it's just feels like a little...

[email protected] Twitter: @NoNeedlessPain

"It's just feels like a little wasp sting, right?" State of the art in managing needle pokes and procedural pain in children

Stefan J. Friedrichsdorf, MD, FAAPMedical Director, Department of Pain Medicine, Palliative Care & Integrative Medicine, Children's Hospitals and Clinics of Minnesota, Minneapolis/St. Paul, MN

Disclosure✤ Consultant for Purdue Pharma Ltd.,

Stamford, CT

✤ The views presented in this lecture are my own. NO conflict of interest exists with my presentation

✤ I do intend to discuss unapproved or investigative use of commercial products or devices (= off-label).

✤ Current Research Support: NIH/NCI [1R25CA151000-01]; Canadian Institutes of Health Research/Human Development, Child and Youth Health [185704]; Internal Research Grants Program (IRGP) Children’s of MN

“I don't mind pain, as long as it doesn't hurt”. Oscar Wilde (1854 – November 30th, 1900).

✤ Appreciate incidence of procedural pain in children

✤ Review evidence for importance of managing procedural pain

✤ Describe importance of the “non-negotiable” components of state-of-the Art procedural pain management: topical anesthesia, positioning, and distraction (& sucrose if <12 months)

Learning Objectives

Pediatric Pain - Status Quo

✤ Under treatment of pain in children

✤ Parents expect pain to be relieved Forgeron PA, Finley GA, Arnaout M. Pediatric pain prevalence and parents' attitudes at a cancer hospital in Jordan. J Pain Symptom Manage. 2006; 31(5):440-8.

✤ Priorities of parents of hospitalized children "Taking care of pain" rated as second highest priority (1st: getting right diagnosis) Ammentorp J, Mainz J, Sabroe S. Parents’ priorities and satisfaction with acute pediatric care. Arch Pediatr Adolesc Med 2005;159:127-131

✤ Parents’ greatest distress: failing to protect their child from pain Tiedeman, M. (1997). Anxiety responses of parents during and after the hospitalisation of their 5 - to -11 year old children. Journal of Pediatric Nursing, 12(2), 110-119. Melnyk BM. Intervention studies involving parents of hospitalized young children: an analysis of the past and future recommendations. J Pediatr Nurs. 2000 Feb;15(1):4-13.

✤ Assumption: everything possible is done Anand’s neonatal surgery studies

Pediatric Pain - Status Quo

✤ USA: adults receive more than two - three times as many analgesic doses as children (with identical diagnoses) (1) Eland JM, Anderson JE: The experience of pain in children. In: Jacox A (ed). Pain: a source book for nurses and other health care professionals. Boston: Little Brown & C0; 1977:453-78 (2) Beyer JE, DeGood DE, Ashley LC, Russell GA. Patterns of postoperative analgesic use with adults and children following cardiac surgery. Pain. 1983 Sep;17(1):71-81. (3) Schechter NL, Allen DA, Hanson K. Status of pediatric pain control: a comparison of hospital analgesic usage in children and adults. Pediatrics. 1986 Jan;77(1):11-5.

✤ The younger children are, the less likely they receive appropriate analgesia Broome ME, Richtsmeier A, Maikler V, Alexander M. Pediatric pain practices: a national survey of health professionals. J Pain Symptom Manage. 1996 May;11(5):312-20.; Nikanne E, Kokki H, Tuovinen K. Postoperative pain after adenoidectomy in children. Br J Anaesth. 1999 Jun;82(6):886-9.

✤ Compared to adults, pediatric patients receive fewer and/or incorrectly dosed analgesics in daily routine Ellis JA, et al. The Clinical Journal of Pain. 2002;18:262-269.

Costs of Pain

✤ USA: 100 million adults affected by chronic pain (incl. joint pain or arthritis)

✤ USA: Total costs Pain 2010: $560-635 billion Gaskin DJ, Richard P. The economic costs of pain in the United States. J Pain 2012 Aug;13(8):715-24.

