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Evidence-Based
Pediatric Pain
- Terms
- Clinical Trials In Pain
Relief: 10 Challenges
- Evidence-Based Pain
Management For Infants
- NICU Procedures
- NICU Pain Protocol
- NOPAIN Trial
- EMLA and Newborns
- Sucrose And Newborns
- To
Make a "24%" Sucrose Solution
- Skin-To-Skin Contact as
Analgesia
- Pediatric
Postoperative Pain
- End Of Life:
Pediatric Cancer
- Effect Of
Distraction on Pain
- Pediatric Pain
Measurement
- Pediatric
Acute vs Chronic Pain
- Evidence-based practice
- Deliberate use of current best evidence from theory, clinical
expertise, and research in making decisions about patient care.
- Consider cost effectiveness and patient practitioner
preferences.
- Randomized controlled (clinical) trial (RCT)
- Experiment in which investigators randomly allocate eligible
people into treatment and control groups to receive or not to receive one or
more interventions that are being compared.
- Results are assessed by comparing outcomes in treatment and
control groups.
- Systematic Review
- Review of a clearly formulated question that uses systematic and
explicit methods to identify, select, and critically appraise relevant research
and to collect and analyze data from the reviewed studies.
- Statistical methods (meta-analysis) may or may not be used to
analyze and summarize the results of the reviewed studies.
- Avoid unnecessary duplication of effort.
Oxford Pain
Internet Site:
www.jr2.ox.ac.uk/Bandolier/painres/painpag//WOW/.
Pain, Palliative and Supportive Care Cochrane Collaborative Review
Group: www.cochrane.org
Best
Practice Network: www.best4health.org
- Use all existing trials to guide our clinical decisions.
- Improve the quality of RCTs in pain relief.
- Improve the quality of reporting the RCTs.
- Find better ways to present the results of trials to front-line
users.
- Ensure that all RCTs, once completed, are promptly available to
the users.
- Ensure that decision makers understand RCTs.
- Integrate findings of clinical trials with information from other
types of research.
- Balance the findings of clinical research with other ways of
knowing.
- Balance the findings of clinical trials with our values,
preferences, and circumstances.
Reference: Jadad AR & Cepeda MS:
Pain Clin Updates 7(2):1-4, 1999. Use of analgesia not related to NICU pain
protocol
- surgical pain management has improved
- procedural pain management has not improved
- several acute pain assessment tools have beginning reliability
and validity
- clinical utility of tools needs evaluation
- additional tools needed for VLBW infants, those with
developmental and neurologic deficits, and with chronic pain
- opioids are safe and effective, tolerance occurs, weaning is
necessary
- acetaminophen for procedure pain needs more study
- EMLA is effective for some procedures
- sucrose and non-nutritive sucking are analgesic
Reference: Stevens B and Koren G: Curr
Opin Pediatr 10:203-207, 1998.
Survey of 14 of 38 Canadian NICUs (11-93 to 2-94)
Daily
logs of procedures/analgesia for 1 week
| N = 239 infants |
(23 - 42 weeks) |
| Total of 2134 invasive procedures |
| Heelstick |
1298/0 |
| IV start |
451/0 |
| Venipuncture |
179/0 |
| Umbilical vessel cath |
31/0 |
ll
Analgesia given 17 times for 7 procedures:
| Arterial puncture |
88\2 |
| Et intubation |
35\2 |
| LP |
28\1 |
| Peripheral arterial line |
6\4 |
| Bladder cath |
6\1 |
| Chest tube insertion |
5\3 |
| Misc others |
7\4 |
Analgesia given for other reason (eg, surgery) during 129
procedures
Total analgesia/anesthesia for 6.8% invasive procedures
Use
of analgesia not related to NICU pain protocol
Reference: Johnston C and others: Clin J Pain
13(4):308-312, 1997.
Retrospective chart review of 31
infants 25-41 weeks
gestation, post abdominal surgery
N = 14 before pain protocol; PRN
intermittent IV opioids
N = 15 after pain protocol; continuous IV opioids
24-48 hrs.
Outcomes post pain protocol:
- less time to extubation; no reintubation
- less time to regain preop weight
- shorter length of stay
- fewer side effects of opioids
- overall lower MS dose for pain relief
- decreased hospital costs
Reference: Furden S., and others: J
Perinat Neonat Nurs, 12:58-69, 1998.
N = 69 neonates, 24-32 weeks' gestation intubated on ventilator
for < 8 hours within 72 hours of birth
| Continuous infusion |
Poor neurologic outcome
* |
Deaths |
| 1. MS |
4% |
0 |
| 2. Midazolam |
32% |
1 |
| 3. Dextrose |
24% |
2 |
* Intraventricular hemorrhage (IVH) or
periventricular leukomalacia (PVL) by cranial ultrasound
Reference: Anand, KS and others: Arch Pediatr Adolesc Med
153:331-338, 1999.
Review: 11 studies, 9 RCTs
Ns: 13-110 (26 weeks to
full-term)
| Procedures: |
| circumcision (3)** |
| heel lancing (4) |
| venipuncture (1)** |
| venipuncture/arterial (1)** |
| lumbar puncture (1) |
| percutaneous venous cath (1)** |
** Reduced physiologic / behavioral
signs
No methemoglobinemia from single dose
Reference: Taddio A and others: Pediatrics 101(2):299,
1998.
