Chapter 13: Pain Management

High-Yield Facts

• Untreated pain in children causes short- and long-term consequences.

• Buffering intradermal lidocaine with 1:9 concentration of sodium bicarbonate will reduce pain from chemical irritation.

• Oral sucrose on a pacifier can provide pain relief for small infants during painful procedures.

• In children, the most painful part of fracture management is obtaining radiographs. This can be reduced by early splinting of the fracture site.

• Behavioral techniques for management of pain include relaxation exercises, deep breathing, distraction, and imagery.

Pain is the most common reason a patient presents for health care. It is often undertreated for children in ED settings despite recognition of its importance.¹

Oligoanalgesia for Pediatric Patients

Untreated pain in children causes short- and long-term consequences. For example, pain in infants can have lasting negative effects on neuronal development, pain threshold and sensitivity, coping strategies, emotionality, and pain perceptions.² Children receive less pain medication than adults for the same emergent complaints. The reasons for this “oligoanalgesia” include persistence of myths that children do not experience or remember pain, fear of using opioids in young patients, and difficulty assessing pediatric pain.³ The effects of untreated pain impact medical outcomes and are remembered even by preverbal children.² These effects may amplify with age: adolescents may avoid medical treatment, adults may refuse to donate blood, and geriatric patients may refuse flu shots because of the fear of needle pain. Children with a history of negative medical experiences show higher levels of anxiety prior to a venipuncture procedure and are less cooperative during the procedure. Further, high pain during medical visits predicts missed future medical appointments and poor health care follow-up. Older children also suffer sequellae: untreated pain from lumbar puncture (LP) increases pain response with subsequent procedures.⁴ Immediate and long-term patient health are affected by inappropriate analgesia.

Pain Assessment

In the ED, the periodic evaluation of pain using the Wong-Baker Faces Pain Scale has become routine for both staff and patients.⁵ Although widely used in the United States, this scale suffers from two methodologic flaws: the smiling anchor to the left is rarely appropriate for anyone in the ED, and cultural and concrete thinking biases may limit endorsement of the tearful face (Fig. 13-1). The Faces Pain Scale—Revised is used more widely throughout the world, especially in the empirical literature (Fig. 13-2).⁶ Other validated options include a vertical, graduated, and colored VAS scale to assess pain.⁷ This upside-down triangle has the topmost part wide and red representing the worst pain and the bottom part narrow and white representing no pain. The scale has been found to be easier to administer than a standard VAS and avoids the most common problem seen with “face”-based scales, choosing higher numbers because of unhappiness rather than pain.