8 Pain management

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Contents

• Objectives
• Introduction to pain
• Types of pain
• Pain assessment in children
• Pain management in children
• Morphine use in children
• Management of specific pains
• Case studies

Objectives

Once you have completed this chapter you should be able to:

1. Define and classify pain according to duration, type and cause.
2. Understand the meaning of total pain.
3. Know how to complete a thorough pain assessment.
4. Know how to use age appropriate pain rating scales.
5. Understand and apply the general principles of pain management.
6. Explain how to use morphine and co-analgesics.
7. List the different types of pain children experience.
8. Describe how to manage procedural pain in children and newborn babies.

Introduction to pain

8-1 What is pain?

Pain is an unpleasant feeling or emotional experience that is associated with actual or potential damage to tissue. It is subjective, meaning it is what the patient experiences.

We must remember that:

• Pain is a common reason to consult a doctor.
• It is a major symptom in many medical conditions.
• It has physical, emotional and spiritual causes.
• It can and does interfere with a person’s quality of life and general functioning.
• It is common for people with ongoing pain to have more than one type of pain.

Pain is subjective and is what the patient says hurts.

See chapter 7 to understand more about spiritual pain.

8-2 What are some of the incorrect beliefs about pain in children?

Common incorrect ideas or myths about pain are:

• Children do not feel pain to the same degree as adults.
• Babies do not feel pain.
• Pain cannot be assessed accurately in children, especially if they cannot tell you.
• Pain does not exist if there is no detectable tissue damage.
• Children will always tell you when they are in pain.
• Children get used to pain.
• Pain relief medications especially opioids are too dangerous for use in children.
• Children will always become addicted to pain relief medications if used for long periods.

8-3 What can happen if pain is left untreated in children?

Children feel pain in exactly the same way as adults do. Therefore, untreated pain can have the following affects:

• Untreated acute pain can lead to metabolic changes that increase morbidity and even mortality.
• Untreated acute pain can result in chronic pain.
• Exposure to painful procedures, especially in newborn babies, can reset the pain threshold for the rest of the child’s life.
• Untreated pain can cause anxiety, depression, irritability and exhaustion.

If pain is not managed well it can have long-lasting effects on how a child will cope with pain for the rest of their life.

8-4 What happens when you do treat children’s pain?

When a child’s pain is well treated the following can happen:

• Morbidity and even mortality can be decreased.
• The child’s quality of life can be improved.
• Insomnia (poor sleeping) can be reduced.
• Depression in older children and adolescents can be lifted, especially if they are experiencing chronic pain.

Types of pain

8-5 Are there different types of pain?

Yes, there are different types of pain children can experience:

• Acute pain which is sudden and is short lived
• Chronic pain which lasts for a longer period of time and is more difficult to treat
• Breakthrough pain which often occurs in between regular dosing of pain medication
• Bone pain caused by breaking of bones or invasion of bone by a disease process such as cancer
• Soft tissue pain which is caused when organs, muscles or other tissues such as skin and mucosa are inflamed or damaged by trauma or the disease process
• Nerve pain occurs from compression or damage to nerves
• Pain which occurs with specific movements or activities
• Pain which is caused by procedures such as taking of bloods, lumbar punctures or dressing of wounds
• Referred pain is when pain from one part of the body is felt in another part of the body
• Phantom pain occurs when there is pain in a part of the body that has been amputated or removed.

8-6 Can pain be classified?

Yes, pain can be classified by the underlying causes:

• Nociceptive pain: Pain caused by tissue damage. This is the most common form of pain.
• Neuropathic pain: Pain caused by nerve damage
• Psychogenic pain: With psychogenic pain these is no obvious physical cause and it is thought to be due to psychological factors.

Pain can be caused by tissue damage, nerve damage or psychological factors.

8-7 What does nociceptive pain due to tissue damage feel like?

This depends on the site of the damage:

• Pain due to damage to skin, mucosa, bone or muscle is localised to the site of the damage and is described as either sharp, aching, throbbing or a gnawing sensation (somatic pain).
• Pain due to damage of deep organs such as the lungs, liver or kidneys is described as either tightening, cramping, squeezing or even as a dull pain (visceral pain).

When tissue is damaged, pain receptors in that tissue send pain signals via the peripheral nerves and spinal cord to the brain.

Nociceptive pain is caused by the activation of the pain receptors in the superficial tissues (somatic pain) or deep tissues (visceral pain).

8-8 What does nerve pain feel like?

Nerve pain (neuropathic pain) is due to either damage or compression of nerves and is described as burning, shooting, stabbing or pins and needles.

Nerve pain is described as a burning, stabbing, stinging sensation or pins and needles.

8-9 What is psychogenic pain?

Psychogenic or emotional pain has no physical basis but is often due to grief or loss or other psychological distresses such as anxiety or depression. This pain will not respond to pain medication.

8-10 What other physical causes of pain are there?

