Introduction:
Undertreatment of acute pain occurs in a substantial percentage of children as compared to adults. Treating adults and children is not the same as there are anatomic, physiologic, pharmacodynamic, and pharmacokinetic variations. There are certain unique barriers in infants and children that may affect the perioperative pain control protocols.
Why Is It Important to Manage Pain in Infants and Children?
Poor pain control in pediatric patients may result in morbidity and mortality. So pain management is very important when treating pediatric patients. There are certain myths that children do not feel the pain, or they do not remember the pain. Such incorrect assumptions can act as a hindrance to pain control protocols.
Pediatric patients cannot conceptualize pain and cannot assess if a subjective experience is a pain. As they have developmental, cognitive, and emotional differences, the degree of pain and even pain assessment becomes difficult. Furthermore, it is even challenging in non-verbal pediatric patients and children with intellectual disabilities.
How Is Pain Management Done in Infants and Children?
The postoperative pain management plan is discussed with the family and the patient before surgery. This will help avoid the anxiety caused to the child during surgery or before surgery. Generally, the oral administration of analgesics is preferred in children for mild to moderate pain. In moderate to severe pain during the postoperative period, regional or intravenous analgesia is administered. The intramuscular route of administration is discouraged mostly as the fear of needles and pain during injection may provoke anxiety in children. This will negatively influence the postoperative pain control strategy as the pediatric patient will choose to remain in silence rather than receive painful injections.
Addressing the drug-related side effects is necessary to remove unwanted distress to the patients. This will also help in improving the compliance of the child with the pain-control program.
What Are the Routes of Administration?
- PCA: Intravenous PCA (patient-controlled analgesia) can be used in pediatric patients as it will provide autonomy and ensure the analgesic requirements are met. The PCA device allows selective medicine dosage, and it can be used as and when required. Children who are at least four years and have the cognitive and physical ability to use this appropriately should be given this device. However nurse controlled or parent-controlled analgesia administration can be followed as respiratory depression may occur in 1.7 percent of the patients. For pediatric patients who cannot use PCA, continuous infusions or intermittent IV administration of opioids can be done to provide postoperative analgesia.
- Rectal Route: Acetaminophen can be administered post-operatively through the rectal route, but it may require a larger dose than usual, 40 milligrams per kilogram, followed by three doses of 20 milligrams per kilogram at six-hour intervals. This will result in appropriate serum analgesic levels.
- Regional Route: Peripheral and neuraxial regional analgesic techniques are also commonly employed techniques for acute pain management in infants and children. Ultrasound-guided regional analgesic techniques will increase efficacy.
- Epidural Route: This is one of the frequently employed methods, and the administration of drugs can either be a single dose or continuous infusion catheter technique. For this purpose, the catheter may be inserted into the epidural space (thoracic, lumbar, and caudal) under general anesthesia. Both opioids and local anesthetics (LA) can be administered through this route for effective pain control. The caudal route is the most common out of all, but careful administration is required in neonates because the immature liver can find it difficult to metabolize an amide type of LA. Adjuvant drugs such as Clonidine can be used for enhanced analgesia during epidural infusion. Post-dural headache is a complication of lumbar puncture.
- Spinal Route: It is the ace anesthetic technique employed in preterm infants who are at risk of postoperative apnea in hernia repair surgery. This technique is employed in a sitting position with the extension of the neck, chin, and head with the help of an assistant.
What Drugs Are Used for Pain Control Post-operatively?
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Morphine is the standard by which other opioids are compared during pain management. However, Morphine does not appear to have an analgesic advantage over other opioids like Hydromorphone when given in equivalent doses.
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Meperidine cannot be used in pediatric patients due to toxicity from its metabolites and also as there are better alternatives.
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Respiratory depression may occur with opioids regardless of the administration route. However, it is not significant and uncommon in pediatric patients.
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Postoperative opioid consumption can be reduced with the use of non-opioid analgesic agents like NSAIDs (non-steroidal anti-inflammatory drugs) and Acetaminophen. It can also improve analgesia levels. It also negates opioid-related side effects, such as postoperative nausea and vomiting.
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Other than these, Ketorolac and Tramadol can be considered adjuncts to analgesic drugs in specific clinical situations.
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Selective COX-2 (cyclooxygenase-2) inhibitors help in reducing inflammation and alleviating pain without disturbing normal platelet function. So these are ideal enough to provide analgesia in children. Acetaminophen in combination with Ibuprofen or Rofecoxib reduces the use of analgesics post-tonsillectomy, according to a study.
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Diclofenac produces adequate and effective pain control when administered after minor surgical procedures. It is given through oral, rectal, and intravenous routes every eight hours. The dosage is 1 milligram per kilogram.
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Pain is not felt during GA. However, without using local anesthesia, pain sensitivity may be increased post-operatively. Hence, a regional block or infiltration is given prior to surgical procedures.
What Are the Non-pharmacologic Approaches to Pain Control?
- Distraction and Imagery: Distraction helps in patients' cooperation during painful procedures and removes the anxiety of the children. Non-procedural talk, videos, games, and toys can be used as distraction tools.
- Virtual Reality: Using smartphone applications and digital technology can help provide distraction and pain reduction for those undergoing painful procedures such as burn treatments, dental procedures, and venipunctures.
- Hypnotherapy: Hypnotherapy has been proven effective in reducing needle-related pain and distress in children.
- Other Techniques: Relaxation and breathing techniques can be followed to eliminate anxiety. Transcutaneous electrical nerve stimulation (TENS), music therapy, and acupuncture are some of the strategies for pain control.
Conclusion:
The effects of untreated pain can cause short-term and long-term ill effects in children. Therefore a thorough perioperative pain control program has to be established. Though it can be challenging to identify the source of pain in children, the non-verbal signs of discomfort have to be taken into account, and an appropriate pain control strategy has to be followed.