pediatric pain management

1. Anthropometry
Yosra raziani
Faculty member of komar university of science and technology

2. ANTHROPOMETRY
the science of measuring the size
Anthropos - "man"
Metron "measurement”
A branch of anthropology that involves the
quantitative measurement of the human body.

3. non-invasive technique for assessing the size,
proportions and composition of the human body.

4. Parameters of anthropometry
Age dependent factors:-
a) Weight
b) Height
c) Head circumference
d) Chest circumference
Age independent factors:-
a)Mid-arm circumference (1-5 years)
b) Weight for height
c) Skinfold thickness
d) Mid upper arm/height ratio

5. Weight
• most reliable criteria of assessment of nutritiom
• periodic recording will help to detect malnutrition in under 5 at early age.
Beam type weighing balance
Electronic weighing scales for infants and children
Bathroom type (very unreliable)
Salter spring machine(in field conditions)

7. Growth Velocity :
A.0-4 months 1.0kg/month(30g/day)
5-8 months 0.75kg/month(20gm/day)
9-12 months 0.50kg/month(15g/day)
1-3 years 2.25kg/yr
4-9 years 2.75 kg/yr
10-18 years 5.0-6.0kg/yr
(0.5kg/month)
B. Weight at 4-5 months 2 x birth weight
Weight at 1 year 3 x birth weight
Weight at 2 years 4 x birth weight
Weight at 7 years 7 x birth weight 9

8. WEECH’S FORMULA
a) 3 – 12 months
Expected weight(kg) = age (months) + 9 / 2
b) 1- 6 years
Expected weight(kg) = age (years) x 2 + 8
c) 7 – 12 years
Expected weight(kg) = age (years) x 7 - 5 / 2

9. Classification of Malnutrition by IndianAcademy of Pediatrics
Weight for age Grade of malnutrition
>80 % Normal
71-80% Grade 1 (Mild)
61-70% Grade 2 (Moderate)
51-60% Grade 3 (Severe)
<50% Grade 4 (very severe)

10. H
E
I
G
H
T

11. Measurement Technique
• Upto 2 years of age-Recumbent Length -Infantometer .
• In older children- Standing Height or Stature- stadiometer is recorded with an accuracy of +/- 0.1cm
.
• Nutritional deprivation over a period of time affects the stature or linear growth of the child .

12. Technique of length measurement
• The infant is placed supine on the infantometer.
• Assistant or mother is asked to keep the vertex or top of the head snugly t
the fixed vertically plank.
• The leg are fully extended by pressing over the knee, and feet are kept
vertical at 90⁰ , the movable pedal plank of infantometer is snuggly
apposed against soles and length is read from scale.

13. Technique for height measurement
• In older children who can stand , height can be measured by
the rod attached to the lever type machine or by stadiometer.
• Child should stand with bare feet on the flat floor against a
wall with fit parallel and with heels buttocks, shoulders and
occiput touching the wall.
• Head should be kept in Frankfurt plane.
• With the help of a wooden spatula or plastic ruler.
The topmost point of the vertex is identified on the wall.

15. Height Velocity
AGE Approximate rate
of increase in
stature
Birth to 3 months 3.5cm/month
3 – 6 months 2.0cm/month
6 – 9 months 1.5cm/month
9 – 12 months 1.3cm/month
2 – 5 years 6 – 8cm/year
5 – 12 years 5cm/year
At birth 50cms
Gain during 1st year 25cms
Gain during 2nd year 12.5cms
Gain during 3rd year 7.5 to 10cms
Gain during 3 – 12
years
5 to 7.5cms
Adolescence
8cms/yr for girls
during 12 to 16 years
10cms/yr for boys
during 14 to 18 years

16. Height Velocity
B] Expected height upto 12 yrs length or height (in cms) =
age in years x 6 +77 ( wheech’s formula )
C] Prediction of adult height
Parental height , Tanner’s formula and Weech’s formula are
used.

17. HEAD CIRCUMFERENCE
• Brain growth takes place 70% during fetal life, 15% during infancy and
remaining 10% during pre-school years.
• Head circumference are routinely recorded until 5 years of age.
• If scalp edema or cranial moulding is present , measurement of scalp edema may
be inaccurate until fourth or fifth day of life .
•The head circumference is measured by placing the tape over the occipital
protuberance at the back and just over the supraorbital ridge and the glabella in
front.