The physical causes of pain can be due to the following:

• Pain due the primary disease, e.g. cancer, HIV or tuberculosis (TB)
• Pain associated with treatment, e.g. medication side effects or chemotherapy
• Pain related to general debilitating disease, e.g. cachexia or pneumonia
• Pain caused by trauma, e.g. a fracture or burn.

8-11 Why is it important to know the cause of pain?

It is important to identify what is causing the pain and what type of pain it is (the underlying mechanism of the pain), because the pharmacological treatment and other interventions will be directed at these.

Determining the cause of pain is important as therapy and interven­tions should be directed at the cause.

8-12 What is meant by the term ‘total pain’?

The concept of ‘total pain’ considers all the aspects and the nature of pain. Pain is a ‘total experience’ and not just physical as it has psychological, spiritual and social components. Total pain includes the physical, emotional, social, spiritual and cultural factors that affect a person’s pain experience.

See chapter 6 for more information on total pain.

Total pain includes physical, psychological, spiritual, social and cultural aspects which affect the child’s pain experience.

Note

The phrase and concept of ‘total pain’ was first used by Dame Cicely Saunders, the founder of the first hospice movement. She said: ‘Total pain is a crisis on every level.’

8-13 What are some of the factors that affect how pain is experienced?

Factors that affect how pain is experienced include the following:

• Physical factors such as untreated pain, nausea, vomiting and constipation
• Psychological (emotional) pain such as anxiety, fear, guilt anger or sadness
• Social pain due to fear, isolation and stigma
• Spiritual pain (suffering) due to possible guilt, anguish and hopelessness.

Physical pain can be aggravated by unre­solved psychosocial and spiritual concerns, therefore these need to be addressed before good pain control can be achieved.

Pain assessment in children

8-14 How can you identify if a child is experiencing pain?

Pain experienced by children is often underestimated and therefore the assessment of pain is often not done well. The effective management of pain depends on a thorough assessment which includes a comprehensive evaluation of the child’s pain, other symptoms, daily functioning ability, clinical and psychosocial history. Accurate assessment requires ongoing conversations between the care providers (parents and family), the child and the healthcare team.

A thorough pain assessment will help identify if a child is experiencing pain.

8-15 Do children express their pain in the same way as adults?

They way in which children express pain changes as they get older and develop better reasoning and communication skills. It is therefore important to know how children of different ages and developmental stages respond to both acute and chronic pain.

8-16 When can children start to express their pain verbally?

Pain assessment in children is often underestimated. Any illness or procedure that would cause pain in an adult will also be painful to a child.

Children can start to verbally express their pain from the age of 2 to 4 years. They will be able to describe pain and its intensity from 5 years, and from 6 years they are able to tell the difference between the levels of pain intensity. Children older than 7 years can explain the nature of their pain.

8-17 Do children always tell you when they are in pain?

Children may not always report or tell anyone about the pain they are experiencing for a number of reasons. Babies, young children and those with certain disabilities may not have developed adequate communication skills to say they have pain.

The reasons older children may be afraid to talk about their pain include the following:

• Reluctance to acknowledge they are sick, especially if they have advanced disease
• Fear of disappointing their parents
• Fear of injections or medication
• Fear of returning to hospital
• Fear of more invasive treatments or procedures
• To avoid experiencing possible side effects from medication.

8-18 What non-verbal signs could indicate that a child is in pain?

There are certain behaviours that will indicate whether the child is experiencing acute or chronic pain.

Acute pain can be identified by certain behaviours which include:

• Facial expressions such as grimacing or frowning
• Groaning or crying and being impossible to comfort
• The child’s posture may be either curled up or flat and straight
• They may be lying very still or thrashing about.

Chronic pain can be identified by certain behaviours which include:

• Fear of being moved
• Posture may be abnormal
• Disinterest in their surroundings or being withdrawn
• Lack of appetite
• Lack of any facial expression
• Irritable and moody
• Getting angry quickly or becoming subdued and quiet
• Not wanting to play or interact with other children
• School performance may be affected.

8-19 Can pain be assessed by just watching a child’s behaviour?

Children have individual strategies of managing or coping with pain. Therefore, their behaviour may not provide a realistic presentation of the intensity of their pain. Conducting a thorough assessment of their pain is what is required in order to manage their pain correctly.

8-20 Is pain assessment a once-off process?

No. The assessment of pain is an ongoing process and not an isolated event. Following the initial assessment, a comprehensive care plan will be drawn up which details the planned pharmacological and non-pharmacological treatments. These treatments need to be evaluated through subsequent pain assessments to determine treatment effectiveness. Then, the care plan should be reviewed and adapted accordingly.

Assessing pain is an ongoing process and not an isolated event.

Note

It has been recommended that due to it being so common, pain should be assessed alongside the other vital signs, namely blood pressure, pulse, respiration and temperature. It should be recognised as the 5^th vital sign.

8-21 What are some of the barriers to good pain assessment and management?

