Post operative pain management in children

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Dr V.K.Dhulkhed Prof and HOD Anesthesiology Krishna Institute of Medical Sciences Karad, Maharashtra Post operative pain management in children

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5 th imp vital sign

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A child’s suffering of pain..

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K.J.S. ANAND et al, THE NEW ENGLAND JOURNAL OF MEDICINE, Vol. 317,November 1987. “ Golden Rule”: What is painful to an adult is painful to an infant untilproven otherwise” – Franck, 1989 current knowledge suggests that humane considerations should apply as forcefully to the care of neonates and young, nonverbal infants as they do to children and adults in similar painful and stressful situations .

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Pain is a personal, subjective experience that involves sensory, emotional and behavioural factors associated with actual or potential tissue injury There is individual variation influenced by genetic makeup, cultural background, age and gender. What is pain?......

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Acute pain is experienced immediately after surgery (up to 7 days) Chronic pain lasts more than 3 months after the injury Postoperative pain

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somatic (arising from skin, muscle, bone), visceral (arising from organs within the chest and abdomen), or Neuropathic (caused by damage or dysfunction in the nervous system). Patients often experience more than one type of pain The type of pain may be

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Emotional and physical suffering, sleep disturbance (with negative impact on mood and mobilisation) CVS (such as tachycardia, Syst and Pulm htn ) intra ventr haemorrhage Increased oxygen consumption RS - atelectasis, retention of secretions and pneumonia Impaired bowel movement or PONV Short term negative effects of acute pain

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Long term negative effects Severe acute pain is a risk factor for the development of chronic pain There is a risk of behavioural changes in children for a prolonged period (up to 1 year) after surgical pain

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Peripheral and spinal structures for pain transmission are present and functional between 1st and 2nd trimester. Nociceptors by 20-30 wks gestation. Cerebral cortex has a full complement of neurons by 20 weeks gestation Neurodevelopment of pain

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Descending inhibitory pathways are not fully developed until mid-infancy. Opioid and other receptors widely distributed A subset of high-threshold mechanoreceptors (HTMRs) have widespread projections throughout dorsal horn laminae Newborns feel pain, hypersensitive to mechanical stimuli and mount stress response Nature Reviews Neuroscience 4 , 158 (March 2003) | doi:10.1038/nrn1070 Neurodevelopment of pain

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Neurocircuit

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Evaluate the environment and provide comfort measures (non-pharmacological) Consider medications if not relieved Pain Agitation Decreased resp effort (guarding) BP & HR increase/decrease Diaphoresis Palmar sweating Metabolic changes Increased Increased HR & RR with activity only No No No PAIN vs AGITATION Difficult to distinguish Agitation describes gross motor behavior and crying

Pediatric vs. Adult:

Pediatric vs. Adult Peds Adult Conus medullaris L3 T12-L2(L1) Dural Sac S3-5 S1 CSF Volume 4ml/kg 2ml/kg SC myelination Incomplete Complete by 12y Epidural fat Low/loose High Albumin/Alpha1-acid Glycoprotein Low normal

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Remember In neonates and preemies the enzyme systems of drug metabolism are immature. GFR is decreased in 1st wk of life. Larger % of body water. Brain and viscera account for disproportionate amount of body mass in neonates. ventilatory responses to hypoxia & hypercarbia

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CAUSE EFFECT ON LA Higher volume of CSF + Lower epidural fat content increased spread Incomplete myelinization (increased endoneural permeability) decreased duration & Latency Decreased plasma proteins (decreased liver metabolism) increased unbound fraction (CNS/CVS toxicity) Peds epidural space depth: 1mm/kg or 1+ 0.15(yrs); o.8+0.05(kg) Pediatrics and LA

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Despite its prevalence, pain in infants, children, and adolescents is often underestimated and undertreated Ellis JA, et al, Clin J Pain. 2002;18:262–269.