18. Expected head circumference in children
Age Head circumference (cm)
At birth 34-35
2 months 38
3 months 40
4 months 41
6 months 42-43
1 year 45-46
2 years 47-48
5 years 50-51

19. Head Circumference Growth Velocity
•During first year there is 12 cm increase in head circumference ,
while 1 – 5 year age , only 5 cm gain occur in head size.
•Adult head size is achieved between 5 to 6 years .
the following formula (Dine’s formula) is used for estimating the head circumference in
the first year of life :
(length in cm + 9.5 ) ± 2.59
2
Till 3 months 2 cm/month
3 months – 1 year 2cm/3 month
1 – 3 year 1cm/ 6 month
3 – 5 year 1cm/ year

20. The term Macrocephaly refers to OFC of more than 2SD
above the mean while Microcephaly refers to OFC more than
3SD below the mean for age , sex , height and weight.

21. Chest circumference
• It is usually measured at the level of nipples, preferably in
mid inspiration.
• Xiphisternum
• In children
<= 5years - lying down position
> 5 years - standing position

22. Relationship between head size with Chest
Circumference:
• At birth: head circumference > chest
circumference by upto 3 cms.
• At around 9 months to 1 year of age:
head circumference = chest circumference,
• but thereafter chest grows more rapidly compared to the brain.

23. • The head circumference is greater than chest circumference
by more than 3 cms in :
a) preterms
b) small-for-date , &
c) hydrocephalic infants
• In malnourished children, chest size may be significantly smaller
than head circumference because growth of brain is less affected
by undernutrition.
Therefore there will be considerable delay before chest
circumference overtakes head circumference.

24. AGE INDEPENDENT CRITERIA FOR ASSESSMENT OF
NUTRITIONAL STATUS
.Mid-upper arm circumference
• Thickness of subcutaneous fat
• Body ratios
• Weight for height
• Body mass index
• Upper segment/ lower segment ratio
• Arm span
• Obesity

25. MID-UPPER ARM CIRCUMFERENCE
• During 1-5 Yrs of age it remains reasonably static between 15-17cms among
healthy children .
• It is conventionally measured over the left upper arm , at a point marked
midway between acromion (shoulder) and olecranon (elbow) with arm bent at right
angle.
• The child is asked to stand or sit with the arm hanging loose at the side.
• MUAC is measured with a fiber glass or steel tape.
• If it is less than 12.5 cm it is suggestive of severe malnutrition.
• If it is between 12.5 -13.5 cm it is indicative of moderate malnutrition.

26. • Bangle test – quick assessment of arm circumference. A fiber glass ring of
internal diameter of 4 cm is slipped up the arm, if it passes above the elbow, it
suggests that upper arm is less than 12.5 cm and child is malnourished.
• Shakir tape – is a fiber-glass tape with
red – less than 12.5 cm
yellow – 12.5- 13.5 cm
green – greater than 13.5 cm
shading so that paramedical workers can assess nutritional status without having
to remember the normal limits of mid arm circumference.

27. Skinfold thickness
• Measured with Herpenden’s caliper
• Triceps or subscapular region
• The skinfold with subcutaneous fat is picked up with thumb and
index finger, and caliper is applied beyond the pinch.
• Fat thickness
>10mm - healthy children 1-6 years
<6mm - is indicative of moderate to
severe degree of malnutrition

29. Body ratios
• Rao & Singh’s weight-height index:
= [weight (kg) / (height)2 cms ] * 100
normal index is more than 0.15
• Kanawati index: (during 3m to 4 years)
= Mid-arm circumference / Head circumference
Normal 0.331
Mild 0.310 – 0.280
Modreate 0.279 – 0.250
Severe < 0.250

30. WEIGHT-FOR-HEIGHT
Weight-for-height = Weight of the patient (kg) X 100
Weight of normal child of same height
The nutritional status can be expressed as follows on the basis of weight-for-height:
Weight-for-Height * Nutritional Status
>90% Normal
85-90 % Borderline Malnutrition
75-80 % Moderate Malnutrition
<75 % Severe Malnutrition

31. Classification
• When malnutrition has been chronic, the child is “stunted”,
weight-for-age is low/normal
height-for-age is low
weight-for-height is normal.
• In Acute malnutrition, the child is “wasted”,
weight-for-age is low
height-for age is normal
weight-for-height is low

32. BODY MASS INDEX (BMI)
calculated by dividing wt in kilograms by the square of ht in metres [kg/m2].
• Ponderal index : - it is another parameter which is similar to BMI and is used for
defining newborn babies with intrauterine growth retardation.
PI = (Body weight in grams) × 100
length (cm)³
• In malnourished small-for-date babies (asymmetric IUGR), ponderal index is <2,
while it is usually more than 2.5 in term appropriate-for-gestation babies and
hypoplastic small-for-date babies.