Barriers experienced by the parents and the child may include:

• Language barriers
• Different spiritual and cultural beliefs; families may have different views or ideas of why and how pain is experienced and expressed, for example, they might feel that pain may be a punishment from God and therefore the child may be reluctant to describe or discuss their pain
• Denial of their child’s condition or prognosis
• Cost of the medication and treatments
• Parent’s resistance to give medication or the child’s reluctance to take medication.

Barriers experienced by professionals may include:

• Not assessing and taking into consideration the emotional, social, cultural and spiritual factors that affect pain
• Believing that every child feels pain in the same way
• Not understanding the developmental stages and how this may affect the way the child recognises and describes their pain
• Lack of pharmacological knowledge especially as it relates to the use of opioids in children
• The misconception that opioids cause respiratory depression therefore doctors may be reluctant to prescribe dosages required according to the pain score on assessment
• No care plans in place thus miscommunication or lack of communication between staff about the treatment goals.

8-22 What do you need to do before you start the pain assessment?

Start by developing a trusting and open relationship with both the child and family. Do your homework by familiarising yourself with the notes and letters in the medical folder to get background knowledge of the child’s history.

8-23 What pain assessment approaches can you use?

There are numerous ways to approach a pain assessment. When assessing pain in children it is necessary to question the child, a parent or carer as well as trying to assess the pain yourself.

8-24 What important questions should be included when asking about a pain history?

These are the important questions to include when taking a pain history during the pain assessment:

• What words do the child and family use for pain?
• What verbal and behavioural cues does the child use to express pain?
• What do the family or caregivers do when the child has pain?
• What do the family or caregivers not do when the child has pain?
• Is the pain restricting the child’s ability to perform normal physical activities like sitting, standing, walking and running?
• Is the pain restricting the child’s willingness or ability to interact with others, and the ability to play?

8-25 Is there a recommended formal approach that can be used to assess children’s pain?

Yes, using the QUESTT approach is a reliable and recommended method of assessing children’s pain.

Using the QUESTT approach is a reliable and recommended method of assessing children’s pain.

8-26 What does QUESTT stand for?

1. Question the child if he or she is verbal. Also question the parents or caregivers of both verbal and non-verbal children.
2. Use pain rating scales where appropriate and where possible.
3. Evaluate both behaviour and physiological changes.
4. Secure the parents’ or caregivers’ involvement in the assessment.
5. Take the cause of the pain into account.
6. Take action and evaluate the results.

See Appendix F for a detailed breakdown of the QUESTT approach.

8-27 What are pain rating scales?

Pain rating scales are assessment tools that measure certain aspects of pain such as the presence, the intensity and sometimes the location of pain. They are based on the persons behavioural and physiological responses to pain and are useful to establish a baseline and to follow the course of the pain being experienced. They are also useful tools to measure the response to treatment and interventions.

Pain rating scales are useful for establishing a baseline of the pain experience and for measuring response to treatment and interventions.

8-28 Are there age-appropriate pain rating scales?

Yes, there are numerous age appropriate tools that can be used to assess a child’s pain, such as:

• Newborn babies – Neonatal infant pain scale (NIPS)
• Non-verbal children or children younger than 3 years – FLACC scale
• Children over 4 years – Revised faces pain scale
• Children over 7 years – Numerical rating scale, word pain scale or PatchSA Colour Tool.

The Numerical Rating Scale is a visual scale with the numbers 0 to 10. Children are asked to indicate their pain intensity by putting a mark on the scale or pointing to the face (if using the Revised Faces Pain Scale) that corresponds to their pain intensity (how much they hurt). The FLACC scale is also scored out of 10.

See Appendix G for examples of the different age appropriate pain rating scales available.

Note

The International Children’s Palliative Care Network developed the ‘ICPCN Children’s Pain Assessment Tool’ – an app that can be downloaded freely on both Apple and android devices. This app incorporates the choice of a faces scale, a numerical scale as well as a scale using fingers. It also keeps a record of the child’s pain levels and detailed information related to the pain.

Pain management in children

8-29 What is the aim of pain management?

The aim of pain management is to improve the quality of life for both the child and the family by relieving their pain, using both pharmacological and non-pharmacological approaches which includes thorough assessment and care planning according to the individual needs of the child.

The aim of pain management is to relieve the child’s pain and improve their quality of life.

8-30 Does a child have a right to be pain free?

Yes. Every child has the right to be pain free.

Note

According to the United Nations Article 37 Rights of the Child Act, all children are entitled to be pain free.

8-31 What are the principles of pain management?

The principles of pain management are the following:

1. Thorough assessment and treatment of the underlying cause if possible, including physical, psychosocial and spiritual factors.
2. Non-pharmacological pain management strategies should always be considered such as massage, a heat pack, or distraction with toys, art or music.
3. The correct choice and dose of analgesia (pain medication) is important.
4. Analgesics should be given regularly to both prevent and treat pain.
5. Oral pain medication should be used whenever possible.
6. Give clear written instructions to the family regarding dosage and frequency.
7. Reassess pain and review the pain management plan frequently.
8. Manage other factors which may aggravate pain, such as fear.

