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Relieving children's pain: improving pain management practice.

In 2009, over 2 million children were hospitalized, and over 5,000 experienced surgery or other painful procedures. Research has shown that as many as 87% of hospitalized children and 77% of parents caring for children at home reported moderate-to-severe pain. If children are experiencing pain and analgesics are available, why are nurses and parents not administering analgesics to relieve children’s pain? Nurses and parents are known to have misconceptions about pain management, particularly about signs of pain, opioid use, and risk for addiction; nurses are concerned about respiratory depression. Nurses are known to discredit children’s self-report of pain; parents might do the same. When children do not receive pain relief, the ramifications are profound such as lower thresholds to painful stimuli and increased pain intensity. How do you know if children are in pain? Ask them! Self-report is the foremost indicator of pain intensity in children 4 years of age and older for children able to self-report. Children 4 to 7 years of age generally understand faces scales while children over age 7 years usually understand numeric scales. When it is unclear if children understand pain intensity scales, nurses can ask children to practice using the scale by rating three to five fictions situations representing no pain to severe pain. Nurses should set a “comfort goal” with children. They can ask: What is an acceptable level of pain? What number do you want your pain to be? This number should be the goal for treatment. When asking children to self-report pain intensity, a valid and reliable measure (e.g., 0–10 Numeric Rating Scale [NRS], Faces Pain Scale–Revised [FPS-R]) should be used. For children unable to provide self-report (such as infants, children with cognitive impairment, critically ill children), assessment of pain behavior is appropriate. As with pain intensity scales, care providers should use valid behavior scales (e.g., Face, Legs, Activity, Cry, Consolability [FLACC], Neonatal Infant Pain Scale [NIPS]). Teaching parents not only provides them with an important role in the management of their children’s pain in the hospital but also prepares them for caring for their children at home after discharge. Pain treatment needs to be appropriate to the level of children’s pain. Although nonpharmacological approaches such as distraction and relaxation can be appropriate for mild pain, analgesics are needed to relieve moderate-to-severe pain. Administration of opioid analgesics (e.g., morphine, oxycodone) in combination with nonopioid analgesics (acetaminophen, nonsteroidal anti-inflammatory drugs) can result in improved pain relief by targeting multiple points of action along the pain pathway. When children are expected to experience pain over a period of time, such as after surgical procedures, around-the-clock analgesic administration is most effective. The addition of nonpharmacological approaches to opioid/ nonopioid combinations can be particularly effective at relieving pain. Analgesics, particularly opioids, can be accompanied by adverse effects. Care providers can anticipate and prevent or treat common side effects (constipation, nausea, vomiting, itching). Nurses must be vigilant for the more serious adverse effects of oversedation and respiratory depression, particularly in children at high risk (e.g., opioid-naive, concurrent sedation medication). To diminish concerns about addiction, nurses need to be knowledgeable about the occurrence and incidence of addiction and teach parents—addiction does not result from receiving opioids, but rather is a neurobiological disease. Nurses and parents are at the forefront of managing children’s pain. Only with accurate knowledge and skills can these care providers be successful in relieving children’s pain. ✜