Pediatric Pain Control

You’re just about to sit down for dinner when the alert goes out: “Medic 13, respond to a 3-year-old male, trauma.” En route you read the dispatch notes and learn the patient was riding his bike and fell off, landed on his arm, and now has an obvious deformity. Upon arrival on scene you assess the patient and confirm there is an obvious deformity of the left elbow, along with a surprisingly large amount of swelling, and the patient cries every time you touch him. 

He is consolable by his mother, and you have no concerns about a head injury. Further exam shows the patient is neurovascularly intact with good pulses to the left wrist and can spontaneously wiggle his fingers and nod his head when you touch them. After determining there are no other obvious injuries to this child, you start to work on how to transport him and what you can do to improve the pain. You wonder: 

• Should I splint it?
• Should I apply an ice pack?
• What kinds of pain medications do I have?
• Should I give narcotics to a child?
• Do I know the dose of narcotics for a child?
• Should I start an IV for pain medications?
• Should I leave this for the hospital to decide?

Background

Nobody wants to be in pain, and when we think of our most sensitive populations, pediatrics commonly come to mind. In a 2018 study researchers found documentation of pain was very infrequent among all patients but especially in those 3 and younger.¹ Of those with documented pain complaints, children received pain medications less than their adult counterparts, with fewer than 15% of pediatric patients having documented analgesics. The Pediatric Emergency Care Applied Research Network (PECARN) highlights pain control in pediatrics in its list of the top 10 topics in need of additional research.² Pain control should be considered an important component of EMS care. 

It is important for EMS clinicians to understand there is more to pain control than just narcotic analgesic medications. Your local protocols likely provide various methods to achieve pain control, and understanding them is an important component of the overall patient care umbrella.³ In pediatrics it is also important to understand that anxiety and pain can look very similar in physical exam findings, and you must be able to identify the differences.⁴ 

Pediatric Pain Scoring Tools 

Pediatric communication varies greatly with patient age and affects the patient’s ability to effectively interact with emergency medical providers, especially during a high-stress critical event. It is important to utilize an appropriate pediatric pain scoring tool to obtain an accurate estimation of pain level. There are multiple tools available for the varying cognitive levels of different-aged children, so choose an appropriate one. 

FLACC—The FLACC score (for face, legs, activity, cry, consolability) considers patient movement and is considered appropriate for patients 2 months and older.⁵ Created by a nurse and physician from Mott Children’s Hospital in Ann Arbor, Mich., the FLACC score has been shown to be an effective way to evaluate pain in infants.⁶ It is scored from a range of 0–10, correlating to the numbers scale. 

FACES—For children who can be interactive but may not understand the numbers scale, roughly 3 and older, the Wong-Baker FACES scale may be a more appropriate tool. The patient is asked which face they feel most like.⁷ This guides EMS pain management. 

Numbers—Of course there is the traditional numbers scale. This is typically the go-to assessment for adult patients: “On a scale from 0–10, with 0 being no pain and 10 being the worst pain in your life, how would you rate your pain?” This traditional scale can be used in pediatric patients as young as 6.⁸ Patients younger than 6 do not have accurate reliability to be able to effectively assess their pain. 

Providing Relief

Once an accurate assessment of the patient’s pain has been obtained, the next step should be control of that pain. There are more than just pharmacological options when dealing with pain control. One of the first tools taught to the new EMT is the position of comfort. Patients, especially children, will naturally gravitate to holding injured portions in positions of comfort—this allows them to self-splint and ease their pain on their own. Additional adjuncts include splinting and ice packs. Splinting can help with musculoskeletal injuries, immobilizing them and decreasing the painful motion of broken bones and torn muscles.

When advancing to pharmacological analgesia, multiple options are available, including ibuprofen, acetaminophen, morphine, and ketamine. After obtaining an appropriate pain score, and always following your local protocols, administer medications as necessary to help alleviate the pain your patient is experiencing. As with everything in EMS, it is important to know what your local protocols allow you to use and the routes and administrations of these different medications.

Another consideration is the need for an IV. Obtaining IV access in pediatric patients can be traumatic for the patient (and sometimes the provider). The emotional distress the patient might experience is another factor. Always consider alternative routes of administration, but if IV access is necessary, be aware of the following:

• Never lie to kids. This is the No. 1 rule. Once you lose a kid’s trust, it is often gone forever. 
• Use kid-friendly wording, like pinch in place of big stick when starting IVs. 
• Explain what you are doing with words the child understands: 
  • Rubber band in place of tourniquet;
  • Cold soap in place of alcohol;
  • Blue rivers in place of veins;
  • Tiny straw in place of IV.

By using some of these techniques, the procedure is likely to go more smoothly. Remember to communicate with the child, not just the family when performing procedures on an awake child.

Why Is This Important?

It’s important to know what to do in a critical pediatric emergency. Plus, pain relief is the humane thing to do. Pediatric patients often don’t receive pain medications in the field, even though they frequently get them in the emergency room.⁹ It is important for EMS clinicians to become comfortable with pediatric patients and providing them adequate pain management. Not only is it the best care for the patients, it’s what’s right for everyone involved.

Finally, EMS providers should not be relying on critical weight-based calculations in the heat of the moment. There are plenty of pediatric dosing aids available; each provider should choose one they are comfortable with and rely on that when the time comes, not their ability to do mental math under stress. 

References

1. Hewes HA, Dai M, Mann NC, Baca T, Taillac P. (2018). Prehospital Pain Management: Disparity By Age and Race. Prehosp Emerg Care, 2018; 22(2): 189–97.

2. Foltin GL, Dayan P, Tunik M, et al.; Prehospital Working Group of the Pediatric Emergency Care Applied Research Network. Priorities for pediatric prehospital research. Pediatr Emerg Care, 2010; 26(10): 773–7.

3. Yousefifard M, Askarian-Amiri S, Neishaboori AM, et al. Pre-hospital pain management; a systematic review of proposed guidelines. Arch Acad Emerg Med, 2019 Oct; 7(1): e55.

4. Cimpean A, David D. The mechanisms of pain tolerance and pain-related anxiety in acute pain. Health Psych Open, 2019; 6(2): 2055102919865161.

5. Merkel SI, Voepel-Lewis T, Shayevitz JR, Malviya S. The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatr Nurs, 1997; 23(3): 293–7.

6. Merkel S, Voepel-Lewis T, Malviya S. Pain assessment in infants and young children: the FLACC scale. Am J Nursing, 2002; 102(10): 55–8.

7. McCaffery M. Choosing a faces pain scale. Nursing2002, 2002 May; 32(5): 68.

8. Kemp C. Most children as young as 6 can use 0–10 scale to rate pain. AAP News, 2018 Jan 4; www.aappublications.org/news/2018/01/04/PainScale010418.

9. Swor R, McEachin CM, Seguin D, Grall KH. Prehospital pain management in children suffering traumatic injury. Prehosp Emerg Care, 2005; 9(1): 40–3.

Sidebar: Pharmacologic Pain Management Options

PO 

• Acetaminophen
• Ibuprofen
• Nitrous oxide (inhaled)

IV

• Fentanyl
• Ketamine
• Ketorolac
• Morphine

IN

• Fentanyl

David Wright, MS, PA-C, NRP, is a pediatric emergency medicine and EMS physician assistant working at Washington University in St. Louis.