Pain Management In Children
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Pain management in children is the assessment and treatment of
pain Pain is a distressing feeling often caused by intense or damaging stimuli. The International Association for the Study of Pain defines pain as "an unpleasant sensory and emotional experience associated with, or resembling that associated with, ...
in
infant An infant or baby is the very young offspring of human beings. ''Infant'' (from the Latin word ''infans'', meaning 'unable to speak' or 'speechless') is a formal or specialised synonym for the common term ''baby''. The terms may also be used to ...
s and
child A child ( : children) is a human being between the stages of birth and puberty, or between the developmental period of infancy and puberty. The legal definition of ''child'' generally refers to a minor, otherwise known as a person younger ...
ren.


Types


Acute

Usually,
acute pain Pain is a distressing feeling often caused by intense or damaging stimuli. The International Association for the Study of Pain defines pain as "an unpleasant sensory and emotional experience associated with, or resembling that associated with, ...
has an obvious cause and is expected to last for a few days or weeks. It is usually managed with medication and non-pharmacological treatment to provide comfort. Acute pain is an indication for needed assessment, treatment and prevention. While a child is experiencing pain, physiological consequences can jeopardize healing and recovery. Unrelieved pain can cause
alkalosis Alkalosis is the result of a process reducing hydrogen ion concentration of arterial blood plasma (alkalemia). In contrast to acidemia (serum pH 7.35 or lower), alkalemia occurs when the serum pH is higher than normal (7.45 or higher). Alkalosis ...
and
hypoxemia Hypoxemia is an abnormally low level of oxygen in the blood. More specifically, it is oxygen deficiency in arterial blood. Hypoxemia has many causes, and often causes hypoxia as the blood is not supplying enough oxygen to the tissues of the body ...
that result from rapid, shallow breathing. This shallow breathing can lead to the accumulation of fluid in the lungs, taking away the ability to cough. Pain can cause an increase in blood pressure and heart rate, putting stress on the heart. Pain also increases the release of anti-inflammatory
steroid A steroid is a biologically active organic compound with four rings arranged in a specific molecular configuration. Steroids have two principal biological functions: as important components of cell membranes that alter membrane fluidity; and a ...
s that reduce the ability to fight infection, increase the metabolic rate and affect healing. Another harmful outcome of acute pain is an increase in sympathetic effects such as the inability to urinate. Pain can also slow the gastrointestinal system. Inadequate pain management in children can lead to psycho-social consequences, including lack of interest in food, apathy, sleep problems, anxiety, avoidance of discussions about health, fear, hopelessness and powerlessness. Other consequences include extended hospital stays, high re-admission rates and longer recovery. Examples of harmful consequences of unrelieved pain include: * Infants who have had more than average heel pricks can have poor cognitive and motor function; * Associations of needles with distress may make later medical treatments more difficult; * Children who have experienced invasive procedures often develop
post-traumatic stress Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that can develop because of exposure to a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on a ...
; * Boys circumcised without anesthesia were found to have greater distress than uncircumcised boys; * Severe pain as a child is associated with higher reports of pain in adults.


Neuropathic

Neuropathic pain Neuropathic pain is pain caused by damage or disease affecting the somatosensory system. Neuropathic pain may be associated with abnormal sensations called dysesthesia or pain from normally non-painful stimuli (allodynia). It may have continuous ...
is associated with nerve injuries or abnormal sensitivities to touch or contact. Though neuropathic pain is relatively uncommon in children compared to adults, greater awareness of these conditions is on the rise. Some causes may include past surgeries and amputations, "autoimmune and degenerative neuropathies", and injury to the spinal cord. Symptoms may include a tingling, shooting, prickling or burning sensation. The pain can be intermittent or continual and is often exacerbates in the evenings. Neuropathic pain can be peripheral or central. Peripheral neuropathic pain refers to disturbance in the function of peripheral nerves while central neuropathic pain refers to nerves in the central nervous system. Though not FDA-approved to address pain in children, anticonvulsants such as gabapentin and pregabalin have been used in severe neuropathic impairment (SNI). Other options are serotonin-norepinephrine reuptake inhibitors (SNRIs). Despite limited studies in children (limited to those with depression), SNRIs such as Venlafaxine have been shown to be effective.


