Page 208 Guide to Pain Management in Low-Resource Settings

196 Glenda E. Gray et al.

program. She has a history of a single episode of broncho- it distributed, and what triggers it? It is necessary to
pneumonia, for which she was hospitalized and received look at the developmental level of the child, and to en-
intravenous antibiotics at the age of 2 months. She has no courage parent and child communication on pain (see
known tuberculosis (TB) contacts, and a tuberculin skin the chapter on pain management in children). Th e
test done in the ward was nonreactive. Her mother com- history and examination should attempt to delineate
plains that she is “weak,” is not drinking well, and has had the area where pain is occurring. Children may com-
persistent sores in her mouth for more than 2 months de- plain about having pain “all over” and may not be able
spite treatment with oral Mycostatin drops. On examina- to tell health care workers the exact location of the
tion she is 79% of her expected weight for her age, with pain. Training parents and caregivers to observe their
generalized lymphadenopathy, severe oral candidiasis ex- children may provide helpful insights into the origin,
tending into her pharynx, and a 3-cm hepatomegaly. severity, and nature of the pain. It is very important
to treat the underlying cause of the pain in addition to
Should we be bothered about procedural pain prescribing analgesia. If the pain is treatment related,
in HIV-infected children?
the drug causing the pain should be switched (e.g., an-
Children infected with HIV experience frequent needle tivirals ddI or D4T for peripheral neuropathies), and
pricks for procedures such as venipuncture to obtain an alternate drug used. If the pain is due to an under-
blood samples, intravenous insertion, injection of medi- lying infectious disease, part of the pain management
cation, or immunizations. Children who are hospital- should be to treat the underlying infection.
ized may experience nasogastric tube insertion, lumbar
punctures, and bone marrow aspirates. Painless, but What treatment can we prescribe for
anxiety-provoking procedures such as CT scans, X-rays, HIV-infected children who are in pain?
or magnetic resonance imaging can also cause distress.
Th e cause of the pain needs to be established. Th e
A study by Staff ord (1991) found that 22 children with
health care worker can initiate pain relief with
HIV experienced a total of 139 painful procedures in
paracetamol (acetaminophen) (30 mg/kg every 4–6
1 year. Th e management of procedural pain should be
hours). Th erapy should be given regularly, not “as neces-
considered by doctors and nurses who look after HIV-
sary.” If this regimen does not relieve the pain, codeine
infected children both for outpatient and in-hospital fa-
phosphate can be added to the paracetamol and given
cilities. Children should be provided with a multicom-
every 4–6 hours. Th e next step is morphine 0.4 mg/
ponent package, based on cognitive-behavioral therapy,
kg orally or 0.2 mg/kg i.v. every 4 hours, which can be
that teaches eff ective coping skills and could include:
increased by 50% or more with each subsequent dose
preparation, rehearsal, breathing exercises for relaxation
until pain is controlled. Once pain control has been
and distraction, positive reinforcement, and pharmaco-
achieved, the total daily amount of soluble morphine is
logical approaches.
divided into 12-hourly doses and given as long-acting
morphine sulfate in a controlled-release form. Neither
Should parents be asked to leave the room
when a HIV-infected child undergoes addiction nor respiratory depression is a signifi cant
a procedure? problem when morphine is used to produce analgesia.
A side eff ect of morphine is constipation. Drowsiness
Th ough children tend to display more behavioral dis-
and itching can occur initially on initiation of morphine.
tress when a parent is present, children prefer to have
their parents present and may experience less subjective
How can painful oral lesions be managed?
distress. In addition, parents generally prefer to be to be
present when their children undergo a medical proce- Symptomatic relief for stomatitis and other painful oral
dure. Th e parent can encourage and coach the child and lesions can be achieved by avoiding irritating food like
reinforce coping strategies. orange juice, by using a straw to bypass the oral lesions,
and by giving cold food, ice cubes, and popsicles. Topi-
How do we assess pain cal medications such as lidocaine 2% (20 mg/mL) can
in HIV-infected children? be used before meals, applied directly to the lesions in

It is important to defi ne the characteristics of the older children to a maximum of 3 mg/kg/day (not to be
pain: How intense is it, what is the quality, where is repeated within 2 hours).