There are many definitions of pain. The International Association for the Study of Pain (IASP) (1979, p. 249) defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” In a commonly accepted definition, pain is whatever the person experiencing the pain says it is, existing whenever the person says it does (Pasero & McCaffery, 2011). The pain threshold will vary among individuals. Both definitions underscore the fact that pain is complex, multidimensional, subjective, and personal. The pediatric pain experience involves the interaction of behavioral, developmental, physiologic, psychological, and situational factors (APS, 2011a).

Over the past three decades, there has been a proliferation of pediatric pain-related research that has led to clinical practice guidelines and additional standards of care for both acute and chronic pain (see publications from the World Health Organization [WHO] at http://www.who.int/publications/en, the American Pain Society [APS] at www.ampainsoc.org/library, the American Academy of Pediatrics [AAP] at www.aap.org/en-us/professional-resources/Pages/Professional-Resources.aspx, the American Society for Pain Management Nursing at http://www.aspmn.org/Organization/position_papers.htm, and the International Association for the Study of Pain (IASP) at http://www.iasp-pain.org/AM/Template.cfm?Section=Publications).

WHO’s three-step analgesic ladder was developed in the early 1980s to improve treatment for cancer pain. The ladder suggests nonopioid analgesics for mild pain, weak opioids for mild to moderate pain, and opioid analgesics for severe pain, along with accessory medications to prevent breakthrough pain (WHO, 2010). These guidelines are the basis for pain management of children and adults, particularly related to multidrug therapy. Beginning in 1999, the APS has developed and published clinical guidelines related to care of pediatric (and adult) patients with acute and chronic pain associated with sickle cell disease, cancer pain, juvenile chronic arthritis pain, acute pain, and fibromyalgia syndrome pain (APS, 2011c). AAP and APS issued a joint position statement in 2001 with recommendations for the assessment and management of acute pain in infants, children, and adolescents (APS, 2011b). Since 2001, The Joint Commission accreditation standards have continued to address both pain assessment and management by requiring health care agencies to provide pain management education and guarantee all hospitalized patients the right to developmentally appropriate, comprehensive pain assessment and management, from admission until discharge (The Joint Commission, 2011).

One major area of concern is pain management for premature infants, neonates, and very young infants, particularly with regard to painful procedures. Based primarily on animal studies, researchers have speculated that pain experiences of neonates may result in long-term emotional, behavioral, and learning disabilities (AAP & Canadian Paediatric Society, 2006). There is also concern that prolonged exposure to pain or severe pain may increase neonatal morbidity (Mancuso & Burns, 2009).

Anand (2007) suggests that it is difficult to accurately assess and then manage pain in preterm neonates because they do not produce “specific” responses to acute pain on a consistent basis. Further, for these nonverbal patients, pain assessment is based solely on observed behavioral and physiologic responses to acute pain (such as facial expressions), and there is significant variability in the subjective interpretation of an infant’s pain level by different practitioners (Anand, 2007).

Important determinants of the long-term outcomes of infant pain include timing, degree of injury, and the analgesic used. There are also concerns for older children in relation to their memories of painful experiences (Busoni, 2007). Long-term consequences of childhood pain may include negative reactions to painful events and poor acceptance of health care interventions later in life (Von Baeyer, Marche, Rocha, et al., 2004).

Advances in research, knowledge, and clinical expertise have led to significant increases in academic literature, research studies, and practice guidelines and standards regarding pediatric pain management. However, improvements are still needed in the following areas: research on nurse-physician collaboration for pediatric pain management and barriers to suitable pain management; education of health care providers about appropriate, effective pain management; increased information about pain management in neonates and infants; and testing for the safety and efficacy, specifically in children, of new analgesics as they are introduced.

Obstacles to appropriate pain management in children include belief in myths, knowledge deficits, inaccuracy of pain assessment and pain assessment measures, insufficient awareness of pain management interventions, lack of confidence regarding efficacy of pain management, lack of communication with children and their parents, and personal attitudes and beliefs about pain (APS, 2011a; Rieman & Gordon, 2007; Twycross, 2007a).