Cancer pain

Cancer pain in children may be caused by the cancer itself or the side effects of treatment. Tumors can cause pain in two different ways, either by the physical pressure it places on organs or by occluding normal bodily functions. Treatment such as surgery and injections can also lead to significant pain for the patient. If untreated, the pain can suppress the immune, interfere with sleep, and increase the chance of depression. Many different health care professionals will manage the child's pain and are referred to as the patient's
palliative care Palliative care (derived from the Latin root , or 'to cloak') is an interdisciplinary medical caregiving approach aimed at optimizing quality of life and mitigating suffering among people with serious, complex, and often terminal illnesses. Wit ...
team, these include oncologists, anesthesiologists, neurologists, surgeons, psychiatrists, and pharmacists. Hospitals may also hire individuals who specialize in music or art therapy, these therapies include acupuncture, biofeedback, massage therapy, and hypnosis. Treatment of the cancer pain is tailored to the child based on age, treatment, and side effects. The goal is to achieve sufficient background control of pain and minimize any acute exacerbation of severe pain. Oftentimes medications such as non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, or opiates are used to manage the pain. Additionally, non-pharmacological can also be used to manage the child's pain, this includes distracting the child, massages, acupuncture, heat/cold therapy, exercise, and quality sleep.


Chronic

Chronic pain in children is unresolved pain that affects
activities of daily living Activity may refer to: * Action (philosophy), in general * Human activity: human behavior, in sociology behavior may refer to all basic human actions, economics may study human economic activities and along with cybernetics and psychology may st ...
and may result in a significant amount of missed school days. Chronic pain is present for long periods of time and is characterized as mild to severe. Chronic pain has also been described as the pain experienced when the child reports a headache, abdominal pain, back pain, generalized pain or combination of these. Chronic pain can develop from disease or injury and can occur simultaneously with acute pain. Children who experience chronic pain can have psychological effects. Caring for a child in pain may cause distress to the caregiver, may cause costs due to healthcare or lost wages from time off work, and may stop caregivers from leaving the house.


Diagnosis

Assessment of pain in children depends on the cooperation and developmental stage of the child. Some children cannot assist in their assessment because they have not matured enough cognitively, emotionally, or physically. The following sections list signs of distress and possible pain in children by age group:


Younger infants

* Inability to distinguish the stimulus from the pain * Ability to exhibit a reflexive response to pain * Expressions of pain ** Tightly closed eyes ** Open mouth resembling a square rather than an oval or circle ** Eyebrows lowered and tightly drawn together * Rigid body * Thrashing * Loud crying * Increase in heart rate, even while sleeping


Older infants

* Deliberate withdrawal from pain and possible guarding * Loud crying * Painful facial expressions


Toddlers

Toddlers show signs of distress and possible pain by: * Expressing pain verbally * Thrashing extremities * Crying loudly * Screaming * Being uncooperative * Palpating (examining with the hands) a source of pain * Anticipating a pain-inducing procedure or event * Requesting to be comforted * Clinging to a significant person, possibly one perceived as protective


School-age children

School-age children show signs of distress and possible pain by: * Anticipating the pain but less intensively, (understands concepts of time, i.e., imminent vs future pain) * Stalling, trying to talk out of the situation where pain is anticipated * Having muscular rigidity


Adolescent

Adolescents show signs of distress and possible pain: * With muscle tension, but with control * With verbal expressions and descriptions


Quantitative pain assessment

Although pain is subjective and can occur in a continuous spectrum of intensities, there are assessment tools that compare pain levels over time. This kind of assessment incorporates pain scales and requires a high enough developmental level for the child to respond to questions. A verbal response is not always necessary to quantify pain.


