Tips for primary care clinicians assessing and managing pediatric acute pain

Acute pain occurs when an injury is inflicted, and the sensation is sent from the site of injury to the brain. Pain due to an injury is transmitted through neuronal tracts in the spinal cord, travels to the brain’s thalamus and periaqueductal gray leading to the feeling of pain. Facilitatory ascending inputs, such as stress, anxiety, depression, or poor sleep hygiene, can increase the perception of pain. Inhibitory ascending inputs, such as distractions, proper sleep, school attendance, and exercise, can decrease the perception of pain. In addition, there are neurothalamic tracts that can attenuate or reduce the source of pain.

If the pain sensation continues untreated, it can lead to central sensitization and a decreased response to standard acute pain treatment, leading to refractory pain that is more difficult to treat.

Pain treatment and infants in the NICU

Infants who receive care in the NICU experience dozens and even hundreds of painful procedures during their stay and are at risk for complications if that pain is not appropriately addressed. [Barker: 1995]Exposure to severe pain in the NICU without adequate pain alleviation has been associated with interventricular hemorrhage, hypoxia, coagulopathy, increased intracranial pressure, respiratory incoordination, etc. [Anand: 1999] [Johnston: 1997]

Helpful techniques to manage acute pain
Topical anesthetics, sucrose solutions, breastfeeding, appropriate positioning, and distractions are all helpful techniques to minimize pain during pediatric procedures.

Medications for pain
Short-acting opioids are appropriate for treatment in an acute pain crisis when non-opioid options have been exhausted. The use of one opioid at a time is recommended when treating acute pain. Mixed analgesic medications (e.g., acetaminophen/oxycodone) have been shown to have poor outcomes in children.

Increasing medications
Small interval increases can lead to central desensitization of pain. Increasing opioid medication dose by 30% to 100% is an appropriate increase for poorly controlled pain.

Risk of opioid overdose
Practitioners should always assess the risk of opioid overdose when prescribing opioids and the need to prescribe naloxone.

Circumcision
Another common painful procedure in pediatric care includes male neonatal circumcisions. Circumcised infants show stronger pain responses to subsequent routine procedures or painful injuries if they had inadequate or partial treatment of pain during their circumcision. [Taddio: 1997] Dorsal block and EMLA topical cream, traditional pain management modalities for circumcision, diminish pain, but newer studies suggest ring blocks are a slightly better way to treat pain in circumcisions. Sugar solutions, pacifiers, and music used on their own were also found to be ineffective, although sucrose paired with non-nutritive sucking was more effective. [Stevens: 2016] A bundle for pain management, including pharmacologic and non-pharmacologic means, would likely be most helpful in mitigating pain during the procedure and afterward. Inadequate or incomplete pain treatment has the potential to result in long-term consequences such as enhanced pain responses, fear, chronic pain, sensitization to future pain, and treatment-resistant pain. [Weisman: 1998]

Appropriate pain management requires a close partnership with caregivers and families to ensure optimal patient experience. These approaches should take into account the individual patient and the type of pain being addressed.

Some institutions have recommended best practices for specific scenarios, such as vaccination. The University of Minnesota has created a multimodal approach during immunizations. This strategy has been immensely effective in minimizing pain or painful experiences in outpatient settings. There are 4 steps in this process from Children’s Minnesota Comfort Promise are:

• Create comfortable positions to help accomplish coping strategies. Examples are age-dependent:
  • Children 0-12 months of age can be held, swaddled, and have pacifiers or sweeties.
  • Teenagers can choose to watch or not and use distractions like electronics to help cope and give more control over the process.
• Provide topical anesthetics such as cold sprays or EMLA.
• Provide oral sucrose, as studies have shown some sucrose can be more effective than opioids for acute pain. Additionally, breastfeeding children should try feeding at the same time. Breastfeeding during the time of vaccinations can minimize pain. [Harrison: 2016] [Gray: 2002]
• Distractions such as rubbing the site, electronics, parent coaching, and bubbles can help reduce pain and increase the effectiveness of coping with traumatic needle experiences.

