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POSTOPERATIVE PAIN
MANAGEMENT IN PEDIATRIC
PATIENTS
Ezz El-Din Fikri Ismail, MD, DHPE
Prof. of Anesthesia & Pain Medicine
Al-Azhar University, Cairo, Egypt
ezzismail@yahoo.com
Outline
• Causes of under-treatment of pain in children.
• Management of Acute Pain in Children:
• Non- pharmacological.
• Pharmacological
• Post-operative pain control in children.
• Recommendations from American Pain Society and
American Academy of Pediatrics.
Introduction
• Pain is both a sensory and emotional personal
experience, making assessment complex
(Melzack & Wall, 1965).
• Despite many research in recent years, pediatric pain is
often underestimated and undertreated
(Craig & Pillai Riddell, 2003).
Introduction
• The nervous system is sufficiently developed to process
nociception before birth.
• Children must be assumed to experience pain from birth
onward.
• Infants and young children may experience a greater
neural response following a noxious stimulus than do
adults due to:
• a more robust inflammatory response &
• the lack of a central inhibitory influence,.
Misconceptions that lead to Under-
treatment of Pain in Children
1. False belief that infants & children do not feel pain, or
suffer less from it than adults.
2. Lack of routine pain assessment in children.
3. Lack of knowledge regarding newer modalities & proper
dosing strategies for the use of analgesics in children.
4. Fears of respiratory depression or other adverse effects
of analgesic medications.
5. The belief that preventing pain in children takes too
much time and effort.
Committee on Psychosocial Aspects of Child and Family Health, American Academy of
Pediatrics; Task Force on Pain in Infants, Children and Adolescents, American Pain Society
Management of Acute Pain in Children
• Acute pain is more common than chronic pain in children.
• Pain from injury or illness is transient:
• can be easily managed by parents and caretakers.
• Iatrogenic acute pain is common & ranges from:
• needle stick procedures (immunizations, screening blood tests)
• acute severe pain e.g. surgery.
• Management include:
• Non-pharmacological
• Pharmacological
Non-pharmacologic Pain Management
• These include psychological strategies, education and
parental support.
• For children undergoing repeated painful procedures:
• Cognitive-Behavioral Therapy (CBT) interventions, which
decrease anxiety and distress, can be quite effective.
• They are not adequate as the sole means of pain relief for
most painful procedures.
Walco GA, Halpern SL, Conte PM. Pain in Infants and Children. In: Tollison CD,
Satterthwaithe JR, Tollison JW, eds. Practical Pain Management. Philadelphia; 2002
Management of Acute Pain in Children
Non-pharmacologic Pain Management
• CBT techniques take
time to learn:
• simple distraction
techniques that divert
attention away from painful
stimuli, or
• positive incentive
techniques which provide a
small reward (e.g., stickers
or prizes).
• Not adequate alone.
Management of Acute Pain in Children
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Management of Acute Pain in Children
Pharmacologic Pain Management
• Most of the major organ systems are anatomically well
developed at birth,
• their functional maturity is often delayed.
• These systems rapidly mature approaching a functional
level similar to adults before 3 months of age.
Management of Acute Pain in Children
Physiology & Pharmacology, 1
• Most analgesics (including opioids and local anesthetics)
are conjugated in the liver.
• Newborns (premature infants) have delayed maturation of
enzyme systems involved in drug conjugation.
• Many of these hepatic enzyme systems mature over the
first 1 – 6 months of life.
Management of Acute Pain in Children
Physiology & Pharmacology, 2
• Glomerular filtration rates are diminished in the first week
of life, esp. in premature infants,
• sufficiently mature to clear medications & metabolites by 2 weeks
of age.
• Newborns have a higher % of body weight as water &
less fat compared with older patients.
• Therefore, water soluble drugs have larger volumes of
distribution.
Management of Acute Pain in Children
Physiology & Pharmacology, 3
• Newborns have reduced plasma conc. of both albumin
and alpha-1 acid-glycoprotein than older children.