✤ Heart disease: $243 billion

✤ Cancer: $188 billion

✤ Diabetes: $ 188 billion

Costs of Pain

✤ Childhood pain brings significant direct and indirect costs from healthcare utilization and lost wages due to taking time off work to care for the child Ho, I. K., Goldschneider, K. R., Kashikar-Zuck, S., Kotagal, U., Tessman, C., & Jones, B. (2008). Healthcare utilization and indirect burden among families of pediatric patients with chronic pain. Journal of Musculoskeletal Pain, 16 (3), 155–164. Sleed, M., Eccleston, C., Beecham, J., Knapp, M., Jordan, A. (2005). The economic impact of chronic pain in adolescence: Methodological considerations and a preliminary costs-of-illness study. Pain, 119 (1- 3), 183–190.

Inappropriate Analgesia: Why Bother...?✤ Children with persistent pain suffer

more physical symptoms in adult life, more anxiety and more depression 1946 Medical Research Council and 1958 National Child Development Study

✤ Inadequate analgesia for initial procedures in children diminishes effect of adequate analgesia in subsequent procedures Weisman SJ, Bernstein B, Schechter NL: Consequences of inadequate analgesia during painful procedures in children. Arch Pediatr Adolesc Med 1998. 152:147-9

✤ NICU: increased morbidity & mortality Anand KJ, Barton BA, McIntosh N, Lagercrantz H, Pelausa E, Young TE, et al. Analgesia and sedation in preterm neonates who require ventilatory support: results from the NOPAIN trial. Neonatal Outcome and Prolonged Analgesia in Neonates. Arch Pediatr Adolesc Med. 1999 Apr;153(4):331-8

Trauma & posttraumatic stress disorder (PTSD)✤ US soldiers in Iraq after serious

injury: Use of morphine during trauma care reduces risk of subsequent development of PTSD Holbrook TL, Galarneau MR, Dye JL, Quinn K, Dougherty AL. Morphine use after combat injury in Iraq and post-traumatic stress disorder. The New England journal of medicine. 2010 Jan 14;362(2):110-7.

✤ Children (n=48) with injury that led to hospital treatment: Morphine was associated with lower levels of PTSD at follow-up 6 months later Nixon RD, Nehmy TJ, Ellis AA, Ball SA, Menne A, McKinnon AC. Predictors of posttraumatic stress in children following injury: The influence ofappraisals, heart rate, and morphine use. Behaviour research and therapy. 2010 Aug;48(8) 810-5.

✤ 6-16 year-olds (n=24) with acute burns: Children receiving higher doses of morphine had a greater reduction in PTSD symptoms over 6 months Saxe G, Stoddard F, Courtney D, Cunningham K, Chawla N, Sheridan R, et al. Relationship between acute morphine and the course of PTSD in children with burns. Journal of the American Academy of Child and Adolescent Psychiatry. 2001 Aug;40(8):915-21.

✤ 12- to 48-month-old (n=70) children with acute burns admitted to a major pediatric burn center: Management of pain with higher doses of morphine associated with decreasing number of symptoms of PTSD in the months after major trauma. Stoddard FJ, Jr., Sorrentino EA, Ceranoglu TA, Saxe G, Murphy JM, Drake JE, et al. Preliminary evidence for the effects of morphine on posttraumatic stress disorder symptoms in one- to four-year-olds with burns. J Burn Care Res. 2009 Sep-Oct;30(5):836-43.

Pain Education

✤ Oregon: Veterinary Practice Act was amended in 2010 to include pain control as a mandatory part of veterinary practice.

✤ OAR 875-015-0030 Minimum Standards: Minimum pain management is now mandated by rule and may not be omitted by the veterinarian or declined by the client.

✤ Pain education for North American medical students limited, variable, often fragmentary Mezei L, Murinson BB. Pain education in North American medical schools. The journal of pain : official journal of the American Pain Society. 2011 Dec;12(12):1199-208.

✤ Canada twice the USA median

http://www.cartoonistgroup.com

Procedural Pain in Children

Procedural Pain: A call for action

✤ What are children most afraid of coming to our clinical service?

✤ Needle procedures (incl. vaccine injections) performed in childhood are a substantial source of distress

✤ It is estimated that up to 25% of adults have a fear of needles Guideline statement: management of procedure-related pain in children and adolescents.J Paediatr Child Health 2006;42(Suppl 1):S1-29. with most fears developing in childhood Hamilton JG. Needle phobia: a neglected diagnosis. J Fam Pract 1995;41:169-75

✤ with most fears developing in childhood Hamilton JG. Needle phobia: a neglected diagnosis. J Fam Pract 1995;41:169-75

✤ Untreated pain can have long-term consequences including✤ preprocedural anxiety✤ hyperalgesia✤ needle fears✤ avoidance of health care (including nonadherence with vaccination schedules Taddio A, Chambers CT, Halperin SA, et al. Inadequate pain management duringchildhood immunizations: the nerve of it. Clin Ther 2009;31(Suppl 2):S152-67.)

