Mary Puchalski, MS, RNC, APN/CNS


March 19, 2008

What is the preferred method of treating pediatric pain following minor surgery, such as an appendectomy?


Response from Mary Puchalski, MS, RNC, APN/CNS
Adjunct Faculty, University of Illinois, Chicago College of Nursing, Chicago, Illinois; Clinical Nurse Specialist, Neonatal/Pediatrics, Elmhurst Memorial Hospital, Elmhurst, Illinois


It is always interesting when a question comes up about treating pain in pediatric patients. The myth persists that because children differ in their responses to medications that they also differ in their responses to pain. The plain truth is that if it is painful for an adult, it is painful for a child -- so if an adult would get morphine, then a child should get morphine.

Pain in pediatric patients has historically been undertreated. Study after study finds that we treat pain less aggressively in the pediatric patient because we are afraid of the side effects of medication, or we just do not believe that they are in pain because they do not "look like" they are in pain.[1,2,3,4,5,6,7] Most pediatric nurses believe that they are very good at assessing pain, but research does not support this belief.[8,9,10,11] What we think about pain, coupled with our own experiences with pain, determines how we assess and treat pain and can be a barrier to appropriate treatment.[12,13,14,15,16,17]

The hallmark of pain intervention in the pediatric population is simple: If you think something is painful, have ever experienced it as painful, or have seen others in pain in similar situations, then it is also painful for a child.

The phrase "minor surgery" is misleading. "Minor surgery" leads one to think that the procedure is less painful than other surgeries. However, surgery means that there is an incision made by a scalpel, which is always painful and has the potential to cause ongoing pain. When an invasive procedure has been done, we should assume that pain exists. We should treat pain preemptively and be alert for continuing pain.[18,19,20]

So how should we treat pain following surgery in children? Initially, the child will need an opioid analgesic. Concurrent administration of acetaminophen in suppository form potentiates the opioid's analgesic action, thereby lowering the dosage of opioid required for pain relief.[21] When given on a scheduled basis rather than "as needed" (PRN), analgesics are more effective, and the cumulative dose of medication is lower.[22,23]

After 24 hours, analgesia may or may not be required depending on the child and on how extensive the procedure was. The golden rule is to ask the child (if he or she is able to verbalize) to rate the pain using a developmentally appropriate pain assessment tool. For nonverbal children and infants, ask parents, "Do you think your child is in pain?" and assess the child using a nonverbal pain scale, such as the Face, Legs, Activity, Cry, Consolability (FLACC) scale.

One final rule for pediatric patients: Never give a pain medication as an intramuscular injection, unless there is no intravenous access. The pain of the injection is an unnecessary event. Children can be traumatized by the treatment of their pain.


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