• This may lead to higher conc. of unbound drug (active)
• greater drug effect or drug toxicity.
• Newborns, esp. premature infants, have diminished
ventilatory responses to hypoxemia and hypercarbia.
• These ventilatory responses can be further impaired by
CNS depressant drugs e.g. opioids & benzodiazepines.
Management of Acute Pain in Children
Paracetamol, 1
• It is the most commonly used analgesic agent due to:
• excellent safety profile
• lack of significant side effects
• It is the mainstay for mild to moderate pain.
• It is often combined with opioid analgesics for severe pain
• Infants and children produce high levels of glutathione
(GSH) as a part of hepatic growth:
• this may provide some protection against overdose hepatotoxicity.
Pediatric Pain: Pharmacological Management
Paracetamol, 2
• It inhibits prostaglandin synthesis in the hypothalamus.
• It reduces hyperalgesia mediated by substance P.
• It reduces nitric oxide generation involved in spinal
hyperalgesia induced by substance P or NMDA.
• It has an opioid sparing effect.
Paracetamol, 3
• Recommended oral dose: 10 -15 mg/kg.
• Daily maximum oral dose should not to exceed:
• 75 mg/kg for children,
• 60 mg/kg for term neonates <10 days of age, and
• 45 mg/ kg for premature infants > 34 weeks gestational age.
• Single rectal dose of 30 - 45 mg/kg:
• produced plasma conc. in the effective range.
• subsequent doses of 20 mg/kg, at 6 hours interval.
Pediatric Pain: Pharmacological Management
Paracetamol: IV Dose Guide
Age/ weight Dose Max. daily dose
1 month – 50 Kg 15 mg/kg
up to 6 hourly
60 mg/kg/day
> 50 Kg 1 g up to 6 hourly 4 g/ day
Perioperative Analgesic Pharmacology in Children
http://www.anaesthesiauk.com/documents/perioperative_analgesic_pharm_for_children.pdf
Nonsteroidal Anti-inflammatory Drugs
• Pharmacodynamics and pharmacokinetics of NSAIDs in
children are not much different than in adults.
• The half-life is significantly longer in the newborn period,
• The incidence of GI & renal problems in children may be
less than that encountered in adults.
• Rectal and oral bioavailability are both good
• So, for short cases they are best given orally preoperatively.
Pediatric Pain: Pharmacological Management
NSAIDs
• Ibuprofen is used for
• mild to moderate pain,
• it is available in a liquid form.
• It has a better safety profile
than ketorolac.
Pediatric Pain: Pharmacological Management
NSAIDs
• Ketorolac (parenteral)
has been used for the
treatment of postop.
pain in children:
• as a single agent.
• as an adjuvant to opioid
analgesia.
• 0.5 mg/kg IV every 6
hours for up to 48 hrs.
Pediatric Pain: Pharmacological Management
Pediatric Pharmacotherapy (17) 2011
NSAIDs
• COX-2 inhibitor
(celecoxib) is available for
oral administration:
• In patients with juvenile
arthritis, celecoxib 6
mg/kg twice daily was as
effective as naproxen
7.5mg/kg twice daily.
Foeldvari I et al. A prospective study comparing celecoxib with naproxen in
children with juvenile rheumatoid arthritis. J Rheumatol. 2009
Pediatric Pain: Pharmacological Management
Dose Guidelines for Non-opioid Analgesics
Pediatric pain management. (2010). Journal of American Medical Association
http://www.amacmeonline.com/pain_mgmt/printversion/ama_painmgmt_m6.pdf
Pediatric Pain: Pharmacological Management
NSAIDs Dose Guide
Drug Route Dose
Ibuprofen Oral < 20 kg
> 20 kg
5 – 10 mg/kg up to 6 hourly
200 mg 6 hourly
Diclofenac Oral/ Rectal 1 – 3
mg/kg
Up to 3 mg/kg in divided doses
Perioperative Analgesic Pharmacology in Children
http://www.anaesthesiauk.com/documents/perioperative_analgesic_pharm_for_children.pdf
Codeine
• Codeine is a poor opioid analgesic:
• causing more nausea and constipation than other opioids.