33. PROPORTIONAL TRUNK AND LIMB GROWTH
•The mid-point of the body in newborn is at umbilicus whereas in an adult the mid-
point shifts to the symphysis pubis due to greater growth of limbs than trunk.
•The UPPER SEGMENT (vertex to upper edge of symphysis pubis) to LOWER
SEGMENT (symphysis pubis to heels) ratio at birth is 1.7 to 1.0 .
•This gradually becomes 1.0 to 1.1 in healthy adults.
• In infants upper segment (crown to symphysis pubis) can be measured by using
infantometer
.
• The lower segment is obtained by subtracting the upper segment from total length.

34. • Infantile upper segment to lower segment ratio(trunk
abnormally large or limbs abnormally small) is seen in :
1. Achondroplasia
2. Cretinism
3. Short limbed dwarfism
4. Sexual precocity
5. Bowed legs

35. • Advanced upper segment to lower segment ratio (trunk
abnormally short or limb abnormally long) is seen in:
1. Arachnodactyly
2.Hypogonadism
3.Eunuchoidism
4.Turner Syndrome
5.Klinefelter’s Syndrome
6.Chondrodystrophy
7.Spinal deformities (rickets, pott’s spine)

36. ARM SPAN
•It is the distance between the tips of middle fingers of both
arms outstretched at right angles to the body, measured
across the back of the child.
•In under-5 children , arm span is 1 to 2 cm smaller than
body length.
•During 10-12 years of age , arm span = height.
•In adults arm span is more in adults by 2 cm.

37. •Abnormally large arm span is seen in patients with
1)Arachnodactyly (Marfan syndrome)
2)Eunuchoidism
3)Klinefelter’s Syndrome
4)Coarctation of aorta
•Arm span is short compared to height in patients with :
1)Short limbed dwarfism
2)Cretinism
3)Achondroplasia

38. ADVANTAGES OF ANTHROPOMETRY
• Less expensive & need minimal training
• Readings are reproducible.
• Objective with high specificity & sensitivity
• Measures many variables of nutritional significance
(Ht, Wt, MAC, HC, skin fold thickness, waist & hip
ratio & BMI).
• Readings are numerical & gradable on standard
growth charts

39. Limitations of Anthropometry
Inter-observers errors in measurement
Limited nutritional diagnosis
Problems with reference standards, i.e. local versus international
standards.
Arbitrary statistical cut-off levels for what considered as
abnormal values.

40. Assessing Vital Signs

41. Introduction
Assessing vital signs or cardinal sign is a routine
medical procedure. And somehow determines
the internal functions of the body
Vital signs composes of the following:
I.Body temperature
II.Pulse
III.Respiration
IV.Blood pressure

42. Body Temperature
It is a balance between the internal and external
environment of the body, or
It is the balance between the heat produced by the
body and the heat lost from the body.
It is measured in heat units, called degrees

43. Two types of Body temperature
• CORE Temperature
• SURFACE temperature

44. CORE Temperature
it is the temperature of the deep tissues of the
body, such as the cranium,thorax, abdominal
cavity and pelvic cavity.
It remains relatively constant (37 °C/ 98 °F)
An accurate measurement is usually done
using
a pulmonary catheter.

45. SURFACE temperature
the temperature of the skin, the subcutaneous
tissues and fat
It constantly rises and falls in relation to the
environment
It varies from 20 °C (68 °F) to 40 °C (104 °F)

46. Sites commonly used in taking BT
I. Oral- most common
II. Axilla –mostly used in infants and children
III. Rectal- second choice
IV. Tympanic membrane- most favorable site

48. Factors that affect heat production
I. BMR
II. Muscle Activity
III. Thyroxine output
IV. Sympathetic stimulation
V. Fever

49. Types of Thermometer
1. Mercury in glass
◦ Oral thermometer have a long, slender tips
◦ Rectal thermometer have a short, rounded tips
2. Electronic thermometer
◦ Digital thermometer
3. Chemical thermometer
4. Temperature sensitive strip
5. Infrared thermometer
◦ Tympanic thermometer

50. Digital thermometer is commonly used in infants and children
insert it at the axillary region closed the arm and wait for timer to bustle
Remember when
taking BT in
infants and
children make
sure that the
patient is not in
distress mood
because any
change in the
activity will
directly affect the
BT reading.

