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Pain in Children

Updated: Mar 7, 2022



Pathophysiology differences in Children

Dorsal horn - Excess of excitatory mechanisms. Inhibition maturation is delayed

Little is known about intercortical network connections

Somatosensory cortex is always activated

Unbalanced descending modulation commonly

Less endogenous control over noxious stimuli


Long term effects

These can be through physiological changes or psychological changes

The setting of pain experience, severity, duration - all these likely affect long term outcomes

However there is not clear evidence that prolonged changes continue into adolescence or young adulthood


Sensitisation mechanisms in children

Peripheral: Increased peripheral nerve sprouting

Dorsal horn/Spinal: Central sensitisation, disinhibition, neuroimmune priming (microglia)

Cortical: Alterations in reward related pathways and stress response


How does pain affect children's lives?

Physical - They can become less active with deconditioning and falling behind physical milestones. Can increase obesity. Can increase stress (with loss of the protective exercise)

Social - Loss of social interaction, sport involvement, loss of friends and play times

Academics - Can affect learning more through loss of time at school than true cognitive issue

Sleep - 50% of kids can have sleep difficulties with pain and this affects everything

Family - These are affected by loss of work, income, organisation, increased psych distress


History taking specifics

Sleep / Mobility / Schooling / Play/leisure / Emotional state

Pain measurement scores for kids:


Neonatal infant pain scale.

FLACC - Young children

Faces pain scale - after age 4-5

Numeric rating scales can commonly be used for > 8 yo children


Paediatric pain profile (kids with disabilities)


 

Management


Non pharmacological

Behavioural

Breathing exercises (can use bubble blowers, poppers), modelling coping behaviours, desensitisation (very slow graduated movements), positive reinforcement


Cognitive

Imagery (child is asked to imagine an enjoyable experience), education and information (appropriate for the child), coping statements and being positive "I can do this", distraction including TV, conversation, games etc.


Sweet solutions can be used - thought to help assist descending modulation of pain


Pharmacological considerations

Some medications cannot be used (e.g. aspirin)


Pharmacokinetics - Total body water is higher, protein concentration and binding is different, changes in drug metabolism (e.g. slower excretion and metabolism)


Pharmacodynamics - Pain scores and drug levels have poor correlation. Possibly due to plasma differences and pharmacodynamic variability.


Doses - Doses are commonly done by age, weight compared to a centile, and/or lean body weight calculations. If very obese, all doses are done on lean body weight. (These are calculated by working out centile for height and matching this to expected weight. E.g. 97% centile for height, find that centile for weight).

 

Procedural pain


Procedural strategy

IM injections - Don't need to aspirate. Don't tell them it won't hurt. Inject most painful last.


Physical strategy

Keep them upright and rub skin before injection is given


Psychological strategy

Use lots of distraction techniques


Infant strategies

Breastfeeding and sweet tastes on tongue can help


Pharmacological strategies

Topical anaesthetics can be used

Cooling agents, and the use of panadol or ibuprofen, have not been shown to help


Family Strategies

Preparation/education/information - these can help.

 

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