Pain in Children - A Practical Guide for Primary Care

Dedication

Foreword

Preface

Acknowledgements

Table of Contents

Contributors

Part I: General Considerations

Chapter 1

Pain and the Primary Pediatric Practitioner

Introduction

1. Managing Pain in Children: Your Ethical Obligation

2. Development of Pain Systems

3. Individual Differences in Pain Response

3.1. Genetics of Pain Response

3.2. Temperament

4. Consequences of Untreated Pain in the Young

Take-Home Points

References

Chapter 2

Developmental Issues in Understanding, Assessing, and Managing Pediatric Pain

Introduction

1. The Child in Pain

2. The Role of the Caregiver

3. Domains of Development

3.1. Physical Growth

3.2. Cognitive Capabilities

3.3. Emotional Processing

3.4. Behavioral Competence

3.5. Social Interaction

4. Stages of Development

4.1. Newborns

4.2. Infants

4.3. Toddlers

4.4. Preschoolers

4.5. Elementary School-Aged Children

4.6. Adolescence

Take-Home Points

References

Chapter 3

Measurement and Assessment of Pediatric Pain in Primary Care

1. Measurement of Pain: Why and How?

2. Pain Measurement in Primary Care Versus Specialized Settings

3. How Pain is Measured

4. Interpretation and Use of Pain Scores

5. Neonates, Infants, and Toddlers up to 2 Years

6. Preschool-Age Children (3 to 5 Years)

7. School-Age Children (6 to 12 Years)

8. Adolescents

9. Children with Developmental Disabilities

10. Children in Critical Care

11. Four Brief Case Examples

11.1. Self-Report Numerical Pain Scores in a Headache Diary

11.2. Self-Report Faces Pain Scores in Repeated Injections

11.3. Observation by Parents to Control Post-Tonsillectomy Pain at Home

11.4. Physician’s Use of a Global Numerical Rating Scale in a Busy Infant Ward

Take-Home Points

References

Chapter 4

Pain Management for Children with a Developmental Disability in a Primary Care Setting