51. Temperature conversion
°C = (Fahrenheit – 32 ) x 5/9
Convert 100 °F
°F = (Celsius x 9/5) + 32
◦ Convert 40 °C
◦ Normal/ Average temperature is between 36-37.9 °C or
96.8 – 100.3 °F

52. Pulse Rate
Is a wave of blood created by contraction of left
ventricle of the heart
Generally, the pulse wave represents the stroke
volume output and the compliance of arteries.

53. Peripheral pulse- is a pulse located in the periphery of the body
Apical pulse- is a central pulse located at the apex of the heart
1. A pulse is commonly assessed by palpation or auscultation.
2. 3 middle fingers are used for palpating all pulse site, except for apical pulse.
3. Stethoscope is used in assessing apical pulse and fetal heart tones.
4. Doppler ultrasound is used for pulses that is to difficult to assess.

54. Pulse site
1.Temporal
2. Carotid
3. Apical- at the apex of the heart.
▪ In Children 7 to 9 years old, the apical pulse is located between the 4th and 5th
intercostal space
▪ In Young Children below 4 years old , it is located at the left side of midclavicular line
▪ In Children between 4 and 6 years old it is at the midclavicular line.
4. Brachial- at the anterior part of the arm in children.
5. Radial
6. Femoral
7. Popliteal
8. Posterior Tibial
9. Dorsalis pedis.

56. Assessing the Pulse
. When assessing the pulse, there is a need to take note of
the following
1. rate
2. rhythm
3. volume
4. arterial wall elasticity
5. presence or absence of bilateral equality.

58. Respiration

59. BLOOD PRESSURE

60. PAIN IN children

61. What is Pain?
For infants and children the provider should recognize the
potential for pain and suspect that a child is in pain. AHCR Guidelines
1992
An unpleasant sensory and emotional experience associated with
actual or potential tissue damage or described in terms of such
damage.
IASP Pain Definition (1994, 2008)

62. What is Pain?
”
Pain is whatever the person experiencing it says it is, existing whenever the person
says it does. (Mc Cafery, 1999)
Pain is a subjective experience and is probably the most bewildering and
frightening experience kids will have.

63. History of pain in children
• Before 1970 - no formal research looking at pain
management in children
• Swafford and Allen,1968: “pediatric patients
seldom need medication for pain relief”
• 1974 – 13/25 children received no analgesia after
surgery such as nephrectomies, palate repairs and
traumatic amputations

64. Do children feel pain?
• Pain fibers present at end of 2nd trimester
• Increased heel sensitivity post heel sticks
• Crying increases for days post circumcision
• 6 month olds-anticipate and avoid pain

65. So, what are the facts?
• Newborn infants have functional nervous systems
which are capable of perceiving pain
• Physiologic means of assessing pain (VS) can be an
unreliable predictor of pain
• Infants often develop an increase in signs of
discomfort with repeated painful procedures
• Premature infants can have unpredictable responses
to painful stimuli
• Unmanaged pain in the neonatal period can cause
long term developmental complications

66. • Active children cannot be in pain
• Generally there is a “usual” amount of pain associated with
any given procedure
• If children are asleep then they are pain free
• Giving narcotics to children is addictive and dangerous
• Narcotics always depress respiration in children
• Infants don’t feel pain
• The less analgesia administered to children the better it is
for them

67. PAIN MANAGEMENT MYTHS
• Neonates do not feel pain the same as adults
• Infants are less sensitive to pain than adults
• Neonates have no memory of pain.
• Children will tell you when they are having pain.
• If a child can be distracted, he is not in pain.
• Neonates are not able to tolerate the effects of analgesics.
• Narcotics can lead to addiction in children.
• Infants become accustomed to pain.
• Lack of assessment skills
• Lack of pain treatment knowledge

68. Why is Pain Assessment Important?
• Provides an avenue for more effective management of pain
• Promotes communication between the child, parents and
health professionals
• Supports evidence based practice
• Provides continuity through the hospital
• Allows children to indicate the intensity of their pain

