Elsevier

The Lancet

Volume 387, Issue 10013, 2–8 January 2016, Pages 83-92
The Lancet

Review
Current concepts in management of pain in children in the emergency department

https://doi.org/10.1016/S0140-6736(14)61686-XGet rights and content

Summary

Pain is common in children presenting to emergency departments with episodic illnesses, acute injuries, and exacerbation of chronic disorders. We review recognition and assessment of pain in infants and children and discuss the manifestations of pain in children with chronic illness, recurrent pain syndromes, and cognitive impairment, including the difficulties of pain management in these patients. Non-pharmacological interventions, as adjuncts to pharmacological management for acute anxiety and pain, are described by age and development. We discuss the pharmacological management of acute pain and anxiety, reviewing invasive and non-invasive routes of administration, pharmacology, and adverse effects.

Introduction

Pain is a common symptom in children presenting to emergency departments. Under-treatment of pain (commonly labelled oligoanalgesia) has been frequently reported particularly in younger children, those with cognitive impairment, and children in developing countries. Organisations such as the Joint Commission International have made pain assessment and management a priority issue.1 Initiatives include recording of pain scores, staff education, and quality improvement processes.2, 3, 4, 5 Such efforts have fostered advances in the pharmacological and non-pharmacological treatment of pain in children. We review the state of emergency-department pain management in children, including recognition, assessment, and non-pharmacological and pharmacological treatment.

Section snippets

Recognition and assessment of pain

Pain as a presenting complaint for episodic illnesses, acute injuries, or exacerbation of chronic conditions, accounts for up to 78% of emergency department visits.6 Musculoskeletal injuries are common;7, 8, 9 27–42% of children sustain a fracture before the age of 16 years.10, 11 Other common causes include headache, otalgia, sore throat, and abdominal distress.7, 12, 13, 14 About half of patients report their pain as moderate to severe.7, 15, 16 A visit to a noisy, crowded emergency

Pain in children with chronic illness

Acute pain is common in children with chronic illnesses such as sickle cell disease, haemophilia, juvenile idiopathic arthritis, inflammatory bowel disease, hereditary angioedema, cancer, Mediterranean fever, Fabry disease, and Gaucher disease. Some typical features of acute pain (eg, tachycardia, diaphoresis, facial expression) might not manifest in these children, as they attenuate with time in chronic pain.29 These children and their families often have heightened fear and anxiety related to

Physical comfort measures and distracting activities

Psychological, behavioural, and physical interventions, stratified by age and development, can be used as adjuncts to pharmacological management.59, 60, 61, 62, 63, 64 In children, disorders causing acute pain are often accompanied by anxiety and distress. A stepwise approach to managing acute pain and anxiety combines pharmacological and non-pharmacological interventions as integrated treatment (figure 1).

Non-pharmacological approaches can be divided into two general categories: physical

Analgesic therapy

Analgesic therapy is warranted whenever non-pharmacological approaches are insufficient, or when they are unlikely to achieve the needed pain relief when given alone. We present various recommended options in Table 1, Table 2. Inhaled nitrous oxide and parenteral ketamine are often administered for sedation and analgesia during procedures; however, we do not discuss these drugs further here given the limited published experience for non-procedural analgesia in children.

Routes of administration

The oral and intranasal

Future directions

Future initiatives in emergency-department paediatric pain management will focus on developing condition-specific protocols to optimise pain recognition, assessment, and management, especially for children with cognitive impairment, recurrent pain syndromes, and chronic illness. How can we know when we have successfully provided sufficient analgesia, and when our efforts remain inadequate? When does anxiety predominate over pain such that anxiolytic agents might be more effective than

Search strategy and selection criteria

We searched the Cochrane Library, Medline, PubMed, and relevant specialty journals (all from 1980 to January, 2014). We used the search terms “pediatric pain”, “pain assessment”, “pain management”, “chronic pain”, “pain scores”, “pain protocols”, and “emergency department”. We selected publications from the past 15 years with an emphasis on the past 3 years, but we did not exclude commonly referenced and influential older publications. We also searched references of articles identified by our

References (118)

  • M Hennequin et al.

    Pain expression and stimulus localisation in individuals with Down's syndrome

    Lancet

    (2000)
  • C Rattaz et al.

    How do children with autism spectrum disorders express pain? A comparison with developmentally delayed and typically developing children

    Pain

    (2013)
  • MA Hoving et al.

    Efficacy of intrathecal baclofen therapy in children with intractable spastic cerebral palsy: a randomised controlled trial

    Eur J Paediatr Neurol

    (2009)
  • KD Young

    Pediatric procedural pain

    Ann Emerg Med

    (2005)
  • PJ Morgane et al.

    The limbic brain: continuing resolution

    Neurosci Biobehav Rev

    (2006)
  • L Heimer et al.

    The limbic lobe and its output channels: implications for emotional functions and adaptive behavior

    Neurosci Biobehav Rev

    (2006)
  • BV Murthy et al.

    Pharmacokinetics of tramadol in children after i.v. or caudal epidural administration

    Br J Anaesth

    (2000)
  • K Resch et al.