✤Taddio A, Appleton M, Bortolussi R, Chambers C, Dubey V, Halperin S, et al. Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline. CMAJ : Canadian Medical Association journal 2010 Dec 14;182(18):E843-55.


Procedural Pain in the Neonate

✤ Critically ill infant may experience >480 painful procedures during NICU stay Barker DP (1995) Arch Dis Child Fetal Neonatal Ed 72:F47-8; Johnston CC (1997) Clin J Pain 13:308-12

✤ Exposure to severe pain on NICU, without adequate treatment, has negative long-term consequences

✤ á morbity (hypoxia, coagulopathy, respiratory inccordination, increased intracranial pressure) ✤ á risk of IVH✤ á mortality Anand KJS (1999) Arch Pediatr Adolesc Med 153:331-8


Pain in the Neonate: Why bother?✤ Neonates at 33 weeks

gestational age admitted to NICU experienced average of 10 painful procedures / day; 79 % were performed without any type of analgesia. Carbajal, R., Rousset, A., Danan, C., Coquery, S., Nolent, P., Ducrocq, S., et al. Epidemiology and treatment of painful procedures in neonates in intensive care units. The Journal of the American Medical Association 2008, 157, 1058-64.

✤ Poorly managed pain has serious short- and long term consequences: Each painful event causes immediate physiological and behavioral instability Holsti L, Grunau RE, Oberlander TF, Whitfield MF. Specific Newborn Individualized Developmental Care and Assessment Program movements are associated with acute pain in preterm infants in the neonatal intensive care unit.

d l ( )

✤ Significant relationship between physiological markers of neonatal pain and oxidative stress Slater L, Asmerom Y, Boskovic DS, Bahjri K, Plank MS, Angeles KR, et al. Procedural pain and oxidative stress in premature neonates. The journal of pain 2012 Jun;13(6):590-7.

✤ Repetitive procedural pain in preterm infants is associated with reduced early body growth and head circumference, after accounting for multiple medical confounders Vinall, J., S. P. Miller, et al. (2012). "Neonatal pain in relation to postnatal growth in infants born very preterm." Pain 153(7): 1374-1381.

✤ Pain ratings at 4-6 months routine vaccination higher for circumcised versus uncircumcised boys Taddio A (1994) Lancet, 344:291-2

✤ Preterm infants: Poorer cognition and motor function associated with higher number of skin-breaking procedures Grunau RE, Whitfield MF, Petrie-Thomas J, Synnes AR, Cepeda IL, Keidar A, et al. Neonatal pain, parenting stress and interaction, in relation to cognitive and motor development at 8 and 18 months in preterm infants. Pain. 2009 May;143(1-2):138-46.

✤ Memory of previous painful experience has great influence on pain experience during subsequent procedures Versloot J, Veerkamp JSJ, Hoogstraten J: Children’s self-reported pain at the dentist. Pain 2008. 137:389-94

Procedural pain: A call for action

How Do We Manage Needle Pain in Children?

Friends

“Well, it is not rocket surgery”Joe Tribbiani

“Non-Negotiable” components of a “needle-poke” protocol✤ Positioning✤ Integrative (non-pharmacological) therapies✤ Topical Anesthesia✤ 0-12 months: Sucrose

Other Considerations✤ Possibly other pharmacological approaches✤ Consider appropriate sedation, if excellent analgesia cannot be achieved

Essential Components of Procedural Pain Management

1/4Positioning

“Non-negotiable” Components of Procedural Pain Management in Children

Pediatric Positioning in 1985

✤ To reduce pain at the time of injection, do not place children in a supine position during vaccination (grade E recommendation, based on level I evidence). Taddio A, Appleton M, Bortolussi R, Chambers C, Dubey V, Halperin S, et al. Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline. CMAJ : Canadian Medical Association journal 2010 Dec 14;182(18):E843-55.

