Page 274 Guide to Pain Management in Low-Resource Settings

262 Dilip Pawar and Lars Garten

Table 1
Clinical bedside pain assessment scale
No pain Child can cough eff ectively
Mild pain Child can breathe deeply but cannot cough without distress
Moderate pain Child can breathe normally but cannot cough or take a deep breath without distress
Severe pain Child is distressed even during normal breathing

Table 2
Parental assessment scale
No pain Playful, comfortable in bed, no discomfort in turning over, calm face, when crying
easily comforted by parents
Mild Complains of discomfort at the site of surgery on movement
Moderate Facial grimace present, pain and discomfort at site of surgery on movement
Severe Persistent crying and restlessness, pain even without movement

Are simple bedside assessment tools available? for treatment of moderate to severe pain. For mild to
moderate pain therapy, use nonpharmacological meth-
In the clinical practice of the All India Institute of Medi-
cal Sciences (AIIMS) in New Delhi, a clinical bedside ods, and a formula of 30% sucrose with a pacifi er. Local
anesthetics can be used for wound care (see Table 7 for
pain assessment scale and a parental assessment scale
have been developed (Tables 1 and 2), which have prov- frequently used drugs and their dosage regimes.)
en helpful even with illiterate parents.
What do the pain management terms “by the
ladder,” “by the clock,” “by mouth,” and “by the
Pain management child” mean?
Pain management in children should follow the WHO
What drugs can be used for eff ective
pain control in children? analgesic stepladder (“by the ladder”), be administered
on a scheduled basis (“by the clock,” because “on de-
Local anesthetics for painful lesions in the skin or mu- mand” often means “not given”), be given by the least
cosa or during painful procedures, e.g., lidocaine, TAC invasive route (“by mouth”; whenever possible give pain
(tetracaine, adrenaline [epinephrine], cocaine) or LET medication orally and not by i.v. or i.m. injection), and
(lidocaine, epinephrine, and tetracaine). be tailored to the individual child’s circumstance and
Analgesics for mild to moderate pain (such as needs (“by the child”).
post-traumatic pain and pain from spasticity), e.g.,
paracetamol (acetaminophen) or nonsteroidal anti-in- What nonpharmacological methods can
fl ammatory drugs (e.g., ibuprofen or indomethacin). be used to relieve pain, fear, and anxiety
Opiates for moderate to severe pain not respond- in children?
ing to treatment with analgesics, e.g., codeine (moderate If the child and parents agree and if it helps, the follow-
pain, alternatives are dihydrocodeine, hydrocodone, and ing additional methods (for local adaption) can be com-
tramadol) and morphine (moderate to severe pain; al- bined with pain medications.
ternatives are methadone, hydromorphone, oxycodone, • Emotional support (whenever possible allow par-
buprenorphine, and fentanyl). ents to stay with their child during any painful
Note: aspirin is not recommended as a fi rst-line an- procedures).
algesic because it has been linked with Reye’s syndrome, • Physical methods (touch, including stroking,
a rare but serious condition aff ecting the liver and brain. massage, rocking, and vibration; local application
Especially avoid giving aspirin to children with chicken of cold or warm; controlled deep breathing).
pox, dengue fever, and other hemorrhagic disorders. • Cognitive methods (distraction, such as singing
In neonates and infants up to 3 kg body weight, or reading to the child, listening to the radio, play
opioids alone have been shown to be eff ective drugs activities, or imagining a pleasant place).