Pain scales

A
pain scale A pain scale measures a patient's pain intensity or other features. Pain scales are a common communication tool in medical contexts, and are used in a variety of medical settings. Pain scales are a necessity to assist with better assessment of pai ...
measures a patient's pain intensity and other features. Pain scales can be based on observational (behavioral) or physiological data, as well as self-report. Self-report is considered primary and should be obtained if possible. Pain measurements help determine the severity, type, and duration of pain. They are also used in diagnosis, to determine a treatment plan, and to evaluate the effectiveness of treatment. Pain scales are available for neonates, infants, children, adolescents, adults, seniors, and persons with impaired communication. Pain assessments are often regarded as "the 5th
vital sign Vital signs (also known as vitals) are a group of the four to six most crucial medical signs that indicate the status of the body's vital (life-sustaining) functions. These measurements are taken to help assess the general physical health of a p ...
".


Causes

The causes of pain in children are similar to the causes in adults. Pain can be experienced in many ways and depends on the following factors in each child: * Prior painful episodes or treatments * Age and
developmental stage Stages of development may refer to: Biology *Developmental biology, the study of the process by which animals and plants grow and develop *Prenatal development, also called fetal development, or embryology *Human development (biology), the proc ...
* Disease or type of trauma * Personality * Culture * Socioeconomic status * Presence of family members and family dynamics.


During treatment

Clinicians responsible for a child monitor the child frequently in tertiary care centers (hospitals). Pharmacological and non-pharmacological treatments are used to manage the pain. Parents or caregivers are also requested to provide their own pain assessments. At the beginning of pharmacological treatment, clinicians monitor the child for adverse reactions to the medications. The levels of some medications are monitored to ensure that the child is not overmedicated and does not receive toxic levels of any drug. The levels also indicate whether there would be enough drug in the blood to be effective in managing the pain. Medications are metabolized differently between children of the same age. Factors that influence the levels of medications controlling pain include the height, weight, and body surface of the child, as well as any other illnesses. Some medications may have a
paradoxical effect A paradoxical reaction (or paradoxical effect) is an effect of a chemical substance, such as a medical drug, that is opposite to what would usually be expected. An example of a paradoxical reaction is pain caused by a pain relief medication. Parado ...
in children, which is an effect that is the opposite of the expected effect. Clinicians monitor for this and any other reactions to medication.


After treatment

Post-procedural treatment in children is primarily prescription opioids. Morphine is effective and relatively safe, and is often used with moderate to severe pain. Codeine and tramadol should be avoided especially in children younger than 12 years old since metabolism varies due to genetic differences between individuals, and, in the case of tramadol, this medication has not been well studied in children. However, other interventions include medications classified as non-opioid analgesics, which are useful in post surgical treatment. For example, acetaminophen or ibuprofen can be used as a non-opioid analgesics. Unlike acetaminophen, ibuprofen has anti-inflammatory property which can be useful for pain in inflammatory conditions. Aspirin is not used in pediatric population due to its association with Reye's syndrome.


Management


Atraumatic measures

Because children process information differently from adults, treatment centers for children often use atraumatic measures to reduce anxiety and stress. Examples include: * Allowing the parent or caregiver to be present for painful procedures * Using a treatment room for painful procedures to ensure that the child's room is a place where little pain can be expected * Establishing other "pain-free zones" where no medical procedures are allowed, such as a playroom * Offering choices to the child to give them some control over the procedures * Modelling procedures with dolls and toys * Using age-appropriate anatomical terms and other vocabulary.


