Kinder, Gentler Pain Management Mary A. Hegenbarth, MD, FAAP, FACEP Sedation Coordinator, Section of Emergency Medicine Medical Director, ED PAWS (Pediatric Acute Wound/Sedation) Service [email protected]

Alison Monroe, CCLS Emergency Department Child Life Specialist [email protected]

Objectives Describe alternatives for non-invasive pain management in children  Pharmacologic options  

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Intranasal drug administration—fentanyl Topical anesthesia—J-tip lidocaine

Support positive coping   

Preparation, including appropriate language Comfort positioning Distraction

ED Pain Management—What’s the Problem? Inadequate pain management of children in EDs well documented  Alexander 2003—analgesia for long bone fractures and burns for different ages in ped ED 

Compared 6-24 mo vs. 6-10 yr olds Only 35% of 6-24 mo got analgesia vs. 52% of school age  Burns—only 50% of 6-24 mo got analgesia (21% narcotics) vs. 75% of school age (100% narcotics) 

Alexander J, Ann Emerg Med 2003; 41:617

Why is children’s pain undertreated?  

Multifactorial problem Have good medications, but underused 

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Starting IV is a barrier, especially in young children  Uncooperative  Technically difficult

Needlestick pain often not addressed 

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Seen as minor procedure by staff, but very feared by children Topical anesthetics typically have required long application times (30-60 min)

Intranasal fentanyl for acute pain  

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It’s fast (faster than starting an IV) It’s non-invasive It works!   

Rapid absorption Significant analgesia within 10 min 70% bioavailability

Intranasal Drug Delivery 

Nasal mucosa   

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Part of dose goes directly into brain (nose-brain pathway) Many drugs well absorbed   

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Large surface area (180 cm2 in adult) Rich blood supply Higher drug levels than oral/rectal

Fentanyl Midazolam Ketamine

MAD (mucosal atomizer device) allows easy, effective administration Resource: www.intranasal.net

Opiate levels—Intranasal vs IV

www.intranasal.net

Intranasal Fentanyl—ED Studies 

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IN fentanyl worked as well as IV morphine in placebo controlled RCT IN fentanyl given sooner than IV morphine (~30 min vs 60 min) More children receive analgesia once IN fentanyl implemented Majority have decreased pain within 10 minutes Borland M. Ann Emerg Med 2007;49:335-340 Holdgate A. Acad Emerg Med 2010;17:214-217 Saunders et al, Acad Emerg Med 2010;17:1155

IN Fentanyl— Dosage/Administration  

IV formulation 50 mcg/mL Dosage 1.5-2 mcg/kg, max 100 mcg (1 mL/nostril) 

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70% bioavailability

Head tilted back ~45° Divide dose between nostrils Onset 5-10 minutes May repeat ~0.5-1 mcg/kg after 10 minutes Prepare for IV if needed, or give PO medication Doesn’t sting or taste bad

IN Fentanyl— Contraindications/Complications 

Contraindications  

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Complications (very rare)  

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Drug hypersensitivity Nasal blockage/trauma/epistaxis (?URI) Nausea/vomiting Itching Respiratory depression Rigid chest (theoretical, not reported) Reversal—naloxone (IM if no IV)

Monitoring—pulse ox?

Topical Anesthesia for Needle Procedures 

LMX or EMLA  

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Require 30-60 minutes Can be used if time allows LMX works a little quicker

J-tip lidocaine   

CO2 powered needleless injection Works rapidly (< 5 min) Better anesthesia than LMX/EMLA for IV placement

Spanos et al, Pediatr Emerg Care 2008;24:511 Jimenez et al, Anesth Analg 2006;102:411.

J-tip Lidocaine  

1% buffered lidocaine jet injection Topical anesthesia for needlesticks 

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Onset 1-3 minutes  

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IV/venipuncture LP 5 min—nickel sized area 10-15 min—quarter sized area

Duration ~90 minutes Depth of anesthesia 8 mm at 5 min Warn child of “pop can” whoosh

You can make a difference!  

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Noninvasive, fast, effective pain control Reduce needlestick pain/apprehension Reduce trauma of ED visit Simple, easy to incorporate Children and families very appreciative Staff like it too!

Supporting Positive Coping in the Emergency Setting Alison Monroe, CCLS Emergency Department Child Life Specialist Children’s Mercy Hospitals and Clinics 2401 Gillham Rd, KC, MO 64108

Preparation •Preparation leads to a reduction in procedural distress (Chen, et al (1999) ; Claar, et al (2002); Ellerton & Merriam (1994); Lizasoain & Polaino, et al (1995)), more cooperation from the child (Zahr, (1998); Zeilikovsky, et al (2000), and has a positive impact on future procedures (Claar, et al (2002)

•Preparation promotes understanding of medical interventions and experiences. •Manipulating materials fosters understanding of their use, and provides the opportunity for patients to ask questions and express and cope with fears related to the procedure or experience. •The patient can participate in developing an individualized coping plan. •Children may not understand adult terminology: “Child Life Suggested Words or Phrases”

Preparation Can Include: 

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Verbal description of procedural steps or experiences Manipulation of appropriate medical materials Reviewing past experiences with similar/same event to address possible misconceptions

When Providing Preparation  

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Be honest with the patient Include any pharmaceutical interventions in preparation (i.e. jtip, numbing creams, or Buzzy) Use developmentally appropriate language  

Concrete descriptions Developmentally appropriate terminology

Procedural Support 

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Procedure support decreases distress and anxiety (Bowen & Dammeyer (1999); Dahlquist, et al (2001); Dahlquist, et al (2002); Fanurik, et al (2000); Kazak, et al (1998); Smart (1997); Kleiber (1999)), increases cooperation (Zelikovsky, et al (2000))improves physiological functioning (Castes, et al (1999)), and reduces need for sedation (Smart (1997)). Procedural Support can be provided to help facilitate effective coping during any stressful event. A coping plan should be devised prior to the event The support should be tailored to each patient’s needs (developmental level, amount of stimulation, area of procedure)

Considerations for Procedural Support and Distraction  

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The environment of the room The developmental level of the patient The patient’s desired coping plan Comfort positioning

Why Position for Comfort? 

