Page 279 Guide to Pain Management in Low-Resource Settings

Pain Management in Children 267

patients on infusion. All children on opioid medica- neuropathic pain. Pharmacological management must
tion should be monitored carefully for at least the fi rst be combined with supportive measures and integrative,
24 hours, including children on PCA without back- nonpharmacological treatment modalities such as mas-
ground infusion. Sedation always precedes respiratory sage, acupuncture, relaxation, and physiotherapy. Physical
depression in opioid overdose. Th erefore, observation methods include a cuddle or hug from the family, mas-
of the patient’s alertness is the key to safety monitoring. sage, transcutaneous electrical nerve stimulation, com-
A monitoring frequency of check-ups every 4 hours is fortable positioning, physical or occupational therapy, as
considered to be safe to detect increasing sedation. A well as rehabilitation. Cognitive-behavioral techniques
decrease of respiratory rate below 30% of basal resting include guided imagery, hypnosis, abdominal breathing,
value may also be used as an alarm parameter. Oxygen distraction, and storytelling. Th e treatment plan should
saturation is a better monitor than apnea/respiratory include passive, and if possible, active coping skills, to be
rate monitors as it would detect airway obstruction ear- implemented considering the child’s wishes and those of
lier, but for the average situation and patient outside the his or her family.
intensive care ward, there is no indication that regular
sedation control would be inferior to pulse oximetry.
Pearls of wisdom

A diff erent story: do children • For eff ective pain management in children, it is
also experience chronic pain? very important to know how to assess pain in dif-
ferent age groups.
Yes they do, but little is known about the epidemiology • For perioperative pain management it is neces-
of chronic pain in children, even in the affl uent coun- sary to have basic knowledge of the specifi c phar-
tries. Chronic pain is commonly observed in adoles- macokinetics and pharmacodynamics in this spe-
cents. Common conditions are headache, abdominal cial age group.
pain, musculoskeletal pain, pain of sickle cell disease, • Th ere should be an analgesia plan or algorithm
complex regional pain syndrome, and post-traumatic or available on the ward for typical therapeutic situ-
postoperative neuropathic pain. Children with cancer or ations. Nonpharmacological treatment options
AIDS suff er from varying degrees of pain as the disease should be integrated into the analgesia plan.
progresses. Recurrent pain becomes chronic because of • Apart from perioperative pain management, a ba-
failed attempts to adjust and cope with an uncontrol- sic ability to diagnose and manage simple chronic
lable, frightening, and adverse experience. Over time it pain syndromes should be available. Th e majority
is the weight of this experience that leads the patient to of patients, almost 80–90%, may be managed by
develop concomitant symptoms of chronic physical dis- simple means, which should be available even in
ability, anxiety, sleep disturbance, school absence, and remote or very low-resource environments. Only
social withdrawal. Parents report severe parenting stress a small percentage of patients need invasive tech-
and dysfunctional family roles. Th ere is a greater psy- niques like epidural analgesia, which might be
chological element in chronic pain as compared to acute limited to referral centers.
pain as in adults. • With regard to monitoring of analgesia side ef-
fects, nothing can substitute for vigilance and fre-
How is chronic pain quent clinical assessment.
in children treated? • No child should be withheld adequate and safe
analgesia because of insuffi cient knowledge.
Assessment of chronic pain should establish not only
the site, severity, and other characteristics of pain, but
also the physical, emotional, and social impact of pain. Table 4
Dose of caudal bupivacaine (0.125–0.25%)
Treatment should include specifi c therapy directed
0.5 mL/kg for penile and anal surgery
to the cause of pain and associated symptoms such as
0.75 mL/kg up to lumbar spine
muscle spasms, sleep disturbance, anxiety, or depression.
1.00 mL/kg up to T10
Standard analgesics such as NSAIDs and opioids may be
1.25 mL/kg upper abdominal up to T6
used, along with antidepressants and anticonvulsants in