Orlando, FL—The management of pediatric pain is multimodal, with the goal of improving function in addition to decreasing pain, said Sharon K. Wrona, DNP, RN-BC, PNP, PMHS, AP-PMN, at the 2015 Annual Conference of the Rheumatology Nurses Society.1
Pain can be acute, such as nociceptic pain, or chronic (persistent). The etiology of chronic pain in younger patients is unclear. Chronic pain results from damage or pathologic changes to the peripheral or central nervous system, and approximately 15% to 25% of children and adolescents suffer from various chronic pain complaints. Unlike acute pain, chronic pain does not serve a protective function.
It is important to use an age-appropriate pain scale when assessing pain, advised Wrona, Program Director, Comprehensive Pain Services, Nationwide Children’s Hospital, Columbus, OH. On a pain scale, “not all kids can tell you what number they have,” she said.
The characteristics of the pain may influence treatment. “If you don’t know what type of pain it is, you might be treating it the wrong way,” said Wrona. Musculoskeletal pain, for example, tends to respond better to nonsteroidal anti-inflammatory drugs (NSAIDs) or muscle relaxants.
“The most important thing is asking how their pain is affecting and impacting their life,” she said. Usually, adolescents want to exert their independence, and chronic pain associated with a chronic illness can impact this independence as well as affect their social life. Addressing these aspects of their pain is important. Also, ask about fatigue when assessing pain.
She advises using a health-related quality-of-life assessment tool to measure the effects of treatment on function when managing pain in pediatric patients.
“Medicines are great, but a pill is not going to fix everything,” she said, emphasizing that treatment must be multimodal. “We focus on function, which will hopefully give you better outcomes.”
Pharmacologic treatments include NSAIDs, acetaminophen, opioid analgesics, ketamine, and topical anesthetics, usually in some combination. Some patients can tolerate a particular medication in a class but not another.
Among the opioids, if treating with hydrocodone with acetaminophen, instruct patients not to take additional acetaminophen to avoid acetaminophen toxicity. Tapentadol works on multiple pain receptors and may be advantageous in patients with mixed pain. Tramadol is available in short-acting and long-acting forms and was recently reclassified as a Schedule IV opioid analgesic.2
Methadone is inexpensive and has a liquid formulation “so if we have kids that need a longer-acting agent, and a fentanyl patch is not an option, and they can’t swallow pills, we can use methadone; it lasts 8 to 12 hours and sometimes up to 24 hours,” Wrona said. Methadone requires additional vigilance because it can accumulate and produce delayed sedation, and it can also interact with other drugs metabolized by cytochrome P450 enzymes.3
Intravenous ketamine is a dissociative anesthetic drug with analgesic properties in subanesthetic doses that has opioid-sparing effects.
In addition to acetaminophen and NSAIDs, adjunctive medications include anticonvulsants, antidepressants, muscle relaxants, and local and topical anesthetics.
Physical therapy in the form of a specific exercise prescription is an important component of treatment, not only to improve function in pediatric patients with chronic pain and rheumatologic conditions, but also to minimize the amount of medications needed. The aim is gradual exposure to exercise/activity, but realize that pain flares will occur.
The physical therapy plan should extend beyond “just the area that hurts,” Wrona said. Communication with the physical therapist should emphasize improving overall function, including range-of-motion/flexibility, strength, and aerobic capacity, rather than focusing solely on the chief complaint.
- Wrona SK. Pediatrics: pain management. Presented at: 2015 Annual Conference of the Rheumatology Nurses Society; August 6-8, 2015; Orlando, FL.
- US Department of Justice, Drug Enforcement Administration, Office of Diversion Control. Controlled substances - by CSA Schedule - July 2015. www.deadiversion.usdoj.gov/schedules/orangebook/e_cs_sched.pdf#search=scheduleofcontrolled substances. Published July 21, 2015. Accessed September 8, 2015.
- Methadone hydrochloride oral solution [package insert]. Columbus, OH: Roxane Laboratories, Inc; July 2012.