✤ When feasible, offer choice to child (parent’s lap?)

Positioning

http://www.rch.org.au/comfortkids/resources.cfm?doc_id=10140

2/4Distraction &

Integrative therapies


Cochrane Review: 28 trials, 1951 children 2-19 years - needle-procedures (immunizations and injections). Uman LS, Chambers CT, McGrath PJ, Kisely SR. Psychological interventions for needle-related procedural pain and distress in children and adolescents. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD005179

Effective:✤ Distraction ✤ Hypnosis ✤ Combined cognitive-behavioral interventions

✤Promising but limited evidence: ✤ Information/preparation✤ Nurse coaching plus distraction✤ Parent positioning plus distraction✤ Distraction plus suggestion

Integrative Therapies for Needle Procedures

✤ To reduce pain at the time of injection among children four years of age and older, offer to rub or stroke the skin near injection site with moderate intensity before and during vaccination (grade B recommendation, based on level II-1 evidence) Taddio A, Appleton M, Bortolussi R, Chambers C, Dubey V, Halperin S, et al. Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline. CMAJ : Canadian Medical Association journal 2010 Dec 14;182(18):E843-55.


✤ Children (5-10 yrs) perceive their parents as worried, when they reassure (e.g. “it’s okay”) - whereas distraction is associated with increased child coping McMurtry CM, Chambers CT, McGrath PJ, Asp E. When "don't worry" communicates fear: Children's perceptions of parental reassurance and distraction during a painful medical procedure. Pain. 2010 Jul;150(1):52-8.

✤ Parent coaching: Certain types of parental behaviours (e.g., nonprocedural talk, suggestions on how to cope, humour) have been related to decreases in children’s distress and pain, whereas others (e.g., reassurance, apologies) have been related to increases in children’s distress and pain. Taddio A, Chambers CT, Halperin SA, et al. Inadequate pain management during childhood immunizations: the nerve of it. Clin Ther 2009;31(Suppl 2):S152-67.)


Hypnosis in Pediatric Practice: Imaginative Medicine in ActionBy Laurence Sugarman, MD

A documentary for child health professionals

Distraction

✤ Reduction of fear and anxiety

✤ Determine if the child wishes to watch or be distracted

✤ Young children: books, bubbles and pinwheels

✤ Coaching roles for parents

✤ Older children: video games and biofeedback

Distraction

3/4Topical Anesthesia


✤" To reduce pain at the time of injection, encourage parents to use topical anesthetics during vaccination of children (grade A recommendation, based on

level I evidence). Taddio A, Appleton M, Bortolussi R, Chambers C, Dubey V, Halperin S, et al. Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline. CMAJ : Canadian Medical Association journal 2010 Dec 14;182(18):E843-55.

✤" Topical anesthetics are considered safe for children of all ages. However, administration of excessive doses and/or prolonged application times can lead to serious adverse effects, including irregular heartbeat, seizures and difficulty breathing www.hc-sc .gc .ca/dhp-mps/medeff/advisories-avis/public/_2009/emla ametop_pc-cp-eng.php

✤" For children undergoing vaccination, there is insufficient evidence for or against the use of skin-cooling techniques (vapocoolants, ice, cool/cold packs) to reduce pain at the time of injection (grade I recommendation, based on conflicting level I evidence).

Topical Local Anesthetics

EMLA versus LMX

✤ EMLA Cream (lidocaine 2.5% and prilocaine 2.5%) vs Ela-Max LMX 4% Lidocaine Topical Anesthetic Cream (1) Koh JL, Harrison D, Myers R, Dembinski R, Turner H, McGraw T: A randomized, double-blind comparison study of EMLA and ELA-Max for topical anesthesia in children undergoing intravenous insertion. Paediatr Anaesth 2004. 14(12):977-82; (2) Eichenfield LF, Funk A, Fallon-Friedlander S, Cunningham BB: 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):1093-9

✤ Ela-Max LMX: 30 minutes application as effective as 60 minutes

✤ EMLA application for preventing pain during IV insertion in Children

✤ Analgesia duration:

✤ EMLA 1-2 hours vs. LMX 1 hour

✤ Skin time:

✤ EMLA 4 hours vs. LMX 2 hours

Ametop gel (4% amethocaine [tetracaine])

