Obvious Pediatric Pain (6 months-18 years) - Curbside
Obvious Pediatric Pain (6 months-18 years)
Editors: Dan Imler, MD
Inclusion Criteria  (Any one criteria present)
  • Obvious significant pain (source not important)
Exclusion Criteria
  • Hx of high risk airway disease, surgery or tracheostomy
  • Respiratory distress or oxygen requirement
  • Head/mid-face trauma, LOC or mental status changes
  • Toxic appearance
Consultation with physician qualified to manage acute pain.

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Total Notes: 3

1 Pediatric pain

Pain is a common presenting symptoms of a wide variety of disorders and injuries in the pediatric patient. It is usually divided into two categories:

  • Nociceptive pain - activation of nocioceptors from tissue damage or inflammation
  • Neuropathic pain - activation of damaged nerve fibers (compression, ischemia, etc.)

Addressing the pain a patient is experiencing depends on the origin of that pain and the personal characteristics of the patient themselves (history of pain, personal beliefs, developmental stage, etc.) as well as associated symptoms such as anxiety. This pathway was designed to address pain regardless of source for emergent management. If the source of pain is not readily available it is pertinent to investigate that source, but not necessarily at the expense of providing adequate pain management in the ensuing time period.

Our model is based on the World Health Organization (WHO) stepwise approach to pain. This model emphasizes:

  • The use of non-pharmacologic measures
  • The use of oral analgesics to avoid additional pain (e.g. intramuscular medications)
  • Regular assessment of pain
  • Pharmacology based on assessment of the intensity of pain
    • Mild: NSAIDs
    • Moderate to severe: appropriate opioids (e.g. morphine, oxycodone, fentanyl, etc.)
  • Adjuvant pharmacological therapy (e.g. antidepressants, anxiolytics)for relevant patients

  1. Pediatric clinical practice guidelines for acute procedural pain: a systematic review.
    Lee GY, Yamada J, Kyololo O, Shorkey A, Stevens B.
    Pediatrics. 2014 Mar;133(3):500-15.
  2. Development of the World Health Organization Guidelines on Cancer Pain Relief and Palliative Care in Children.
    McGrath PA
    J Pain Symptom Manage. 1996;12(2):87.
  3. WHO Guidelines on the Pharmacological Treatment of Persisting Pain in Children with Medical Illnesses
    World Health Organization
    2012. ISBN-13: 978-92-4-154812-0

2 Non-pharmacologic pain control

There are many strategies other than medication which have been shown to improve acute pain in pediatric patients. These strategies have variable levels of success. These include:

  • Provider interventions
    • Child life involvement
    • Family/parental involvement
  • Physical interventions
    • Heat stimulation
    • Cold stimulation
    • Massage
    • Acupuncture
  • Cognitive interventions
    • Guided imagery
    • Distraction
    • Hypnosis
  • Behavioral interventions
    • Biofeedback
    • Desensitization
    • Operant conditioning
    • Modeling positive coping behaviors
    • Relaxation techniques
    • Art, music and play therapy

  1. Pain in Children: Assessment and Nonpharmacological Management.
    Srouji R, Ratnapalan S, Schneeweiss S.
    International Journal of Pediatrics. 2010;2010:474838.
  2. Management of procedure related pain in children and adolescents. Guideline statement: paediatric and health division.
    Royal Australasian college of physicians.
    Journal of Paediatric and Child Health. 2006;42:51–529.
  3. Use of distraction with children during an acute pain experience.
    Vessey JA, Carlson KL, McGill J.
    Nurs Res. 1994 Nov-Dec;43(6):369-72.
  4. Procedural-support music therapy in the healthcare setting: a cost-effectiveness analysis.
    DeLoach Walworth D.
    J Pediatr Nurs. 2005 Aug;20(4):276-84.
  5. Comparative study of distraction versus topical anesthesia for pediatric pain management during immunizations.
    Cohen LL, Blount RL, Cohen RJ, Schaen ER, Zaff JF.
    Health Psychol. 1999 Nov;18(6):591-8.
  6. Psychological interventions for needle-related procedural pain and distress in children and adolescents.
    Uman LS, Chambers CT, McGrath PJ, Kisely S.
    Cochrane Database Syst Rev. 2006 Oct 18;(4):CD005179.
  7. Nurse coaching and cartoon distraction: an effective and practical intervention to reduce child, parent, and nurse distress during immunizations.
    Cohen LL, Blount RL, Panopoulos G.
    J Pediatr Psychol. 1997 Jun;22(3):355-70.
  8. Preparing children for venous blood sampling.
    Harrison A.
    Pain. 1991 Jun;45(3):299-306.
  9. Pain- and distress-reducing interventions for venepuncture in children.
    Tak JH, van Bon WH.
    Child Care Health Dev. 2006 May;32(3):257-68.
  10. Effects of distraction using virtual reality glasses during lumbar punctures in adolescents with cancer.
    Sander Wint S, Eshelman D, Steele J, Guzzetta CE.
    Oncol Nurs Forum. 2002 Jan-Feb;29(1):E8-E15.
  11. Blowing away shot pain: a technique for pain management during immunization.
    French GM, Painter EC, Coury DL.
    Pediatrics. 1994 Mar;93(3):384-8.

