Page 268 Guide to Pain Management in Low-Resource Settings

256 Dilip Pawar and Lars Garten

morphine) followed by enteral morphine (if the child to be “opioid-resistant,” start oral morphine medication
needs to be ventilated, use morphine i.v. infusion) on a on a regular basis as fi rst-line therapy, and increase
regular basis for ongoing background pain. For any ad- the dosage if an additional reduction in pain without
ditional procedures, e.g., change of dressing, use an ad- dangerous medication side eff ects is possible. Try non-
ditional morphine bolus as necessary. Th ink also about steroidal anti-infl ammatory drugs in addition. Com-
anxiety management, which plays an important role in bine medication with nonpharmacological methods.
children with burns. Often the use of benzodiazepines If there is no satisfactory pain relief with this regime
such as oral lorazepam or i.v. midazolam is benefi cial. sometimes the use of adjuvants (e.g., gabapentin, tricy-
Combine medication with nonpharmacological methods clic antidepressants, or anticonvulsants) has to be con-
(see below). Use a behavioral pain assessment scale (e.g., sidered—application of adjuvants should be done by
the FLACC scale) for monitoring pain severity and as- experienced pain specialists.
sessing the eff ect of your therapy. When pain decreases,
wean the patient off the medication.
What is the present status of pain
Case report 2 (“postoperative pain in the management in children?
neonate”)
Despite the fact that we understand pediatric pain bet-
Joyce, a 7-day-old newborn baby, was operated on for
ter now, children tend to receive less analgesia than
esophageal atresia. Now the nurse reports that the child
adults, and the drugs are often discontinued sooner. Th e
seems to be in great pain. How can you assess and treat
safety and effi cacy of analgesic drugs are not well stud-
the pain in this child?
ied in this age group, and the dosages are often extrapo-
Th e baby suff ers from acute postoperative pain.
lated from adult studies or pharmacokinetic data. Also,
Evaluate the pain with help of a pain rating scale for ne-
the fear of respiratory depression and addiction to opi-
onates and infants (e.g., NIPS). After major surgery you
oids are two important issues for reduced usage of these
should expect moderate to severe pain. Th e baby needs
potent analgesics in children.
very close monitoring in a neonatal intensive care unit.
Th e major problem in treating pain in children, es-
Use i.v. morphine for pain management, combined with
pecially younger ones, is the diffi culty of pain assess-
nonpharmacological methods.
ment. When we cannot assess pain levels or pain relief
Case report 3 (“cancer pain”) eff ectively, we are not sure which pain relief measures
are needed and when. Th e other important factor in
Dhanya, a 10-year-old girl with an incurable meta-
most of the developing countries (where 80% of the
static tumor of the bone who is on oral paracetamol
world’s population lives) is the lack of infrastructure in
(acetaminophen) and codeine, is experiencing increased
terms of availability of trained nursing staff or lack of
pain. How could you help her? Assess pain with, e.g., the
drugs and equipment for even simple procedures.
Faces pain rating scale. If paracetamol and codeine are
at maximum dose, a change of opioid is necessary. Stop
codeine and start oral morphine medication. Continue What is the physiology
oral morphine on a regular basis at home, after instruct- of pain in children?
ing the parents properly. Th ink of opioid side eff ects—if
not already started, begin prophylactic therapy by giv- Right or wrong? Procedures such as circumcision, su-
ing preventive remedies. Combine medication with non- turing, or other minor operations on young infants can
pharmacological methods. be performed without anesthetic or pain medication,
because children’s nervous systems are immature and
Case report 4 (“neuropathic pain”) unable to perceive and experience pain as adults do.
Nasir is a 6-year-old boy suff ering from AIDS. He is Wrong. Even neonates respond to noxious stimula-
brought to you by his parents. He is on antiretroviral tion with signs of stress and distress. Today, we know
therapy but has severe neuropathic pain in his legs re- that a 24-week-old fetus possesses the anatomical and
lated to the HIV infection. What would be your fi rst neurochemical capabilities of experiencing nocicep-
line of therapy? Assess pain with, e.g., the Faces pain tion, and related research suggests that a conscious
rating scale. Even if neuropathic pain is often declared sensory perception of painful stimuli is present at these