The two beliefs of parents and nurses that are most likely to interfere with the provision of adequate pain relief in infants and children are fear of respiratory depression and fear of addiction. Table 39-1 lists and refutes other prevalent myths about pain and pain management in children.

Nurses who recognize the importance of implementing appropriate pain management strategies need ongoing access to the most current information. The Internet can be a powerful tool for instant, up-to-date information. Nurses and families are cautioned to ensure that they obtain information from trustworthy websites. Box 39-1 lists some suggested Internet resources. Given the rapidity with which Internet information changes, it is essential to verify the appropriateness of the website and accuracy of the information presented.

Pain in children is multidimensional and subjective (APS, 2011a). It is affected by the type and duration of pain, developmental level, emotional status, previous pain experiences, culture and ethnicity, personality type, gender, genetic variations, and parental response to the child’s pain. These factors should all be taken into consideration when assessing an infant or a child in pain. Consequently, assessing pain in infants and children is more challenging than in adults. Infants and young children may not have the language or cognitive abilities to communicate their pain. Their crying and verbal responses occur for many other reasons including hunger, sleepiness, and anxiety. Accordingly, the nurse must use a combination of behavioral and physiologic signs together with an appropriate pain assessment tool to determine the pain level in infants and some children (Von Baeyer & Spagrud, 2007) (Box 39-2).

Vital signs data such as heart rate, blood pressure, respiratory rate, and oxygen saturation have been reported to provide information about neonatal acute pain. However, these physiologic signs are also affected by other factors such as illness, fever, and medications, and there is little evidence to support using changes in vital signs to assess pain (Herr, Coyne, McCaffery, et al., 2011).

Behavioral and some physiologic signs can play an important role in pain assessment of children who are giving a verbal report of pain that differs from their nonverbal behaviors. An example might be a child who gives a verbal report of little or no pain out of concern that someone will become angry or that pain medication might involve an injection. Visually, the nurse might see the child grimacing, perhaps with tears, lying rigidly in bed and not moving. Such nonverbal behaviors would lead the nurse to speak and interact gently with the child about the actual level of pain to ensure appropriate pain management. Children who suffer from chronic pain may not demonstrate behavioral changes that are noticeable to the nurse, and they may be unable to accurately describe their pain level. It is important to assess the impact of pain on a child’s daily life including sleeping, eating, attending school, social and physical activities (e.g., play or sports), and interactions with family and peers (APS, 2011b). Changes in these areas, such as being unwilling or unable to play with peers, may be subtle signs that a child is experiencing pain (Busoni, 2007).

Although older children may be able to verbalize their discomfort, they are often afraid of treatment that includes a painful procedure such as an injection. They may have also been told to “be brave” and not verbalize or demonstrate the pain they are experiencing. Increasingly, it is also seen that even children as young as 5 or 6 years may be fearful of taking pain medication because of the emphasis on “saying no” to drugs. Such an emphasis is meant to focus on illegal substances or inappropriate use of prescription medications. Despite this fact, some children translate this to mean they should not use any drugs, even appropriate and necessary pain medications. Nurses need to provide developmentally appropriate education to children and their parents to overcome barriers to pain assessment and management.

Pain assessment and treatment are influenced by the cultural beliefs and practices of children and their families. Working to understand the impact of cultural differences on pain management is a crucial aspect of pediatric nursing care (Al-Atiyyat, 2009; Briggs, 2008; D’Arcy, 2009; Kirmayer, 2008; Narayan, 2010). Transcultural nursing literature can assist nurses to understand the diversity in nonverbal expressions of pain (facial expressions and other body language), words used for pain, descriptions of pain, and rating of pain noted among different cultures. Evidence supporting the validity of pain assessment scales for children from different cultures needs to be examined as a basis for nursing practice.

