Pediatric Pain Management

An Evidence-Based Approach

Maria Luisa Ramira, DNP, APRN, FNP-BC, CEN; Susan Instone, DNSc, APRN, PNP-BC; Mary Jo Clark, PhD, RN


Pediatr Nurs. 2016;42(1):39-46. 

In This Article

Abstract and Introduction


Numerous studies have shown that in comparison to adults, children do not receive analgesia (oligoanalgesia) and are not adequately treated for pain. Several organizations, including The Joint Commission and Institute of Medicine (IOM) have emphasized patients' rights to pain management and the need for initial assessment and ongoing evaluation. Nurses are responsible for assessing patients' pain and implementing appropriate pain management in the emergency department (ED). Evidence suggests that nurses' lack of knowledge about pain assessment in children contributes to inadequate pain management. Studies also show that the use of pain assessment tools appropriate to a child's age and cognitive development play a vital role in improving pain assessment documentation, prompting nurses to provide pain medication. The purpose of this quality improvement project was to improve nurses' assessment and management of children's pain in an emergency department. A total of 1,200 EMRs of pediatric patients ages 3 months to 6 years of age were reviewed before and after an educational intervention (600 before and 600 after the intervention). Pain education for ED nurses improved pain assessment and management among children.


Pain is one of the most common and challenging complaints of patients seen in the emergency department (ED), accounting for over 60% of ED visits (Berben et al., 2008; Galinski et al., 2011, Yanuka, Soffer, & Halpern, 2008). Pain can accompany any disease or traumatic condition regardless of the patient's ability to communicate. The prevalence of children's pain in the emergency department is well documented (Alexander & Manno, 2003; Drendel, Brousseau, & Gorelick, 2006; Herd, Babl, Gilhotra, & Huckson, 2009). Studies on oligoanalgesia (inadequate pain management) have been ongoing, suggesting that patients receive inadequate pain medication in the emergency department despite efforts to improve pain management (Motov & Khan, 2009; Rupp & Delaney, 2003; Todd, Cowan, Kelly, & Homel, 2010; Weng, Chang, & Lin, 2010). Several studies at local, national, and global levels showed that children do not receive analgesia and are not adequately treated compared to adults, including children diagnosed with long bone fractures (Alexander & Manno, 2003; Forgeron et al., 2009; Le May et al., 2009; Razzaq, 2006). Similarly, a cross-sectional analysis of 24,707 ED visits reported that 44% of children have minimal pain control in spite of pain documentation (Drendel et al., 2006).

Several studies have shown that if pain is not adequately treated, short-term and long-term effects occur, including exaggerated pain during procedures. The long-term effects of untreated pain include chronic anxiety responses and intensified pain sensitivity through adolescence (Kennedy, Luhmann, & Zempsky, 2008). Oligoanalgesia also weakens the effects of analgesia with subsequent and numerous procedures and contributes to a tendency to develop chronic pain ailments, brain abnormality, and anti-social behaviors (Cramton & Gruchala, 2012; Olmstead, Scott, & Austin, 2010).

Health care organizations have been using evidence-based practice (EBP) to improve clinical practice and patient care. Using evidence from reliable research has the potential to ensure that the best practice is integrated to solve clinical problems or issues to optimize patient outcomes (Melnyk & Fineout-Overholt, 2011). The Iowa Model of Evidence-Based Practice (EBP) (Titler et al., 2001) provided the organizational structure for the implementation of change in pain assessment and practice in one southern California metropolitan ED. Steps of the Iowa Model include problem or knowledge-focused triggers, prioritizing the problem, team building, synthesizing the best evidence, designing change in practice, implementing the intervention, monitoring the outcomes, and disseminating of results. Continued evaluation of the quality of care following the change in practice is also required (see Figure 1).

Figure 1.

Iowa Model – Pediatric Pain Management Emergency Department
Source: Tiller et al., 2011. Used/Reprinted with permission from the University of Iowa Hospitals and Clinics. Copyright 2015. For permission to use or reproduce the model, please contact the University of Iowa Hospitals and Clinics at 319-384-9098.

Applying this model to the pain management project, baseline data regarding inadequate pain assessment served as the problem-focused trigger. Guidelines on pain management from hospitals and other organizations generated the knowledge and awareness. In keeping with the hospital's mission to provide quality patient care and satisfaction, pain management became a priority for the emergency department, and a Pain Project Team was formed. The team conducted a literature review, critiquing and synthesizing relevant information to find the most up-to-date, evidence-based practice. Sufficient evidence was available to proceed with the change in practice. Pain education sessions were provided to the nurses. Post-intervention data were collected, and findings were shared with stakeholders. Based on results of the project, recommended changes, such as annual education training for the ED nurses, were implemented, the ED pain protocol was revised, and continued monitoring of pain assessment through quarterly EMR audit was instituted.