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In 16% analgesics were not ordered post–op. Narcotics ordered prn were not given 39% of the time Only 25% were pain free on the day of surgery. 40% had moderate to severe pain . 1983 Mather & Marker landmark study

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Pain management has a humanitarian role Improves quality of life for the patient Reduces morbidity Medical and economic benefits - rapid recovery and discharge from hospital Postoperative Pain Management –Good Clinical Practice European Society of Regional Anaesthesia and Pain Therapy 2005 Benefits

ABCs of Pain Management:

ABCs of Pain Management Recommended by AHCPR*, USA and American Pain Society A- Ask and anicipate pain regularly. Assess pain systematically with appropriate pain assessment tools and techniques. B- Believe,involve the patient and family in their reports of pain C- Choose multimodal** and multidisciplinary pain control options appropriate for the patient, family and setting. D- Deliver interventions in a timely, logical, coordinated fashion in a calm environment and monitor . E- Empower patients and their families. Enable patients to control their course to the greatest extent possible. Expand knowledge of principles and techniques. * Agency for Health Care Policy and Research ** pharmacologic, cognitive, behavioral , and physical

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Q uestion the child U se a pain rating scale E valuate the behaviour and physiological changes S ecure parents involvement T ake cause of pain into account T ake action and evaluate results ABCs of……. Nothing calms a child more than a confident parent Assessing pain QUESTT (Wong et al, 1999 )

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Use their language (sore, ouch, hurt) Be developmentally appropriate Consider using dolls/toys as a medium Consider other issues Non-verbal children are very vulnerable to having their pain under estimated ABCs of…….

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Should begin during PAE,continue with the intraop management. Optimising analgesia Administer analgesia Utilise other comfort measures Review within short period i.e. at expected peak effect of drug Don’t assume the analgesia has worked Take action if analgesia is ineffective Document findings clearly for others The strategy for pain management

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Attack all 4 phases of nociception. NSAIDs can decrease inflammatory response (transduction); Neural blockade inhibits signals from reaching the CNS (transmission); Opiates enhance central inhibitory input at spinal cord (modulation); Thorough pre- and postop teaching can prevent anxiety (perception). The strategy .........

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A balanced, or multi-modal technique of combination of two or more drugs from the following  groups is logical: LA Paracetamol , NSAIDS Opioids NMDA anatgonists (low dose ketamine) Sympathetic agonists (clonidine) For parenteral opiods -mandatory to also prescribe anti-emetics and naloxone The strategy .........

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Self-report measures are “gold standard,” require cognitive and language development 2 yr children report the presence and location of pain, but no cognitive skills 3 yr-can use a simple 3-level pain intensity “no pain,” “a little pain,” or “a lot of pain.” 4 yr-can usually manage 4- or 5-item scales >5yr-ability to rate pain affect (emotional) emerges 8 yr -rate the quality of pain* *McGrath PA, Gillespie J. Handbook of Pain Assessment. 2nd ed. ; 2001:97–118 What measuring scale…….??

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13-21 narcotic drugs Non -pharmacological measures 0-6 Non- pharmacological measures 7-12 Non- pharmacological measures Consider non-narcotic drugs SCORE

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7-10 Severe Pharmacologic: (primary method) -Narcotic intermittent bolus -Consider narcotic infusion 0-3 Mild Non Pharmacologic Pharmacologic -Acetaminophen (primary method) 4-6 Moderate Non Pharmacologic -See above Pharmacologic: (primary method) -Narcotic bolus

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FACE scale < 4 indicates satisfactory analgesia. Treat If FLACC Score-5 or over

Facial Expression of Physical Distress :

Facial Expression of Physical Distress NASO- LABIAL FOLD deepened

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Ramsey Sedation Scale 1.Fully awake and oriented 2.Awake, sleepy 3.Asleep but easily awaken by verbal command 4.Asleep but easily awaken by motor stimulation 5.Asleep and can not be awaken by verbal or motor stimulation Over sedation- Ramsay Sedation Scale >4

Modified WHO Analgesic Ladder:

Pain Step 1 ± Nonopioid ± Adjuvant Pain persisting or increasing Step 2 Opioid for mild to moderate pain ± Nonopioid ± Adjuvant Pain persisting or increasing Pain persisting or increasing Step 3 Opioid for moderate to severe pain ± Nonopioid ± Adjuvant Invasive treatments Opioid Delivery Quality of Life Modified WHO Analgesic Ladder Proposed 4 th Step Deer, et al., 1999 FLACC WHO Analgesic Ladder