Assessment According to Developmental Level

Neonates and Infants

The fact that neonates and young infants have immature central nervous systems that lack myelinization of pain fibers has led clinicians in the past to believe that they are incapable of perceiving pain. However, in recent years, substantial research has demonstrated that neonates and infants do feel pain and that infants whose pain is not addressed can experience long-term, negative consequences (AAP & Canadian Paediatric Society, 2006; Anand, 2007; APS, 2011a; Golianu, Krane, Seybold, et al., 2007). Franck, Greenberg, and Stevens (2000) noted the difference between the nociceptive processes for infants and adults: Infants may actually have a lower pain threshold and perceive pain more intensely than older children and adults because of immature control mechanisms in the nervous system that limit their ability to modulate the pain experience.

Assessing acute pain in neonates and infants is difficult and is primarily based on behavioral and certain physiologic indicators. Rapid changes in an infant’s behavioral state and sleep/activity patterns signal the likelihood of pain. Behaviors that often serve as indicators of infant pain include crying, fist clenching, grimacing, wrinkling of the forehead, fussiness, and restlessness (Anand, 2007; Boyle, Freer, Wong, et al., 2006). Facial expression is considered the most consistent cue available when judging pain in infants and children (Schiavenato, 2008). Facial expression, in combination with short latency to onset of cry and a long duration of the first cry cycle, typifies infants’ reactions to painful procedures. Cries associated with pain are higher pitched, tense, and harsh; they may sound different from those associated with hunger, discomfort, and stress. Therefore, parents and nurses may be able to differentiate between the usual cries of infants and the cries of pain.

Motor movements associated with pain in the neonate and infant progress from a generalized body response to more purposeful movements. For example, infants ages 9 to 12 months can use their hands to push the nurse away if they perceive a painful action is about to begin. The responses of neonates to painful stimuli are sometimes described as total body responses (Figure 39-1). The infant’s extremities may thrash about, and some infants exhibit tremors. Older infants may rub the painful area, pull away, or guard the involved body part.

The responses of infants to pain are greatly determined by their state immediately before painful stimulation; pain scores are higher and behavioral changes are greater when infants are awake and active compared to when they are asleep (Badr, Abdallah, Hawari, et al., 2010). Although preterm infants lack the autonomic functions and maturity to handle stress, it remains unclear if repeated exposure to pain results in heightened responses or desensitization (Badr et al., 2010). The nurse must be cognizant of this information to make a beginning assessment of pain through observation of an infant’s facial expressions, motor response, and cry. Neonates who are experiencing prolonged or persistent pain may not exhibit the usual behavioral signs of pain seen in neonates who are experiencing acute pain and, instead, exhibit signs and symptoms of energy conservation (AAP & Canadian Paediatric Society, 2006; Anand, 2007).

Physiologic changes may be more difficult to assess and serve as just one part of a complete pain assessment. A nurse should suspect that an infant experiences pain before physiologic changes are observed. Increases in blood pressure, heart rate, and respiratory rate and decreases in arterial oxygen saturation have been associated with pain in neonates, although these changes can be linked to other alterations such as agitation. Crying may also affect the infant’s physiologic responses. Distinguishing between pain and agitation is sometimes difficult. If an infant is simply agitated, yet is treated for pain, the cause of the agitation may remain untreated.

The behavioral and physiologic indicators discussed are components in several different pain assessment tools used for the preverbal or nonverbal child. The reliability and validity of these assessment tools have been studied extensively. In order to provide high-quality care, it is important that nurses use pain assessment tools rather than rely on personal, subjective appraisals of infant behavioral and physiologic indicators.