Non-pharmacological

Depending on the source of pain, there are many non-pharmacological options to be considered. Also, depending on the age of the child, different approaches may be more suitable. Non-pharmacological methods to manage discomfort during immunizations or painful procedures in young babies (up to 12 months of age): * Oral treatment with a sweet-tasting solution: This can be done either by sucking on a soother (
pacifier A pacifier is a rubber, plastic, or silicone nipple substitute given to an infant to suckle upon between feedings to quiet its distress by satisfying the need to suck when it does not need to eat. Pacifiers normally have three parts: an elongate ...
) or by placing a small amount of sweet-tasting solution in their mouths * Comforting the baby during and after the injection *
Breastfeeding Breastfeeding, or nursing, is the process by which human breast milk is fed to a child. Breast milk may be from the breast, or may be expressed by hand or pumped and fed to the infant. The World Health Organization (WHO) recommends that br ...
during painful procedures has been found to be more effective in controlling pain than
placebo A placebo ( ) is a substance or treatment which is designed to have no therapeutic value. Common placebos include inert tablets (like sugar pills), inert injections (like Saline (medicine), saline), sham surgery, and other procedures. In general ...
or positioning. Breastmilk or 'sugar' water has a similar effect, though studies in preterm infants have yet to be done. * Skin-to-skin care (
kangaroo care Kangaroo care also called skin-to-skin contact (SSC), is a technique of newborn care where babies are kept chest-to-chest and skin-to-skin with a parent, typically their mother (occasionally their father). Kangaroo care, named for the similarity ...
) is thought be effective for pain control during painful procedures. * Gently rocking the baby *
Swaddling Swaddling is an age-old practice of wrapping infants in blankets or similar cloths so that movement of the limbs is tightly restricted. Swaddling bands were often used to further restrict the infant. Swaddling fell out of favour in the 17th cent ...
* Suckling (non nutritive) Non-pharmacological treatments for older children include: * Carefully explaining a procedure with pictures or other visual aids * Letting the child choose the injection site. * Chest-to-chest hugging * Allowing the child to ask questions of medical staff * Touring the place where the procedures will occur * Allowing small children to play with dolls or other toys with a clinician to understand the procedure * Allowing older children to watch a video that explains the procedure * Providing distraction with songs, stories, toys, color, videos, TV, or music * Using relaxation techniques such as deep breathing or massage Non-pharmacological treatment for pain associated with
venipuncture In medicine, venipuncture or venepuncture is the process of obtaining intravenous access for the purpose of venous blood sampling (also called ''phlebotomy'') or intravenous therapy. In healthcare, this procedure is performed by medical labor ...
in children includes
hypnosis Hypnosis is a human condition involving focused attention (the selective attention/selective inattention hypothesis, SASI), reduced peripheral awareness, and an enhanced capacity to respond to suggestion.In 2015, the American Psychologica ...
and distraction. These treatments reduced self-reported pain and when combined with
cognitive-behavioural therapy Cognitive behavioral therapy (CBT) is a psycho-social intervention that aims to reduce symptoms of various mental health conditions, primarily depression and anxiety disorders. CBT focuses on challenging and changing cognitive distortions (suc ...
(CBT) the reduction of pain was even greater. Other interventions have not been found to be effective and these are suggestion, blowing out air, and distraction with parent coaching did not differ from control for pain and distress. For children and adolescents who experience chronic pain- behavioral treatment, relaxation training, cognitive behavioral therapy (CBT) and acupuncture have been proven to be effective for some patients. For recurrent abdominal pain a 2017 Cochrane review found some evidence that CBT and
hypnotherapy Hypnotherapy is a type of mind–body intervention in which hypnosis is used to create a state of focused attention and increased suggestibility in the treatment of a medical or psychological disorder or concern. Popularized by 17th and 18th cen ...
were effective in reducing pain for the short term. For children over one year of age, there is no strong evidence to suggest that eating or sucking on a sweet tasting solution has an analgesic effect.


