Pain in children all over the world frequently goes unrecognised and unmanaged. Many countries across the world have little or no access to appropriate analgesics while others have excellent drug policies and availability. In 2012, the WHO published comprehensive evidence-based new guidelines for assessing and managing persisting pain in children with medical illnesses. Based on the WHO Pain Ladder, the new guideline highlights techniques in assessing pain, access to pain management as the right of the child and changes the ladder from 3 steps to a ‘two step approach’. This article aims to summarise and emphasise important parts of the guideline but reading the full guideline is recommended.
The Classification of Pain
Defining the type of pain can assist greatly in directing management. Pain can be classified according to the following:
- the pathophysiological mechanism of pain (nociceptive or neuropathic pain);
- the duration of pain (chronic or acute, breakthrough or incident pain);
- the aetiology (malignant or non-malignant);
- the anatomic location of pain.
The Evaluation of Paediatric Pain
Optimal pain management begins with accurate and thorough pain assessment. It is very important in assessing a child’s pain to consider the potential underlying cause of the pain, the age and development of the child, the behaviour of the child and the opinion of both the child and caregiver. The International Association for the Study of Pain (IASP), describes pain as the 5th vital sign and should be assessed as frequently as BP or respiratory rate.
Questioning the child and caregiver to determine the site, severity, aggravating and relieving factors of the pain should be done using language that the child can understand and relate to. In addition to thorough history taking, pain rating tools can be used. Different tools for pre-verbal and verbal children are available in the guideline and help to measure the baseline pain and response to the chosen management.
A thorough physical examination is essential and each location of pain should be carefully evaluated. During the examination, the examiner should watch carefully for any reactions from the child, such as facial grimacing, abdominal rigidity, involuntary flexion, and verbal cues, which may indicate pain. Any change in normal physical function caused by pain should be assessed.
Remember that physical pain can manifest as emotional lability, sleep disturbances and changes in appetite and therefore a holistic approach to assessment is required.
Principles for the pharmacological management of pain
Correct use of analgesic medicines will relieve pain in most children with persisting pain due to medical illness and relies on the following key concepts:
• using a two-step strategy
• dosing at regular intervals
• using the appropriate route of administration
• adapting treatment to the individual child
The WHO Ladder
The three step ladder has been abandoned now for children in favour of a two-step approach.
For mild pain Paracetamol and/or Ibuprofen should be prescribed according to the child’s weight and given regularly. If the child is under 3 months of age Paracetamol should be used alone. The evidence for the use and safety of other NSAIDs is insufficient at this stage.
Moderate to Severe Pain
For moderate to severe pain the second step now advocated is a strong opioid, thus leaving out the original “step 2”, weak opioids such as Codeine or Tramadol. The reason for this is that there is insufficient evidence supporting the use and safety of Tramadol in children and the metabolism of Codeine is complex and variable. Codeine is a prodrug that needs to be metabolised to morphine. It has been shown that many young children are not able to convert Codeine and hence may not enjoy the analgesic effects. Some children are ultra-rapid metabolisers of Codeine and therefore run the risk of toxicity. Overall it is believed that Codeine not be used for managing persisting pain in children. This is not to say that both Tramadol and Codeine are now contra-indicated in children, but until more robust evidence is available, low dose strong opioids are preferred. In those health facilities where strong opioids are not available, a trial of Tramadol or Codeine may be reasonable.
The most commonly available strong opioid is Morphine which remains the gold standard in treating moderate to severe persisting pain in children with medical illnesses. Unlike Paracetamol and Ibuprofen, the dose of Morphine needed is the dose that treats the child’s pain. This needs to be titrated carefully and doses individualised for each patient. There is no ‘ceiling dose’ of Morphine. Morphine may cause constipation and a concomitant laxative should be prescribed. Doses and details of how to prescribe can be found in the guideline and in a previous PEDMED article.
Pethidine should no longer be used, because it is considered inferior to morphine due to its toxicity on the central nervous system. Other viable opioids include Fentanyl, Hydromorphone and Oxycodone. The pharmacological profiles can be found in the guideline.
Adjuvant medicines have a primary indication other than for pain management, but have analgesic properties in some painful conditions. They may be co-administered with analgesics to enhance pain relief. Examples would be the use of steroids in bone pain or Gabapentin in neuropathic pain. Unfortunately there is a dearth of evidence in this area, particularly in children and the guideline currently cannot recommend the use of any of the adjuvant medications currently in use. However, there are other paediatric guidelines available for the treatment of neuropathic pain in children when steps one and two are not sufficient to control the child’s pain.
This guideline really highlights the need for better pain management for all children with medical illnesses that suffer with persisting pain. While there is a paucity of evidence in the field, there is more than enough research proving that we need to be assessing and managing pain more effectively. In South Africa health providers have relatively good access to medicines and with such well-developed guidelines there is no longer an excuse for leaving a child in pain.
Readers are invited to take an online survey to understand the role the ICPCN can play in improving pain management in children around the world. This survey can be accessed at: https://academictrial.az1.qualtrics.com/SE/?SID=SV_4UEhXWgCW2p6XM9
This article first appeared in PedMed, a South African magazine focusing on paediatric and adolescent medicine.
About the author: Dr Julia Ambler co-founded the organisation Umduduzi, Hospice Care for Children in December 2012. The mission of the organisation is to bring compassion, dignity, relevant care and relief from discomfort and pain to children diagnosed with a life threatening or life limiting illness within KZN. This is done through direct patient care, mentorship, empowerment of caregivers, training and advocacy. You can contact Julia via email at firstname.lastname@example.org