Effective pain management can only be achieved by a thorough assessment which includes a physical, psychosocial and spiritual evaluation.

8-32 How do you manage a child’s pain?

You will need to manage a child’s pain with both non-pharmacological and pharmacological measures in order to adequately treat pain.

8-33 Is there a general approach to pain management?

Yes. Use a general approach that covers all the principles of pain management:

1. Reverse the reversible by treating the underlying cause.
2. Determine the type of pain to decide on the most suitable treatment, for example, is the pain nociceptive or neuropathic in origin?
3. Use medications to address the cause of the pain.
4. Use pain medications to manage the pain.
5. Use non-pharmacological measures such as distraction methods to help relieve pain where possible.
6. Address associated psychosocial distress such as separation anxiety.
7. Continually re-evaluate the pain and its response to treatment.

8-34 What non-pharmacological measures can you use to help control a child’s pain?

Non-pharmacological measures should always be used alongside pharmacological measures even when strong analgesia is used. They help children cope with and understand their pain or anticipated pain from a procedure for example.

8-35 What non-pharmacological methods could be used to manage a newborn babies pain?

The following techniques may be useful:

• Swaddling: Use a thin sheet and do not swaddle higher than the shoulders. Feet and legs should be able to move and the hips should be able to bend. Check that the baby does not get too hot.
• Breastfeeding during procedures
• Non-nutritive sucking such as a dummy with sucrose 24% (see 8-52).

8-36 What non-pharmacological methods can be used to manage pain in babies and older children?

Common methods include:

• Positioning is important. If the child is able to communicate verbally you can ask what is comfortable for them. If non-verbal, observe their face and body language (moaning, trying to move or change in facial expression) to see where they are most comfortable. Tell the child before moving them that you are going to turn or change their position. If a child is unhappy, see if changing their position helps.
• Babies and children need to be handled calmly and without sudden movements or noises. Be aware of how their illness has affected them and what might frighten them. For example, a baby who has had many heel pricks may be sensitive about their feet being touched and will react badly.
• Any heating method, such as a warm (not hot) heating pad or a very gently heated ‘happy hugger’ or ‘beanbag’ can be used on areas on the body that are painful but where there are no open wounds. A towel should be wrapped around the item before it is placed against the child’s body. Do not place any heating product near the child’s face, genital area or any area where they are numb or where there is broken skin. Some children will find heat pads comforting and others not. You have to see what works best for each child. Be very careful not to burn the child.
• Distraction techniques should be used in order to draw the child’s attention away from their pain:
  • Babies can be distracted with toys, pulling funny faces, cuddles, sounds, aromatherapy massage, gentle rocking, or being walked or pushed in a pram.
  • Older children can enjoy therapies like aromatherapy massage, music, and art. Read or tell them a story, help them blow bubbles, use puppet play, use TV shows or play video’s and DVD’s according to the resources available. Playdough is easy to make with simple ingredients and can be used to distract a child while procedures are performed.
• Music therapy can help a child to calm down by regulating their breathing and helping distract them from their pain.
• Art therapy can help the child feel more in control of their lives and less frustrated. Art can include drawing, painting (brush or finger painting), using clay or playdough or chalk on a floor.
• Aromatherapy is the use of gentle massage with appropriate essential oils (preferably done by a qualified aromatherapist).

Note

Other techniques that can assist are hypnosis, guided imagery and reflexology but these require qualified therapists.

The child’s environment will play an important role in how comfortable they feel. Try to make their room friendly and welcoming and as noise free as possible. Encourage family members to bring toys, personal bedding, anything that makes the space more familiar. Make sure the room or ward smells fresh and that there is adequate fresh air and light.

Non pharmacological measures must always be used alongside pharmacological measures to manage a child’s pain.

Note

Non-pharmacological measures are especially important in helping children cope with chronic pain. They work by increasing stimulation of the descending inhibitory pathway which decreases the amount of ascending pain signals received by the brain.

8-37 How can you manage children’s pain pharmacologically?

Use the World Health Organization (WHO) broad principles of analgesia for pain management.

8-38 What are the WHO broad principles of analgesic use?

1. By the appropriate route

The oral route is the best for analgesia. If the child is unable to swallow, is comatose or has repeated vomiting, other routes will need to be considered.

Other routes include:

• Buccal (spray or drops onto the side of the mouth)
• Intranasal (spray or drops into the nose)
• Rectal
• Subcutaneously
• Intramuscularly (but should be avoided where possible)
• Intravenously
• Topically onto the skin
• A spinal or epidural nerve block.

2. By the clock

Important principles include:

• Analgesics should be given regularly at a fixed time or on fixed schedule if the child is experiencing persistent pain. This is much better than on a ‘as needed’ (prn) basis where the child must experience pain first before they can get treatment. With ‘as needed’ treatment, fear that pain cannot be controlled may worsen pain and anxiety.
• Dosage intervals are based on the duration of action of drugs: 4 hourly for oral opioids.
• Regular doses will achieve better pain control rather than treating each new pain episode.
• Smaller regular doses will achieve better pain control rather than treating each new pain episode with a large dose.

