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Pediatric pain management has been a controversial topic in medicine throughout the last decade. Under treatment of pediatric patients is a main concern due to the communication barrier. There are a few misconceptions that can lead to the under treatment of pain in the pediatric patient: • The myth that infants and children do not feel pain, or suffer less from it than adults. • Lack of routine pain assessment in children. • Lack of knowledge regarding newer modalities and proper dosing strategies for the use of analgesics in children. • Fears of respiratory depression or other adverse effects of analgesic medications. • The belief that preventing pain in children takes too much time and effort. (CITE)

The most commonly used scales in newborns are the Premature Infant Pain Profile (PIPP) and the CRIES Postoperative Pain Scales.6-8 The FLACC (Face, Legs, Activity, Cry and Consolability) Scale is a behavioral scale that is used on assessment of postoperative pain in children between the ages of 2 months and 7 years (CITE).


 * add picture of FLACC behavioral pain scale****

Starting at about 18 months of age, children are able to report pain and at about 3 or 4 years of age children are able to use more descriptive words for pain and able to point to its location. Self reporting is the preferred strategy for pain management.

The different pain scales used in children are Poker Chip Scale, Wong-Baker Faces Scale, the Faces Pain Scale-Revised and the Oucher Scale. The Oucher Scale (www.oucher.org) which is available in different ethnic versions permits children to rate their pain intensity by matching it to photographs of other children’s faces depicting increasing levels of pain and is well accepted in children over 6 years of age. The Poker Chip Scale asks children to quantify their pain in “pieces of hurt,” with more poker chips representing more pain (CITE).

Poker Chip Tool Instruction Sheet

• Say to the child: “I want to talk with you about the hurt you may be having right now.” • Align the chips horizontally in front of the child on the bedside table, a clipboard, or other firm surface. • Tell the child, “These are pieces of hurt.” Beginning at the chip nearest the child’s left side and ending at the one nearest the right side, point to the chips and say, “This (first chip) is a little bit of hurt and this (fourth chip) is the most hurt you could ever have.” • For a young child or for any child who may not fully comprehend the instructions, clarify by saying, “That means this (one) is just a little hurt, this (two) is a little more hurt, this (three) is more yet, and this (four) is the most hurt you could ever have.” • Do not give children an option for zero hurt. Research with the Poker Chip Tool has verified that children without pain will so indicate by responses such as, “I don’t have any.” • Ask the child, “How many pieces of hurt do you have right now?” • After initial use of the Poker Chip Tool, some children internalize the concept “pieces of hurt.” If a child gives a response such as “I have one right now” before you ask or before you lay out the poker chips, proceed with asking how many pieces of hurt the child has now. • Record the number of chips on a pain flow sheet. • Clarify the child’s answer by words such as, “Oh, you have a little hurt? Tell me about the hurt.”

Nonpharmocological pain management is another great way to treat pain in the pediatric patient. This treatment includes psychological strategies, education and parental support. The aim is to decrease anxiety and distress. When implementing these strategies, they time time and patience. Distraction techniques are the main idea when children are introduced to painful stimuli (i.e.: giving stickers or prizes).

Pharmocological approaces are also necessary for treating the pediatric patient in pain. Acetaminophen is the most commonly used analgesic agent in pediatric practice. Acetaminophen is a very safe drug and has minimal side effects.