mother pulls you aside to tell you that her son has had bad experiences with IV placement in the past, and she is very concerned about the associated pain. Meanwhile, one of the nurses tells to you that the on-call surgery resident will come to see your patient with possible acute appendicitis, but she will be delayed. The surgeon requested that you defer pain medication until her return to the ED, since pain medication will “ruin” her examination. You consider what to do next…

The last patient of your shift is a 21-day-old infant who presents with a fever to 38.3°C (100.9°F). The patient has had upper respiratory symptoms for 1 day. On examination, she has some upper respiratory congestion but is otherwise well appearing. You order blood, urine, and cerebrospinal fluid studies to conduct a full evaluation for occult infection. The parents expresses apprehension about the lumbar puncture, but eventually agree to the procedure. You begin to think about how best to treat your young patient’s procedural pain while maximizing the likelihood of a successful lumbar puncture...

Introduction

Pain, as defined by the International Association for the Study of Pain, is “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.”¹ The quality and location of pain may alert the emergency clinician to the presence of disease processes. Additionally, pain is a frequent—but often preventable—side effect of many of the diagnostic studies and treatments performed in the emergency department (ED), ranging from simple intravenous (IV) line placement to a complex fracture reduction.

For a variety of reasons, adequate treatment of pain can be one of the most challenging aspects of emergency medicine practice. First, pain is subjective. Despite the development of sophisticated pain scales, patient self-report is the best source of pain measurement in communicative patients. This can often lead to confusion when patient pain reports do not match emergency clinician expectations. Second, the pressures resulting from the volume of critical patients seen in the ED can make optimum pain management a seemingly impossible goal and lower its priority. Third, young patients’ developmental levels can make quantifying and qualifying their pain difficult and can reduce their ability to advocate for the treatment of their pain. Fourth, unfounded concerns from both emergency clinicians and consultants regarding “masking” pain and interfering with accurate diagnoses may lead emergency clinicians to undertreat pain. Finally, the concerns emergency clinicians and patients’ families have regarding side effects and the unclear potential for addiction may make emergency clinicians reluctant to use certain effective pain medications.

Despite these barriers, there are compelling reasons to treat pain in the ED. The relief of suffering is one of the fundamental goals of medicine. The adequate treatment of pain increases patient satisfaction.² Despite long-standing myths, all patients (including neonates) feel pain,³ and there is convincing evidence that exposing young patients to painful stimuli can have both short-term and long-term negative consequences.^4-7

Pain has been traditionally undertreated in all populations, but this is especially true in pediatric patients. The purpose of this issue of Pediatric Emergency Medicine Practice is to help emergency clinicians recognize pain in children, develop strategies to successfully manage pain in pediatric patients, and address specific areas where controversy in pain management exists.

Critical Appraisal of the Literature

A literature search was performed in Ovid MEDLINE^® and PubMed using multiple combinations of the search terms pain, pain management, analgesia, adverse events, side effects, children, pediatric, and emergency department. The Cochrane Database of Systematic Reviews was also consulted. Articles relevant to pediatric pain management were selected, reviewed, and included in the references, as were citations that appeared in review articles, clinical practice guidelines, and policy statements. Articles were chosen for inclusion if they were published after 1995; however, important articles published before this date were included for completeness and historical perspective. Over 400 articles were reviewed, 201 of which were chosen for inclusion in this review.

For many years, there was a paucity of data on acute pain management in a few small, often contradictory, studies. Recently, the Cochrane Library has published more actionable recommendations, but there is still a lack of in multicenter randomized controlled trials. In addition, there are few data on the long-term effects of exposure of pediatric patients to pain in the ED.

The History of Pain Treatment

Despite the clinical and ethical imperative for clinicians to treat pain and reduce patient suffering, pain in both adult and pediatric patients has traditionally been undertreated.^8-11 Underutilization of pain medication has been particularly pronounced in children, since, historically, it has been though that children “…seldom need medication for relief of pain. They tolerate discomfort well.”¹² This has frequently led to children either not receiving analgesics or receiving insufficient doses of analgesics. In the past, many believed that infants did not experience pain; historically, cardiac surgeries have even been performed on neonates without analgesia.¹³ Numerous studies in the 1980s quantitatively demonstrated a pronounced lower usage of analgesics for definitively painful conditions in children versus adults.^8,14 A study published in 1990 documented this phenomenon in the ED, showing that children received analgesics significantly less frequently than adults (28% vs 60%, P < .001) when presenting with painful conditions.⁹

Despite improved understanding of pediatric pain as well as the introduction of newer, safer agents, the use of sedation and analgesia remains highly variable across patients and hospitals.^15-17 However, as a greater understanding of the negative consequences of untreated pain has developed, many in the medical community began to refute the misperceptions surrounding pediatric pain,¹⁸ and a concerted effort to make the ED an “ouchless” place for children began to develop.² Today, a variety of modalities, both pharmacologic and nonpharmacologic, are available for pediatric patients to help minimize the pain and anxiety associated with an ED visit.