✤ Cochrane Review: “Although EMLA is an effective topical anaesthetic for children, amethocaine is superior in preventing pain associated with needle procedures.” Lander JA, Weltman BJ, So SS. EMLA and Amethocaine for reduction of children's pain associated with needle insertion. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD004236

✤ EMLA and amethocaine gel comparable efficacy for procedural pain relief in children, but EMLA requires longer application time (60 vs 30 minutes) Murat I, Gall O, Tourniaire B: Procedural pain in children: evidence-based best practice and guidelines. Reg Anesth Pain Med. 2003 Nov-Dec;28(6):561-72

EMLA® and Neonates

✤ In neonates, EMLA reduces the behavioral pain response to venipuncture but not heel lance Taddio A, Ohlsson A, Einarson TR, Stevens B, Koren G: A systematic review of lidocaine-prilocaine cream (EMLA) in the treatment of acute pain in neonates. Pediatrics 1998. 101(2):E1

✤ Single doses (up to x4/day) have not been associated with methemoglobinemia Taddio A, Ohlsson A, Einarson TR, Stevens B, Koren G: A systematic review of lidocaine-prilocaine cream (EMLA) in the treatment of acute pain in neonates. Pediatrics 1998. 101(2):E1

✤ Effective for neonates > 34 weeks gestation for lumbar puncture Kaur G, Gupta P, Kumar A: A randomized trial of eutectic mixture of local anesthetics during lumbar puncture in newborns. Arch Pediatr Adolesc Med 2003, 157(11):

1065-70

✤ EMLA -> Prilocaine -> Methemoglobinemia (case studies, inflamed skin)

✤ Premies: LMX 4% for 15 minutes

1% Buffered Lidocaine

✤ Buffered subcutaneous Lidocaine as effective as Ela-Max LMX for preventing pain during IV insertion in children Luhmann J, Hurt S, Shootman M, Kennedy R. A comparison of buffered lidocaine versus ELA-Max before peripheral intravenous catheter insertions in children. Pediatrics 2004. 113(3 Pt 1):e217-20

✤ Intradermal: More effective than placebo in preventing pain during IV insertion in children (1) Fein JA, Boardman CR, Stevenson S, Selbst SM: Saline with benzyl alcohol as intradermal anesthesia for intravenous line placement in children. Pediatr Emerg Care 1998. 14(2):119-22 (2) Klein EJ, Shugerman RP, Leigh-Taylor K, Schneider C, Portscheller D, Koepsell T: Buffered lidocaine: analgesia for intravenous line placement in children. Pediatrics 1995. 95(5):709-12

✤ Effective use: Distraction during the needle stick

✤ Pain from a 30 gauge needle stick may be barely noticeable.

✤J-tip: single-use, disposable, carbon-dioxide-powered, needleless lidocaine injector

J-Tip (Lidocaine)

LET Anesthesia

✤ 3mL LET-gel: Lidocaine 4%-Epinephrine 0.18% -Tetracaine 0.5%

✤ Singer AJ, Stark MJ. Pretreatment of lacerations with lidocaine, epinephrine, and tetracaine at triage: a randomized double-blind trial. Acad Emerg Med. 2000 Jul;7(7):751-6.

✤ Sitting upright

✤ Distraction

✤ Topical Anesthesia

✤

4/4Age 0-12 months:

Sucrose


✤ Reduces pain (PIPP, VAS) and cry during painful procedure, such as venipuncture Stevens B, Cochrane Database of Systematic Reviews 2004, Issue 3

✤ Role of endogenous opioids - naloxone blunts effect

✤ Effective dose (24%): 0.05 - 0.5 mL (= 0.012 - 0.12 g)✤ Administration 2 minutes prior to mild - moderately painful procedure✤ Duration ~ 4 min✤ Does not prevent development of hyperalgesia Taddio A, Shah V, Atenafu E, Katz J. Influence of repeated painful procedures and sucrose analgesia on the development of hyperalgesia in newborn infants. Pain. 2009 Jul;144(1-2):43-8.