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Family centered care  Parents who interact with their child during a procedure are calmer and have increased satisfaction Developmental focus  Sitting up in infancy is accompanied by sense of control  Lying children down results in a loss of control and is frightening  When developmental milestone reached, the mere act of making child lie down usually results in struggle to get up

* Cummings, E., Reid, G., Finley, G., McGrath, P. & Ritchie, J. (1996). Prevalence and source of pain in pediatric inpatients. Pain, 68, 25-31. **Chen, E., Craske, M. & Katz, E. (2000). Children’s memories for painful cancer treatment procedures; Implications for disress. Child Dev., 71, 933-947

Why Position for Comfort? (cont.) 

Psychosocial focus  IVs are the 2nd most common cause of worst pain experienced during hospitalization *  Fear, anxiety and tension heighten a child’s response to pain  Painful procedures result in negative memory and greater pain in future procedures**

* Cummings, E., Reid, G., Finley, G., McGrath, P. & Ritchie, J. (1996). Prevalence and source of pain in pediatric inpatients. Pain, 68, 2531. **Chen, E., Craske, M. & Katz, E. (2000). Children’s memories for painful cancer treatment procedures; Implications for disress. Child Dev., 71, 933-947

Back to Front

Infant Cradle

Infant Front to Front

Positioning for IV Start

Straddle School Age

Back to Front School Age

Side Sitting

Positioning for IM Injection

Front to Back School Age

Straddle School Age

Side Sit School Age

Let Them Be in Control •Children don’t get to make a lot of decisions when visiting the hospital. They have to endure multiple procedures/tests, they lose privacy, their schedule is changed, etc. Acting out is common in children trying to regain control of their environment.

•Offering children as many appropriate choices as possible can help put a child at ease. Many choices can be very simple, such as: •How would you like to sit? •Do you want the lights on or off? •Which toy would you like to play with? •Would you like to see what is happening? •Would you like a countdown?

References Bowen, A.M. & Dammeyer, M.M. (1999). Reducing children's immunization distress in a primary care setting. Journal of Pediatric Nursing , 14, 296-303. Castes, M., Hagel, I., Palenque, M. Canelone, P., Corao, A., & Lynch, N.R. (1999). Immunological changes associated with clinical improvement of asthmatic children subjected to psychosocial intervention. Brain, Behavior, and Immunity , 13, 1-13. Chen, E., Zeltzer, L. K., Craske, M. G., & Katz, E. R. (1999). Alteration of memory in the reduction of children's distress during repeated aversive medical procedures. Journal of Consulting and Clinical Psychology , 67, 481-490. Claar, R.L., Walker, L.S., & Barnard, J.A. (2002). Children's knowledge, anticipatory anxiety, procedural distress, and recall of esophagogastroduodenoscopy. Journal of Pediatric Gastroenterology and Nutrition , 34, 68-72. Dahlquist, L.M. et al. (2001). Adult command structure and children's distress during the anticipatory phase of invasive cancer procedures. Children's' Health Care , 30, 151-167. Dahlquist, L.M., Busby, S.M., Slifer, K.J., Tucker, C.L., Eischen, S., Hilley L., & Sulc, W. (2002). Distraction for children of different ages who undergo repeated needle sticks. Journal of Pediatric Oncology Nursing , 19, 22-34. Ellerton, M.L. & Merriam, C. (1994). Preparing children and families psychologically for day surgery: An evaluation. Journal of Advanced Nursing , 19, 1057-1062.

References continued Fanurik, D, Kohl, J.L., & Schmitz, M.L. (2000). Distraction techniques combined with EMLA: Effects on IV insertion pain and distress in children. Children's Heath Care 29, 87-101 Kazak, A.E., Penati, B., Brophy, P., & Himelstein, B. (1998). Pharmacologic and psychologic interventions for procedural pain. Pediatrics , 102, 59-66. Kleiber C, Harper DC. (1999) Effects of distraction on children's pain and distress during medical procedures: a meta-analysis. Nursing Research Jan-Feb;48(1):44-9. Lizasoain, O., & Polaino, A. (1995). Reduction of anxiety in pediatric patients: effect of a psychopedagogical intervention programme. Patient Education & Counseling , 25, 1722. Smart, G. (1997). Helping children relax during magnetic resonance imaging. MCN, The American Journal of Maternal Child Nursing , 22, 237-241 Zahr, L.K. (1998). Therapeutic play for hospitalized preschoolers in Lebanon. Pediatric Nursing , 23, 449-454. Zelikovsky, N. Rodrigue, J.R., Gidyez, C. & Davis, M.A. (2000). Cognitive behavioral and behavioral interventions help young children cope during a voiding cystourethrogram. Journal of Pediatric Psychology , 25, 535-543.

Questions? Contact Information: Alison Monroe [email protected] 816.234.3000 x57757

Sandy Bruner [email protected] 816.234.3000 x57759 Amelia Ryan [email protected] 816.234.3000 x57805