Pathophysiology differences in Children
Dorsal horn - Excess of excitatory mechanisms. Inhibition maturation is delayed
Little is known about intercortical network connections
Somatosensory cortex is always activated
Unbalanced descending modulation commonly
Less endogenous control over noxious stimuli
Long term effects
These can be through physiological changes or psychological changes
The setting of pain experience, severity, duration - all these likely affect long term outcomes
However there is not clear evidence that prolonged changes continue into adolescence or young adulthood
Sensitisation mechanisms in children
Peripheral: Increased peripheral nerve sprouting
Dorsal horn/Spinal: Central sensitisation, disinhibition, neuroimmune priming (microglia)
Cortical: Alterations in reward related pathways and stress response
How does pain affect children's lives?
Physical - They can become less active with deconditioning and falling behind physical milestones. Can increase obesity. Can increase stress (with loss of the protective exercise)
Social - Loss of social interaction, sport involvement, loss of friends and play times
Academics - Can affect learning more through loss of time at school than true cognitive issue
Sleep - 50% of kids can have sleep difficulties with pain and this affects everything
Family - These are affected by loss of work, income, organisation, increased psych distress
History taking specifics
Sleep / Mobility / Schooling / Play/leisure / Emotional state
Pain measurement scores for kids:
Neonatal infant pain scale.
FLACC - Young children
Faces pain scale - after age 4-5
Numeric rating scales can commonly be used for > 8 yo children
Paediatric pain profile (kids with disabilities)
Management
Non pharmacological
Behavioural
Breathing exercises (can use bubble blowers, poppers), modelling coping behaviours, desensitisation (very slow graduated movements), positive reinforcement
Cognitive
Imagery (child is asked to imagine an enjoyable experience), education and information (appropriate for the child), coping statements and being positive "I can do this", distraction including TV, conversation, games etc.
Sweet solutions can be used - thought to help assist descending modulation of pain
Pharmacological considerations
Some medications cannot be used (e.g. aspirin)
Pharmacokinetics - Total body water is higher, protein concentration and binding is different, changes in drug metabolism (e.g. slower excretion and metabolism)
Pharmacodynamics - Pain scores and drug levels have poor correlation. Possibly due to plasma differences and pharmacodynamic variability.
Doses - Doses are commonly done by age, weight compared to a centile, and/or lean body weight calculations. If very obese, all doses are done on lean body weight. (These are calculated by working out centile for height and matching this to expected weight. E.g. 97% centile for height, find that centile for weight).
Procedural pain
Procedural strategy
IM injections - Don't need to aspirate. Don't tell them it won't hurt. Inject most painful last.
Physical strategy
Keep them upright and rub skin before injection is given
Psychological strategy
Use lots of distraction techniques
Infant strategies
Breastfeeding and sweet tastes on tongue can help
Pharmacological strategies
Topical anaesthetics can be used
Cooling agents, and the use of panadol or ibuprofen, have not been shown to help
Family Strategies
Preparation/education/information - these can help.
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