Medication

Acute pain, chronic pain, neuropathic pain and recurrent pain in children is most often managed with medication. Most of these medications are
analgesic An analgesic drug, also called simply an analgesic (American English), analgaesic (British English), pain reliever, or painkiller, is any member of the group of drugs used to achieve relief from pain (that is, analgesia or pain management). It ...
s. These include
acetaminophen Paracetamol, also known as acetaminophen, is a medication used to treat fever and mild to moderate pain. Common brand names include Tylenol and Panadol. At a standard dose, paracetamol only slightly decreases body temperature; it is inferior ...
, NSAIDs,
local anesthetic A local anesthetic (LA) is a medication that causes absence of pain sensation. In the context of surgery, a local anesthetic creates an absence of pain in a specific location of the body without a loss of consciousness, as opposed to a general an ...
s,
opioid Opioids are substances that act on opioid receptors to produce morphine-like effects. Medically they are primarily used for pain relief, including anesthesia. Other medical uses include suppression of diarrhea, replacement therapy for opioid us ...
s, and medications for neuropathic pain. Regional anesthesia is also effective and recommended whenever possible. It is important to use caution when administering opioids to neonates and young infants. There is a higher risk for apnea and hypoventilation in this population, due to their decreased breathing response. The effectiveness and adverse effects associated with the use of the injectable NSAID
ketorolac Ketorolac, sold under the brand names Toradol, and Biorolac among others, is a nonsteroidal anti-inflammatory drug (NSAID) used to treat pain. Specifically it is recommended for moderate to severe pain. Recommended duration of treatment is less ...
postoperatively or following or during surgery is not clear due to insufficient quantity and quality of evidence. It is not clear from clinical trials if it is more effective to provide pain control around the clock or provide pain relief as needed for children recovering from surgery.


Chronic pain treatment

Chronic pain is treated with a variety of medications and non-pharmacological interventions. The World Health Organization recommends using a two step treatment approach based on the level of pain in children. The first step explains mild pain treatment, while the second step considers moderate to severe pain. Opioids, such as morphine, is an example of a drug of choice for moderate-severe pain in children with medical illnesses. Some side effects of opioid use can include cognition deficits, dependence, altered mood, and disturbances of endocrine development. Non-pharmacological treatment for children to help relieve periodic pain includes counseling and
behavior modification Behavior modification is an early approach that used respondent and operant conditioning to change behavior. Based on methodological behaviorism, overt behavior was modified with consequences, including positive and negative reinforcement continge ...
therapy. The American Association of Pediatrics states that psychological interventions, such as relaxation and cognitive strategies, have strong evidence for pain management.


Acute pain treatment

The approach to acute pain should take into account the severity of the pain. Non-opioid analgesics, such as paracetamol (
acetaminophen Paracetamol, also known as acetaminophen, is a medication used to treat fever and mild to moderate pain. Common brand names include Tylenol and Panadol. At a standard dose, paracetamol only slightly decreases body temperature; it is inferior ...
) and NSAIDs, can be used alone to treat mild pain. For moderate to severe pain, it is optimal to use a combination of multiple agents, including opioid and non-opioid agents.


Postoperative pain

A panel, including the American Pain Society and American Society of Regional Anesthesia and Pain Medicine, recommends multimodal analgesia, which they define as a combination of pharmacological agents and non-pharmacological techniques to treat postoperative pain. A significant benefit of this technique is that non-opioid analgesics used in combination with opioids can decrease the amount of opioids required and reduce the risk of opioid-related side effects. Medications can be delivered as needed or around-the-clock depending on the patient's needs. For children, intravenous patient-controlled analgesia (IV-PCA) can be used when parenteral administration is preferred. IV-PCA allows for consistent opioid levels, which can be a better alternative to scheduled intramuscular injections. In addition, studies have shown that children as young as 6 years old can use the IV-PCA correctly.


Dental pain

For projected moderate to severe pain, analgesics can be used on a regular schedule for the first 36 to 48 hours after a dental procedure. NSAIDs are preferred over other analgesics to treat acute mild to moderate postoperative pain, due to the inflammatory component of dental pain. Alternating between the NSAIDs and acetaminophen in combination is another option. In addition, these two agents are considered equivalent or better than opioids for managing musculoskeletal pain, which includes dental pain.