Physiology of Pain

The physiology of the pain response is complex and multifactorial. The traditional model of pain transmission is “bottom-up,” wherein a specific level of painful stimulus causes a proportional signal from the periphery, through the spinal cord to the brain, and leads to a specific, predictable level of pain. New insights into the physiology of pain, however, have led scientists to reconsider this model. A new, “top-down” conception of pain has developed, in which painful stimuli are thought to be subject to modification in both the spinal cord and the brain.¹⁹ The patient's age and temperament, past experience, personal and familial beliefs, culture, and genetics are a few of the factors that may alter the final perception of a single painful stimulus. Pain pathways also demonstrate significant plasticity. Unlike other processes, exposure to painful stimuli results in upregulation of pain pathways, potentially leading to pain hypersensitivity,²⁰ with these effects being greatest early in life.²¹

In both infants and children, painful stimuli can result in long-term harmful effects. Full-term infants who had circumcisions in the immediate neonatal period have been shown to have significantly greater pain response to vaccinations at 4 and 6 months than infants who were not circumcised.²² One study of pediatric cancer patients receiving a lumbar puncture (LP) examined the relationship between procedural pain and past experience. It found that, despite all patients receiving the same analgesia during the study LP, patients who had received fentanyl during a previous LP had lower pain scores than those who had received placebo during a previous LP.²³ Another study found that the number of invasive procedures performed during a hospital stay was directly associated with ongoing posttraumatic stress responses 6 weeks after discharge, and increased medical fears 6 weeks and 6 months after discharge.²⁴ Psychological outcomes of painful procedures extend into adulthood, with people who experienced more medical fear and pain as children having more medical fear as adults.²⁵

Risk Management Pitfalls for Pediatric Pain Management

2. “The kid was faking it. I had a patient with the same problem last week, and she didn’t complain nearly as much!”

Pain is a multifactorial process. It is influenced not only by the stimulus that is causing the pain but also by the patient’s age, temperament, past experiences, and understanding. All of these factors may lead to real, physiologic amplification of a given painful stimulus. It is important to recognize these differences and not minimize patients’ self-report of pain.

4. “I always prescribe opioids to patients with musculoskeletal injuries at the time of discharge to make sure their pain is well controlled.”

Numerous studies have found no difference between NSAIDs and oral opioids in the treatment of fracture-related pain after ED discharge, with opioids having more side effects. Additionally, in one study, receipt of a legitimate opioid prescription as an adolescent was associated with a 33% increase in the risk of opioid misuse later in life.²⁰⁰ While opioids do have a role in the outpatient management of musculoskeletal pain, they should be used judiciously and as part of a care plan that also includes ibuprofen or acetaminophen.

5. “He’s only 4 and would not talk to me. I thought he was just scared; how was I supposed to know he was in pain?”

The gold standard and most desirable method for pain assessment is based upon self-report of pain by the patient. All children should have pain measured, and pain scales have been validated and developed to assist with pain measurement in preverbal children. The FLACC (see Table 1) is used to assess preverbal children or children who are unable to communicate pain. The FPS-R and CAS are self-report pain scales that have been used in children as young as 4 years.

Tables and Figures

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the author, are highlighted.