Toddlers

The toddler in pain tends to cry longer than the infant. As verbal abilities become more advanced, the toddler can vocalize displeasure when a painful experience occurs. The toddler may ask for parents, use words that indicate discomfort (“ouch,” “hurt”), and even verbalize negative emotions about the nurse. The toddler may also try to delay the nurse’s implementation

CRITICAL THINKING EXERCISE 39-1

You are about to care for Tanika, a full-term neonate (weight = 3500 g) who had surgery 24 hours ago for a fundoplication and placement of a gastrostomy tube. The nurse reports that Tanika has slept for short periods throughout the shift, sucks vigorously on her pacifier, and occasionally cries. The nurse notes that she has not medicated Tanika for pain because she does have periods when she sleeps for 15 to 30 minutes. Her blood pressure is 98/74, pulse rate 170, and respiration rate 50.

1. What would be your first nursing action?

2. What principles related to pediatric pain management would apply to this infant?

of a procedure judged as painful. The older toddler can often localize the pain and point to the body part that hurts.

Generalized restlessness, guarding the site, and touching the painful area are signs of pain in the toddler (Figure 39-2). The toddler may associate discomfort with a particular procedure, such as a dressing change, and may run from the nurse when approached. The toddler’s facial expressions can indicate anger and fear. The child may avoid eye contact or look sad. In response to discomfort and pain, the toddler may also demonstrate regression to earlier, more comfortable behaviors such as lying on a parent’s lap in a fetal position.

Preschoolers

Preschoolers are egocentric. Relating only to the present, they have difficulty associating discomfort with any positive outcome, and this can intensify their pain experience. For example, the preschooler will not understand that débriding a painful burn will ultimately have a positive effect. Children in this age-group are able to describe the location and intensity of pain.

Preschoolers tend to think pain will magically go away and that experiencing pain is punishment for some previous thought or deed. They also fear body mutilation, particularly of the genitals. Preschoolers may deny pain from a surgical incision, for example, in order to avoid an invasive procedure such as a pain medication injection. They may also cry and struggle in an attempt to escape from the procedure. Preschoolers can regress to earlier, more comfortable behaviors, such as thumb sucking, in response to pain, or they can withdraw and not participate in play activities.

School-Age Children

School-age children can describe pain and relate it to a specific body part, as well as quantify pain intensity. They are beginning to understand the need for painful procedures. They fear body harm and have an awareness of death. Therefore, they may appear to overreact to illness or injury. As in other age-groups, the school-age child remembers previous pain experiences, which will affect the current response. The child’s culture, gender, and cognitive abilities will also affect the pain experience (Finley, Kristjansdottir, & Forgeron, 2009).

Nonverbal and behavioral cues are very important in assessing a school-age child’s pain. The child may exhibit a stiff body posture, may withdraw, or may be found quietly sobbing (Figure 39-3). If the school-age child resists a treatment, cries loudly, or otherwise acts in an aggressive manner, the child may later deny the behavior. School-age children may also attempt to procrastinate or bargain to delay a painful procedure. As with younger children, the school-age child may demonstrate regressive behaviors when experiencing pain.

Adolescents

Adolescents can think abstractly and understand cause and effect. They can describe and quantify pain intensity and their feelings about pain. They can also discuss the strategies to help manage their pain. They are able to perceive and understand pain at a physical, emotional, and cognitive level. However, having these abilities does not mean the adolescent will use them. Adolescents are often confused by control issues and are uncertain of their roles as they move from childhood to adulthood. Regression may also occur at this age in relation to pain.

Because adolescents are egocentric, they tend to think that others focus on their behaviors and therefore, adolescents may

NURSING QUALITY ALERT

Assessing Pain in Children

• The use of a pain assessment tool is imperative in the assessment of pain in children and the evaluation of pain management interventions. The tool used is documented in the patient’s medical record.

• If the child is unable to express or quantify pain, use parents as one of the first resources to assist in assessing the child’s pain and response to interventions.

• Behavioral changes such as guarding, body positioning, crying, grimacing and other altered facial expressions, and changes in activity level, may or may not be seen in a child experiencing pain.

