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Nervous System
numeric scales (i.e., 1 to 10) and word graphic scales
(i.e., “none,” “a little,” “most I have ever experienced”)
can be used. Another supplementary strategy for assess-
ing a child’s pain is to use a body outline and ask the
child to indicate “where it hurts.”
Pain Management
The management of children’s pain basically falls into
two categories: pharmacologic and nonpharmacologic.
In terms of pharmacologic interventions, many of the
analgesics used in adults can be used safely and effec-
tively in children and adolescents. However, it is criti-
cal when using specific medications to determine that
the medication has been approved for use with chil-
dren and that it is dosed appropriately according to the
child’s weight and level of physiologic development.
Age-related differences in physiologic functioning, nota-
bly in neonates, will affect drug action. Neonates have
decreased fat and muscle and increased water, which
increases the duration of action for some water-soluble
drugs; neonates also have decreased concentration of
plasma proteins (albumin and
α
1
-glycoprotein), which
increases the unbound concentration of protein-bound
drugs.
58
Neonates and infants also have decreased levels
of the hepatic enzymes needed for metabolism of many
analgesics. The levels of these hepatic enzymes quickly
increase to adult levels in the first few months of life.
Drug clearance in the 2- to 6-year-old age group is actu-
ally higher than adult levels because of the larger hepatic
mass relative to body weight.
58,60
The renal excretion of
drugs depends on renal blood flow, glomerular filtration
rate, and tubular secretion, all of which are decreased in
neonates, particularly premature neonates. Renal func-
tion reaches adult levels by 1 year of age.
58,60
The overriding principle in all pediatric pain manage-
ment is to treat each child’s pain on an individual basis
and to match the analgesic agent with the cause and
intensity of pain.
60
A second principle involves main-
taining the balance between the level of side effects and
pain relief such that pain relief is obtained with as little
opioid and sedation as possible. One strategy toward
this end is to time the administration of analgesia so
that a steady blood level is achieved and, as much as
possible, pain is prevented. This requires that the child
receive analgesia on a regular dosing schedule, not “as
needed.” Also, most drugs are packaged primarily for
adult use, and dose calculations and serial dilutions
may predispose to medication errors. Common errors
include milligram–microgram errors, decimal point
errors, confusion between daily dose and fractional dose
(e.g., 100 mg/kg/d divided by 6 hours versus 100 mg/kg
per dose every 6 hours), and dilution errors.
60
Nonpharmacologic strategies can be very effective
in reducing the overall amount of pain and amount of
analgesia used. In addition, some nonpharmacologic
strategies can reduce anxiety and increase the child’s
level of self-control during pain. Pacifiers and sucrose are
being used in the NICU. The effects of sucrose (sweet
taste) are believed to be opioid mediated because its
effects are reversed by naloxone (an opioid antagonist).
59
Distraction helps children of any age divert their atten-
tion away from pain and onto other activities. Common
attention diverters include bubbles, music, television,
conversation, and games. Relaxation techniques and
massage therapy are particularly useful in children with
chronic pain. Other nonpharmacologic techniques can
be taught to the child to provide psychological prepara-
tion for a painful procedure or surgery. These include
positive self-talk, imagery, play therapy, modeling, and
rehearsal. The nonpharmacologic interventions must be
developmentally appropriate and, if possible, the child
and parent should be taught these techniques when the
child is not in pain (e.g., before surgery or a painful pro-
cedure) so that it is easier to practice the technique.
Pain in Older Adults
Among adults, the prevalence of pain in the general
population increases with age. Prevalence reports for
persistent pain in older adults ranges from 25% to
80%, depending on whether the older adults are com-
munity dwelling or reside in a nursing home.
61
Among
the common causes of pain in older adults are musculo-
skeletal disorders such as osteoarthritis and chronic low
back pain; rheumatologic diseases such as rheumatoid
arthritis and polymyalgia rheumatica; and neurologic
conditions such as diabetic neuropathy, postherpetic
neuralgia, and central post-stroke pain.
Unrelieved pain can have significant functional, cog-
nitive, emotional, and societal effects in the elderly.
61,62
Decreased activity because of pain can lead to myofas-
cial deconditioning and gait disturbances, which in turn
can result in injuries from falls. Pain in the elderly has
been associated with impaired appetite, increased sleep
disturbances, and in some cases a decrease in cognitive
function. These consequences can lead to less than opti-
mal participation in rehabilitation efforts and decreased
quality of life. Increased costs because of health care use
have also been attributed to unrelieved pain in the elderly.
Pain Assessment
The assessment of pain in the elderly can range from
relatively simple in a well-informed, alert, cognitively
intact individual with pain from a single source and
no comorbidities to extraordinarily difficult in a frail
individual with severe dementia and many concurrent
health problems.
61,63,64
When possible, a patient’s report
of pain is the gold standard, but behavioral signs of pain
should be considered as well. Accurately diagnosing
pain when the individual has many health problems or
some decline in cognitive function can be particularly
challenging. In recent years, there has been increased
awareness of the need to address issues of pain in indi-
viduals with dementia. The Assessment for Discomfort
in Dementia Protocol is one example of the efforts to
improve assessment and pain management in these indi-
viduals. It includes behavioral criteria for assessing pain
and recommended interventions for pain. Its use has
been shown to improve pain management.
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