3. By the child

Important principles include:

• Treatment will need to be individualised to each child as no fixed dose will be appropriate for every child.
• Adjust the medication and dosages according to the response and possible side effects.

4. By the ladder

Important principles include:

• The original WHO three step (mild-moderate-severe) pain ladder for the management of persistent pain is very helpful in children. This approach consists of a choice of analgesia that is administered according to the child’s level of pain severity.
• For mild pain (grade 1 to 3) a non-opioid such as paracetamol (Panado) and/or a non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen (Brufen) should be offered as the first step.
• For moderate pain (grade 4 to 7) low dose morphine (50% of usual pain starting dose) with or without co-analgesia, should be used as the second step. Avoid using weak opioids such as codeine or Tramadol in young children. The reason being that there is insufficient evidence supporting the use and safety of Tramadol in children and the metabolism of codeine is complex and variable.
• For severe pain (grade 8 to 10) a strong opioid such as morphine, with or without co-analgesia, should be used on step 3.
• Treatment options depend on the severity of the pain and the option should change if the pain severity changes.
• Never combine a weak opioid with a strong opioid as they compete with one another (bind with the same receptors).

Figure 8-1: The original World Health Organization (WHO) pain ladder.

The WHO broad principles of analgesia state use by the appropriate route, by the clock, by the child and by the ladder.

8-39 What is a co-analgesic?

Co-analgesics are medications with a primary indication other than pain but have been found to have pain relieving properties and can be used alongside all analgesics on the WHO pain ladder. Co-analgesics (previously referred to as adjuvants) are especially useful for neuropathic pain.

Examples of co-analgesia include the following:

• Corticosteroids e.g. prednisone
• Antidepressants e.g. amitriptyline
• Anticonvulsants e.g. carbamazepine, gabapentin, pregabalin
• NMDA-receptor channel blockers e.g. ketamine
• Beta blocker e.g. clonidine
• Antispasmodics e.g. hyoscine butylbromide
• Muscle relaxants e.g. diazepam, baclofen

Co-analgesics are used alongside analgesics to manage pain even though their primary indication is not for pain.

8-40 Which non-opioid and opioids can you use to treat children’s pain effectively?

The WHO pain ladder can be used to decide which drug to use:

Type	Severity of pain	Example	Dose
Non-opioid	1–3	Paracetamol	10–15mg/kg 4 to 6 hourly
Weak opioid	4–7	Low dose morphine Tramadol (> 12 years)	0.05–0.1mg/kg 4 hourly 1–2mg/kg every 6 hours
Strong opioid	8–10	Morphine	Oral: 0.1–0.2 mg/kg 4 hourly IVI bolus: 0.1 mg/kg IVI infusion: 20µg /kg/hour

Figure 8-2: The most common non-opioid and opioids being used to treat pain in children.

The WHO pain ladder is used to determine which analgesic should be used depending on the child’s pain intensity.

Morphine use in children

8-41 What are some of the incorrect beliefs about morphine use?

Unfortunately, there are many fears and a lack of knowledge that surround the use of morphine, particularly in children. However, if used correctly, it is a useful medication that helps to control moderate to severe pain. Morphine is a medication listed on the South African Essential Drug List (EDL) for use in palliative care.

Some of the incorrect beliefs about using morphine include:

• Children will develop an addiction to morphine.
• Morphine will suppress their respiration.
• Morphine will shorten a child’s life expectancy.
• If morphine is prescribed, it means the child is nearing the end of their life.

8-42 What are some facts about morphine use?

The following are important facts to understand about using morphine:

• Addiction is not a problem if the correct dose of morphine is administered for true pain and the dose titrated up or down in the correct amounts (increments).
• Respiratory depression can be avoided by steadily increasing morphine doses in the correct amounts according to the pain level.
• Using morphine does not shorten a child’s life. It can improve the quality of life and bring comfort to both the child and the parents because the child is pain free.
• Morphine is used to control pain and it should be given at any stage of the illness or condition if the child’s pain is moderate to severe.
• Morphine can help extend the child’s life because they are not always fighting pain.
• Morphine can also be titrated downwards and stopped if the pain is resolved.

8-43 How do you use morphine in children?