69. Challenges with Assessing Children !
• Lower levels of verbal fluency / non-verbal children
• May not verbally communicate presence of pain unless
specifically asked
• Pain highly individualized
• Parents often called upon to provide pain ratings - can
be different to patients perspective

70. The Questt Tool
• Question the child
• Use pain rating tools
• Evaluate behavior and physiological changes
• Secure parents involvement
• Take the cause of pain into account
• Take action and evaluate the results

71. Pain Assessment Tools
• Newborn/ Infant:
▪ CRIES
➢Developed for use in preterm and ft infants in ICU
➢Measures crying, O2 sat, HR, BP, expression and sleeplessness
▪ Neonatal Infant Pain Scale (NIPS)
➢Evaluates facial expression, cry, breathing, arms, legs and state
of arousal
▪ Premature Infant Pain Profile (PIPP)
➢Gestational age, behavioral state, HR, O2 sat, brow bulge, eye
squeeze, and nasolabial furrow; often used for procedural and
post-op pain

72. PIPP (Premature Infant Pain Profile)
• Uses both behavioral and physiologic reactions
to pain
• Measures behavioral state, HR, sat, and 3
facial expressions which are indicative of pain
in preemies (brow bulge, eye squeeze, and
nasolabial furrow)
• Takes into account gestational age
(postconceptual)

73. NIPS (Neonatal Infant Pain Scale)
• Behavioral cues scale
• rates crying, facial expression, breathing
patterns, tone of arms and legs, and state of
arousal at one minute intervals
• should be used taking other physiologic
factors into account

74. CRIES scale
• C-crying
• R-requires O2
• I-increased VS
• E-expression
• S-sleepless
Simple and easy to use-uses a scale of 1-10,
similar to APGAR scoring
score of 4 or greater requires intervention
objective and behavioral categories

75. CRIES neonatal postoperative Pain Scale

76. Pain Assessment Tools
• Toddler
▪ FLACC
▪ Oucher
▪ Faces pain-rating scale
• Preschooler
▪ Oucher
▪ Faces Pain-rating Scale (usually 3 and over)
▪ FLACC
➢Acronym for face, legs, cry and consolability
▪ Body Outline (3 and over)

77. FLACC Scale
• F-face (expression)
• L-legs (tone)
• A-activity
• C-cry
• C-consolability
score is tallied, similar to APGAR (0,1, or 2 for
each category)
greater than 4 is indicative of pain
behaviorally based

79. Wong Baker Faces

80. Oucher Pain Scale

81. Pain Assessment Tools
• School Age
▪ Numeric Pain Scale (9 yrs- adult)
▪ Oucher
▪ Faces pain-relating scale
▪ Poker chip scale
▪ Work graphic
▪ Visual analogue

82. Pain Assessment Tools
• Adolescent
▪ Numeric Pain Scale
▪ Oucher
▪ Faces Pain-relating scale
▪ Poker chip
▪ Work graphic
▪ Visual analogue
▪ Adolescent pediatric pain tool

83. Numeric Pain Scale
• Numeric Rating Scale
▪ Let’s say 0 means no pain and 10 means the worst pain
anyone could have. How much pain do you have? (score
0-10)

84. Criteria For Selecting A Pain Tool
• Established as valid and reliable
• Developmentally appropriate
• Easily and quickly understood
• Liked by patients, families and clinicians
• Inexpensive
• Appropriate for different languages and culture

85. The Effects of Pain
• Physiological Effects
▪ changes in vital signs,
pupils
• Behavioral Cues
▪ how the baby acts when
she is in pain
• Hormonal/Metabolic
Responses
▪ what happens chemically

86. Physiological Responses
• variations in HR
• variations in BP
• increased ICP
• increased or decreased RR
• decreased sats or increase in oxygen requirement
• change in color (pale, poor perfusion or red,
increased perfusion)
• increased or decreased muscle tone

87. Behavioral Cues
• crying
▪ can vary from high
pitched, tense to soft
moaning or whining
• facial expressions
▪ grimacing
▪ quivering of chin
▪ squeezing eyes shut
▪ furrowed brow
• difficult to soothe,
comfort or calm
• body movements
▪ limb withdrawal
▪ fist clenching
▪ hypertonicity or
hypotonicity
• state changes
▪ changes in sleep-wake
cycles
▪ changes in activity
levels-increased
fussiness or irritability