3 Assessment of pain intensity

The assessment of pain intensity is one of the primary drivers of pain management and thus should be quickly and repeatedly completed during evaluation of a pediatric patient with pain. Quantification of the pain intensity may be accomplished through self-report (1-10 pain scales, Wong-Baker FACES) or through observational tools for non-verbal patients. There are many observational tools which have been developed, however our pathway utilizes the Revised Face, Legs, Activity, Cry, Consolability (r-FLACC) scale as it has been shown to have the highest clinical utility in comparative studies. Patient with neurologic or developmental disabilities may be difficult to quantify, however r-FLACC may be useful in these children as well as clinical assessment and caregiver input. However, it should be noted that underreporting of pain with observational tools have been show as compared to self-report in children 3-7 years old.

  1. Analgesics for the treatment of pain in children.
    Berde CB, Sethna NF
    N Engl J Med. 2002;347(14):1094.
  2. The creation, validation, and continuing development of the Oucher: a measure of pain intensity in children.
    Beyer JE, Denyes MJ, Villarruel AM
    J Pediatr Nurs. 1992;7(5):335.
  3. Pain in children: comparison of assessment scales.
    Wong DL, Baker CM
    Pediatr Nurs. 1988;14(1):9.
  4. A systematic review of faces scales for the self-report of pain intensity in children.
    Tomlinson D, von Baeyer CL, Stinson JN, Sung L
    Pediatrics. 2010;126(5):e1168.
  5. Measuring pain accurately in children with cognitive impairments: refinement of a caregiver scale.
    Breau LM, Camfield C, McGrath PJ, Rosmus C, Finley GA
    J Pediatr. 2001;138(5):721.
  6. Psychometric properties of the non-communicating children's pain checklist-revised.
    Breau LM, McGrath PJ, Camfield CS, Finley GA
    Pain. 2002;99(1-2):349.
  7. The revised FLACC observational pain tool: improved reliability and validity for pain assessment in children with cognitive impairment.
    Malviya S, Voepel-Lewis T, Burke C, Merkel S, Tait AR
    Paediatr Anaesth. 2006;16(3):258.
  8. The reliability and validity of the Face, Legs, Activity, Cry, Consolability observational tool as a measure of pain in children with cognitive impairment.
    Voepel-Lewis T, Merkel S, Tait AR, Trzcinka A, Malviya S
    Anesth Analg. 2002;95(5):1224.
  9. A survey of signs, symptoms and symptom control in 30 terminally ill children.
    Hunt AM
    Dev Med Child Neurol. 1990;32(4):341.
  10. Medical and nursing problems of children with neurodegenerative disease.
    Hunt A, Burne R
    Palliat Med. 1995;9(1):19.
  11. Pain assessment in nonverbal children with severe cognitive impairments: the Individualized Numeric Rating Scale (INRS).
    Solodiuk J, Curley MA
    J Pediatr Nurs. 2003;18(4):295.
  12. A comparison of the clinical utility of pain assessment tools for children with cognitive impairment.
    Voepel-Lewis T, Malviya S, Tait AR, Merkel S, Foster R, Krane EJ, Davis PJ
    Anesth Analg. 2008;106(1):72.
  13. Discordance between self-report and behavioral pain measures in children aged 3-7 years after surgery.
    Beyer JE, McGrath PJ, Berde CB
    J Pain Symptom Manage. 1990;5(6):350.
  14. Pain, anxiety, distress, and suffering: interrelated, but not interchangeable.
    Berde C, Wolfe J
    J Pediatr. 2003;142(4):361.