• It is available as an oral solution:
• the most commonly administered in young children.
• It is often given in combination with acetaminophen (10:1)
• Codeine’s analgesic effects derive from its metabolic
conversion to morphine via
• the enzyme O-demethylates
Pediatric Pain: Pharmacological Management
Methadone
• Methadone is available as an oral solution.
• It can provide excellent analgesia with TID dosing:
• because of its long half-life.
• Oral and intravenous doses are similar:
• oral bioavailability of 60% to 90%.
• It requires careful titration to prevent delayed sedation.
• Fatal respiratory depression may occur:
• with highest risk at initiation and with dose increases.
• QT interval prolongation & serious arrhythmia
• torsades de pointes.
Pediatric Pain: Pharmacological Management
Intravenous Opioids
• Opioids should be administered to children via
• oral or intravenous route.
• IM injections should be avoided.
• Intermittent IV boluses of morphine, hydromorphone or
fentanyl can provide rapid pain relief but for short duration:
• dosing interval should be every 2 to 4 hours.
• PCA or NCA used to avoid fluctuations in plasma conc.
• Meperidine is generally not recommended when other
opioids are available (toxic normeperidine: seizures).
Pediatric Pain: Pharmacological Management
Continuous Opioid Infusions
• For toddlers and children:
• initial morphine infusion rates are roughly: 1.25 mg/kg/hr.
• In newborns the initial infusion rates are much lower and
• range from 0.005 to 0.01 mg/kg/hr.
• Cardiorespiratory monitoring is required for infants less
than 3 months of age.
• Adjustment of these rates should be based on clinical
signs of either inadequate pain relief or increased
somnolence.
Pediatric Pain: Pharmacological Management
Patient Controlled Analgesia (PCA)
• With appropriate preop. teaching and encouragement,
children as young as 6 to7 y can use PCA pump.
• Children between 4 & 6 y, require encouragement from
their parents & nurses to push button before anticipated
painful movements or procedures.
• For infants and children unable to use PCA button, nurse
controlled analgesia (NCA) permit small titrated dosing of
opioids.
Pediatric Pain: Pharmacological Management
PCA
• Morphine is the most extensively studied in children.
• Basal infusions improve sleep quality:
• hypoxemia when used for postoperative pain management.
• One solution for this is to combine:
• PCA in bolus-only mode with
• round-the-clock adm. of NSAIDs and/or acetaminophen.
• For children with acute pain associated with chronic
illness, most developed some tolerance to opioids:
• larger basal infusion is preferred to control disease-related pain.
Pediatric Pain: Pharmacological Management
Topical Anesthetics
• Local anesthetics should be injected into the skin to be
effective.
• Topical anesthetics are available to provide pain relief
prior to needle-stick procedures that children must
undergo in the first 6 years of life.
Pediatric Pain: Pharmacological Management
Eutectic Mixture of Local Anesthetics (EMLA)
• Eutectic mixtures of LAs are effective in reducing pain
from dermatologic procedures, venipuncture etc.
• lidocaine/prilocaine and lidocaine/tetracaine
• EMLA cream must be applied in a thick layer.
• It requires 30 to 60 minutes to become fully effective.
• New topical approaches to improve outcomes with EMLA:
• patch delivery,
• heat enhanced delivery.
Pediatric Pain: Pharmacological Management
Infiltration of Local Anesthetics
• In urgent or emergent situations:
• infiltration of 1% lidocaine can reduce the pain associated with
venous or arterial cannulation.
• Intradermal injection pain can be lessened by:
• use of a smaller needle &
• buffering of LA with the addition of NaHCO3 (ratio 4:1).
• A bio-injector uses compressed CO2 to inject lidocaine
rapidly beneath the skin.
Pediatric Pain: Pharmacological Management
Regional Anesthesia and Analgesia
• Regional anesthetic techniques are used in children to:
• decrease GA requirements
• aid in postop. pain management.