✤ Breastfeeding✤ Effective in term infants (superior to sweetening agents) (1) Shah PS, Cochrane Database of Systematic Reviews 2006, Issue 3 (2) Gray L, Miller LW, Philipp BL, Blass EM. Breastfeeding is analgesic in healthy newborns. Pediatrics. 2002 Apr;109(4):590-3. (3) Weissman A, Aranovitch M, Blazer S, Zimmer EZ. Heel-lancing in newborns: behavioral and spectral analysis assessment of pain control methods. Pediatrics. 2009 Nov;124(5):e921-6.

✤ Ineffective in preterm infants? Holsti L, Oberlander TF, Brant R. Does breastfeeding reduce acute procedural pain in preterm infants in the neonatal intensive care unit? A randomized clinical trial. Pain. 2011 Nov;152(11):2575-81.

Sucrose for Children 0-12 months

University Teaching Hospital in Lusaka, Zambia, Africa (Nov 2011)

Mother’s Milk (Sucrose) for Children 0-12 months

Infants

Classification of Procedures on NICU (from clinicians’ opinions)

✤ No pain (0-2): head u/s, chest x-ray, diaper change✤ Discomfort (2-4): nasal prongs, eye exam (no manipulation), nasal/oral

suction, NG tube, extubation✤ Real pain (4-6): tracheal suction, umbilical cath, bladder cath, S/Q

injection, remove CVL/art line/Tcp✤ More pain (6-7): heel stick, I/M injection, venipuncture, peripheral IV,

remove chest tube✤ Lots of pain (7-8): arterial puncture, tracheal intubation, arterial catheter,

CVL catheter✤ Unbearable pain (8-10): circumcision, lumbar puncture, chest tube

placement, bone marrow biopsy

K. J. S. Anand, MBBS, D.Phil., FAAP, FCCM, FRCPCH: Pain in Neonates: assessment, management, long-term effects; Feb 2007

Procedural Pain

NeonatesNonpharmacologic, supportive measures:

✤ Breastfeeding (Shah PS, Cochrane Database of Systematic Reviews 2006, Issue 3)

✤ Sucrose (Stevens B, Cochrane Database of Systematic Reviews 2004, Issue 3

✤ Nesting/Swaddling✤ Kangaroo care (Gray, Pediatrics 2000; Johnston APAM 2003)

✤ Dimming light & noise

Taddio A, Appleton M, Bortolussi R, Chambers C, Dubey V, Halperin S, et al. Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline. CMAJ : Canadian Medical Association journal 2010 Dec 14;182(18):E843-55.

Premature 28-36 wks: For heelstick - Kangaroo care more effective than oral glucose, which is more effective than placebo Freire NB, Garcia JB, Lamy ZC. Evaluation of analgesic effect of skin-to-skin contact compared to oral glucose in preterm neonates. Pain. 2008; 139(1):28-33. Epub 2008

Integrative Therapies for Neonates

✤ Morphine does NOT provide adequate analgesia for acute procedural pain among preterm neonates Carbajal R, Lenclen R, Jugie M, Paupe A, Barton BA, Anand KJ. Morphine does not provide adequate analgesia for acute procedural pain among preterm neonates. Pediatrics. 2005 Jun;115(6):1494-500.

✤ Providing natural warmth [Ohmeda-Ohio 3000 Infant Warmer System] to newborn infants during a painful procedure decreases the crying and grimacing on par with the "gold" standard treatments of sucrose or pacifier. Gray, L., C. W. Lang, et al. (2012). "Warmth is analgesic in healthy newborns." Pain 153(5): 960-966.

Integrative Therapies for Neonates

1. Avoid Painful Procedures

2. Sucrose, Pacifier, Kangaroo Care, Swaddling

3. Topical Anesthetic Cream

4. Acetaminophen (Paracetamol) PO or PR

5. Opioids (Fentanyl, Morphine) - slow infusion plus bolus

6. Local Anesthetics: SC infiltration; nerve blocks

7. Deep Sedation/Analgesia or General Anesthesia

Medium - Severe Pain

Mild (- Medium) PainAnand KJS, Bergqvist L, Hall RW, Carbajai R: Acute Pain Management in Newborn Infants. International Association for the Study of Pain: Clinical

Updates. Dec 2011. Vol XiX, Issue 6, pp 1-6

Suggested Ladder of Pain Management for Neonates

http://www.rch.org.au/comfortkids/resources.cfm?doc_id=10140

dummy (Aus.) =Pacifier (US)