    Topical anesthesia for pediatric lacerations: a randomized trial of lidocaine-epinephrine-tetracaine solution versus gel

    Ann Emerg Med

    (1998)
  • AF Merry et al.

    Combined acetaminophen and ibuprofen for pain relief after oral surgery in adults: a randomized controlled trial

    Br J Anaesth

    (2010)
  • The Joint Commission

  • RJ Boyd et al.

    The efficacy of structured assessment and analgesia provision in the paediatric emergency department

    Emerg Med J

    (2005)
  • S Eisen et al.

    Introduction of a paediatric pain management protocol improves assessment and management of pain in children in the emergency department

    Arch Dis Child

    (2007)
  • LJ Somers et al.

    Improving the delivery of analgesia to children in pain

    Emerg Med J

    (2001)
  • RM Kennedy et al.

    Emergency department management of pain and anxiety related to orthopedic fracture care: a guide to analgesic techniques and procedural sedation in children

    Paediatr Drugs

    (2004)
  • A Downing et al.

    A study of childhood attendance at emergency departments in the West Midlands region

    Emerg Med J

    (2006)
  • C Cooper et al.

    Epidemiology of childhood fractures in Britain: a study using the general practice research database

    J Bone Miner Res

    (2004)
  • RT Migita et al.

    Sedation and analgesia for pediatric fracture reduction in the emergency department: a systematic review

    Arch Pediatr Adolesc Med

    (2006)
  • AL Hryhorczuk et al.

    Pediatric abdominal pain: use of imaging in the emergency department in the United States from 1999 to 2007

    Radiology

    (2012)
  • DM Walker et al.

    Emergency department treatment of primary headaches in children and adolescents

    Curr Opin Pediatr

    (2008)
  • SR Pitts et al.

    National Hospital Ambulatory Medical Care Survey: 2006 emergency department summary

    Natl Health Stat Rep

    (2008)
  • M Fitzgerald et al.

    The neurobiologic basis of pediatric pain

  • CC Johnston et al.

    Development of psychologic responses to pain and assessment of pain in infants and toddlers

  • AL Drendel et al.

    Pain assessment for children: overcoming challenges and optimizing care

    Pediatr Emerg Care

    (2011)
  • A Chiaretti et al.

    Current practice and recent advances in pediatric pain management

    Eur Rev Med Pharmacol Sci

    (2013)
  • Good practice in postoperative and procedural pain management, 2nd edn

    Paediatr Anaesth

    (2012)
  • GA Finley et al.

    Not small adults: the emerging role of pediatric pain services

    Can J Anesth

    (2014)
  • A Gaffney et al.

    Measuring pain in children: Developmental and instrument issues

  • T Voepel-Lewis et al.

    Do 0-10 numeric rating scores translate into clinically meaningful pain measures for children?

    Anesth Analg

    (2011)
  • RC Manworren et al.

    Clinical validation of FLACC: preverbal patient pain scale

    Pediatr Nurs

    (2003)
  • A Goldman et al.

    Pain and palliative care

  • NL Schechter et al.

    Pediatric pain: new directions from a developmental perspective

    J Dev Behav Pediatr

    (1999)
  • JC Tsao et al.

    Experimental pain responses in children with chronic pain and in healthy children: how do they differ?

    Pain Res Manag

    (2012)
  • FL Porter et al.

    Long-term effects of pain in infants

    J Dev Behav Pediatr

    (1999)
  • A van Staa et al.

    “What we want”: chronically ill adolescents' preferences and priorities for improving health care

    Patient Prefer Adherence

    (2011)
  • E Barbi et al.

    Managing chronic pain in children and adolescents: procedural sedation should be considered

    BMJ

    (2003)
  • U Balottin et al.

    Psychopathological symptoms in child and adolescent migraine and tension-type headache: a meta-analysis

    Cephalalgia

    (2013)
  • C Di Lorenzo et al.

    Chronic abdominal pain in children: a clinical report of the American Academy of Pediatrics and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

    J Pediatr Gastroenterol Nutr

    (2005)
  • G Primavera et al.

    Clinical utility of Rome criteria managing functional gastrointestinal disorders in pediatric primary care

    Pediatrics

    (2010)
  • KR Goldschneider

    Complex regional pain syndrome in children: asking the right questions

    Pain Res Manag

    (2012)
  • RS Perez et al.

    Evidence based guidelines for complex regional pain syndrome type 1

    BMC Neurol

    (2010)
  • Cited by (132)

    • The effect of buzzy and cold spray on pain, anxiety, and fear of children during venipuncture in pediatric emergency department in Turkey; A randomized controlled study

      2023, Journal of Pediatric Nursing
      Citation Excerpt :

      Pain, anxiety, and fear are frequently seen in children who apply to the emergency department (ED) due to episodic diseases, acute injuries, and exacerbation of chronic disorders (Krauss et al., 2016; Pancekauskaitė & Jankauskaitė, 2018).

    View all citing articles on Scopus
    View full text