88. Developmental characteristics of children responses to pain
• Yong infant
• Older infant
• Young child
• School age child
• adolescent

89. “ The single most reliable indicator of the
existence and intensity of acute pain -
and any resultant affective discomfort or
distress- is the patient’s self-report”

90. Hormonal/Metabolic Responses
• increase in epinephrine and norepinephrine,
growth hormone and endorphins
• decrease in insulin secretion
• increased secretion of cortisol, glucagon, and
aldosterone…which leads to
• increased serum glucose, lactate, & ketones
• can lead to lactic acidosis
Is your “stress response” secondary to the
surgery/procedure or the pain afterwards?

91. Hormonal/Metabolic Responses
Changes in hormone levels affect the
absorption of fat, protein, and glucose, which
subsequently affect
HEALING AND GROWTH!
PAIN CONTROL IS MORE THAN A MATTER OF
COMFORT-
CONTROLLING PAIN DECREASES COMPLICATIONS

92. Factors Affecting Pain Response
• Gestational age-as preterm infants develop,
their responses become more sustained and
interpretable
• Environmental factors-external noise,
temperature, light
• Intensity and duration of insult-repeated
painful procedures decrease infant’s ability to
react to pain but not their perception of it
• Behavioral state-less reactive when in sleep
states than wake states

93. Long Term Effects of Untreated Pain
• Newly studied area-until recently, babies were
not thought to “remember” pain
• Some experts believe that untreated pain in
the newborn period forces abnormal
pathways to form in the brain
• This aberrant brain activity results in impaired
social/cognitive skills and specific patterns of
self- destructive behavior
• Studied MRI’s of newborns-reactions to pain
transferred into similar electrical reactions
to any kind of stressful situation

94. What can we do?
Common sense tells us that not all crying babies
are in pain.
A chronically stressed baby in the NICU may not
react at all to pain.

95. Pain assessment in specific populations
• Pain in neonates
• Children with communications and cognitive impairment
• Cultural differences
• Children with chronic illness and complex pain

96. Assessment of Pain in the Newborn
• Pain scales use behavioral cues such as quality
of cry, breathing pattern, facial expression, &
muscle tone, as well as changes in VS &
increase in oxygen requirement.
• Proponents maintain that use of scales
decreases nurse to nurse variability of pain
med administration
• Limitations include differentiating between
pain and agitation, difficulty assessing
premature infants’ behavior, and few scales
for use with intubated/sedated patients

97. Common pain states in children
• Painful and invasive procedure
• Postoperative pain
• Burn pain
• Recurrent Abdominal pain
• Cancer pain

98. PQRSTU mnemonic
Provocative/Palliative factors (For example, "What makes your pain better
or worse?")
Quality (For example, use open-ended questions such as "Tell me what your
pain feels like," or "Tell me about your 'boo-boo'.")
Region/Radiation (For example, "Show me where your pain is," or "Show me
where your teddy hurts.")
Severity: Ask child to rate pain, using a pain intensity scale that is
appropriate for child's age, developmental level, and comprehension.
Consistently use the same pain intensity tool with the same child.
Timing: Using developmentally appropriate vocabulary, ask child (and
family) if pain is constant, intermittent, continuous, or a combination. Also
ask if pain increases during specific times of the day, with particular
activities, or in specific locations.
How is the pain affecting you (U) in regard to activities of daily living (ADLs),
play, school, relationships, and enjoyment of life?

99. Prevent or Minimize Pain
• Cluster blood draws or use
arterial line whenever
possible to minimize sticks
• Use smallest gauge needle
possible
• Use minimal amounts of
tape/use tape remover to
remove it
• Premedicate prior to painful
or invasive procedures

100. Pain Management
• Developmental support is the first step in
managing all levels of pain
▪ 4 handed care-support infant in a flexed position
▪ parental involvement-give parents a chance to help
support their baby
▪ facilitate hand to mouth contact, offer pacifier-
sucking causes endorphins to be released
▪ swaddling, holding
▪ minimize external stimuli such as noise & light

101. Circumcisions
• ASPMN statement
• circumcisions are painful
• Unrelieved pain from circs can cause adverse
stress responses such as breath holding, apnea,
gagging, and vomiting
• neonates have the right to an anesthetic to
prevent the pain of the procedure
• suggest use of blocks or EMLA cream as well as
sucrose pacifier and developmental support to
assist these babies with coping

