Are you neglecting children in pain?

When Barbara Weintraub, RN, MPH, MSN, was caring for a 7-year-old boy with a large elliptical laceration over his knee, a lidocaine injection was needed. As soon as the child saw the suture set, he began to scream and jump on the bed. "It was clear that I would be unable to suture him in that condition," she recalls.

Weintraub, who is a pediatric emergency services coordinator at Northwest Community Hospital in Arlington Heights, IL, made a bargain with the boy: She would give him 10 minutes to calm down. "In the meantime, I had the technician wheel in a TV/VCR and put in one of his favorite movies," she says. "After seeing that he was engrossed in the movie, I returned to the room. I told him I was going to suture and again prepare to infiltrate with lidocaine."

Weintraub was able to complete the somewhat extensive laceration repair without holding the child down, without tears, and without any additional discomfort for that patient. "Distraction is truly one of the greatest tools there is in treating pediatric pain," she says.

Steps you can take

Research has repeatedly shown that pain management in children is frequently inadequate, reports Pat Spurlock, RN, clinic administrator at Neurological Associates of Des Moines (IA) and former service line director for emergency services at Mercy Medical Center, also in Des Moines. Spurlock recommends informing colleagues about the physiological effects of pain. "Pain increases the demand for oxygen, which can be critical in a child with low oxygen saturation," she says. "It also results in decreased blood flow impacting organ profusion."

Here are ways to improve pain management in children:

• Use distraction. Distraction techniques work particularly well for children, says Weintraub. "A television playing a movie or headphones with music can do wonders to relieve both pain and anxiety in children," she advises.

• Use the most age-appropriate method to assess pain. These include the Wong-Baker Faces pain scale, numeric, or descriptive scales, says Weintraub. "Pre-verbal children should be assessed for muscle tone, activity, and facial expression," she says. If children don’t understand adult assessment tools, they can’t give you a response that accurately reflects their severity of pain, says Spurlock. "This could result in an overdose of medications or undertreatment," she adds.

• Watch for nonverbal cues. Nurses need to be alert to nonverbal cues, even in older children, as they may fear the treatment and try to hide their pain, says Weintraub. She points to the following signs: not making eye contact, rocking back and forth or alternatively lying completely still and refusing to move. "Other cues can include silent tears and refusal to play, read, or engage in other favorite activities," she says.

• Address pain caused by ED interventions. Consider not only the pain the child arrives with, but the pain you cause by caring for them, says Weintraub. For instance, a child who presents with mild to moderate dehydration in need of intravenous (IV) hydration will experience pain upon IV insertion, she notes. Weintraub recommends applying ice or a topical anesthetic to the site of an intramuscular injection prior to the injection. "Because the child is stable, there is more than enough time for EMLA to be applied and to take effect," she says. "Don’t let your time restraints dictate your pain control measures."

• Address newborns. Remember that even newborns do experience pain, says Weintraub. "They not only remember it, but can suffer adverse physiologic outcomes due to the additional stress and catecholamine release that pain can cause," she adds.

Allow parents to stay with the child. Allowing the parent to stay with the child and even hold the child when necessary, works well again in relieving pain and anxiety, says Weintraub. "This is true for both child and parent," she adds.

• Use dosage charts. Use dosage charts for pain management that provide calculations by kilo and interval, says Spurlock. "This will expedite time to administration," she explains. (For ordering information, see "Resources," at the end of this article.)

• Hold seminars in your ED. Spurlock recommends asking a clinical pharmacist, especially one who has specialized in pediatrics, to educate nurses on new products or delivery systems that have proven to be effective treatments for pain. A pain clinician would be another good choice for an inservice, says Spurlock. "They are current on delivery methods as well as the clinical application to each setting," she notes. "Their experience in many settings can be invaluable as they share their knowledge and answer questions that ED nurses face in their daily practice."

Provide nurses with the latest research on pain management during orientation, at staff meetings, or inservices and assess staff competency annually, says Spurlock. "So much new research is published annually, it is very difficult to keep informed and sometimes even to know the validity of the study," she notes. (See recommended reading list at the end of this article.)

Resources

For more information about pain management in pediatric patients, contact:

• Pat Spurlock, RN, Neurological Associates of Des Moines, 1601 N.W. 114th St., Suite 338, Des Moines, IA 50325. Telephone: (515) 223-1917. Fax: (515) 223-0284. E-mail: DJTNeuro@aol.com.

Barbara Weintraub, RN, MPH, MSN, Northwest Community Hospital, 800 W. Central Road, Arlington Heights, IL 60005. Telephone: (847) 618-5432. Fax: (847) 618-5419. E-mail: bweintraub@nch.org.

A Pediatric Drug Chart quick reference guide is available. The fifth edition (Product Code IN094A) is a 7 x 10-inch chart with drug dosages for 37 medications, including those used for pain management. The cost is $9 including shipping. To order, contact:

Emergency Training Associates, 105 Glen Hill Court, Union Bridge, MD 21791. Telephone: (800) 367-0382 or (410) 775-7663. Fax: (410) 775-0691. Web: www.emsbooks.com. (Click on "Bookstore" and then "Reference.")

Recommended reading

Here is a partial listing of pain management studies that pertain to patients in the ED:

• Attard A, Corlett M, Kidner N, et al. Safety of early pain relief in patients with acute abdominal pain. BMJ 1992; 305:554-556.

• Ferrell B, McCaffery M, Rhiner M. Pain and addiction: An urgent need for change in nursing education. J Pain Symptom Manage 1992; 7:117-124.

• Lenehan G. On making pain a priority. J Emerg Nurs 1992; 18:91-92.

• Menegazzi J, Paris P. A randomized controlled trial of the use of music during laceration repair. Ann Emerg Med 1991; 20:348-350.

• Pace S, Burke T. Intravenous morphine for early pain relief in patients with acute abdominal pain. Acad Emerg Med 1996; 3:1,086-1,091.

• Steward GM, Simpson P, Rosenberg N. Use of topical lidocaine in pediatric laceration repair: A review of topical anesthetics. Pediatr Emerg Care 1998; 14:419-423.

• Tanabe P, Thomas R, Paice J, et al. The effect of standard care, ibuprofen, and music on pain relief and patient satisfaction in adults with musculoskeletal trauma. J Emerg Nurs 2001; 27:124-131.

• Tanabe P, Buschmann M. A prospective study of ED pain management practices and the patients’ perspective. J Emerg Nurs 1999; 25:171-177.

• Tanabe P. Recognizing pain as a component of the primary assessment: Adding D for discomfort to the ABCs. J Emerg Nurs 1995; 21:299-304.

• Turturro M. Pain management in the ED: Prompt, cost effective, state-of-the-art strategies. Emerg Med Pract 1999; 1:1-16.

• Wright W, Price S, Watson W. NSAID use and efficacy in the emergency department: Single doses of oral ibuprofen versus intramuscular ketorolac. Ann Pharmacother 1994; 28:309-312.