REBEL Cast Episode 49: Pediatric Pain Management Pearls with Sebrina Perkins

Background: There has been lots of research published in past years on how to minimize pain and anxiety in children brought to the ED. Unfortunately, as we all know there is often a lag time from research publication to clinical application. It has been my experience that health care professionals tend to provide inconsistent and inadequate pain control for children. In this episode of REBEL Cast we are going to interview Sebrina Perkins, a pediatric emergency medicine physician working for the Greater San Antonio Emergency Physicians (GSEP) group, on pediatric pain management pearls.

REBEL Cast Episode 49 – Pediatric Pain Management Pearls with Sebrina Perkins

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Assessment of Pain:

In adults this is usually, on a scale of 0 – 10, with 0 being no pain and 10 being the worst pain imaginable. In kids this can be much more complex as communication in some age groups is very limited.

Individual self-reporting is the preferred method of assessment as pain is a subjective experience

It is also important to have ongoing assessments

Kids >8 Years: Should be able to answer the same questions we ask adults (i.e. Visual Analog Scale and/or Numerical Rating Scale)

Kids 4 – 8 Years: Use pain scales with visual cues (Personally I like the OUCHER Scale) Provides photos of multiple ethnicities as shown below

Use pain scales with visual cues (Personally I like the OUCHER Scale)

Kids <4 Years: Very limited communication; Can use the FLACC Scale (Faces, Legs, Activity, Cry, Consolability) Scale (Range 0 -10)

Intranasal (IN) Medications:

Intranasal atomizers are a super easy way to give medications.

The caveat here is you generally do not want to give more than 1mL per nostril (Volumes greater than this result in excess drug running off into the pharynx and decreasing efficacy)

If possible use both nostrils to increase surface area

What about dosing of IN medications:

Topical Agents for Needle Sticks:

One of the goals in IV placement in kids is to reduce procedural pain. Potential topical options include: Lidocaine-Prilocaine 5% Cream (EMLA):Needs to be covered with occlusive dressing; Takes 1hr until clinical effect; Not ideal for ED due to long onset of effect Tetracaine 4% Gel (Ametop): Onset of action 30 – 40min Liposomal Lidocaine 4% Cream (LMX):Onset of action 30 min Vapocoolant Spray (Pain Ease, Instant Ice): evaporation induced cooling provides transient anesthesia Jet Injection Systems (J-Tip): Needle free injection system with air that delivers 0.2mL of 1% buffered lidocaine SQ; Onset of action 1 – 3 min Lunoe MM et al [4] Randomized controlled trial J Tip (Intervention) vs Vapocoolant Spray (Control) vs Sham-Vapooolant Spray (Sham) to reduce pain in 205 children 1 – 6 years of age Timeline of Events: Baseline –> Device –> Venipuncture Primary Outcome: Child’s pain experience rated on FLACC pain scale (0 – 10) from Device to Venipuncture Mean Change in Pain Scores from Device to Venipuncture): Intervention: Decreased by 0.26 Control: Increased by 2.82 Sham: Increased by 1.68 Mean Change in Pain Scores Overall (Baseline to Venipuncture): Intervention: Increased by 1.61 Control: Increased by 3.71 Sham: Increased by 2.33 No or Mild Pain at Venipuncture: Intervention: 45% Control: 23% Sham: 30% Overall 1 st attempt venipuncture was not different between groups No Severe Adverse Events



J-Tip vs EMLA for Peripheral IV [9] RCT: 116 Children, 7 – 19 years of age, randomized. No pain at time of IV insertion = 84% in J-Tip group vs 61% in EMLA group

J-Tip vs Placebo for LP [10] RCT: 55 Children, Infant – 3 months needing LP randomized. J-Tip reduced pain and length of crying compared to Placebo

Bottom Line: J Tip reduces venipuncture pain in young children with no change in venipuncture success and no increase in adverse outcomes compared to vapocoolant spray or sham treatment

Topical Agents for Laceration Repairs:

Topical agents will generally be preferred over injection with a needle in kids. One option includes: Lidocaine 4%-Epinephrine 0.1%-Tetracaine 0.5% (LET): Effective for superficial lacerations; Onset of action 20 – 30 min for face/scalp and 45min for extremities, but lasts up to 11hrs