• Physiologic changes are only one source of information when assessing pain in the neonate or infant. Other states, such as fear and anxiety, may also cause physiologic changes. Physiologic changes tend to occur during an acute pain experience and then return to normal; they may not be valid indicators of sustained or chronic pain.

suppress manifestations of pain. In addition, they may not report pain because they believe that the nurse knows when they hurt; subsequently, they expect to receive pain medication when they need it and not just when they ask for it. Adolescents tend to exhibit fewer outward signs of pain as compared to younger children. Signs observed may include increased muscle tension, withdrawal, and decreased motor activity. Hospitalized adolescents use words such as “sore,” “like an ache,” “pounding,” and “miserable” to describe pain.

Assessment Tools

Consistent, appropriate use of a pain assessment tool is essential to pediatric pain management. A number of valid and reliable pain assessment tools are available to help the nurse make a more accurate pain assessment. Both self-report and behavioral instruments are available. Examples of these tools are detailed in Table 39-2. Children benefit when pain assessment tools are used because they are given a simple and effective way to communicate the pain they are experiencing. Assessment tools provide more objective data, reducing the chance that discreet signs of pain will be overlooked. Unfortunately, they are not always used consistently and correctly in clinical settings. Using a tool in a way other than the developer intended may invalidate the pain assessment.

TABLE 39-2

PAIN ASSESSMENT TOOLS

TOOL	DESCRIPTION	AGE
Adolescent and Pediatric Pain Tool (APPT) (see Figure 39-6)	Three-part tool composed of a body outline, an intensity scale, and a pain descriptor word list (Savedra, Tesler, Holzemer, et al., 1992).	8-17 yr
CRIES pain scale	Five behavioral categories: Crying, Requires O2 for SaO2 <95%, Increased vital signs, Expression, Sleepless; 02 for each with total score from 0-10. A higher score indicates greater pain or distress (Krechel & Bildner, 1995).	Neonates; 0-6 mo
COMFORT Behavior Scale	Six categories are scored: Alertness, Calmness/Agitation, Respiratory response (if on ventilator) or Crying (if breathing spontaneously), Physical Movement, Muscle Tone, Facial Tension; 1-5 for each category with total score from 6-30. A higher score indicates greater pain or distress (Van Dijk, Peters, Van Deventer, et al., 2005).	Infants and children in critical care settings
FLACC	Five behavioral categories: Face, Legs, Activity, Cry, Consolability. Each scored from 0-2, resulting in a total score from 0-10. A higher score indicates higher pain or distress (Merkel, Voepel-Lewis, & Malviya, 2002).	Infants and preverbal or nonverbal children
FACES Pain Rating Scale (see Figure 39-5)	Six cartoon faces with neutral to gradually increasing painful expressions, corresponding to an analog scale with words ranging from a happy face (0; No Hurt) to a crying face (5 or 10; Hurts Worst). Accommodates a 0-5 or 0-10 system (Hockenberry & Wilson, 2009).	3 yr and older
Numeric Rating Scale (NRS)	Patient is asked to give a number that reflects the pain level: 0 = no pain; 13 = mild; 46 = moderate; 710 = severe (Pasero & McCaffery, 2011).	Child 9 yr and older
Oucher pain scale (see Figure 39-4)	A poster with a 0-100 scale for older children and a six-picture photographic scale for young children who cannot count to 100; 0 is no pain and 100 is the greatest pain. Five versions available: Caucasian/white, Asian (boy or girl), First Nations (boy or girl), Hispanic, and African-American/Black (Beyer, Villarruel & Denyes, 2009).	3-12 yr
Poker Chip Tool	Four poker chips are used, with each chip representing a piece of hurt. One poker chip represents a little hurt, and four chips represent the most hurt the child could have (Hester, Foster, Jordan-Marsh, et al., 1998).	4-12 yr
Visual Analog Scale (VAS)	Usually a 10-cm line with one end representing “no pain” and the opposite end “the worst pain” (Cline, Herman, Shaw, et al., 1992).	7-18 yr

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