Pediatric Pain Management

Assessing pain in pediatric patients presents perioperative providers with unique challenges. Depending on the developmental age and the setting of care, the best way to ascertain the underlying cause for pain varies. Anesthesia providers are accustomed to treating postoperative pain, but what if a child with known cancer presents to the hospital with pain and is not having surgery? What are the common medical causes of pain in the pediatric patient? What are safe options for treating pain in children? Anesthesia providers will face these questions several times throughout their career and should be equipped to address them safely. 

Pain in pediatric patients may be categorized as nociceptive or neuropathic. Of nociceptive pain types, somatic and visceral subtypes exist. The source of pain can be surgery, orthopedic fractures, abdominal pathology (e.g., pancreatitis, appendicitis), tumors, gastroesophageal reflux, constipation, ingestions, and others. Patients with specific pathologies such as sickle cell anemia, cancer, and developmental delay may present with challenges to the anesthetist. Furthermore, hunger, anxiety, and situational distress may confuse the accurate assessment of a child’s pain state. Behaviors indicative of the presence of pain include crying, poor feeding, moaning, grimacing, inconsolability, stiffening, abnormal positioning, aggression, or, rarely, laughing.  

Assessing pediatric pain can be challenging due to communication difficulties. In the very young patient, less than 4 years, the source of pain may be difficult to localize. Determining how pain impacts daily function such as school attendance, mood, and play from parents may point to the severity of pain. Self reporting pain in older children is essential, and one study showed that standardized observational tools, such as the revised FLACC tool, underestimate pain in children in relation to self-reports [1]. Patients of the ages of three to eight years may be able to share their pain severity using a modified 6-point visual analog scale (VAS) or a questionnaire.  Importantly, a trustworthy parent or caregiver should be able to assist with information regarding medication dosage, frequency, and response.  

Pain and anxiety related to procedures should be first managed with non-pharmacological strategies. In children with verbal understanding, a description of the procedure and the steps which will occur in their care can allay anxiety. Furthermore, a calm, quiet environment are mainstay strategies to decrease stress during procedures or surgery. One meta-analysis found that children undergoing needle-based procedures responded to distraction through music, video, clowns, or hypnosis, underlining that medications may not always be appropriate for children [2].  

Mild pain in children may be safely treated with non-opioid analgesics such as NSAIDs (e.g., ibuprofen 4-10 mg/kg every six hours) or acetaminophen (10-15 mg/kg every 6 hours). For moderate to severe pain, combining these more conservative therapies with opioids may effectively relieve symptoms. The risks of respiratory depression, somnolence, nausea, vomiting, pruritus, tolerance, and others should be discussed with the parents and/or caregiver. While opioids such as morphine, hydromorphone, hydrocodone, oxycodone, and fentanyl may be safely administered when given weight-appropriate doses, the Food and Drug Administration has advised against usage of codeine or tramadol in any child under age twelve [3]. Patients with specific polymorphisms of CYP2D6 genes who are “hyper-metabolizers” may succumb to the effects of active metabolites of either of these potentially lethal medications. Furthermore, aspirin should be avoided in children due to its notorious association with Reye syndrome. Methadone is a safe analgesic option when used in experienced hands. Drug accumulation with repeated doses is a concern with methadone, and patients should be monitored appropriately [4]. 

The use of patient controlled analgesia (PCA) represents a common clinical question for anesthesia providers. Adolescent or mature preadolescent children who can characterize their pain – and whose pain is not relieved by conservative measures – may be candidates for PCA. Basal rates may judiciously be used in pediatric patients at night to assist with sleep. The risks of opioid infusion must be weighed against the perceived benefit of improved night-time analgesia and therefore should be used cautiously. 

Treating pediatric pain presents challenges to the anesthesiologist. Pediatric patients may refuse to take oral medications, necessitating alternative delivery routes, such as intravenous, intramuscular, or per rectum. There has been increased interest in the use of intravenous acetaminophen in the perioperative realm, given the ease of administration, safety, efficacy and rapid onset of action. Providers should be cautious of acetaminophen overdose. Furthermore, anesthesia providers should be conscientious of the significant cost to formulations of IV acetaminophen. The use of drug classes aimed at controlling chronic neuropathic pain such as antidepressants and  anticonvulsants may be employed at weight-appropriate dosing. 

Page BreakReferences: 

1. Beyer JE et al. Discordance between self-report and behavioral pain measures in children aged 3-7 years after surgery. J Pain Symptom Manage. 1990;5(6):350-6. 

2. Birnie KA et al. Psychological interventions for needle-related procedural pain and distress in children and adolescents. Cochrane Database Syst Rev. 2018;10:CD005179.  

3. Mitchell RB et al. Clinical Practice Guideline: Tonsillectomy in Children (Update)-Executive Summary. Otolaryngol Head Neck Surg. 2019;160(2):187-205.  

4. Mercadante S & Bruera E. Methadone as a First-Line Opioid in Cancer Pain Management: A Systematic Review. J Pain Symptom Manage. 2018;55(3):998-1003.