Other Considerations

(5) (Intranasal) Systemic Analgesia(6) Sedation


✤ Nasal mucosa richly vascularized

✤ Fenestrated epithelium drains by way of the facial and✤ sphenopalatine veins ✤ ⇒ Avoiding first pass metabolism

Intranasal Opioid Application

http://intranasal.net/deliverytechniques/default.htm

✤ Drops or spray diluted in normal saline 0.9%✤ Pharmacokinetic profile similar to i.v. in children✤ Mucosal Atomization Device (MAD)


✤ Drops or spray diluted in normal saline 0.9%✤ Pharmacokinetic profile similar to i.v. in children

✤ RCT✤ 24 children (4-8 years)✤ Burn dressing changes✤ Control: oral morphine✤ Titrated until pain free ⇒ intranasal dose slightly higher (1.4 mcg/kg + 15mcg Q5min) ⇒ pain relief comparable ⇒ safety profile acceptable, no serious adverse eventsBorland ML, Bergesio R, Pascoe EM, Turner S, Woodger S. Intranasal fentanyl is an equivalent analgesic to oral morphine in paediatric burns patients for dressing changes: a randomised double blind crossover study. Burns. 2005 Nov;31(7):831-7.


✤ RCT✤ 32 children (4-8 years)✤ Postoperative analgesia✤ Control: i.v. fentanyl✤ Titrated until pain free ⇒ intranasal dose slightly higher (1.4 mcg/kg) ⇒ pain relief comparable ⇒ safety profile acceptable, no serious adverse events Manjushree R, Lahiri A, Ghosh BR, Laha A, Handa K. Intranasal fentanyl provides adequate postoperative analgesia in pediatric patients. Can J Anaesth. 2002 Feb;49(2):190-3.

✤ Case report✤ Acute pain ER✤ 48 children (3-12 years)✤ Dose applied every 5 minutes as required✤ Median dose: 1.5 mcg/kg✤ ⇒ good pain control✤ ⇒ no side effects✤ Borland ML, Jacobs I, Geelhoed G. Intranasal fentanyl reduces acute pain in children in the emergency department: a safety and efficacy study. Emerg Med (Fremantle). 2002 Sep;14(3):275-80.


If good procedural analgesia not feasible with the “4 Non-Negotiables”, consider:

(1) Mild sedation: Nitrous gasZier, J. L. and M. Liu (2011). "Safety of high-concentration nitrous oxide by nasal mask for pediatric procedural sedation: experience with 7802 cases." Pediatric emergency care 27(12): 1107-1112.

or (2) Moderate/deep sedation (e.g. ketamine, propofol)

Note:A sedative alone (such as a benzodiazepine) can never be a substitute for procedural analgesia.

Sedation

IV Access Under Nitrous Gas22 months-old, LMX in place, needed IV for radiologic procedure, history of challenging IV access in the past

Thanks to Patricia D. Scherrer MD, Medical Director, Sedation ServicesChildren's Hospitals and Clinics of Minnesota

www.cmaj.ca/cgi/content/full/cmaj.101720/DC1

✤ Choose your language: “Would it be okay, if you are bothered less this time when we access your port-a-cath?”

✤ Offering choice to child is key

✤ Make nitrous gas available

✤ Treatment protocol for painful procedures is expected standard of care in 21st century: Non-negotiable:

✤ positioning, topical anesthesia, integrative therapies, sucrose✤ plus/minus sedation; systemic anesthesia

Conclusions Procedural Pain

Just say stop!www.pediatric-pain.ca

Zempsky WT. Optimizing the management of peripheral venous access pain in children: evidence, impact, and implementation. Pediatrics. 2008 Nov;122 Suppl 3:S121-4.

Zempsky WT. Pharmacologic approaches for reducing venous access pain in children. Pediatrics. 2008 Nov;122 Suppl 3:S140-53.

Further Reading

Twitter: @NoNeedlessPain

Stefan J. Friedrichsdorf, MD | Medical DirectorDepartment of Pain Medicine, Palliative Care & Integrative Medicine Children's Hospitals and Clinics of Minnesota2525 Chicago Ave S | Minneapolis, MN 55404 | USA612.813.6450 phone | 612.813.6361 fax

[email protected]

www.childrensmn.org/services/PainAndPalliativeCare

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