Although these approaches are focused on vaccinations, there have been positive outcomes by applying these strategies to other areas involving fear-provoking or painful procedures such as abscess drainage, IV placements, lab draws, etc. Providing pain-reducing strategies in both outpatient and inpatient settings for our patients is important to decrease negative outcomes and improve adherence to future medical interventions.

See also:

• Behavioral Management of Pain
• Pediatric Pain Assessment & Rating Scales

Non-opioid medications
Children with acute pain can most often be managed successfully with non-opioid medications, such as ibuprofen or acetaminophen.

Opioids
In cases of severe acute pain or when treatment with non-opioids is ineffective, opioids can be very effective for acute pain. Opioids for chronic pain are not recommended. The following guidelines can help providers when an opioid is deemed necessary. These medications have a great benefit in helping patients and can be used safely when approached with care.

Choosing a single opioid for the treatment of the patient is the safest and most effective approach. Using more than one type of opioid at the same time can lead to ineffective treatment with inadequate dosing of one or both opioids and an increase in side effects. Single-agent treatment allows for a clearer clinical picture during titration and a higher likelihood of an effective dose with a much lower risk of oversedation or unintentional overdose.

Short-acting opioid medications such as morphine, oxycodone, or hydromorphone can be used in significant acute pain crises. Extended-release opioid medications (should not be used for acute pain as they can lead to inadequate treatment or potential overdose. Moreover, long-acting opioids can be difficult to titrate precisely as they come in larger dose formulations than their short-acting counterparts.

For severe pain that is not adequately treated with the first dose of a medication, appropriate management for titrating opioids is to increase the opioid dosing by 50% and monitor for effect. When titrating opioids, monitor closely to ensure good pain management without increased sedation or (in very severe cases) changes in respiration. Once the pain is managed, the dose can be de-escalated. For patients on scheduled opioid pain medication, a PRN dose equal to 10% of the daily total scheduled doses is an appropriate place to start.

For example, If a patient is prescribed hydromorphone 2mg every 4 hours with inadequate treatment of pain, increasing by 50% would equate to 3mg every 4 hours. For breakthrough pain, appropriate management could be to give 10% of the patient’s daily opioid use per day. A patient receiving hydromorphone 2mg every 4 hours for their pain crisis has a daily opioid use of 12 mg/day; thus, 1.2 mg as needed for breakthrough pain would be an appropriate PRN plan.

Increasing Dose
When patients are experiencing severe, poor pain control, even with the approach described above, providers can increase opioid dosing by 75%-100% or greater. Consultation with a pharmacist or pain specialist may be helpful.

It is recommended to avoid increasing opioids in small increments, as small interval increases over a prolonged period may lead to central sensitization and development of a primary pain disorder, requiring higher and higher doses of opioids in the future. An increase of 30 to 50% allows for better pain control and less risk of incomplete treatment. Trying to spare opioids during a crisis can inversely result in a higher/unnecessary level of opioid exposure.

Risks
There are a few therapeutics to be aware of and avoid if possible. Medications with mixed analgesic properties, such as hydrocodone/acetaminophen (Norco) or oxycodone/acetaminophen (Percocet), often lead to limited pain control and a risk of accidental overdose from the non-opioid component if caregivers give additional doses of acetaminophen on top of the combination medicine. Codeine, an opioid frequently mixed with other products, is not recommended as its metabolism varies enough to cause respiratory suppression at “normal” doses in children with high metabolisms. Tramadol does not manage pain effectively and should be avoided as well.

Opioids are an essential tool in the best practice of acute pain management in the pediatric patient population. Concerns about misuse and adverse side effects should be addressed with appropriate guidelines and education around opioid management. Another tool in safe pain management is naloxone, which can serve the dual purpose of safety for the patient and safety for those close to the household. Pediatricians should be especially mindful of prescribing naloxone to patients on high doses of opioids for chronic pain, patients transitioning from 1 opioid to another, patients discharged home from emergent medical care in the context of opioid poisoning or overdose, patients on long-acting opioid medications, and patients who have had a period of abstinence before restarting opioids.

Pediatric Integrative Medicine (see NW providers [0])
May be helpful to direct components of management, including traditional and complementary modalities in a safe and evidence-based manner.

• G89.1x, Acute pain, further specified by site or cause
• R52, Pain, unspecified (applies to generalized pain)