Pediatric Pain: Making Needles Hurt Less because First Impressions

Pediatric Pain: Making
Needles Hurt Less
because First Impressions
are Lasting
Mary Walters, RN, CPN
Learning Objectives
1. Describe at least one developmental
characteristic of a child’s response to
pain in each age group.
2. List at least 2 medications used to
reduce anxiety and pain during painful
procedures such as IV starts in children.
3. Identify the mechanism of action for the
use of sucrose before painful
procedures in neonates and young
infants.
Developmental Characteristics of
Children’s Response to Pain
Young Infants
•Generalized body response
of rigidity or thrashing
•Loud crying
•Facial expression of pain
•Demonstrates no
association between
approaching stimulus and
subsequent pain
Facial Expression of physical distress in infants
( Hockenberry, Wilson, & Winkelstein, Wong’s Essentials of Pediatric Nursing 7th
Edition, Elsevier Mosby 2005, page 643.)
Developmental Characteristics of
Children’s Response to Pain
Older Infants
•Localized body response
with deliberate withdrawal
of stimulated area
•Loud crying
•Facial expression of pain
and/or anger
•Physical resistance,
especially pushing the
stimulus away after it is
applied
Developmental Characteristics
of Children’s Response to Pain
Toddler/Preschool age
•Loud crying, screaming.
•Verbal expressions of “Ow,”
“Ouch,” or “It hurts”.
•Thrashing of arms and legs.
•Attempts to push stimulus
away before it is applied.
Developmental Characteristics
Cont.
School age
•May display all behaviors
of young child, especially
during painful procedure,
but less anticipatory
period.
•Stalling behavior, such as
“Wait a minute” or “I’m not
ready.”
•Muscular rigidity, such as
clenched fists, white
knuckles, gritted teeth,
contracted limbs, body
stiffness, closed eyes,
wrinkled forehead.
Developmental Characteristics Cont.
Adolescents
•Less vocal protest.
•Less motor activity.
•More verbal expressions, such
as “It hurts” or “You’re hurting
me.”
•Increased muscle tension and
body control.
The Challenges of Pain Management
Challenges
Barriers to the treatment of pain in
children
•Myth that children do not feel pain the
way adults do .
-No consequences if they do.
•Lack of assessment and reassessment
for the presence of pain.
•Misunderstanding of how to conceptualize
and quantify a subjective experience.
•Lack of knowledge of pain treatment.
•The notion that addressing the pain in
children takes too much time and effort.
•Fears of adverse effects of analgesic medication.
*Based on: AAP/APS. Pediatrics. 2001;108 (3):793-797.
Embracing What We Can Change
•Minimize patient/family anxiety
•Allow child a sense of control
•Promote coping skills during
painful procedures
•Encourage the presence of
family members
•Provide patient-friendly
environment
•Use available interventions
*Based on: AAP/APS. Pediatrics. 2001;108 (3):793797.
Guidelines Support a Multi-Modal Approach
AAP Committee on Pediatric Emergency
Medicine
•Create a favorable environment for patients
in the pediatric ED
•Incorporate child life specialists and others
trained in non-pharmacologic stress reduction
•Family presence should be offered during
painful procedures
•Painless administration of anesthetics and
analgesics should be practiced when possible
AAP=American Academy of Pediatrics; APS=American Pain Society
1 AAP/APS. Pediatrics. 2001;108 (3):793-797.
2 Zempsky W, et ak. Pediatrics. 2004;114(5):1348-1356.
American Pain Society & American Academy of
Pediatrics
APS/AAP
•Use a multimodal approach to pain
management
•Approach should be multidisciplinary
•Involve families and tailor interventions to
individual child
•Provide a calm environment to procedures
to reduce stress-producing stimulation
•Advocate for effective use of pain
medication for children to ensure
compassionate and competent pain
management
More Helpful Tools
•Tootsweet
•Versed
•L.M.X./Emla
•Buffered Lidocaine
•J-tip
Toot Sweet or Sweet-ease
Sucrose can be used for:
•Short
ShortShort-term procedural pain
•For
For babies younger than 6 months
•Must
Must have proper dosing
•Must
Must be given 2 minutes prior to
procedure
•Do
Do not use more then 2 doses
•Dose
Dose range is 0.10.1-0.7 mls
Versed (Midazolam)
Sedative and used for amnesia prior
to procedures
Intranasal: 0.2mg/kg
Oral for infants 6 months and older:
older 0.250.5mg mg/kg
IV for infants 6 months to 5 years:
years 0.050.1mg/kg titrate carefully to total dose of
0.6mg/kg may be required
6 years to 12 years: 0.025mg -0.05mg/kg
titrate to total dose of 0.4mg/kg
(Taketomo, Hodding,& Kraus, Pediatric Dosage Handbook 15th edition, LexiComp 2008-2009,page 1178-1181.)
EMLA
Cream: 5% eutectic mixture of lidocaine
and prilocaine (prescription only)1
Indication
Normal intact skin for local analgesia or
genital mucus membranes for superficial
minor surgery and as pretreatment for
infiltration anesthesia
Application
• Amount used depends on size of child
•Apply in thick layer at site of procedure
•Must be covered with an occlusive dressing
•At least 60 min prior to procedure/needle stick
•Wipe off prior to procedure
L.M.X.4
Lidocaine (4%) in a liposomal
delivery system
Indication:
•Minor cuts and abrasions
Application:
*Do not clean site prior to application
*Works best begin by rubbing a small
amount into the site for 30 seconds
*Occlusive dressing not required but
can be used especially for children
*30 to 60 minute application time
Buffered Lidocaine
Indication for usage:
•Use 31 gauge needle
•For intradermal injection
•Create “wheel” at insertion site
•Wait
Wait 1-2 minutes before
starting IV
J-TIP
Combination Therapy
• Use of Sucrose and Emla for small
infants
•Use of LMX and Buffered
Lidocaine
•Use of Midazolam and Clonodine
Keys to becoming a believer
•Raise
Raise the bar
-Promote awareness of the need to address
pain associated with venous access
and other painful procedures
•Increase
Increase knowledge of entire staff by
-Sharing data
-Developing guidelines
-Internal practices
-Utilize patient and family experiences
•Support
Support staff buybuy-in to process change
-Communicate successes
-Involve key players in decision making
Finally……
“Advocate for the effective
use
of pain medication for
children to
ensure compassionate and
competent management of
their pain.”
- AAP/APS Guidelines 2001