PAIN
PREVENTION IN CHILDREN
Evelyne
Pichard-Leandri
Centre for
the Diagnosis & Treatment of Pain in Adults and Children Institut Gustave
Roussy,
Introduction.
The development of paediatrics and its associated techniques has been
accompanied by an increase in the number of diagnostic, radiological, surgical
and biological investigational procedures performed outside the operating room.
Different sedatives and/or analgesics are, as a consequence, being administered
in diverse settings (the paediatrician's practice, the dentist's practice,
emergency unit), beyond the anaesthetist's control. This has immediately posed
safety-related problems.
A consensus
is still awaited for extremely different practices but we will try to formulate
a few rules. Which examinations are painful? How to assess the pain caused?
What is the investigational setting? How can painful invasive tests be
organised? and, if possible, how can they be avoided? Finally, how to choose
and design a protocol for the prevention of iatrogenic or inflicted pain? These
are the questions that care-providers have to address and that we will try to
deal with here.
What
examinations are painful? How to evaluate them?
Results of a
survey. In 1989, a survey conducted in the General
Paediatric Unit headed by Prof. Dommergues (University Hospital Bicétre)
attempted to evaluate the prevalence of pain in children hospitalised by
interviewing parents, children and nurses.
First
observation: a divergence was noted between parents' feelings, what the child
was experiencing and what the nursing staff was experiencing; children and
parents being more sensitive or more vulnerable to pain perception.
Painful
examinations were vein punctures, access to vein puncture sites, dressings,
lumbar puncture, bone marrow aspiration, placement of various catheters but
also physiotherapy, rehabilitation, placement of a gastric catheter,
fiber-optic exploration of the oesophagus, pharyngeal aspiration, collection of
micro-specimens, radiological examinations with injection of contrast medium,
limb immobilisation for perfusion, scintigraphy, adhesive sterile pouch for
urine collection.
Methods for
assessment of treatment. Induced acute pain. Although it is
easy for a child older than 6 to use a self-administered evaluation, it is a
far a more delicate matter for children younger than 5 or 6 years for whom only
behaviour or acute distress scores exist.
Setting in
which painful events occur. Numerous factors have an influence on the impact of
pain on the child and how pain is felt by the child: culture, age, degree of
anxiety, means of communication, degree of anxiety in parents, the extent to
which the procedure is invasive, the duration of the procedure, the child's
fears and expectations, the child's ability to cope, how vulnerable he/she is,
his/her past history, the prognosis of the disease, the confidence
care-providers, parents, and the child have in sedation or drugs and in
particular, in opioids.
How can
these problems be dealt with? How to deal with these problems can be summarised
in three points:
1) Organise
investigational diagnostic procedures:
a) avoid
them: Ask the question: Is the examination necessary? Why has it been requested.
Whet information will the result provide? This is how we realise that some
examinations could be avoided;
b) replace
painful tests by a less painful one: e.g. using a pulse oximeter avoids an
arterial puncture, grouping investigational procedures, the timing of the
procedure for which the nurse's opinion can be decisive (here the nurse can
protect the child);
c) choice
of instruments: all current efforts are being directed towards the quality of
the instruments, their adaptation or the decision to collect micro-samples
thanks to very fine needies;
d) alternatives
to painful procedures: the venous access can be replaced by the oral route,
rectal route, etc.;
e) organising
investigational procedures: this involves respecting the environment improving
comfort to attenuate stress and pain, preparing the child (informing,
comforting, supported as much as possible by the participation of the parents).
2)
Administration of medication:
a) local
anaesthetics: 2 techniques can be used in children. Direct injection with doses
of lidocaine (maximum 2 to 5 mg/kg) and percutaneous analgesics (EMLA®
ointment);
b) analgesics:
these are level 11 drugs such as Nabulphine, Codeine or level 111 drugs such as
Morphine, Fentanyl or other compounds under evaluation;
c) sedatives:
They are not analgesics. They induce amnesia which makes the patient forget the
procedure. They are: Diazepam, Midazolam intravenously or via the rectal route.
Finally, a mixture of equivalent moles of oxygen and nitrous oxyde (Entonox®)
has been used for a long time in the Scandinavian countries. There is still
occasionally hesitation to adopt its use although it is a sedative analgesic
which does not induce loss of laryngeal reflex and has demonstrated it
beneficial non toxic effects for millions of painful procedures world-wide.
How to
choose and what to choose? Choosing a medication strategy and a mode of
administration depends on the pain and/or the place. We propose a simple model
used by our team which respects safety regulations and which could be a basis
for discussion for providing such care.
Conclusion.
Medical teams are all conscious of the fact that daily procedures are painful
and traumatic for children.
A number of
solutions exist and among them are drugs, the logical allies of other techniques
that are rigorously organized.