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28. Gausche-Hill M, Brown KM, Oliver ZJ, et al. An evidence-based guideline for prehospital analgesia in trauma. Prehosp Emerg Care. 2014;18(Suppl 1):25-34. (Consensus guideline)
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30. Alexander J, Manno M. Underuse of analgesia in very young pediatric patients with isolated painful injury. Ann Emerg Med. 2003;41(5):617-622. (Retrospective cohort; 180 subjects)
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32. Browne LR, Studnek JR, Shah MI, et al. Prehospital opioid administration in the emergency care of injured children. Prehosp Emerg Care. 2016;20(1):59-65. (Retrospective cross-sectional study; 1368 subjects)
33. Murphy A, McCoy S, O’Reilly K, et al. A prevalence and management study of acute pain in children attending emergency departments by ambulance. Prehosp Emerg Care. 2016;20(1):52-58. (Retrospective cross-sectional study; 6371 subjects)
34. Galinski M, Picco N, Hennequin B, et al. Out-of-hospital emergency medicine in pediatric patients: prevalence and management of pain. Am J Emerg Med. 2011;29(9):1062-1066. (Prospective cohort; 258 subjects)
35. Johnston C, Gagnon A, Fullerton L, et al. One-week survey of pain intensity on admission to and discharge from the emergency department: a pilot study. J Emerg Med. 1998;16(3):377-382. (Prospective cross-sectional pilot study; 286 subjects)
36. Rogovik AL, Goldman RD. Prehospital use of analgesics at home or en route to the hospital in children with extremity injuries. Am J Emerg Med. 2007;25(4):400-405. (Prospective cohort study; 310 subjects)
37. Hennes H, Kim MK, Pirrallo RG. Prehospital pain management: a comparison of providers’ perceptions and practices. Prehosp Emerg Care. 2005;9(1):32-39. (Survey; 155 respondents)
38. Rahman A, Curtis S, DeBruyne B, et al. Emergency medical services provider comfort with prehospital analgesia administration to children. Prehosp Disaster Med. 2015;30(1):66-71. (Survey; 191 subjects)
39. Izsak E, Moore JL, Stringfellow K, et al. Prehospital pain assessment in pediatric trauma. Prehosp Emerg Care. 2008;12(2):182-186. (Retrospective chart review; 696 subjects)
40. Ward ME, Radburn J, Morant S. Evaluation of intravenous tramadol for use in the prehospital situation by ambulance patients. Prehospital Disaster Med. 1997;12(2):158-162. (Prospective case-control; 142 subjects)
41. Vergnion M, Degesves S, Garcet L, et al. Tramadol, an alternative to morphine for treating posttraumatic pain in the prehospital situation. Anesth Analg. 2001;92(6):1543-1546. (Randomized double-blind parallel study; 105 subjects)
42. Bruns BM, Dieckmann R, Shagoury C, et al. Safety of pre-hospital therapy with morphine sulfate. Am J Emerg Med. 1992;10(1):53-57. (Prospective cross-sectional study; 84 subjects)
43. DeVellis P, Thomas SH, Wedel SK, et al. Prehospital fentanyl analgesia in air-transported pediatric trauma patients. Pediatr Emerg Care. 1998;14(5):321-323. (Retrospective cohort; 131 subjects)
44. Karlsen AP, Pedersen DM, Trauter S, et al. Safety of intranasal fentanyl in the out-of-hospital setting: a prospective observational study. Ann Emerg Med. 2014;63(6):699-703. (Prospective observational study; 903 subjects)
45. Bendall J, Simpson P, Middleton P. Effectiveness of prehospital morphine, fentanyl, and methoxyflurane in pediatric patients. Prehosp Emerg Care. 2011;15(2):158-165. (Retrospective comparative study; 3312 subjects)
46. Reid C, Hatton R, Middleton P. Case report: prehospital use of intranasal ketamine for paediatric burn injury. Emerg Med J. 2011;28(4):328-329. (Case report)
47. Schauer SG, Arana AA, Naylor JF, et al. Prehospital analgesia for pediatric trauma patients in Iraq and Afghanistan. Prehosp Emerg Care. 2018;22(5):608-613. (Retrospective cohort study; 3439 subjects)
48. Buckland DM, Crowe RP, Cash RE, et al. Ketamine in the prehospital environment: a national survey of paramedics in the United States. Prehosp Disaster Med. 2018;33(1):23-28. (Survey; 14,739 respondents)
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50. Kochman A, Howell J, Sheridan M, et al. Reliability of the Faces, Legs, Activity, Cry, and Consolability Scale in assessing acute pain in the pediatric emergency department. Pediatr Emerg Care. 2017;33(1):14-17. (Prospective observationalstudy; 66 subjects)
51. Stinson JN, Kavanagh T, Yamada J, et al. Systematic review of the psychometric properties, interpretability and feasibility of self-report pain intensity measures for use in clinical trials in children and adolescents. Pain. 2006;125(1-2):143-157.(Systematic review)
52. Birnie KA, Hundert AS, Lalloo C, et al. Recommendations for selection of self-report pain intensity measures in children and adolescents: a systematic review and quality assessment of measurement properties. Pain. 2019;160(1):5-18. (Systematicreview)
53. Bailey B, Bergeron S, Gravel J, et al. Comparison of four pain scales in children with acute abdominal pain in a pediatric emergency department. Ann Emerg Med. 2007;50(4):379-383. (Randomized controlled trial; 84 subjects)