102. (WHO)Principles of Pediatric Acute Pain Management

103. Management of Mild Pain
• developmental support
• parental involvement
• Acetaminophen-excellent choice for mild post
operative pain (hernias, etc) especially in opioid-naïve
patients
• ibuprofen - analgesic, non-narcotic NSAID; no studies
to assess safety in babies less than 3 months old
• EMLA cream to prevent pain with planned procedures
(circumcisions, etc.) recommended in babies >36 weeks
GA or > 2 weeks old (don’t use with Tylenol)

104. Don’t you love Sucrose?
• sucrose is the most studied
treatment to help babies deal
with mild or procedural pain
• shown to help with LP’s,
circumcisions, venipunctures,
and heelsticks
• sucrose and sucking each
cause the release of
endorphins-putting these 2
treatments together has
been proven to decrease pain
in newborns

105. Management of Moderate Pain
• developmental support
• parental involvement
• acetaminophen with codeine-analgesic, narcotic
only comes in PO form which limits its usability
• ketorolac (torodal) - analgesic, non-narcotic, NSAID;
time limited use, works best when given around the
clock for 48 hours post op in addition to other
analgesics

106. Management of Severe Pain
• developmental support
• parental involvement
• pharmacological management
▪ medications given on a prn basis result in
peaks and valleys of pain relief
▪ pain is better controlled if medication is given
prior to the climax of pain
▪ continuous drip or regularly scheduled doses
maintain a constant level of analgesia

107. Management of Severe Pain
• Morphine
▪ Intermittent 0.05 mg-0.2mg/kg/dose may
give q1-8 hours
▪ Continuous load with 100mcg/kg, then 10-
15 mcg/kg/hr
▪ can have significant respiratory side
effects
▪ observe for abdominal distension,
decreased bowel sounds, and urinary
retention

108. Management of Severe Pain
• Fentanyl
▪ Intermittent 1-4mcg/kg/dose may give q2-4
hours
▪ Continuous 1-5mcg/kg/hour
▪ good choice for cardiac patients due to
decreased CV side effects
▪ can cause chest wall rigidity in neonates
when given IVP
• Meperidine (demerol) - not recommended for
pediatrics 2° toxic CNS metabolites

109. Management of Severe Pain
• Methadone
▪ respiratory effects outlast analgesia at such
dosing levels
▪ drug of choice to support narcotic weaning
• Hydromorphone (dilaudid)
▪ analgesic, narcotic; not for patients with
significant respiratory distress
▪ the injectable form contains benzyl alcohol
which is not recommended for neonates

110. GOALS OF MANAGEMENT
• Decrease pain and suffering
• Promote family bonding
• Increase patient comfort
• Promote normal coping mechanisms
• Decrease patient risk from complications
• Prevent negative long term developmental outcomes
HAPPY, HEALTHY BABIES!

111. Guiding principles
Minimize intensity and duration of pain
Maximize coping and recovery
Break the pain-anxiety cycle
Interventions

112. Pain management
Pharmacologic
Non-pharmacologic

113. Pharmacologic Pain Control
• Pain Medications include:
▪ Opioids
▪ Nonsteroidal anti-inflammatory drugs (NSAIDs)
▪ Non-narcotic analgesics (acetaminophen)

114. Non-pharmacological

115. No pharmacological intervention should be provided without a non-
pharmacological intervention
Julie Griffiths

116. World Health Organization (WHO)
Principles of
Pediatric Acute Pain Management
• By the clock
• With the child
• By the appropriate route
• WHO Ladder of Pain Management

117. By the Clock
Regular scheduling ensures a steady
blood level
Reduces the peaks and troughs of PRN
dosing
PRN = as little as possible???

118. With the Child
Analgesic treatment should be
individualized according to:
• The child’s pain
• Response to treatment
• Frequent reassessment
• Modification of plan as required

119. Correct Route
Oral
Nebulized
Buccal
Transdermal
Sublingual
Intranasal
IM
IV / SC
Rectal

120. HAPPY, HEALTHY KIDS!

121. You are the KEY!
Babies are unable to communicate their pain to
the untrained eye…
However, you have the tools to assess your
babies for pain and make it better!!

122. Any question?

123. • Peresent by:
• Yosra razyani
• Master of pediatric nursing
• Email:zh.ruzyani@yahoo.com