Remember that Babies Really Do Feel Pain



Remember that Babies Really Do Feel Pain


Angela Kendrick MD



Pediatric pain management may be as “simple” as providing a single-shot caudal with local anesthetic for postoperative pain relief or as “complex” as providing consultative and management services for children with sickle cell disease, cancer pain, or complex regional pain syndromes.

This chapter is intended to provide you with some strategies for evaluating pediatric pain, to remind you of important pharmacokinetic and anatomic differences between infants and children, on the one hand, and adults, on the other, and to provide you with some tips on avoiding common mishaps associated with the treatment of acute pain in children.


EVALUATION OF PAIN

You must choose the appropriate pain scale. Pain scales are the tools you use to document the presence and severity of pain and the effectiveness of your treatment.

There are a number of behavior-based pain scales. The Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS) (Table 128.1 ) was developed by McGrath et al. to assess pain in the postanesthesia care unit (PACU). Six categories of behavior (crying, facial expression, verbal expression, movement of torso, touching of wound, and movement of legs) are observed and scored, and an appropriate number is charted to indicate the presence or intensity of a response.

The Face, Legs, Activity, Cry and Consolability (FLACC) scale (Table 128.2 ) is simpler than CHEOPS and is popular for the assessment of both infants and older, nonverbal patients. Parents or chronic caregivers of children with cognitive impairment have been shown to be sensitive to their child’s method of expressing pain. This input can be invaluable for interpreting the developmentally disabled child’s responses.

Observing physiologic parameters (heart rate, respirations, blood pressure, body temperature) is standard practice in evaluating a patient’s overall condition. Physiologic variables are also incorporated into pain assessment, with rapid shallow breathing, elevated heart rate, and increased blood pressure possibly indicating the presence of pain.

Other methods of pain assessment, such as verbal self report, use of numeric scales, and use of the faces scale, are appropriate for use in older
children but have their disadvantages. For example, the child may want to avoid a potential painful encounter (fear of needles), so the child denies any pain. A child may fail to understand ordinal numbers and pick a higher “better” number, or the child may pick the smiley face on the faces scale because it is the face he or she likes the best.








TABLE 128.1 CHILDREN’S HOSPITAL EASTERN ONTARIO PAIN SCALE (CHEOPS). RECOMMENDED FOR CHILDREN 1 TO 7 YEARS OF AGE; A SCORE GREATER THAN 4 INDICATES PAIN.
























































































































































ITEM

BEHAVIORAL

POINTS

DEFINITION

SCORE


Crying

No crying

1

Child is not crying.

Moaning

2

Child is moaning or quietly vocalizing; silent cry.

Crying

2

Child is crying, but the cry is gentle or whimpering.

Scream

3

Child is in a full-lunged cry; sobbing; may be scored with complaint or without complaint.


Facial

Composed

1

Neutral facial expression.

Grimace

2

Score only if definite negative facial expression.

Smiling

0

Score only if definite positive facial expression.


Verbal

None

1

Child not talking.

Other complaints

1

Child complains, but not about pain, e.g., “I want to see mommy” or “I am thirsty.”

Pain complaints

2

Child complains about pain.

Both complaints

2

Child complains about pain and about other things, e.g., “It hurts; I want my mommy.”

Positive

0

Child makes any positive statement or talks about others things without complaint.


Torso

Neutral

1

Body (not limbs) is at rest; torso is inactive.

Shifting

2

Body is in motion in a shifting or serpentine fashion.

Tense

2

Body is arched or rigid.

Shivering

2

Body is shuddering or shaking involuntarily.

Upright

2

Child is in a vertical or upright position.

Restrained

2

Body is restrained.


Touch

Not touching

1

Child is not touching or grabbing at wound.

Reach

2

Child is reaching for but not touching wound.

Touch

2

Child is gently touching wound or wound area.

Grab

2

Child is grabbing vigorously at wound.

Restrained

2

Child’s arms are restrained.


Legs

Neutral

1

Legs may be in any position but are relaxed; includes gentle swimming or serpentine-like movements.

Squirming or kicking

2

Definitive uneasy or restless movements in the legs or striking out with foot or feet (or both).

Drawn up or tensed

2

Legs tensed or pulled up tightly to body and kept there.

Standing

2

Standing, crouching, or kneeling.

Restrained

2

Child’s legs are being held down.


From McGrath PJ. Medical Algorithms. www.medal.org, with permission.

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Jul 1, 2016 | Posted by in ANESTHESIA | Comments Off on Remember that Babies Really Do Feel Pain

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