Cancer pain

Cancer pain is managed differently in children. Typically, medical history, physical examinations, age and overall health of the child are evaluated. The type of cancer may influence decisions about pain management. The extent of the cancer, and the tolerance of the child to specific medications, procedures or therapies are also taken into account, as well as the preferences of the parent or caregiver. Medications used to treat cancer pain include non-steroidal anti-inflammatory drugs (NSAIDs) and opioids.


Non-steroidal anti-inflammatory drugs (NSAIDs)

Non-steroidal anti-inflammatory drugs Non-steroidal anti-inflammatory drugs (NSAID) are members of a therapeutic drug class which reduces pain, decreases inflammation, decreases fever, and prevents blood clots. Side effects depend on the specific drug, its dose and duration of ...
(NSAIDs): * Used as treatment for pain and as an
anti-inflammatory Anti-inflammatory is the property of a substance or treatment that reduces inflammation or swelling. Anti-inflammatory drugs, also called anti-inflammatories, make up about half of analgesics. These drugs remedy pain by reducing inflammation as o ...
. * Can be administered as oral tablet or liquid. * It is recommended to use the lowest dose and shortest duration possible to control pain. * NSAIDs are not approved for infants under 3 months old. * General adverse effects for NSAIDs: **
Renal The kidneys are two reddish-brown bean-shaped organs found in vertebrates. They are located on the left and right in the retroperitoneal space, and in adult humans are about in length. They receive blood from the paired renal arteries; blood ...
impairment **
Hepatic The liver is a major organ only found in vertebrates which performs many essential biological functions such as detoxification of the organism, and the synthesis of proteins and biochemicals necessary for digestion and growth. In humans, it i ...
impairment ** Gastrointestinal issues (nausea, diarrhea, constipation, flatulence) **
Dyspepsia Indigestion, also known as dyspepsia or upset stomach, is a condition of impaired digestion. Symptoms may include upper abdominal fullness, heartburn, nausea, belching, or upper abdominal pain. People may also experience feeling full earlier t ...
** Rash ** Dizziness ** Abdominal pain * Contraindicated for: ** Hypersensitivity reactions ** Cardiac impairment **
Reye's syndrome Reye syndrome is a rapidly worsening encephalopathy, brain disease. Symptoms of Reye syndrome may include vomiting, personality changes, confusion, seizures, and loss of consciousness. While hepatotoxicity, liver toxicity typically occurs in the ...
** Coagulation defects * Ibuprofen 5–10 mg/kg every 6–8 hours (Max dose 1200 mg/day)


