Case of the Month #25: Procedural pain management in children by Dr Eveline Matthews

T’s assessment is consistent with uncontrolled acute pain. She displays evidence of peri-procedural fear and pain-related anxiety. Her mother also displays evidence of pain-related anxiety. Uncontrolled acute pain and pain-related anxiety are risk factors for poorly controlled procedural pain.
 

Acute Pain

Poorly controlled acute pain can have multi-dimensional negative consequences, including delayed wound healing, psychological distress and an increased risk of transition to chronic pain (1-3). A retrospective study on paediatric burns patients during their first dressing change found that those with mild baseline pain scores had a 5.5 times increased risk of having moderate-to-severe pain during the procedure (4). Ensuring adequate baseline analgesia is imperative before commencing a potentially painful procedure. Pain assessment is a key component of effective acute pain management. Validated methods of acute pain assessment have been reviewed in a previous FPM Case of the Month on pain assessments in children from February 2021. In this case, T’s pain was not adequately managed, illustrated by her high pain scores when her arm was touched and her behaviours, such as not using her arm and being protective over it.  The pain team advised optimising her baseline analgesia by utilising all 6 doses of oramorph and ensuring regular pain assessment.
 

Pain-related Anxiety

Psychosocial factors have been implicated in the paediatric pain experience. Parental anxiety also contributes to child procedural pain. A recent study on paediatric venepuncture showed that children with parents with effective coping had better procedural pain outcomes than parents who exhibited distress-promoting behaviours (5). Recognition of pain-related anxiety allows for its targeted management. A systematic review of non-pharmacological pain management strategies during paediatric burn dressing changes reported their effectiveness in relieving procedural anxiety and pain (6).