Pediatric Pain Management

1. Pediatric Pain Management Mark V. Boswell, MD, PhD

2. Outline I. Pain Measurement II. Pediatric Pain Syndromes III. Non-drug Therapies III. Parents and Children

3. I. Pain Measurement

4. Pain in Children (Self-Report) Numeric and spatial scales Visual analogue scale Age 7 and older Analogue chromatic continuous scale Red indicates pain; pink no pain Age3 and older Pain thermometer Age 4 and older

5. Faces Scales Self report Older children Accuracy affected by ethnicity gender Choice of anchors

6. McGrath�s scale (nine faces) Ages 3-4 and older

7. Oucher Scale (Beyer) Ages 3-12 yrs Don�t suggest results Be systematic Trend over time Not the only measurement

8. Pain in Neonates and Infants (Behavioral Assessment Scales) Children�s Hospital of Eastern Ontario (CHEOPS) Measures 6 items: cry, facial expression, verbal complaints, position and movement, touching or pointing to wound May overestimate pain due to fear or anxiety during acute medical procedures May not be useful for postoperative pain

9. Postoperative Pain Scales Multi-item behavioral checklists May be correlation with physiologic parameters DC Children�s Hospital Pain and Discomfort Scale Pediatric oncology use Ages 2-6 yrs Assesses 17 items Physiologic, behavior, self-report Note: differentiate acute and procedural pain from chronic pain

10. II. Pediatric Pain Syndromes

11. Epidemiology Children commonly experience recurrent benign pain Headaches Abdominal pain Chest pain Limb Pain Overall incidence: 4-10%

12. Headache Headache is most common pediatric pain syndrome Remember the differential diagnoses (Organic Headaches): Meningitis Encephalitis Cerebral abscess Vascular malformations Trauma Tumors (meningeal and others) Degenerative disorders ICP

13. Epidemiology of Headache in Pediatrics Tension common (relatively uncommon before puberty) Migraine headache 5% 13% of adults with chronic daily headache had symptoms develop in childhood or adolescence Early morning persistent headache worrisome

14. Epidemiology of Migraine Migraine without aura twice as frequent as with aura Prevalence: 5% children and 17% in adolescents Boys and girls about equal frequency Female 2-3 times greater after age 16 Several classifications May have abdominal pain

15. Migraine Headache Definition - Recurrent headache with three of the following: Recurrent abdominal pain with/without nausea and vomiting Throbbing unilateral headache Visual, sensory or motor aura Relief of pain by sleep Family history of migraine Girls more likely to develop migraine during adolescence Treatment similar to adults

16. Common Migraine Migraine without aura Usually not unilateral Bifrontal or bitemporal 70% have abdominal pain Increases over 30 min to 2 hours then subsides when vomiting occurs Rarely causes intense suffering One to two episodes per month Family history in 90% of cases

17. Complicated Migraine Neurologic signs develop during headache and persist after termination AVM or tumor in differential diagnosis Basilar migraine - basilar and posterior cerebellar artery constriction Vertigo, tinnitus, diplopia, blurred vision Ophthalmoplegic migraine - rare in children 3rd nerve palsy Amaurosis fugax may be rare variant Hemiplegic migraine - more common in children than adults

18. Indications for Neuroimaging with Headache 1 Abnormal neurological signs Recent school failure, behavioral changes, change in growth rate Focal neurologic signs during aura with fixed unilaterality Focal neurologic sxs with headache Headache awakens from sleep Early morning headache

19. Indications for Neuroimaging with Headache 2 Migraine with seizure Cluster headache Vascular sxs precede headache (20-50% risk of tumor or avm) Child < 6 yrs whose primary complaint is headache Brief cough headache

20. Recurrent Abdominal Pain 2nd most common pain syndrome No organic cause evident Three occasions in 3 month period Alters child�s normal activity Incidence: 10%to 15% of pediatric population Greater number of females More often in middle childhood Somatic complaints: fatigue and dizziness

21. Etiology of Recurrent Abdominal Pain Definition excludes: Neurologic, metabolic, hematologic, GI or gynecologic diagnoses Acute pain due to surgical disorders (eg, appendicitis) Psychophysiologic etiology Stressors: depression, family conflicts, etc Physiologic sequelae: autonomic instability, lactose intolerance, constipation Differential dx: chronic constipation, Giardia, GERD, Lactase deficiency, abdominal migraine Organic pain usually located away from umbilicus

22. Clinical Aspects of Recurrent Abdominal Pain Characteristic presentation: after age 6, with midline, paroxysmal pain Periumbilical pain most common Epigastric pain with early satiety, bloating, belching Pain below umbilicus, cramps, bloating, altered bowel pattern (analogous to IBS) Autonomic and intestinal motility abnormalities After thorough workup, most important treatment is reassurance

23. Acute Appendicitis Most common condition requiring emergency laparotomy Incidence: 4/1000 children under age of 14 Diagnosis difficult in young children Perforation: 30-60%; greatest risk in children 1-4 yrs old Incidence peaks in adolescents Cases occur more often in males

24. Clinical Manifestations of Appendicitis Luminal obstruction most common cause Triad: pain, nausea with vomiting, and fever Initially, pain is periumbilical Pain precedes emesis Many patients will have elevated WBC and shift but primary reason for laboratory studies is to exclude other causes: UTI, hemolytic-uremic syndrome, etc CT more sensitive and specific than US

