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Pediatric Pain ___________________________________ Kimberly Wittmayer, MS, APN, PCNS-BC, RN-BC Pediatric Pain Service Advocate Children‟s Hospital, Oak Lawn, Illinois

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___________________________________ ___________________________________ ___________________________________ ___________________________________ Objectives • The learner will be able to list barriers to pediatric pain management • The learner will be able to identify proper pain assessment tools for the neonate and pediatric patient • The learner will be able to describe interventions for neonatal and pediatric pain • The learner will be able to demonstrate knowledge of instances in which procedural pain management is warranted and recall proper interventions to such procedures. • The learner will be able to demonstrate a pain assessment on simulated neonatal and pediatric patients and develop a pain plan

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___________________________________ ___________________________________ ___________________________________ ___________________________________ Disclosures Nothing to disclose

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___________________________________ Myths & Misconceptions • Infants do not feel as much pain as adults – Neural pathways are in place in utero and mature up until adulthood.

• Infants cannot feel pain because of an immature nervous system – Myelin doesn‟t influence generation of nerve impulse – Painful stimuli are transmitted by both myelinated & unmylinated fibers.

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Myths & Misconceptions • Young children cannot indicate where pain is located – Children as young as 4 can demonstrate on body charts where they hurt without knowing the name of the body part. – Intensity is able to be self reported by age 3-4

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• A child playing cannot be in pain – Children use distraction and play as a means of diversion and coping mechanism

• The child is asleep, therefore cannot be in pain

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– Persistent pain can lead to exhaustion 5

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Myths & Misconceptions • Opioids are not safe to use in infants or children – No more dangerous than they are to adults – No greater risk of respiratory depression

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• Must dose based on weight (kg)

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Pediatric Pain Assessment: Behavioral Scales Premature Infant Pain Profile (PIPP) • •

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(Stevens, et al., 1996 & revised 2014)

Pre and term infants Looks at contextual indicators

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– Gestational age, behavioral state – HR, O2 sats, brow bulge, eye squeeze, and nasolabial furrow.

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Each indicator is evaluated on 4 pt scale (0, 1, 2, 3) – Possible total score of 18-21 – Score of 6 or less = minimal to no pain – Score of >12 = moderate to severe pain

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High rigor, reliability and validity Interrater reliability, ICC: .93-0.96 , Intrarater reliability: .94 -.98 Content validity, construct validity:

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Construct validity in clinical setting, p < .0001

– in preterm neonates p =.0001 – in term neonates p < .02

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Pediatric Pain Assessment: Behavioral Scales Premature Infant Pain Profile (PIPP) • •

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(Stevens, et al., 1996 & revised 2014)

Pre and term infants Looks at contextual indicators

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– Gestational age, behavioral state – HR, O2 sats, brow bulge, eye squeeze, and nasolabial furrow.

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Each indicator is evaluated on 4 pt scale (0, 1, 2, 3) – Possible total score of 18-21 – Score of 6 or less = minimal to no pain – Score of >12 = moderate to severe pain

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High rigor, reliability and validity Interrater reliability, ICC: .93-0.96 , Intrarater reliability: .94 -.98 Content validity, construct validity:

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Construct validity in clinical setting, p < .0001

– in preterm neonates p =.0001 – in term neonates p < .02

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Pediatric Pain Assessment: Behavioral Scales

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Pediatric Pain Assessment: Behavioral Scales CRIES (Krechel & Bildner, 1995) • • •

Full term Neonates (32-60 weeks gestational age) Post-operative 3 point scale (0, 1, 2)

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3 behavioral and 2 physiologic measures:

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Reliability and validity Interrater reliability: .72 (p