The way to use morphine in children is to:

• Begin with an oral starting dose of morphine syrup (morphine sulphate) for pain.
• Oral morphine should be prescribed every 4 hours as it does not have a long-lasting action. In newborn infants, or when there is hepatic or renal dysfunction, it can be prescribed 6 to 8 hourly.
• The starting dose of oral morphine is 0.2 mg/kg 4 hourly.
• Morphine needs to be given regularly and not as an ‘as needed’ dose.
• An extra dose is called a breakthrough dose (BTD) which can be administered if the child is experiencing pain before the next regular dose is due. Usually the breakthrough dose is 50 to 100% of the regular dose. Morphine takes up to 30 minutes to have an effect so a breakthrough dose should not be given less than 30 minutes after the regular dose.
• Morphine is a versatile analgesic as it does not have a ‘ceiling effect’, therefore it can be titrated upwards if pain is not controlled by the current dose. There is no maximum dose for morphine in chronic pain and increasing morphine in steps (incrementally) continues to provide increasing analgesic effect.
• If the morphine has to be stopped after using it for longer than 10 to14 days the child will need to be weaned off it slowly to prevent withdrawal symptoms.

Morphine is the recommended drug for treating moderate to severe pain in children with medical conditions requiring palliative care.

Note

Medication with a ‘ceiling effect’ are drugs where a maximum dose exists above which no further analgesic effect is obtainable. Morphine is not one of these drugs.

8-44 How is the increased dose of morphine calculated?

If the pain control is not adequate and breakthrough doses are needed, the total daily dose should be increased. To calculate this new daily dose, add up all the 4 hourly and breakthrough doses given in the past 24 hours. Then divide this 24 hour dose by 6 to give the new 4 hourly dose. Remember to increase the breakthrough dose as well (50% of regular dose). If breakthrough doses are not being given and pain is not controlled, make empiric increases of 30–50% of the previous dose.

8-45 Does morphine have side effects?

Yes,. Therefore when morphine is prescribed, it is important that the correct medications are prescribed with the morphine to counteract these side effects. It is also very important to explain to the family what the possible side effects of morphine are when it is prescribed and what will be done to lessen these side effects.

8-46 What are the common side effects of morphine?

The most common side effects that may be experienced by the child are as follows:

1. Short term effects:
   • Drowsiness and sedation which will improve after 2 to 3 days
   • Nausea and vomiting which will improve after 5 to 7 days. Therefore, an anti-emetic (anti-nausea medication) may need to be prescribed when starting morphine.
2. Ongoing effects:
   • Constipation. Therefore, a laxative will need to be prescribed prophylactically.
3. Rare effects include:
   • Hyperactivity
   • Pruritus (itchy skin)
   • Urinary retention.

Morphine does cause common side effects but these can be lessened by being prepared for them and treating them correctly.

Note

Children on long standing opioids for pain management can develop tolerance, and physiological dependence will be observed if opioids are withdrawn too suddenly.

8-47 What medications are used to manage nausea, vomiting and constipation caused by morphine?

For nausea and vomiting the medication of choice is Ondansetron (Zofran) in older children and Metoclopramide (Maxolon) in infants.

For constipation the medication of choice is either Lactulose or Sorbitol.

See appendix H for more information on acccessing the drug formulary.

See chapter 9 for more detail on the management of nausea, vomiting and constipation.

Management of specific pains

8-48 What are the types of difficult pain that children may experience?

Not all pain is the same and there are certain types of pain that will need alternative treatment and approaches as they do not always respond well to first line treatments, like opioids, and may need co-analgesia added to the treatment plan. This pain is often referred to as ‘difficult pain’.

The different types of difficult pain a child can experience are:

• Neuropathic pain
• Bone pain
• Headaches
• Pain due to spasticity or increased muscle tone
• Procedural pain.

See appendix H for dosages of co-analgesics.

Co-analgesia can be very helpful when treating difficult pain.

8-49 What is procedural pain?

Procedural pain is pain that occurs during procedures or interventions like dressings or treatments.

8-50 Is it important to treat procedural pain?

Yes, as procedural pain is an important cause of anxiety and fear in children. Often procedures are performed on children without any preparation because healthcare workers dislike performing them and would rather get them over with as quickly as possible. It is important to take your time in preparing for painful procedures in children as this type of pain, if undertreated, may have long term effects on the child’s ability to cope with or tolerate pain in future.

Procedural pain needs to be treated in order to help reduce anxiety and fear. If procedural pain is not managed well it can have long-lasting effects on how a child will cope with pain for the rest of their lives.

8-51 How should you manage procedural pain?

The following are the principles of managing procedural pain:

• Prepare yourself by planning how you will manage the procedure beforehand.
• Ensure a safe and child friendly environment for the procedure. If possible, do this away from the child’s bed in order for them not to associate their bed with a painful experience.
• Prepare the family or caregiver who may be assisting as to what you will be doing and how they can assist.
• Prepare the child in an age appropriate way:
  • Explain what you are going to be doing.
  • Manage their fear by allowing some control. Discuss the options available and seek to answer any questions they may have.
  • Be honest; if they ask if the procedure will hurt tell them that you will try your best to make it as pain free as possible.
  • Reassure the child that they are doing well throughout the procedure and not only afterwards.
• Use both pharmacological and non-pharmacological interventions to manage pain and any anxiety; for example, if you are inserting an intravenous line, use topical anaesthetic on the site as well as distraction methods such as blowing bubbles.
• After the procedure, acknowledge and praise the child by using positive affirmations like ‘you did so well’ or ‘I am so proud of how still you sat through this procedure’.