Introduction

1. What is a Developmental Disability and Where is the Pain?

2. What Is an SNI and How Can it Lead to Painful Conditions?

3. Pain Expression in SNI

4. Pain Assessment

5. Investigation of Pain in a Child with an SNI

6. Pain Management

6.1. Analgesics

6.2. Drug Interactions

6.3. Drug Trials

6.4. Acute Pain

Take-Home Points

Recommended Reading Material

References

Chapter 5

Remote Management of Pediatric Pain

Introduction

1. Pediatrician to Patient and Family

1.1. Assessment at a Distance

1.2. Treatment at a Distance

1.3. Schools at a Distance

1.4. When to Refer to a Pain Service

2. Pediatric Pain Specialist Care to Patient and Family

2.1. Pediatric Pain Clinic Assessment at a Distance

2.2. Pediatric Pain Clinic Treatment at a Distance

2.3. Pediatric Pain Clinic and Schools at a Distance

2.4. Pediatric Pain Clinic and Distance Specific Treatments

3. Professional-to-Professional Consultation

4. Ethical/Legal Issues

5. Conclusion

Take-Home Points

References

Appendix A

Part II: Acute Pain Management

Chapter 6

Pain Management in the Primary Care Office

Introduction

1. Pains in Normal Growth and Development

1.1. Teething

1.2. Colic

1.3. Growing Pains

2. Pain Associated with Acute Infections

2.1. Otitis Media

2.2. Pharyngitis

2.3. Summary

3. Pain Associated with Minor Injuries

4. Creating a Pain-Friendly Office

4.1. Setting the Stage

4.2. Education

4.2.1. Parents and Children

4.2.2. Staff Education

4.3. Cultivating Relationships with Outside Providers

4.4. Office Environment

5. Summary

Take-Home Points

References

Chapter 7

Topical Anesthetics and Office-Based Procedures

Introduction

1. Needle Procedures: Immunizations, Venous Access, and Heel Lance

1.1. Prior to the Needle Procedure

1.1.1. Preparation

1.1.2. Site

1.1.3. Needle Type

1.1.4. Injectate Properties

1.2. During the Procedure

1.2.1. Parental Demeanor

1.2.2. Distraction

1.2.3. Topical Anesthetics

1.2.4. Complementary Analgesia for Infants

1.2.5. Physical Methods

1.2.6. Simultaneous Injection

2. Urinary Catheterization

3. Summary and Other Procedures

Take-Home Points

References

Chapter 8

Analgesic Medications for Acute Pain Management in Children

Introduction

1. Nonsteroidal Anti-Inflammatory Drugs

1.1. Nonspecific Cyclooxegenase Inhibitors

1.1.1. Acetylsalicylic Acid (Aspirin)

1.1.2. Acetaminophen

1.1.3. Ibuprofen

1.1.4. Naproxen

1.1.5. Etodolac

1.1.6. Ketorolac

1.2. COX-2 Inhibitors

2. Opioids

2.1. Agonists and Antagonists

2.2. Adverse Drug Reaction

2.3. Recommended Doses

2.4. Morphine

2.4.1. Fentanyl

2.4.2. Hydromorphone

2.4.3. Meperidine

2.4.4. Methadone

2.4.5. Codeine

2.4.6. Oxycodone and Hydrocodone

2.4.7. Tramadol

2.4.8. Nalbuphine

2.4.9. Naloxone

3. Approaches to Opioid Use

3.1. Patient-Controlled Analgesia

3.2. Continuous Opioid Infusions

4. Nontraditional Analgesics

4.1. Antidepressants

4.2. Anticonvulsants

Take-Home Points

References

Chapter 9

Pain Management in the Emergency Department

Introduction

1. Advances in ED Pain Management

1.1. Procedural Sedation and Analgesia

1.2. Simple Procedural Pain Management

1.3. Acute Abdominal Pain

2. Nonpharmacologic Interventions

3. Pharmacologic Interventions

4. Preparing the Patient for an ED Visit

5. Pre-Hospital Pain Management

Take-Home Points

References

Chapter 10

Preparing Children for Invasive Procedures and Surgery

Introduction

1. Factors Associated with Pediatric Pain During Invasive Procedures

1.1. Nonmalleable Predictors of Children’s Pain and Distress

1.2. Malleable Predicators of Children’s Pain and Distress

2. Assessment of Pain, Distress, and Coping

3. Interventions for Acute Procedures

3.1. Pharmacologic Approaches

3.2. Psychological Interventions for Procedure-Related Pain

4. Interventions to Reduce Presurgical Anxiety

4.1. Midazolam

4.2. Parental Presence

4.3. Preparation Programs

5. When to Refer

5.1. For Further Information

Take-Home Points

References

Chapter 11

Pain Relief After Outpatient Surgery