Review: 13 studies, all RCTs
| Meta-analysis: |
5 studies |
| N=271 |
|
|
4 term infants; 1 preterm |
|
4 heel lance |
|
1 venipuncture |
|
1 circumcision |
|
|
| Placebo control: |
water or no intervention |
| Sucrose solutions: |
3 - 50% |
| volume: |
0.05 - 2 ml |
|
| Administered by dropper, syringe, or
pacifier |
| Time before procedure: |
0.5 - 3 min. |
|
|
| Results: |
dose of 2 ml of 12% sucrose effective |
|
slight additional benefit from 24% |
|
no additional benefit from > 24% |
| No adverse effects reported, but also
not monitored |
Reference: Stevens B and others: Acta Pediatr 86:837-842,
1997.
- 1 measuring teaspoon table sugar + 4 teaspoons water
(20 ml)
metal teaspoon set = 4.24 gm sugar (21.2%)
plastic teaspoon set = 4.70 gm
sugar (23.5%)
- "packet" of sugar + 2 teaspoons water (10 ml)
average
packet = 2.9 gm sugar (29%)
| N = 30 |
fullterm newborns |
| RCT: |
diapered infant whole body contact |
|
against mother's chest |
|
control: swaddled in crib |
|
intervention 10 - 15 min.*** before heel
lance and during and post 3 minutes after lance |
| Outcome measures: |
% of time crying and facial grimace
and change in HR |
| Results: |
significantly reduced (P < .0001)
outcome measures in contact group |
|
crying reduced by 82% |
|
grimacing reduced by 65% |
*** Timing considered
critical but variations not tested.
Reference: Gray L and others: Pediatrics 105(1): E14, Jan.
2000.
Prospective study of analgesic use and pain
intensity on post-op day 1
3 hospitals in Spain ( 4-92 to 3-93)
N
= 348 (3-14 years)
- 52% of children were prescribed analgesic
- 26% of analgesics were written on fixed schedule: only 2/3 were
given as prescribed
- 51% "received no treatment whatsoever"
- Increased age NOT associated with increased dose
- 80% of analgesics were NSAIDs and paracetamol
(acetaminophen)
- most frequent route - rectal
- only 4 children received MS, fentanyl, or pethidine
(meperidine)
- 50% of children reported moderate to unbearable pain
(> 25% maximum intensity score)
- 20% of these reported severe to unbearable pain (> 50%
maximum intensity score)
Reference: Banos JE and others: Eur J Pain 3:275-282,
1999.
Survey of 103 parents whose child died of cancer (1990
-1997)
Interviews conducted average 3.1 years after death
Focused on
quality of life during last month of life
| Deaths: |
79% progressive disease |
|
21% treatment-related complication |
|
49% in hospital; 45% in ICU |
|
almost 50% of those in hospital had ventilator support during
last 24 hr |
| Parental reports: |
89% of children experienced
substantial suffering from one of 4 problems:
fatigue, pain, dyspnea, poor
appetite |
- More than 50% suffered from 3 or more of these problems
- Pain treated in 76%, successful in 27%
- Dyspnea treated in 65%, successful in 16%
- Documentation by MDs of symptoms significantly different from
parental report
- Involvement of hospice: child more calm, peaceful before
death
? effect on pain control not mentioned
Reference: Wolfe J and others: NEJM 342 (5):326-333,
2000.
| Meta-analysis of 19
studies (17 RCT; 2 repeated measures) |
| |
N=535, ages 3-15 yr,
M=6.6 yr. |
| |
Variety of distraction methods (e.g.,
music, party blower, kaleidoscope) |
| |
Variety of medical procedures (e.g.,
IV, LP, BMA, IM, dental) |
| |
Outcome measures: self-reported pain
and/or observed behavioral distress |
| Results: |
|
|
Pain - average
effect size: 0.62 (= or - 0.42) |
| |
Measurement + sampling error:
35% |
| |
Distraction did not decrease
perceived pain |
| |
Distress - average
effect size: 0.33 (+ or - 0.17) |
| |
Measurement + sampling error:
74% |
| |
Distraction did decrease observed
behavioral distress |
Reference: Ref: Kleiber C & Harper DC: Nurs Res
48(1):44-49, 1999.
- Child self-report instruments numerous with variable psychometric
support
- Child behavior instruments numerous with variable psychometric
support
- Infant behavior instruments numerous with variable psychometric
support—need more research with preterm infant
- Numerous comprehensive reviews exist (e.g., Finley & McGrath,
1998)
- Instruments for special populations extremely limited: examples:
- Cognitively impaired children (Fanurik & others,
1999)
- Sensory disorders—tactile scale for children with
impaired sight (Westerling, 1999)
- Research on clinical utility of scales very limited
- Extensive research on procedural and postoperative pain
- Strong research on selected diseases, e.g., cancer and sickle
cell disease
- Very limited research on chronic pain (McGrath & Finley,
1999)
TAKE A PROJECT AND MAKE A
DIFFERENCE GOLDEN RULES FOR PAIN RELIEF
Whatever is painful to adults, is painful to children until proven
otherwise.
Pain control must be based on scientific facts, not on
personal beliefs or opinions.
References
Bibliography: Evidence Based Pediatric
Pain
Practical Application Of Evidence-Based
Practice
Guidelines For Pain Management During Newborn
Circumcision
Guidelines For Atraumatic Skin/Vessel
Punctures
Bibliography: Evidence Based Pediatric
Pain
"Ouchless" Emergency Department
(Kennedy & Luhmann, 1999)
Guidelines For Critical Review Of Pain Measurement Tools (Hester,
1993)
Guidelines For The Management Of Acute And Chronic Pain In Sickle
Cell Disease (American Pain Society,
1999)
Quick Reference Guide For Clinicians: Acute Pain Management In
Infants, Children And Adolescents: Operative And Medical Procedures (Agency For Health Care Policy And Research,
1992)
Cancer Pain Relief and Palliative Care in Children (WHO, 1998)
March 15, 2002
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