8-52 How can you manage procedural pain in newborn babies?

Non-nutritive sucking is a technique whereby a dummy is dipped in a sugar (sucrose) or glucose solution and given two minutes before a painful procedure. It is the most effective method for minor procedures such as heel pricks or taking blood samples.

Breastfeeding during the procedure can also be used to reduce the pain.

Note

If the newborn is at no risk for necrotizing enterocolitis (NEC) give a 24% solution of sucrose. If infant is at risk give a 12% solution.

Non-nutritive sucking is an effective way to treat procedural pain in newborn infants.

Case study 1

Nosipho is an 8-month-old girl with severe nappy rash. Her chin constantly quivers and she frowns frequently. She whimpers on and off and moans when she turns over and lies on her back. She is consoled when her mother hugs or talks to her. Presently she is lying quite still. She is however holding her hands in tight fists and her toes are tightly curled over.

1. What do you think is wrong with Nosipho?

A child of 8 months cannot always verbally communicate that they are in pain but watching Nosipho’s behaviours may indicate that she is in pain. These behaviours include her grimacing and moaning constantly, and not being comforted once picked up. She also has her fists clenched and her toes curled, which are also signs that indicate pain.

2. If you had to classify her pain, what type of pain do you think she is experiencing?

A nappy rash involves the skin and surrounding tissue therefore the type of pain she is experiencing will be nociceptive somatic pain.

3. How would you assess Nosipho’s pain?

Assess Nosipho’s pain by completing a thorough pain assessment using the QUESST approach. This will include using an age appropriate pain assessment tool.

4. What pain rating scale would you use to assess her pain?

Nosipho is 8 months old so an age appropriate pain rating scale would be the FLACC scale which gives a score out of 10 that will indicate the severity of her pain.

5. How would you interpret a FLACC score of 6 out of 10 for Nosipho?

The score of 6 indicates that Nosipho is in moderate pain.

6. What approach would you use to manage Nosipho’s pain?

It will be necessary to identify and to treat the underlying cause of the nappy rash as well as treat her pain both pharmacologically and non-pharmacologically. Use the WHO pain ladder principles to treat her pain, these being:

1. By the mouth
2. By the clock
3. By the child
4. By the ladder.

As she has moderate pain she will need to be treated with pain medication such as tilidine (Valoron).

Case study 2

Peter is an 11-year-old boy with an incurable metastatic tumour of the bone, who describes his pain as 9 out of 10 when asked. He is on oral paracetamol and codeine as needed but is experiencing increasing shooting pains in his feet. He is becoming more withdrawn and refuses to see his peers when they visit him. He says he is angry at God for cursing him with cancer. Before he was diagnosed with his cancer, he was part of his school’s soccer team and shared with his mother that he hoped he would one day play soccer for his country.

1. What type of different pains do you think Peter is experiencing?

Peter is experiencing pain in all aspects of his life. He has physical pain from his cancer, psychosocial pain as he is withdrawn and does not want his peers to visit him, and spiritual pain as he is angry at God for cursing him with cancer. He is experiencing total pain.

2. Who in the healthcare team can possibly help him with his pains?

Palliative care uses a team approach therefore he will more than likely need a doctor, nurse, physiotherapist and occupational therapist to assess and manage his physical pain both pharmacologically and non-pharmacologically. A social worker, psychologist or counsellor will help assist him with his psychosocial pain and, if he agrees, a visit from a spiritual worker to assess and support him with his spiritual pain.

3. On what step of the WHO ladder is his current treatment of paracetamol and codeine.

Codeine is a weak opioid prescribed for moderate pain which, when using a pain assessment scale, would be a score of between 4 to 7 out of 10. It has been recommended that codeine not be used to treat persistent pain in children. Paracetamol can be prescribed for any level of pain.

4. What would you recommend be prescribed to help manage his pain?

He describes his pain as 9 out of 10 which is severe so he should be started on step 3 of the WHO pain ladder to help control his pain. A strong opioid like oral morphine is the drug of choice for severe pain. It is important that oral morphine be given 4 hourly as prescribed and not ‘as needed’ (prn).

5. What co-analgesics could assist with his shooting pains?

Peter is complaining of increasing shooting pains in his feet. The description ‘shooting pain’ suggests neuropathic pain. Neuropathic pain does not always respond well to opioids. A trial of a co-analgesics could be started.

6. What information would it be necessary to give to the family about the use of morphine?

There are many myths and misconceptions surrounding the use of morphine. It would be necessary to discuss these with Peter and his family and to educate them on the use of morphine. It is important to reassure the family that Peter will not become addicted to morphine as long as it is given correctly, according to therapeutic doses consistent with his pain levels.

7. What other information about the common side effects of morphine would need to be explained to the family?

It would be very important to explain the possible side effects of morphine and what will be done to alleviate these. The common side effects of morphine are:

• Drowsiness, which will improve in 2 to 3 days
• Nausea and vomiting, which may last 5 to 7 days
• Constipation, which will need a laxative.

