Pain Management in Infants Essay

The treatment and alleviation of pain constitute a basic human right that exists regardless of age. Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Previous experience and management of pain, even from very early stages in life, alter the responses and behavior toward further “painful” experiences and events. Hence, no two people experience pain the same way, which adds to the complexity of the management of pain.Pain Management in Infants Essay

Unfortunately, even when pain is obvious, children frequently receive no or inadequate treatment for pain and painful procedures. The newborn and critically ill child are especially vulnerable to receiving no treatment or under-treatment. The conventional notion that children neither respond to nor remember painful experiences to the same degree that adults do is inaccurate. Many of the nerve pathways essential for the transmission and perception of pain are present and functioning by 24–29 weeks of gestation. Research in newborn animals has revealed that failure to provide analgesia for pain results in “rewiring” of the nerve path-ways responsible for pain transmission in the dorsal horn of the spinal cord, resulting in increased pain perception of future painful insults. This confirms human newborn research that found that the failure to provide anesthesia or analgesia for newborn circumcision resulted not only in short-term physiologic perturbations but also in longer-term behavioral changes.

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Nurses are traditionally taught or cautioned to be wary of physicians’ orders and patients’ requests for pain management, as well. The most common prescription order for potent analgesics, “to give as needed” (pro re nata, PRN), in reality means “to give as infrequently as possible.” The PRN order also means that either the patient must know or remember to ask for pain medication or the nurse must be able to identify when a patient is in pain. Neither requirement may be met by children in pain. Children less than 3 years of age and critically ill children may be unable to adequately verbalize when they are in pain or where they hurt. Moreover, they may be afraid to report their pain. Several studies have documented the inability of nurses, physicians, and parents/guardians to correctly identify and treat pain, even in postoperative pediatric patients.Pain Management in Infants Essay

Societal fears of opioid addiction and lack of advocacy are also causal factors in the understatement of pediatric pain. Unlike adult patients, pain management in children is often dependent on the ability of parents/guardians to recognize and assess pain and on their decision whether to treat or not. Parental misconceptions concerning pain assessment and pain management may therefore also result in inadequate pain treatment. Even in hospitalized patients, most of the pain that children experience is managed by their parents/guardians. Parents/guardians may fail to report pain either because they are unable to assess it or are afraid of the consequences of pain therapy. In one study, false beliefs about addiction and the proper use of acetaminophen and other analgesics resulted in the failure to provide analgesia to children. In another, the belief that pain was useful or that repeated doses of analgesics lead to medication underperformance resulted in the failure of the parents/guardians to provide or ask for prescribed analgesics to treat their children’s pain. Parental/guardian education is therefore essential if children are to be adequately treated for pain.

All of these factors make children an extremely vulnerable group. Fortunately, the past 25 years have seen substantial advances in research and interest in pediatric pain management and in the development of pediatric pain services, primarily under the direction of pediatric anesthesiologists. Pain service teams provide pain management for acute, postoperative, terminal, neuropathic, and chronic pain. Nevertheless, the assessment and treatment of pain in children are important aspects of pediatric care, regardless of who provides it. Failure to provide adequate control of pain amounts to substandard and unethical medical practice.Pain Management in Infants Essay

PAIN ASSESSMENT

The perception of pain is a subjective, conscious experience; operationally, it can be defined as “what the patient says hurts” and existing “when the patient says it does.” Infants, preverbal children, and children between the ages of 2 and 7 years may be unable to describe their pain or their subjective experiences. This has led many to conclude incorrectly that children do not experience pain in the same way that adults do. Clearly, children do not have to know (or be able to express) the meaning of an experience to have an experience. Therefore, because pain is essentially a subjective experience, it is becoming increasingly clear that the child’s perspective of pain is an indispensable facet of pediatric pain management and an essential element in the specialized study of childhood pain. Sometimes there is an over reliance on objective assessments of pain, whether from a healthcare professional or parental/guardian assessment.Pain Management in Infants Essay This objective assessment, though sometimes important, should remain only a minor partner in the assessment and management of pain, as objective assessments are also subject to bias and preconceived notions. Indeed, pain assessment and management are inter-dependent, and one is essentially useless without the other. The goal of pain assessment is to provide accurate data about the location and intensity of pain, as well as the effectiveness of measures used to alleviate or eradicate it.

Instruments currently exist to assess pain in children of all ages. Indeed, the sensitivity and specificity of these instruments have been widely debated and have resulted in a plethora of studies to validate their reliability and validity. The most commonly used instruments measure the quality and intensity of pain and are “self-report measures” that make use of pictures or word descriptors to describe pain. Pain intensity or severity can be measured in children as young as 3 years of age by using either the Oucher scale (developed by Judith E. Beyer, RN, PhD; Antonia M. Villarreal, RN, PhD; and Mary J. Denyes, RN, PhD)—a two-part scale including both a numeric scale (from 0 to 100) and a photographic scale of six photographs of a young child’s face expressing increasing degrees of discomfort—or a visual analog scale—a 10-cm line with a distraught, crying face at one end and a smiling face at the other. The visual analog scale has been validated by both sex and race. In our practice, we use the six-face Wong-Baker FACES Pain Rating Scale (developed by Dr. Donna Wong and Connie M. Baker), primarily because of its simplicity (Figure 1). This scale is attached to the vital sign record, and nurses are instructed to use it or a more age-appropriate self-report measure whenever vital signs are taken.Pain Management in Infants Essay