Page 82 Guide to Pain Management in Low-Resource Settings

70 Richard A. Powell et al.

even at this age, are able to express their pain using sim- Adolescents (13–18 years)
ple language. Health care providers should be sensitive Adolescents may verbalize their pain, deny pain in the
to such developmental diff erences.
presence of their peers, have changes in sleep patterns
or appetite, be infl uenced by cultural beliefs, exhibit
Preschoolers (3–5 years)
muscle tension, display regressive behavior in the pres-
Preschool children may verbalize the intensity of their
ence of their family, or be unable to sleep.
pain, see pain as a punishment, thrash their arms and
At this age, the child can appear relatively un-
legs, attempt to push stimuli away before they are ap-
communicative or express a disdainful disposition.
plied, be uncooperative, need physical restraint, cling
Th is tendency can in part be countered by the health
to their parent or guardian, request emotional support
care provider expressing genuine interest in what the
(e.g., hugs and kisses), or be unable to sleep.
adolescent has to say, avoiding confrontation or gener-
At this age, as for school-aged children (see be-
ally negative sentiments (which can cause anxiety and
low), the child needs to be able to trust the health care
avoidance), focusing the conversation on the adoles-
provider, who needs to overcome the child’s potential
cent rather than the problem (e.g., by asking informal
reservations concerning strangers and perceived au-
questions about friends, school, hobbies, family), and
thority fi gures. Th is aim can be achieved by conducting
avoiding deliberate moments of silence, which generally
the assessment process at a tempo, in a language, and
prove unproductive.
with a demeanor that is suited to the child (e.g., taking
As a consequence of this diversity across age
more time, where possible, using open-ended questions
groups (especially in children’s cognitive abilities to
to encourage children to discuss what they are experi-
comprehend what is being asked, and verbal abilities to
encing, and using appropriately supportive and encour-
articulate what is being thought or felt), the pain evalu-
aging body language).
ation tool selected for the assessment process must be
appropriate to the individual child. Moreover, given
School-aged children (6–12 years)
that behavior alone is not necessarily a reliable indica-
Th e school-aged child may verbalize pain, use an objec-
tor of experienced pain, and self-reporting has potential
tive measure of pain, be infl uenced by cultural beliefs,
limitations, a pain rating scale should ideally be used in
experience pain-related nightmares, exhibit stalling be-
conjunction with an investigation of physiological pain
haviors (e.g., “Wait a minute” or “I’m not ready”), show
indicators, such as changes in blood pressure, heart rate,
muscular rigidity (e.g., clenched hands, white knuckles,
and the patient’s respiratory rate (see Chapter 26 on
gritted teeth, contracted limbs, body stiff ness, closed
Pain Management in Children for additional informa-
eyes, or wrinkled forehead), engage in the same behav-
tion).
iors as preschoolers, or be unable to sleep. At this age,
the child may be more reserved, feeling genuine fears
Does pain assessment diff er
and anxieties (e.g., they may deny the presence of pain
because they fear the consequences, such as a physical with the aged?
examination or injection).
Aged patients present additional challenges in that
However, school-aged children are more articu-
they may be visually or cognitively challenged, hearing
late and cognitively advanced. As such, they are more
impaired, or infl uenced by socially determined norms
curious about their own body and health and may ask
regarding the reporting of negative feelings (e.g., not
spontaneous questions of the health care provider (e.g.,
wanting to appear to be a social burden). Geriatric pa-
“What is happening to me?” “Why do I have a stomach-
tients (i.e., patients with advanced biological age with
ache?”). Th ey can also begin to understand cause and
multiple morbidities and—potentially—multiple medi-
eff ect issues, enabling the health care provider to give
cations) are especially problematic when they have de-
them age-sensitive explanations (e.g., “You have a pain
mentia. Such patients normally receive inadequate an-
in your stomach because you have a lump there which
algesia due to their inability to communicate their need
is making it hurt”). Th ey also may want to be involved
for it. (Defi ning “the aged” in low-resource settings can
in their own clinical care and, where possible, be given
be problematic. Th e United Nations defi nition of “older
choices about what will happen to them.
people” is commonly associated with a legal entitlement