Pediatric clients are usually grouped according to developmental stage. Infants are usually defined as birth to 1 year of age; children, 1 year
through 11 years of age; and adolescents, 12 through 18 years of age. Children may be further grouped into toddlers, preschoolage children, and school-age children. All three groups have different levels of physical and psychosocial development, and differing developmental tasks. Both physical and psychosocial developmental stages should be considered when developing assessment and treatment plans for pain in the pediatric client. Elements at each stage of development affect how pain is perceived and relief measures that will be appropriate and helpful.

The healthy child is more apt to experience acute forms of pain rather than chronic pain. Chronic pain is a factor in pediatric chronic illnesses or conditions and in congenital conditions. Acute pain may be the result of illness or occur with trauma, surgical intervention, or invasive diagnostic or treatment procedures. Pain in this client population is seen across treatment settings, from home to outpatient ambulatory settings, surgical and dental settings, inpatient acute care facilities, long-term care facilities, and hospice. Simple acute pain is one of the most frequent reasons for accessing pediatric care. This type of pain is often related to middle ear infection or swimmer’s ear, teething pain, abdominal pain related to gastroenteritis or appendicitis, sore throat related to streptococcus infection or tonsillitis, or pain as the result of accidental trauma.

The parent or adult caregiver is frequently the first one to identify the pain because of changes in the child’s activity or demeanor. Depending on the changes noted and the adult’s perceived severity of the pain or an
assumption on the part of the adult as to the possible cause of the pain, independent measures for pain relief will be used or the child’s healthcare provider will be called. Parents of young children who suffer frequent ear infections, for example, become expert at identifying pain-related behaviors such as changes in sleep and eating patterns, crying that is different from the norm, or self-comforting behaviors such as rubbing or tugging the affected ear. Experience builds a set of assessment parameters for these parents, and attention is more rapidly paid to these behaviors as indicating pain in the child.

It is crucial to include the parent’s input in assessment.

Historically, pediatric clients have had less successful interventions for pain than adults. The reasons for this vary. The child’s ability to express or communicate pain through behavior is often lacking and is sometimes unrecognized. It is important to remember that a child is not a small adult. A healthcare provider cannot successfully provide interventions for what cannot be comprehensively assessed. To provide more successful intervention, better assessment tools and parameters must be identified for this population. Poor assessment impacts administration of analgesics or opioids when the medication is ordered on an as-needed (PRN) basis. Pain medication is often ordered to be given PRN, resulting in less effective pain relief for the often difficult-to-assess pediatric client. A PRN dosing schedule treats pain rather than attempting to keep the client relatively pain-free.

Many healthcare providers are reluctant to use opioids in the pain-relief plan for pediatric clients, choosing to use less potent analgesics. Even when opioids have been ordered, many nurses hesitate to choose them on a PRN basis, administering an ordered NSAID instead. As described in the Department of Health and Human Services pain management guidelines, when opioids are used, the dose is usually small, potentially inadequate to relieve pain, and time between doses is long, further hindering pain relief. This may relate to a caregiver’s reluctance to use opioids or inability to effectively assess subtle cues indicating
the presence of pain in the pediatric client. Adding to this problem is the current trend to order pain medication on a PRN basis. When subtle cues are missed in the assessment process, pain increases in severity before medication is offered for relief. Parents are included in the assessment process but are sometimes not believed. The first step to formulating a plan for adequate pain management in children as with all others is adequate, appropriate, and thorough assessment.