Sweet Solutions:

There has been a ton of research on oral sucrose in children <1month of age, but the evidence in children from 1month to 1 year is a bit more limited Harrison D et al [6] Meta-analysis of 68 trials Sweet solution vs placebo: Mean cry time reduced by almost 25 seconds Sweet solution vs placebo: Reduction in standardized pain scores of -0.90 on a scale of 0 – 10 Clinical Bottom Line: Sweet solutions reduce acute procedural pain in infants



Reducing Anxiety:

There are nonpharmacologic and pharmacologic interventions that can be applied:

Nonpharmacologic:

Simple distraction techniques: Bubbles, Books

Technology based distraction: iPads, smart phones, virtual reality

Pharmacologic:

Inhaled Nitrous Oxide: Onset of action 5 minutes and recovery 3 – 5 minutes

Reinoso-Barbero F et al [8] RCT of nitrous oxide/oxygen 50/50 mixture (Intervention) vs nitrogen/oxgygen 50/50 mixture (placebo) in 100 patients aged 1 – 18 years prior to cutaneous, muscle, or bone/joint procedures Primary outcome: Pain observed on a scale of 0 – 10 via the Faces Pain Scale-Revised (RPS-R) or Spanish Observational Pain Scale (LLANTO) Pain Observed via the LLANTO Scale: Intervention: 3.5 Placebo: 6.7 P = 0.01 Pain Observed via the FPS-R Scale: Intervention: 3.2 Placebo 6.6 P = 0.003 More rescue analgesia required in patients not receiving intervention

Inhaled NO vs IV Ketamine for Laceration Repairs [11] RCT: 32 children, age 3 – 10 years, randomized. Shorter recover time (0min vs 21.5min) with comparable pain and satisfaction scores

Clinical Bottom Line: Inhaled nitrous oxide reduced pain and required less rescue analgesia when compared to placebo for minor pediatric procedures

Special Guest:

Sebrina Perkins, MD

Pediatric Emergency Medicine

Greater San Antonio Emergency Physicians (GSEP)

San Antonio, TX

References:

Drendel AL et al. Ten Practical Ways to Make Your ED Practice Less Painful and More Child-Friendly. Pediatric Emergency Medicine 2017. [Link HERE] Cohen LL et al. Evidence-Based Assessment of Pediatric Pain. J Pediatr Psychol 2008. PMCID: PMC2639489 Del Pizzo J et al. Intranasal Medications in Pediatric Emergency Medicine. Pediatr Emerg Care 2014. PMID: 24987995 Lunoe MM et al. A Randomized Clinical Trial of Jet-Injected Lidocaine to Reduce Venipuncture Pain for Young Children. Ann Emerg Med 2015. PMID: 25935844 Bueno M et al. A Systematic Review and Meta-Analyses of Nonsucrose Sweet Solutions for Pain Relief in Neonates. Pain Res Manag 2013. PMID: 23748256 Harrison D et al. Sweet Solutions to Reduce Procedural Pain in Neonates: A Meta Analysis. Pediatrics 2017. PMID: 27986905 Koller D et al. Distraction Techniques for children Undergoing Procedures: A Critical Review of Pediatric Research. J Pediatr Nurs 2012. PMID: 21925588 Reinoso-Barbero F et al. Equimolar Nitrous Oxide/Oxygen vs Placebo for Procedural Pain in Children: A Randomized Trial. Pediatrics 2011. PMID: 21606149 Jimenez N et al. A Comparison of a Needle-Free Injections System for Local Anesthesia Versus EMLA for Intravenous Catheter Insertion in the Pediatric Patient. Anesth Analg 2006. PMID: 16428534 Ferayorni A et al Needle-Free Jet Injection of Lidocaine for Local Anesthesia During Lumbar Puncture: A Randomized Controlled Trial. Pediatr Emerg Care 2012. PMID: 22743744 Lee JH et al. A Randomized Comparison of Nitrous Oxide Versus Intravenous Ketamine for Laceration Repair in Children. Pediatr Emerg Care 2012. PMID: 23187987

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