Introduction

1. Regional Anesthesia for Outpatient Surgery

1.1. Caudal Anesthesia

1.1.1. Single Shot Caudals

1.2. Peripheral Nerve Blocks

1.2.1. Fascia Iliaca Block

1.2.2. Ilioinguinal/Iliohypogastric Nerve Blocks

1.2.3. Penile Blocks

1.3. Conclusions

2. Medication Management of Postoperative Pain

2.1. Acetaminophen

2.2. Nonsteroidal Anti-Inflammatory Drugs

2.3. Opioids

3. The Transition from Recovery Room to Home

Take-Home Points

References

Chapter 12

Regional Anesthesia

Introduction

1. Local Anesthetic Pharmacology

2. Regional Anesthetic Nerve Blocks and their Indications in Children

2.1. Head and Neck Blocks

2.1.1. Occipital Nerve Block

2.2. Upper Extremity Blocks

2.2.1. Interscalene Brachial Plexus Block

2.2.2. Infraclavicular Brachial Plexus Block

2.2.3. Axillary Brachial Plexus Block

2.2.4. Intravenous Regional (Bier) Block

2.3. Truncal Somatic and Visceral Blocks

2.3.1. Intercostal Nerve Block

2.3.2. Paravertebral Block

2.3.3. Rectus Sheath Nerve Block

2.3.4. Ilioinguinal and Iliohypogastric Nerve Block

2.3.5. Penile Block

2.3.6. Celiac Plexus Block

2.4. Lower Extremity Blocks

2.4.1. Lumbar Plexus Block

2.4.2. Femoral Nerve Block

2.4.3. Sciatic Nerve Block

2.4.4. Saphenous Nerve Block

2.4.5. Intravenous Regional (Bier) Block

2.5. Sympathetic Blocks

2.5.1. Stellate Ganglion Block

2.5.2. Lumbar Sympathetic Block

2.6. Neuraxial Nerve Blocks

2.6.1. Epidural Anesthesia (Thoracic, Lumbar)

2.6.1.1. Caudal (Sacral) Epidural Anesthesia

2.6.1.2. Intrathecal (Spinal) Anesthesia

Take-Home Points

References

Part III: Recurrent and Chronic Pain Management

Chapter 13

How to Talk to Parents about Recurrent and Chronic Pain

Case Illustration

Introduction

1. Significance of Recurrent and Chronic Pain

2. A Biopsychosocial Framework

2.1. Explaining the Biopsychosocial Framework to Children and Parents

3. Clinical Evaluation of Recurrent and Chronic Pain

3.1. Communicating about Psychological Contributors and Interventions

4. Engaging the Parent in Counseling by the Physician

5. Guidelines in Making Referrals

Take-Home Points

References

Chapter 14

Multidisciplinary Approaches to Chronic Pain

Introduction

1. Models of Care

1.1. Multidisciplinary Pain Center

1.2. Multidisciplinary Pain Clinic

1.3. Pain Clinic

1.4. Modality-Oriented Clinic

2. Multidisciplinary Centers for Children

3. Organization of the Multidisciplinary Evaluation

3.1. Initial Physical Exam

3.2. Initial Physical/Occupational Therapy Exam

3.3. The Feedback Session

3.4. The MPC and Primary Physicians

3.5. Treatment and Cost-Effectiveness of MPCs

4. Specific Disease Examples

4.1. Complex Regional Pain Syndrome (CRPS) Type I

4.2. Musculoskeletal Pain and Fibromyalgia

4.3. Headache

4.4. Abdominal and Pelvic Pain

5. Conclusion

Take-Home Points

References

Chapter 15

Psychological Interventions for Chronic Pain

Introduction

1. Biofeedback-Assisted Relaxation Training

2. Pain Coping Skills Training

3. Parental Guidance in Behavior Management Techniques

4. Family-Based Intervention

5. Consultation with School Personnel

6. Psychiatric Consultation

Take-Home Points

References

Chapter 16

Complementary and Alternative Approaches for Chronic Pain

Introduction

1. CAM Treatments for Children and Adolescents

1.1. Acupuncture

1.2. Hypnotherapy

1.3. Biofeedback

1.4. Therapeutic Yoga

1.5. Massage

1.6. Meditation

1.7. Other CAM Treatments

2. Guidelines for Clinicians and Parents

Take-Home Points

Recommended Reading

References

Part IV: Common Recurrent and Chronic Pain Problems in Primary Care

Chapter 17

Functional Abdominal Pain

Introduction

1. Definition of FAP

2. Prevalence

3. Etiology

4. Biopsychosocial Model

5. Prognosis

6. Assessment of FAP

7. Treatment

7.1. Pharmacological Therapy

7.2. Dietary Management

7.3. Psychological Interventions

7.4. Other Treatment Options

8. Conclusion

Take-Home Points

References

Chapter 18

Headaches

Introduction

1. Migraine

1.1. Migraine without Aura