54. Tsze DS, Hirschfeld G, Dayan PS, et al. Defining no pain, mild, moderate, and severe pain based on the faces pain scale-revised and color analog scale in children with acute pain. Pediatr Emerg Care. 2018;34(8):537-544. (Prospective observational study; 620 subjects)
55. Brandow AM, Weisman SJ, Panepinto JA. The impact of a multidisciplinary pain management model on sickle cell disease pain hospitalizations. Pediatr Blood Cancer. 2011;56(5):789-793. (Retrospective cohort study; 19 subjects)
56. Richardson J, Smith JE, McCall G, et al. Hypnosis for procedure-related pain and distress in pediatric cancer patients: a systematic review of effectiveness and methodology related to hypnosis interventions. J Pain Symptom Manage. 2006;31(1):70-84. (Systematic review)
57. Evans S, Tsao JC, Zeltzer LK. Complementary and alternative medicine for acute procedural pain in children. Altern Ther Health Med. 2008;14(5):52-56. (Review)
58. Boughton K, Blower C, Chartand C, et al. Impact of research on pediatric pain assessment and outcomes. Pediatr Nurs. 1998;24(1):31-35. (Prospective interventional study; 36 subjects)
59. Ellis JA, Sharp D, Newhook K, et al. Selling comfort: a survey of interventions for needle procedures in a pediatric hospital. Pain Manag Nurs. 2004;5(4):144-152. (Survey of practice and review)
60. Vincent C, Denyes M. Relieving children’s pain: nurses’ abilities and analgesic administration practices. J Pediatr Nurs. 2004;19(1):40-50. (Observational study of convenience sample; 67 subjects)
61. Birnie KA, Noel M, Chambers CT, et al. Psychological interventions for needle-related procedural pain and distress in children and adolescents. Cochrane Database Syst Rev. 2018;10:CD005179. (Systematic review; 59 studies)
62. Martin V. Using distraction techniques with children. Nursing. 2013;43(11):68. (Review)
63. Pillai Riddell R, Racine NM, Gennis HG, et al. Non-pharmacological management of infants and young child procedural pain. Cochrane Database Syst Rev. 2015;12:CD006275-006271. (Meta-analysis; 63 studies)
64. Harrison D, Reszel J, Bueno M, et al. Breastfeeding for procedural pain in infants beyond the neonatal period. Cochrane Database Syst Rev. 2016;10:CD011248. (Systematic review; 10 studies)
65. Taddio A, Soin HK, Schuh S, et al. Liposomal lidocaine to improve procedural success rate and reduce procedural pain among children: a randomized controlled trial. CMAJ. 2005;172(13):1691-1695. (Randomized placebo-controlled study; 142 subjects)
66. Whitlow PG, Saboda K, Roe DJ, et al. Topical analgesia treats pain and decreases propofol use during lumbar punctures in a randomized pediatric leukemia trial. Pediatr Blood Cancer. 2015;62(1):85-90. (Randomized cross-over trial; 26 subjects)
67. Algren CL, Algren JT. Pain management in children. Plast Surg Nurs. 1994;14(2):65-70. (Review)
68. Young K. What’s new in topical anesthesia. Clin Ped Emerg Med. 2007;8(4):232-239. (Review)
69. Zempsky W, Robbins B, McKay K. Reduction of topical anesthetic onset time using ultrasound: a randomized controlled trial prior to venipuncture in young children. Pain Med. 2008;9(7):795-802. (Randomized controlled trial; 70 subjects)
70. Fetzer S. Reducing venipuncture and intravenous insertion pain with eutectic mixture of local anesthetic: a meta-analysis. Nurs Res. 2002;51(2):119-124. (Meta-analysis; 20 studies)
71. Shachor-Meyouhas Y, Galbraith R, Shavit I. Application of topical analgesia in triage: a potential for harm. J Emerg Med. 2008;35(1):39-41. (Case report and review)
72. Liebelt EL. Reducing pain during procedures. Curr Opin Pediatr. 1996;8(5):436-441. (Review)
73. Schreiber S, Ronfani L, Chiaffoni GP, et al. Does EMLA cream application interfere with the success of venipuncture or venous cannulation? A prospective multicenter observational study. Eur J Pediatr. 2013;172(2):265-268. (Prospective observational study; 388 subjects)
74. Eichenfield LF, Funk A, Fallon-Friedlander S, et al. A clinical study to evaluate the efficacy of ELA-Max (4% liposomal lidocaine) as compared with eutectic mixture of local anesthetics cream for pain reduction of venipuncture in children. Pediatrics.2002;109(6):1093-1099. (Randomized controlled crossover trial; 120 subjects)
75. Koh J, Harrison D, Myers R, et al. A randomized, double-blind comparison study of EMLA and ELA-max for topical anesthesia in children undergoing intravenous insertion. Paediatr Anaesth. 2004;14(12):977-982. (Randomized controlled trial; 60subjects)
76. Poonai N, Alawi K, Rieder M, et al. A comparison of amethocaine and liposomal lidocaine cream as a pain reliever before venipuncture in children: a randomized control trial. Pediatr Emerg Care. 2012;28(2):104-108. (Randomized controlled trial;60 subjects)
77. Lunoe MM, Drendel AL, Levas MN, et al. A randomized clinical trial of jet-injected lidocaine to reduce venipuncture pain for young children. Ann Emerg Med. 2015;66(5):466-474. (Randomized controlled trial; 205 subjects)
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