25. Differential for Appendicitis Gastroenteritis: vomiting preceding pain Viral and bacterial (Campylobacter) Mesenteric adenitis Torsion of undescended testis Follicular cysts Pelvic inflammatory disease

26. Recurrent Chest Pain 3rd most common pediatric pain syndrome (Limb pain also common) Chest pain most common between 10-21 yrs of age Costochondritis most frequent cause in children Trauma Muscular Rib anomalies Slipping rib syndrome

27. Cardiac Causes of Chest Pain Not common cause of pain Most common concern of parents Causes of cardiac pain Ischemia Pericarditis Myocarditis Dysrhythmias

28. Structural Causes of Cardiac Pain Left ventricular outflow tract obstruction Hypertrophic obstructive cardiomyopathy Autosomal dominant Mitral valve prolapse Arrhythmias Sometimes painful Myocarditis Kawasaki�s disease Palpitations v. ischemia

29. Limb Pain Growing pains Stress fractures Tibia and fibula School age children Relaxation/stress relief

30. Juvenile Rheumatoid Arthritis Prevalence: 250,000 Overall incidence: 110/100,000 5% of all rheumatoid cases; one of most common rheumatic diseases of children Age of onset < 16 yrs Chronic synovitis Articular erosions Extra-articular manifestations

31. Pathogenesis of JRA Idiopathic synovitis of peripheral joints Soft tissue swelling an effusion 3 prinicipal types: Oligoarthiritis Polyarthritis Systemic-onset HLA-susceptibility, response to viruses and bacterial infections Outcome variable depending on ANA and RF seropositivity

32. Back Pain Incidence: true statistics not known Implications: Pain often sign of significant underlying disorder Tumor, infection, Diagnoses: Developmental (spondylolysis, growth-related conditions; eg Scheurermann�s Kyphosis) Segmental dysfunction (facets and disc) Trauma, sports injuries

33. Osteochondritis (Scheuermann�s Disease) Abnormality at junction of vertebral body and disc Irregularity in ossification and endochondral growth Anterior wedging and kyphosis Thoracic spine in teenagers Persistent back pain Canal narrowing and neurologic deficit Cardiopulmonary effects

34. Pars Interarticularis Defects Greater than 90% at L5/S1 Sports injury; excercise Symptoms: Localized back pain at affected level May be radicular component with slippage Diagnosis: Oblique films, CT, etc Treatment: Conservative to bracing; Surgical fusion if slippage causes progressive symptoms

35. Disc Pain Herniation: 2% of all documented disc herniations occur in children 10% of all causes of back pain under 21 yrs of age Disciitis Incidence: average age 6 yrs Stapylococcus aureus most common pathogen Diagnosis: sed rate, CRP, MRI

36. Bone Tumors in Children Causing Back Pain Benign Osteoid osteoma Fibrous dysplasia Osteoblastoma Malignant Osteosarcoma Ewing�s sarcoma Leukemia and lymphoma Neuroblastoma Wilm�s tumor (renal origin)

37. Scoliosis Definition: Lateral curvature of the spine; 3 dimensional rotational deformity Incidence: curvature > 200 is 0.1 to 1.0% (females slightly more than males; females more likely to progress) Classification Idiopathic (65%) Infantile (very rare) Juvenile Adolescent (most common) Congenital (15%) Neuromuscular (10%) Curvature involves thoracic and lumbar spine Treatment: bracing and surgical correction

38. Sickle Cell Pain Most common hemoglobinopathy 0.3 to 1.3% of African Americans Vaso-occlusive crises Pain Abdomen Chest Extremities Acute on chronic pain

39. Hemophilias Most common inherited coagulation disorders VIII most common (also IX, XI) X-linked recessive Severe: < 1% of factor Hemarthroses Synovitis

40. Complex Region Pain Syndrome More often upper limbs (than lower limbs) Hand, wrist, elbow, shoulder, hips Psychologic issues (stressors) Intelligent Overachievers Competitive Family discord/abuse

41. Burn Pain Acute pain and dressing changes Analgesics NSAIDS Opioids; eg fentanyl Patient-controlled analgesia Anesthesia for dressing changes Propofol

42. Miscellaneous Cancer pain Neuropathic pain CRPS Tumors Chemotherapy Tricyclic antidepressants Anticonvulsants Gabapentin, etc

43. III. Non-Drug Therapies

44. Cognitive Therapy Information Distraction Guided imagery Hypnosis Psychotherapy

45. Behavioral Approaches Exercise Relaxation Biofeedback

46. Physical Methods Physical therapy Acupuncture Massage TENS

47. IV. Parents and Children

48. Chronic and Terminal Illnesses Pain management requires understanding of the family Palliative care and hospice can be difficult - by definition requires a team approach Chronic opioid therapy requires informed consent - the family must understand the issues Joint Commission pain guidelines apply to pediatrics

49. Process Approach Initial pain assessment Child and family teaching Select a pain assessment tool Provide ongoing pain assessment Documentation mandatory

50. References Desparmet-Sheridan JF. Chapter 30, Pain Medicine. A Comprehensive Review. 2nd Edition, 2003. Desparmet-Sheridan JF. Chapter 21, Practical Management of Pain. 3rd Edition. 2000. Schechter, et al Editors. Pain in Infants, Children and Adolescents. Williams and Wilkins, 1993. Nelson Textbook of Pediatrics, various chapters, 17th Edition, 2004