Case study 3

Sihle, a 10-day-old newborn baby who has been diagnosed with a rare and painful brittle bone disease (osteogenesis imperfect), is having 4 hourly heel pricks. He cries, grimaces and his chin quivers every time his feet are touched. His mother is breastfeeding him and he seems to be less distressed when she holds him.

1. Why do you think Sihle cries every time his feet are touched?

Two possible reasons for Sihle’s crying are:

• Newborn babies feel pain just as any other child and as he is having 4 hourly heel pricks he has learnt to associate his feet being touched with pain.
• The pain may also be as a result of the brittle bone disease. The bones in his feet may be broken, causing severe pain when his feet are touched.

2. How would you determine the severity of his pain?

A pain assessment using an age appropriate pain scale tool, such as NIPS, can be used to determine the severity of pain.

3. What simple measures could you use to treat the pain he experiences during heel pricks?

Simple measures will include non-nutritive sucking where a dummy is dipped in a sugar (sucrose) solution and given to him two minutes prior to his heel prick. If his mother is with him, she could hold and breastfeed him while the heel prick is being performed.

It will also be very important to check the pressure being applied to his legs and feet when holding them to perform the heel pricks, as any undue pressure could cause the bones in his feet to fracture and trigger pain.

4. Why is it important to treat this procedural pain?

If his procedural pain is not managed well it can have long-lasting effects on how Sihle will cope with pain for the rest of his life. It is considered a human right to have pain treated no matter what the patient’s age.

Case study 4

Mandy, a 15-year-old girl with multiple sclerosis and weighing 30 kg, is in hospital with a fungating smelly sacral wound. She complains to the nurse that she is in a great deal of pain but the nurse responds that she can’t be in pain as she has had her 4 hourly morphine dose of 2.5 mg an hour before. The nurse explains that Mandy needs to wait for another 3 hours before she can have the next dose. Her mother is very worried about Mandy being on morphine and has said that she is worried Mandy will become addicted to the medication.

1. What dose of morphine is Mandy receiving in 24 hours?

Mandy is currently receiving 2.5mg 4 hourly so therefore she is receiving 15 mg in 24 hours.

2. What dose of morphine would be correct for Mandy to be receiving?

The starting dose of morphine is 0.2 mg/kg 4 hourly which can be titrated upwards according to the response. Mandy weighs 30 kg

0.2 mg x 30 kg = 6 mg per dose 4 hourly (6 mg x 6) = 36 mg/24 hours

Therefore Mandy should be on a total daily dose of 36 mg and not 15 mg.

3. What reasons could there be for her not receiving the correct therapeutic dose?

The doctor could be afraid of using morphine or is unaware as to what the therapeutic dose is for children experiencing chronic pain. The nursing staff may have fears related to overdosing morphine or may be unaware that the dose is too low. The mother’s fears about Mandy becoming addicted to morphine may be influencing the nursing staff resulting in their reluctance to use the correct dose.

4. How could you allay any fears the staff may have in regard to the use of morphine?

Have a conversation with the staff to explore what fears they may have and discuss the benefits and appropriate use and dose of morphine for a young woman of Mandy’s age and weight.

5. How would you increase her daily dose if she has breakthrough pain?

Mandy has a right to have her pain controlled adequately and to be made comfortable. For this reason, it is important that her morphine be titrated upwards to the correct therapeutic dose. Mandy should be given an immediate breakthrough dose of 100% of the regular dose, which is 2.5 mg. Then at her next 4 hourly dose she should start on 6 mg 4 hourly. Continue her on this, giving further 50 to 100% breakthrough doses if required.

To work out the new regular 4 hourly dose, add all the doses she has received in the past 24 hours (regular 4 hourly plus breakthrough doses). This amount is the total she will now need to receive in 24 hours. Divide this total by 6 to determine the new 4 hourly dose.

6. Can Mandy receive any extra doses of morphine if she is still experiencing procedural pain?

Yes. If she is experiencing procedural pain when her dressings are changed, she should be given a breakthrough dose of 50 to 100% of her oral morphine dose 30 minutes before the dressing change.

7. How would you reassure Mandy’s mother about the benefits of giving Mandy morphine?

One of the common myths or misconceptions is the concern of a person becoming addicted to opioids. In order to reassure Mandy’s mother, it is important to have a conversation that answers any questions she has and explains the following points:

• The correct dose of morphine must be given for the level of the pain, according to her weight.
• It must be given at the correct time, namely 4 hourly for oral morphine, and titrated upwards according to the correct schedule.
• Mandy will not become addicted to the morphine. Her mother can also be reassured that Mandy’s quality of life and comfort will be improved, which in turn can aid the healing process.
• Tell Mandy’s mother that the body can get used to or tolerant to morphine and therefore the patient may need a higher dose to relieve the pain. Reassure her that this is a normal phenomenon.