New guidance available on how to assess and manage pain in children

The Canadian Paediatric Society (CPS) has developed a new statement on the assessment and management of pain in children. The document stresses that pain assessment and management are essential components of pediatric care. Pain is underevaluated in many settings, especially in the youngest children and children who are cognitively impaired. Suboptimal pain management can have short- and longer-term negative consequences, including progression of acute discomfort and distress, increased fear and pain during subsequent medical visits, the development of chronic pain, and future avoidance of medical care. Adequate pain management is associated with faster recovery and reduced utilization of healthcare resources. Assessment Appropriate assessment of pain includes pain location, quality, duration and intensity, using a developmentally appropriate tool, as well as repeated assessment(s) post-intervention. In chronic pain, a child’s psychosocial context, with impacts on daily life (e.g., family, sleep, play, school), should also be assessed. Whenever possible, children’s pain should be self-reported. The CPS statement reviews the three most recommended self-reported pain scales: the verbal Numeric Rating Scale-11 (NRS-11), the Faces Pain Scale-Revised (FPS-R), and the Color Analogue Scale (CAS). No single self-report scale has been strongly endorsed for children under six years of age or for the assessment of chronic pain. Observational pain measures and scales are also discussed in the CPS statement. They can help determine discomfort level in preverbal and nonverbal children, by evaluating behavioural signs such as facial expressions, crying, irritability, poor feeding, sleep disturbance and inactivity. Recommended self-reported and observational pain scales are summarized in a table in the CPS statement, including recommended age group, indications (acute, procedural, post-op, chronic pain) and specific comments. The CPS recommends evaluating a child’s pain at the first encounter, with regular reassessments during care. The same scale(s) should be used for each assessment. The goals of pain measurement are to relieve children’s pain and assess their response to treatment. Treatment Pain can be treated early without affecting diagnostic accuracy. Pain relief often makes examination and testing easier, thereby facilitating diagnosis. Pain treatment includes pharmacologic therapy, but concomitant physical and psychological therapies are equally importantly. First-line medications Over-the-counter (OTC) analgesics (e.g., acetaminophen, ibuprofen) can be used as monotherapy for mild to moderate pain or as co-therapy for moderate to severe pain. Ibuprofen is more effective than acetaminophen for the treatment acute pain, musculoskeletal trauma, headache and post-dental extraction pain in children and has a comparable safety profile. Ibuprofen is also comparable to oral morphine for sprains, simple fractures and following minor orthopedic procedures and tonsillectomy, with a lower risk of adverse events. Combining acetaminophen and ibuprofen to manage dental extraction or tonsillectomy pain is superior to acetaminophen used alone. Children with acute moderate to severe pain that is unlikely to be resolved by physical and psychological strategies and first-line analgesics should be offered further pharmacological therapy on an escalating basis. Opioids should be used judiciously, with appropriate dosing assessment to minimize adverse events, and careful monitoring. OTC analgesics should be continued due to their opioid-sparing effects and to reduce adverse events. Codeine should never be used in children under 18 years of age. When opioids are required at hospital discharge, prescriptions should be written for no more than five to 10 doses, over a two- to three-day period. Chronic pain is best managed by combining treatment modalities, including psychological, physical, occupational and pharmacological therapies. Treatment should be individualized, with consideration given to symptom severity, level of function, co-morbidities (including anxiety or depression), and the child’s and family’s ability to actively engage in therapy. The main goals are functional improvement and relief of symptoms. In children with severe functional disability, or when symptom intensity has not improved despite multimodal outpatient treatment, referral to an interdisciplinary chronic pain treatment program is needed. The CPS document includes a table summarizing the recommended doses of oral, intranasal and intravenous doses of pain medications for children and youth, along with specific notes and contraindications. Parents and caregivers should be counselled and trained in appropriate pain assessment and management and provided with clear instructions for therapy and medication use at home. Reference 1. Trottier ED, Ali S, Doré-Bergeron MJ, et al; Canadian Paediatric Society, Acute Care Committee, Hospital Paediatrics Section, Paediatric Emergency Medicine Section. Best practices in pain assessment and management for children. https://cps.ca/en/documents/position/pain-assessment-and-management (accessed December 1, 2022).

New guidance available on how to assess and manage pain in children

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