• Multimodal analgesia provide optimal analgesia:
• LAs, NSAIDs and opioids.
• Single-shot caudal injections of LAs are
• easy to perform for outpatient surgeries.
• Continuous epidural analgesia via catheters:
• provide excellent postop. analgesia for extensive abdominal and
lower extremity procedures.
Pediatric Pain: Pharmacological Management
Dosing guide for bupivacaine,
levobupivacaine and ropivacaine
Single bolus
injection
Maximum
dosage
Continuous
Infusion
Maximum
infusion rate
Neonates 2 mg/kg Neonates 0.25 mg/kg/hr
Children 2.5 mg/kg Children 0.5 mg/kg/hr
Perioperative Analgesic Pharmacology in Children
http://www.anaesthesiauk.com/documents/perioperative_analgesic_pharm_for_children.pdf
http://ether.stanford.edu/library/pediatric_anesthesia/pediatric%20pain%20manage
ment%20and%20regional%20anesthesia/PostoperativePainControlInChildren.pdf
Recommended doses of paracetamol for
postoperative pain relief in children
Route of
administration
Loading
dose
(mg/kg)
Short term
maintenance
(mg/kg/day)
Long term
maintenance
(mg/kg/day)
Oral 25 – 30 80 60
rectal 35 – 40 80 Not
recommended
Oral route is preferable because of wide variations in bioavailability of rectal route.
Postoperative Pain Control in Children. Pediatr Drugs 2003; 5 (11)
Postoperative Pain Control in Children
Postoperative Pediatric Dosages of NSAIDs
Route of
administration
Single dose
(mg/kg)
Number of
daily doses
Maximum
Doses
(mg/kg/day)
Diclofenac
(po or pr)
1 – 2 1 – 3 2 – 4
Ibuprofen
(po or pr)
5 – 10 3 – 4 40
Ketorolac
(po)
0.2 – 0.5 3 – 4 1
Ketoprofen
(po)
1 – 2.5 2 – 3 5
Postoperative Pain Control in Children
Postoperative Pain Control in Children. Pediatr Drugs 2003; 5 (11)
Management of postoperative pain, 1
Minor surgery
Acetaminophen
+
Peripheral NB, caudal block, or wound infiltration
+
IV opioids in single doses, when needed.
Postoperative Pain Control in Children
Postoperative Pain Control in Children. Pediatr Drugs 2003; 5 (11)
Management of postoperative pain, 2
Major Surgery
(abdominal, thoracic, orthopedic, urogenital)
Acetaminophen and NSAID
+
Opioids
(continuous IV in children < 6 years &
PCA in children > 6 years)
OR
Regional Anesthesia
(continuous epidural or continuous paravertebral analgesia)
Postoperative Pain Control in Children
Postoperative Pain Control in Children. Pediatr Drugs 2003; 5 (11)
Recommendations from the American Pain
Society and the American Academy of Pediatrics, 1
1. Expand knowledge about pediatric pain & pediatric pain
management principles and techniques.
2. Provide a calm environment for procedures that reduce
distress-producing stimulation.
3. Use appropriate pain assessment tools and techniques.
4. Anticipate predictable painful experiences, intervene,
and monitor accordingly.
Pediatric pain management. (2010). Journal of American Medical Association
http://www.amacmeonline.com/pain_mgmt/printversion/ama_painmgmt_m6.pdf
Recommendations from the American Pain
Society and the American Academy of Pediatrics, 2
5. Use a multimodal approach to pain management:
• (pharmacologic, cognitive, behavioral, and physical)
6. Use a multidisciplinary approach when possible.
7. Involve families and tailor interventions to individual
child.
8. Advocate for the effective use of pain medication for
children to ensure compassionate and competent
management of their pain.
Pediatric pain management. (2010). Journal of American Medical Association
http://www.amacmeonline.com/pain_mgmt/printversion/ama_painmgmt_m6.pdf
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