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Facts about Pain in Infants and Children

Unrelieved pain in infants can permanently change their nervous system and may "prime" them for having chronic pain.

Changes in Peripheral Nervous System

Sensitization -- ­ sensitivity of receptor (nociceptor)

­ frequency of firing of receptor

Neuronal sprouting -- ­ receptor field, eg, neuromas

When sensitized, receptors respond to new forms of stimulation, eg, hyperalgesia, allodynia

Changes in Central Nervous System

Central sensitization – formation of spontaneous impulses

Wind-up -- ­ in magnitude of response to C fiber activity by dorsal horn neurons

Long-term potentiation – cellular "memory" for pain may lead to ­ responses to nociceptor stimuli

Facilitation – ¯ impulse threshold and ­ intensity of response

Neuronal sprouting -- ­ nerve endings into adjacent laminae (I and II may spread to III)

Children Do Not Tolerate Pain Better Than Adults

Children’s tolerance to pain actually INCREASES with age.

Children Can Tell You Where They Hurt

Children beyond infancy can accurately point to the body area or mark the painful site on a drawing; children as young as three years can use pain scales.

Children Do Not Always Tell The Truth About Pain

Children may not admit having pain to avoid an injection, because of constant pain, or because they believe others know how they are feeling.

Children Do Not Become Accustomed To Pain or Painful Procedures

Children often demonstrate INCREASED behavioral signs of discomfort with repeated painful procedures.

Consequences of inadequate analgesia during painful procedures in children

N = 21 children, BMA or/and LP, RCT placebo vs transmucosal fentanyl (TF)

Placebo group rated pain higher than TF group

Placebo group then received TF

Children <8yrs. (n=5) still rated pain higher than TF group

Ref: Weisman SJ, Bernstein B, Schechter NL: Arch Pediatr Adolesc Med 152(2):147-149, Feb 1998.

Behavioral Manifestations of Pain May Not Reflect Pain Intensity

Children’s developmental level, coping abilities, and temperament, such as activity level and intensity of reaction to pain, influence pain behavior.

Coping Behaviors vs Pain/Fear Ratings

N=17 children, ages 3-15 yrs, during LP

Active Behaviors = ¯ Pain Rating

Resists, denies, attacks

Passive Behaviors = ­ Pain Rating

Avoids, cooperates, ignores

Mean Pain Rating = 4.9/6 (SD = 1.5)

Fear Rating: low not related to behaviors

Ref: Broom M, et al: ONS, 17(3):361-367, 1990.

Parents Want to be Involved in Their Child’s Pain Control

Parents need information about assessing pain and using interventions to relieve pain.

Parental presence during painful procedures is generally desirable for the child and parent. N