New Tips for Pediatric Pain Management in the Emergency Department

CLINICAL CONTEXT

According to Fein and colleagues, the administration of appropriate analgesia in the emergency department (ED) varies by age and by the training of the ED team and lags behind analgesia for adults. However, recent studies have shown an increase in the use of opiates for children with long bone fractures. System-wide approaches for pain management awareness and strategies work best if woven into the fabric of the emergency medical system through education and protocol development.

This is a report from the American Academy of Pediatrics, providing information on optimizing comfort and minimizing distress among children and families cared for in the ED setting.

STUDY SYNOPSIS AND PERSPECTIVE

A new report offers clinicians current, practical tips on the most effective ways to manage pain and anxiety among pediatric patients in emergency settings.

"Management of a child's distress during illness or after an injury is an important yet complex aspect of emergency medical care for children," write Joel Fein, MD, MPH, professor of pediatrics and emergency medicine at the University of Pennsylvania School of Medicine and an attending physician in the ED at the Children's Hospital of Philadelphia, and colleagues on the American Academy of Pediatrics committee on pediatric emergency medicine and section on anesthesiology and pain.

"The purpose of this report was to provide information to optimize the comfort and minimize the distress of children and families as they are cared for in the emergency setting," Dr. Fein and colleagues write in their report, which was published online October 29 and in the November issue of Pediatrics.

The authors begin by noting some hopeful trends. "Encouragingly, improvements in the recognition and treatment of pain in children have led to changes in the approach to pain management for acutely ill and injured pediatric patients," they write.

As an example, they note that studies show that clinicians are providing more opiate drugs to children who present with fractures. "Recent advances in the approach and support for pediatric analgesia and sedation, as well as new products and devices, have improved the overall climate of the ED for patients and families in search of the 'ouchless' ED," they write.

Child Life Specialists in ED Improve Care

Still, they stress, to serve patients best, training in pediatric pain assessment and management needs to be woven into overall protocols for all emergency medical services personnel, including emergency medical services agencies, interfacility critical care transport teams, and EDs of hospitals.

They concede that managing pediatric pain presents special challenges in the emergency setting. "In the ED, children often present with a constellation of symptoms but no final diagnosis; they are usually unknown to the treating physician, have a wide range of medical or surgical problems, and are unlikely to be fasting on arrival," the authors write. "These factors make their assessment and the selection of appropriate analgesic intervention more complicated."

Having a child life specialist based in the ED offers major advantages in helping pediatric patients and their families cope with pain, the authors note. These specialists can help reassure children, answer their questions or concerns about what is going on in the ED environment, and support the family involvement in the patients' care.

They can also educate the ED staff on how to use diversionary techniques (such as bubble blowers and pinwheels) to distract children before and during painful procedures.

"[The child life specialist] is one of a few professionals in the emergency setting who is not in a position to cause emotional or physical pain to the child; however, nurses, physicians, and ancillary staff also share in this responsibility and can learn from and teach each other these techniques," the authors write.

Parents May Ease Anxiety, but No Data

They say family members should be allowed, but not required, to be present during painful procedures. Although there is no evidence that having family members present helps reduce pain, the authors note that involving the parent as a coach for the child during procedures can help ease anxiety and distress.

The authors say that when pediatric patients arrive at the ED, it is best if they can be provided a private room. However, they note, if that is not possible, EDs can at least set aside a dedicated pediatric area. Colorful walls, pictures on the ceiling, and a collection of toys and games can help reduce anxiety associated with the unfamiliar environment.

Pain Assessment

Assessing levels of pain can be difficult, the authors note, as pain is, by nature, a subjective experience and may vary according to social, psychological, and experiential factors. "For example, patients who experience chronic pain may not report the same pain level or exhibit the same facial cues and vocalizations as those who are new to the pain experience," they write.

That being the case, assessing pain is more complex than simply obtaining a single pain score. It is also important to pay attention to how patients respond to individual procedures.

The authors note that in children as young as 3 years, several well-validated scales can be used for self-reporting of pain levels. "The revised FACES pain scale, the Wong-Baker Faces scale, and the 10-cm Visual Analog Scale have been used successfully in many EDs caring for children," the authors write.

For assessing pain levels in neonates, the authors recommend the Neonatal Infant Pain Scale; for infants, young children, and those with cognitive impairment, they suggest using the face, legs, activity, crying, and consolability (FLACC) scale.

Controlling Pain From Procedures

With regard to controlling pain associated with needle sticks and other minor procedures, the authors suggest proactive use of topical anesthetics. Some newer topical anesthetics have been found to produce effects more quickly than older products. The authors say a topical liposomal 4% lidocaine cream provides anesthesia in about 30 minutes. Heat-activated systems may shorten the time to anesthesia to as little as 10 to 20 minutes.

In addition to lessening pain, the authors note, topical anesthetics are associated with better accuracy during procedures, as they tend to reduce unnecessary movement.

One recent innovation the authors note is a vibrating device that, when applied over a cold pack, may cut down on the pain of venipuncture and immunizations.

Anesthesia for repair of lacerations employs some similar approaches, as well as others that vary. "Several topical anesthetic/vasoconstrictor combinations, such as lidocaine, epinephrine, and tetracaine, which can be made by the in-hospital pharmacy as a liquid or gel preparation, provide excellent wound anesthesia in 20 to 30 minutes," the authors note.

