Page 271 Guide to Pain Management in Low-Resource Settings

Pain Management in Children 259

Fig. 2. Adapted pain intensity scales (left: pain ladder, right: modifi ed VAS-scale).

3) Respiratory rate cultural beliefs, experience nightmares related to pain,
4) Body movements and crying (AIIMS, FLACC, exhibit stalling behaviors (e.g., “Wait a minute” or “I’m
OPS) not ready”), have muscular rigidity such as clenched
5) Crying is also the ultimate expression of the fi sts, white knuckles, gritted teeth, contracted limbs,
non-pain-related needs of a child such as hunger, body stiff ness, closed eyes, or wrinkled forehead, en-
thirst, anxiety, or parental attention. Th ese factors gage in the same behaviors listed for preschoolers/
should be carefully excluded before considering crying young children, or be unable to sleep.
as a sign of pain. 5) Adolescents may localize and verbalize pain,
deny pain in the presence of peers, have changes in
Do children express their pain
sleep patterns or appetite, be infl uenced by cultural be-
in the same manner as adults?
liefs, exhibit muscle tension and body control, display
No, they do not. Due to developmental diff erences, pain regressive behavior in the presence of the family, or be
expression varies among diff erent pediatric age groups. unable to sleep.
1) Infants may exhibit body rigidity or thrash-
ing, may include arching, exhibit facial expression of Can you assess pain intensity in children
pain (brows lowered and drawn together, eyes tightly by just looking at their behavior?
closed, mouth open and squarish), cry intensely/loudly, As every child has individual strategies of coping with
be inconsolable, draw knees to chest, exhibit hypersen- pain, behavior can be very nonspecifi c for estimation
sitivity or irritability, have poor oral intake, or be un- of pain levels. For example, a school-age girl may spend
able to sleep. hours playing normally with a toy. At fi rst sight, you
2) Toddlers may be verbally aggressive, cry in- may think she is happy and not in pain. But this could
tensely, exhibit regressive behavior or withdraw, exhibit be her behavioral expression for coping with pain (by
physical resistance by pushing painful stimulus away af- distracting her attention from pain and attempting to
ter it is applied, guard painful area of body or be unable enjoy a favorite activity). Th ough a child’s behavior can
to sleep. be useful, it can also be misleading. Using a pain rat-
3) Preschoolers/young children may verbalize inten- ing scale and looking at physiological indicators of pain
sity of pain, see pain as punishment, exhibit thrashing of (changes in blood pressure, heart rate, and respiratory
arms and legs, attempt to push a stimulus away before rate) in addition is recommended.
it is applied, be uncooperative, need physical restraint,
cling to a parent, nurse, or signifi cant other, request Are children able to tell you
if and where they hurt?
emotional support (e.g., hugs, kisses), understand that
there can be secondary gains associated with pain, or be Studies have shown that children as young as 3 years of
unable to sleep. age are able to express and identify pain with the help of
4) School-age children may verbalize pain, use pain assessment scales, accurately. Children are able to
an objective measurement of pain, be influenced by point to the body area where they are experiencing pain