Online assessment of pain in pediatric patients

Online Pediatric Pain Assessment

Pain is a variable term that can express a variety of conditions. In general, it is an unpleasant feeling caused by damaging stimuli, emotional issues, uncomfortability, or the body's response to certain other types of stimuli internally or externally. The International Association for the Study of Pain describes it as: "An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage" (Loeser, 2013). Pain is the body's response to removing unpleasant or damaging situations. It is likely an evolutionary response, one that helps the body learn, removes the injured part so it can heal, to avoid similar experiences, or to let the body know that there is something that requires attention (the Handbook of Chronic Pain, 2007). When it comes to infants and children, though, the vocabulary and cognitive development are often not sophisticated enough to express or describe pain in the same way as adults. In fact, physical and psychological issues surrounding pain affect the child's immediate health, as well as the potential for chronic pain in adulthood, or damage or disease untreated. Caring for children with pain requires even more of an understanding of the cognitive, affective and environmental dynamics that impact management and expression of pain. This is particularly true for infants and children with chronic pain (Carter & Threlkeld, 2012).

Additionally, pain is one of the most common reasons people visit healthcare professionals in the United States. It is a major symptom, affects quality of life of not just the patient but the family as well, and has a complex psychological matrix in that what is mildly painful to one individual is extremely painful to another. In the same way, the human neural system is so complex that pain can emanate from areas that have no pain receptors (the brain, for instance, or amputated limbs) (Woolf, 2010).

Literature Review

Pain in humans is thought to be expressed by dozens of neural receptors, both in the brain and throughout the body's nervous system: acid sensing, potassium sensing, ligand ion sensing, and more. It is complex in that it depends on the type of pain (e.g. A burn, a cut, a sprain), or the area of the body in which the stimuli occurs (some areas have more pain receptors than others). Thus, pain is both a complex sensory and emotional experience, but one essential for survival. Prior to the 1980s, it was thought that the pediatric patient's pain pathways were incomplete and thus many procedures were done without the benefit of anesthetic (circumcisions, heal sticks, venipuncture, hypodermic injections). Now, physicians believed that pain is perceived even in very young infants. The nervous system receives stimuli and then modifies its circuits to improve processing -- learning about pain and pleasure if you will. Because children are unable, though, to report pain due to a lack of verbal skills, there needs to be strict observation to non-verbal clues (high-pitched cries, facial grimacing, body rigidity, etc.) or with older children, assessed through the color or picture scales that help the child's communicative ability (Gould, 2007).

Acute pain, though, is quite common in children from injury, illness or medical procedures. Despite the fact that pain is part of the childhood experience, it is oftentimes undertreated or neglected, even among professionals. Research shows that the most common reasons for this are inadequate knowledge about pain in pediatric patients, or the fact that it takes no only medical expertise, but a keen sense of empathy and psychological assessment for children since pain is subjective. Be that as it may, those caring for pediatric patients are responsible for eliminating or minimizing pain and suffering from children whenever possible. Recent studies indicate that there needs to be a multidimensional approach to the issue (Committee on Psychosocial Aspects of Child and Family Health, 2001).

Assessment of pediatric pain can be difficult, as noted. One research study looked at seventeen methods spanning reports, diaries, behavioral observations, parental or caregiver observations, and clinical aspects. Contrary to past views, it is not that difficult to establish basal levels in children. However, accurate assessment of children's pain is important when diagnosing other illnesses, particularly those that involve invasive procedures, so that the impact of the pain does not overshadow the treatment protocols (Cohen, L., et al., 2007). Healthcare professionals must also understand that neglecting pain in pediatric patients may also have long-term detrimental effects on pain sensitivity the immune functions on the body, adult perception of pain, and even attitudes about healthcare behaviors (Young, 2005).