Opioids

Opioid Opioids are substances that act on opioid receptors to produce morphine-like effects. Medically they are primarily used for pain relief, including anesthesia. Other medical uses include suppression of diarrhea, replacement therapy for opioid us ...
s: * Doses are based on the child's body weight. * They can be administered as oral, parenteral, buccal, transdermal, nasal or rectal formulations. * It is recommended to start at a low dose and
titrate Titration (also known as titrimetry and volumetric analysis) is a common laboratory method of quantitative chemical analysis to determine the concentration of an identified analyte (a substance to be analyzed). A reagent, termed the ''titrant'' ...
up to effect. * General adverse effects for opioids: **
Constipation Constipation is a bowel dysfunction that makes bowel movements infrequent or hard to pass. The stool is often hard and dry. Other symptoms may include abdominal pain, bloating, and feeling as if one has not completely passed the bowel movement ...
**
Hives Hives, also known as urticaria, is a kind of skin rash with red, raised, itchy bumps. Hives may burn or sting. The patches of rash may appear on different body parts, with variable duration from minutes to days, and does not leave any long-lasti ...
**
Nausea Nausea is a diffuse sensation of unease and discomfort, sometimes perceived as an urge to vomit. While not painful, it can be a debilitating symptom if prolonged and has been described as placing discomfort on the chest, abdomen, or back of the ...
**
Vomiting Vomiting (also known as emesis and throwing up) is the involuntary, forceful expulsion of the contents of one's stomach through the mouth and sometimes the Human nose, nose. Vomiting can be the result of ailments like Food-poisoning, foo ...
**
Pruritus Itch (also known as pruritus) is a sensation that causes the desire or reflex to scratch. Itch has resisted many attempts to be classified as any one type of sensory experience. Itch has many similarities to pain, and while both are unpleasant ...
**
Respiratory depression Hypoventilation (also known as respiratory depression) occurs when ventilation is inadequate (''hypo'' meaning "below") to perform needed respiratory gas exchange. By definition it causes an increased concentration of carbon dioxide (hypercapnia ...
The frequency of prescribing for these pain medications has more than doubled from 1990 to 2010 with 20-50% of adolescents who complain of headache, back pain, or joint pain receiving a prescribed opioid. Before an adolescent or young adult is prescribed opioids, they should be screened for risk factors for opioid drug abuse. Prescription drug monitoring programs (PDMs) are now available in 37 states and 11 states have programs in development. The use of opioids can result in a number of complications in children, including respiratory depression and risk for unintended overdose and opioid misuse later in life. These risks can be reduced by the use of NSAIDs (e.g. ibuprofen) and
paracetamol Paracetamol, also known as acetaminophen, is a medication used to treat fever and mild to moderate pain. Common brand names include Tylenol and Panadol. At a standard dose, paracetamol only slightly decreases body temperature; it is inferior ...
. Using NSAIDs and paracetamol can be opioid-sparing, leading to less opioid use in situations such as peri-operative pain management. The efficacy and safety of opioids in children have not been established. A 2014 Cochrane Review for
nalbuphine Nalbuphine, sold under the brand names Nubain among others, is an opioid analgesic which is used in the treatment of pain. It is given by injection into a vein, muscle, or fat. Side effects of nalbuphine include sedation, sweatiness, clamm ...
for postoperative pain treatment in children, reported insufficient evidence of the efficacy and adverse events of nalbuphine in this population; further research is needed in this area. Other side effects of opioids are constipation, fatigue, and disorientation. Children can develop opioid tolerance, where larger doses are needed to have the same effect. Tolerance occurs earlier in children than in adults, especially with prolonged use. When tolerance to opioids develop, it takes a larger dose of the opioid to achieve the same analgesic effect. Non-pharmacological treatments have few side effects.


Treatment for children and adolescents with conditions that are life limiting

For children with lifelimiting conditions including cancer, the evidence supporting or refuting specific treatment approaches is very weak.


Society and culture

The indications that treatment is needed are not always clear for children because of poor assessments and the tendency to undertreat pain.


Research

The use of virtual reality devices has been suggested as a non pharmacological option for distracting children during certain painful procedures, however, further research is required to determine if this approach is effective and also to identify any unwanted effects. The effectiveness and potential side effects or adverse effects associated with many commonly used pain medications in children and adolescents such as paracetamol have not been well studied in the pediatric population as most of the high quality studies showing effectiveness have been conducted in adults.


See also

*
Pain management Pain management is an aspect of medicine and health care involving relief of pain (pain relief, analgesia, pain control) in various dimensions, from acute and simple to chronic and challenging. Most physicians and other health professionals pr ...


References


Bibliography

* * *


External links

{{Medical resources, ICD10={{ICD10, R, 52 , ICD9={{ICD9, 338 , MedlinePlus=002164 , DiseasesDB=9503 , MeshID=D010146
"Palliative Care factsheet"
from WHO
"WHO guidelines on persisting pain in children"
Pain scales Medical assessment and evaluation instruments Pain Pediatrics Palliative care