MINNEAPOLIS – Clinicians consistently undertreat acute pain in hospitalized children, despite parents' expectations that everything possible is being done to relieve their children's suffering.
Data show that with the same procedure, adults are getting many more pain doses than children, Dr. Stefan J. Friedrichsdorf said at the meeting. “Even among children, a 10-year-old is likely to get better analgesia than a 10-day-old for exactly the same procedure,” he added.
Several myths contribute to the abysmal management of acute pain in children, with concern about inducing addiction at the top of the list, said Dr. Friedrichsdorf, a pediatrician and medical director of pain and palliative care at Children's Hospitals and Clinics of Minnesota, Minneapolis.
While there have been reports of opioid use leading to addiction in children with chronic pain, no such cases have been reported in children treated with strong opioids for acute pain, he said.
What's more likely to occur is for staff to confuse tolerance with addiction if children have received opioids for more than 3 days and display signs of withdrawal if the drug is abruptly discontinued instead of carefully titrated down. Still others, out of a belief that the pain is “not that bad” or that pain medications mask the underlying symptoms, will administer such small doses of morphine that the child repeatedly asks the nursing staff for more.
“When you arrive the next day, the nurse says, 'I think he's becoming addicted; shouldn't we switch to codeine?' When, in fact, we are just underdosing,” Dr. Friedrichsdorf said. “This is pseudoaddiction.”
Evidence shows that it is possible to assess symptoms with adequate pain management, with the possible exceptions being compartment syndrome and intracranial injuries, he said at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
Respiratory depression is a common concern in pain management, but should not deter providers from using opioid patient-controlled analgesia (PCA) in children.
A recent meta-analysis involving 14 studies and 402 patients indicates that the addition of a continuous infusion to intravenous opioid PCA is associated with a higher incidence of respiratory events, compared with demand intravenous PCA in adults, but not in pediatric patients (J. Opioid Manag. 2010;6:47-54).
Several professional organizations have weighed in on pediatric pain management, with a recent systematic review identifying no less than 25 cancer-related pain management guidelines published between 2000 and May 2006 (Clin. J. Pain 2010;26:449-62).
Dr. Friedrichsdorf advised providers to familiarize themselves with the Principles of Pediatric Acute Pain Management in the 1998 World Health Organization report: “Cancer Pain Relief and Palliative Care in Children” and the WHO's three-step “ladder” for cancer pain relief. The principles address opioid analgesics commonly used for moderate to severe pain, routes of administration, initial pediatric doses, and dosing intervals.
For example, the initial dose for intravenous or subcutaneous morphine ranges from 0.05 mg/kg to 0.1 mg/kg. Because of the wide variability in individual responses to opioids, this should not be interpreted to mean that all patients should start at 0.05 mg/kg, Dr. Friedrichsdorf said.
“For small kids with small pain, use the lower end of the dose range; use a big dose for big kids with big pain,” he said.
As-needed orders for opioids are commonly used to provide flexibility in dosing, but frequently result in the patient receiving nothing or seesawing between under- and oversedation, Dr. Friedrichsdorf said.
“The golden rule is that we must schedule analgesia and then on top of that, of course, use p.r.n. analgesia and titrate to effect,” he said.
Disclosures: Dr. Friedrichsdorf reported having no conflicts of interest.
'The golden rule is that we must schedule analgesia and then … use p.r.n. analgesia and titrate to effect.'
Source DR. FRIEDRICHSDORF