For managing pain in neonates, the authors say that when appropriately dosed, topical anesthetics are safe and effective, even in newborns and preterm infants.

Recent studies have found that the administration of a 12% to 25% solution of sucrose can help reduce neonatal distress during painful procedures. "Sucrose has been found to decrease the response to noxious stimuli, such as heel sticks and injections, in neonates and has even been demonstrated to reduce subsequent crying episodes during routine care, such as diaper changes," they write. In addition, use of pacifiers, either with or without sucrose, has been demonstrated to reduce neonatal distress.

Sedative hypnotic medications may be needed to reduce pain and distress in children undergoing procedures in the ED. "Emergency physicians are increasingly using short-acting medications such as propofol, alone or in combination with ketamine, for procedural sedation in children," the authors note, adding that published reports have shown that when used according to established protocols, the propofol/ketamine combination is safe.

They also note that some clinicians are hesitant to administer pain medication to children with abdominal pain. In response to those concerns, however, they write, "Administration of pain medication has been demonstrated to preserve the ability to assess patients with abdominal pain and should not be withheld."

They conclude, "Timely administration of analgesia affects the entire emergency medical experience and can have a lasting effect on a child's and family's reaction to current and future medical care. A systematic approach to pain management and anxiolysis, including staff education and protocol development, can provide comfort to children in the emergency setting and improve staff and family satisfaction."

The authors have disclosed no relevant financial relationships.

STUDY HIGHLIGHTS

Pain management in children in the ED is hampered by unfamiliarity with pain assessment tools and techniques, fear of medication adverse effects, and time constraints.

Children's pain is often underestimated because of the failure to account for a wide range of developmental stages, and topical anesthetics may be underused because of concerns about delays in definitive treatment.

Stressful pain experiences can lead to posttraumatic stress syndrome in children.

There are racial/ethnic disparities in pain treatment; for example, black children covered by Medicaid are less likely to receive parenteral sedation and analgesic compared with white children.

Joint Commission standards include mandatory pain assessments for all hospital patients and attention to changes in pain scores in response to treatment.

Pain should be assessed at the same time as vital signs.

Self-report scales from 0 to 10 may be used in adults and older children.

Younger children may be assessed using the revised FACES pain scale, the Wong-Baker Faces scale, and the 10-cm Visual Analog Scale.

Pain in neonates may be assessed using the Neonatal Infant Pain Scale and the FLACC scale.

Use of analgesics in prehospital settings is also limited, despite some evidence that opiates and tramadol can be used to decrease pain scores without causing respiratory depression.

Alternative pain management such as inhaled nitrous oxide or transmucosal medications can offer pain control without a need for intravenous (IV) access.

The incorporation of child life specialists and others trained in nonpharmacological stress reduction can alleviate anxiety and perceived pain before painful procedures.

Family presence can be helpful and supportive in the acute care setting.

Administration of analgesics and anesthetics should be painless or as pain-free as possible.

Topical anesthetics can be placed proactively to control pain associated with IV catheter placement and can improve success rates of procedures: Less movement leads to better accuracy.

Lidocaine buffered with bicarbonate can be injected slowly and almost painlessly with a small-gauge needle, and it can be made in advance and stocked in the ED for up to 30 days.

The pain of intramuscular injections can be minimized by using the shortest needle possible and applying concurrent manual pressure to the injection site.

Topical anesthetic can be used in neonates.

Sucrose can decrease the pain response to noxious stimuli in infants; this effect is strongest in newborns.

A 12% to 25% sucrose solution with or without a pacifier has been shown to reduce pain response in neonates undergoing venipuncture.

Skin-to-skin contact with the mother also reduces pain responses.

Venipuncture is less painful than heel lancing for blood testing in neonates.

Pain management in the ED requires rapid administration of opioids, and the IV route is preferred to the intramuscular route because of rapid relief and dose titration.

Oral, intranasal, transdermal, and inhaled routes should be used as appropriate and may provide rapid pain relief.

For example, transmucosal, aerosolized, and inhaled fentanyl show commensurate action to IV opioids.

However, intranasal delivery may be less tolerated because of nasal burning during administration.

Sedation and hypnotics may be required, and short-acting medications such as propofol with ketamine may be used for procedural sedation.

Nitrous oxide should only be used in conjunction with sedation guidelines and should be avoided in patients with pneumothorax, bowel obstruction, intracranial injury, and cardiovascular compromise.

Appropriate sedation systems and training programs should be in place, with credentialing guidelines to ensure safety.

Administration of pain medication has been shown to preserve the ability to assess patients with abdominal pain and should not be withheld.

Pain medication should be provided in the ED and on discharge even for those with mild to moderate pain.

The systematic approach to pain management in the ED should include protocols, policies, and quality improvement programs.

CLINICAL IMPLICATIONS

Pain assessment with vital signs is part of pain management, and tools are available for pain assessment in children and neonates.

Appropriate pain management and treatment of children in the ED includes reduction of stress and anxiety; use of appropriate topical, IV, transdermal, intranasal, and oral pain medications; and prevention of pain with procedures.

News Author: Steven Fox
CME Author: Désirée Lie, MD, MSEd

Faculty and Disclosures

CME/CE Released: 11/08/2012; Valid for credit through 11/08/2013