Pain, because it is a perception, is really more psychosocial at times since it cannot necessarily be quantitatively measured with any degree of accuracy. Chronic pain in pediatric and adolescent populations, for instance, interferes with growth, development, quality of life, academic, vocational and social success. To appropriately care for these patients, one must involve cognitive and family dynamic factors. It is defined as chronic when it has persisted for at least three months, moving from tissue damage to changes within the neural system. Indeed, chronic pain in his population is impacted by a number of psychosocial factors (stress, negative enviroments, family, friends, school, etc.). Most commonly, chronic pain in this population centers in the head (migraines) abdomen (stress or ulcers) or arms and legs (muscular or skeletal issues that may or may not be the result of growth). These chronic conditiions can be part of arthritis, lupus, leukemia, cancer, or simply hormonal or growth issues that are very difficult to define. For this population, increased communication and a longer term, more multidimmensional plan is necessary that may also need to include alternative treatments (biofeedback, massage, meditation, yoga, accupuncture, etc.) (Carter & Threlkeld).

Analysis

Barriers to the treatment of pain in pediatrics fall into six basic categories: 1) the age-old myth that children do not feel pain in the same was as adults; 2) lack of proper assessment and reassement tools for pediatrics; 3) lack of understanding of the means to quantify subjective pain experiences in children; 4) lack of current knowledge of pain treatment; 5) the idea that assessing and treating pain in pediatric patients is too time consuming and not always necessary; and; 6) fear of adverse reactions in children to analgesic medications ((Committee on Psychosocial Aspects of Child and Family Health).

Because we understand a lack of vocabulary or cognition in children. Facial expression is one of the most effective ways of pediatric assessment, called Primarl Face of Pain (PFP). This is somewhat controversial because it implies a great deal of interpretation and subjective materials. However, over the years, a coding system has developed to evaluate pain expression in children. The oldest and most widely used tool is called the FACS (Facial Action Coding System). This identifies 44 discreet facial units, that represent movements of facial muscles or muscle groupings. While developed in 1978, this tool has undergone considerable restructuring and analysis to the point that it has good psychomatric properties (See Appendix a) (Schiavenato, 2008).

At the same time, it is important to look at other tools and validate their efficacy. The Faces, Legs, Activity, Cry and Consolability (FLACC) pain assessment tool is often used by pediatric nurses to assess pain in children under three years of age. It is an observational tool that is particularly valuable in post-analgesic care. The tool looks at not only the face, but how much the legs move, how active the infant is, how much crying is present, and whether the child can be consoled in any way. The FLACC tool is used to help judge the anagesic choice, since often it is a subjective decision to use opiods or non-opiods to decrease pain. The research then suggests that the FLACC tool be used in conjuction with the nurse's recommendation and observation (Manworren & Hynan, 2003).

Conclusions

In the contemporary medical field, there is no need for any patient to experience unnecessary pain once under treatment. Certainly, there is the need for more research on the manner in which certain drugs interact with younger people, and certainly treatment of children with pain will improve as pain management education evolves. Pain has been defined in the literature as whatever the person says it is, since it is so difficult to establish an actual definition of pain, rather than a scale mode. This, of course, places preverbal children at the greatest risk for inconsistent and often arbitrary measures pain.

There are, of course, a number of interventions that can take place when dealing with pain in children -- from intermittent, to chronic pain, and all levels in between. One of the key elements, however, is observation of behavior and the ability for the advocate nurse to help in the decision-making process that will allow the more effective treatment. Because opiates and other analgesics can be dangerous and, at times, unpredictable for children, it is incumbent upon the neonatal nurse to try other measures to comfort and alleviate pain in children. Often, pain is perceived in children because they do not understand it. and, despite more and more research evidence that shows psychological interventions to be effective, there are indeed challenges for neonatal and child medical professionals. How many children, for instance, can be reached through these interventions in a busy hospital ward? How can the family be taught to help intervene so the nurse can treat multiple patients? What issues surround HMO's and other insurance issues that offer non-traditional pain reduction therapy? Finally, there is the all-encompassing cost factor that asks the medical community to judge the benefits to the outcome. In any case, knowing that there are assessment tools and interventions available, no child should experience unnecessary pain within a medical paradigm (Handbook of Pediatric Chronic Pain, 2011).

Appendix a -- Facial Coding Systems in Pediatric Pain (Schiavento)

APPENDIX B -- NEUROBIOLOGY of PAIN in CHILDREN (McClain)