1.2. Migraine with Aura

1.3. Complications of Migraine

1.4. Other Features Characteristic of Juvenile Migraines

2. Childhood Periodic Syndromes

3. Tension-Type Headache (TTH)

4. New Daily Persistent Headache (NDPH)

5. Referral to Secondary/Tertiary Care

6. Management

6.1. Management of Acute Migraine

6.2. Management of Chronic Migraines

6.3. Managing Chronic Daily Headaches

6.4. Biobehavioral Treatment

6.5. Dietary Modifications and Supplements

6.6. Physical Therapy

6.7. Acupressure and Acupuncture

Take-Home Points

Recommended Reading

References

Chapter 19

Evaluating and Managing Pediatric Musculoskeletal Pain in Primary Care

Introduction

1. Diagnostic Issues in Pediatric Musculoskeletal Pain

1.1. Overview

1.2. Important Considerations when Taking a History

1.3. Physical Exam

1.4. Laboratory Tests

1.5. Radiographs

2. Specific Musculoskeletal Pain Problems

2.1. Back Pain

2.2. Complex Regional Pain Syndrome

3. Follow-Up and Referral

3.1. When to Refer to a Pediatric Rheumatologist

3.2. When to Refer to a Pediatric Pain Clinic

3.3. Other Referrals

Take-Home Points

References

Chapter 20

Pain in Sickle Cell Disease

Introduction

1. Disease Pathophysiology

2. Clinical Characteristics of Vaso-Occlusive Pain

3. Other Pain Syndromes

3.1. Chest Pain

3.2. Headache

3.3. Abdominal Pain

3.4. Avascular Necrosis

4. Pain Treatment in the Home Setting

5. Pain Treatment in the ED

6. Pain Treatment in the Hospital Setting

7. Closing Thoughts

Take-Home Points

References

Chapter 21

Chronic Pelvic Pain

Introduction

1. Evaluation

1.1. History

1.2. Physical Exam

1.3. Testing

2. Primary Dysmenorrhea

3. Endometriosis

4. Irritable Bowel Syndrome

5. Musculoskeletal Pain

6. Interstitial Cystitis

7. Pediatric Pain Center: A Multidisciplinary Approach

7.1. Pharmacologic Therapies

7.1.1. Antidepressants

7.1.2. Anticonvulsants

7.1.3. Tramadol

7.2. Cognitive-Behavioral Therapy

7.3. Physical Therapy

7.4. Complementary and Alternative Medicines (CAM)

Take-Home Points

References

Chapter 22

Palliative Care for the Pediatrician

Introduction

1. Epidemiology

2. Definition of Palliative Care

2.1. Essential Elements of Pediatric Palliative Care

3. Identifying Children Who Might Benefit from Palliative Care

4. The Role of the Primary Care Physician

4.1. Communication

4.2. Coordination of Care

4.3. Respite Care

5. End-of-Life Issues

5.1. Grief and Bereavement

5.2. Complicated Grief

6. Pain and Symptom Management

6.1. Pain

6.1.1. Initiating Therapy

6.1.2. Neonates

6.2. Opioid Side Effects

6.2.1. Idiosyncratic Reactions

6.2.2. Opioid Rotation

6.3. Progressing Pain

6.3.1. Intractable Pain

6.3.2. Total Analgesia

6.4. Dyspnea

6.5. Nausea and Vomiting

6.6. Seizures

Take-Home Points

References

Part V: Special Topics

Chapter 23

Labeling of Pediatric Pain Medications

Introduction

1. Important Lessons from Pediatric Studies

1.1. Pharmacokinetics

1.2. Efficacy

1.3. Safety

2. Regulatory Highlights

3. FDA-Approved Labeling

4. Special Topics: DEA Regulations

5. Pediatric Labeling for Drugs Commonly Used For Analgesia or Anesthesia as of December 2006

5.1. Acute Pain

5.1.1. Acetaminophen, Aspirin, and Nonsteroidal Agents

5.1.2. Opioids

5.1.3. Epidurals

5.1.4. Local Anesthesia

5.1.5. Topical Anesthesia

5.2. Chronic Pain

5.3. Headaches

5.4. Muscle Relaxants

6. Gaps in Labeling

Take-Home Points

Resources

References

Chapter 24

Pediatrician as Advocate

Introduction

1. Barriers to Pain Advocacy in Primary Care

2. Physician as Advocate

3. The Importance of the Message

4. Developing Your Message

5. Story Telling

6. Goal and a Plan of Action: Advocating for Kids’ Pain Outside of the Exam Room

Take-Home Points

References

Chapter 25

Conclusion: What to Do When There is Nothing to Do

Introduction

1. There is Always Something to Offer

2. There is Always Something to Do (at Least by the Patient)

3. FDA Approval and Medication Use

4. Looking Ahead

5. "Good Luck"

Final Take-Home Points

Index