Pharmacological interventions:

Pharmacological interventions Nonopioid analgesics Acetaminophen (Paracetamol), Ibuprofen, Naproxen, Diclofenac, and Ketorolac are available Used alone-adequate to treat mild pain Have a ceiling effect best used in combination with opioids

Acetaminophen:

Acetaminophen Acts on COX-3 enzyme The initial dose up to 20-40 mg/kg rectally before recovery, then orally (10–15 mg/kg) or rectally (20 mg/kg) round the clock (RTC) 4–12 hrly Total daily < 90,60,35 –children,infant,preterm Combined with codein-elixer (120-12mg/5ml) 5,10 ml for 3-6 & 7-12 yr Minimise risk of ovsrdose

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NSAIDs Diclofenac as a premedicant or administered at induction of anaesthesia; dose is 1 mg/kg 8 hrly orally, rectally, or IV, max 2-4 mg/kg/day ,not in < 6mths Ketorolac Tromethamine –orally 0.2-0.5mg/kg onset 20 to 30 minutes -give early, after induction 3-4 times/day, max 1mg/kg/day IV 0.5 mg/kg) to reduce postop bladder spasms after ureteral reimplant procedures not recommended <1 year

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Ibuprofen suspension or a syrup , up to a dose of 10mg /kg/day. Dose be up to 3mg/kg/day also rectally safety under 6 months not established Novel formulations of NSAIDs as eye drops have found application after strabismus correction or laser surgery to the eye. Aspirin not to give <2 years -Reye's syndrome. Experience with NSAIDs is limited

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Opiod Analgesics Morphine elim T½ of 10-20 hrs neonates, 5-10 hrs children Clearance in neonates 50% of infants,25% of adults Use preservative free morphine Myelomeningocele may have Type I Arnold Chiari Malformn -sensitivity to respiratory depression Use of a PCA is OK for child >7 yrs May be used after -craniotomy, thoracotomy , sternotomy, and laparotomy Taking for pain relief is not addiction, no matter how or how much. ( McCaffery ) Incidence of addiction when taken for pain relief is <1%

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Intermittent boluses- 30–100 mcg/kg q 1–2h Continuous IV opiod infusions : useful in the ventilated patient, the very young Morphine : Bolus : 50–100 mcg/kg ;(25–50mcg/kg q 10 min.) Maintenance < 3–6 mth: 5–15 mcg/kg/hr ; > 6 mnths: 25–30mcg/kg/hr Opiod Analgesics......

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PCA with morphine Bolus - 20 mcg /kg Lockout interval 5 min Background - 4 mcg /kg/h(first 24 h) 4hr dose limit is decided after response assessed (approx 300mcg/kg). Children as young as 5yr can use PCA Opiod Analgesics...... Nurse controlled analgesia (NCA) Bolus - 20 mcg /kg, Lockout interval 30 min Background - 20 mcg/ kg/h, (<5kg use no background)

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Epidural : Morphine 15–50 mcg/kg q 6–12 h (Hydomorphone 5 times potent -pruritis less) Infusion 0.2-0.4 mcg/kg/hr oral - 200-400mcg/kg 4 hourly. SC or IM:100-150mcg/kg 4 hourly. At steady-state pl conc.of >20 ng/mL, higher likelihood of resp depression in neonates Opiod Analgesics......

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Fentanyl : Bolus : 0.5–1 mcg/kg Maintenance infusion : )0.5 - 1 mcg/kg/hr Remifentanil 0.05-4 mcg/kg/min Methadone IV advantagious since its longer T½ upto 19 hrs allows less frequent dosing Loading 50mcg/kg q 10 min until analgesia then use "reverse prn " sliding- 70mcg-80/kg , 50mcg-60, 30mcg for severe, mod, mild pain, nothing if somnolent Opiod Analgesics...... Pro re nata - Latin phrase-as the circumstance arises-as needed

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Codeine orally /per rectum for mild to moderate pain with paracetamol. Also SC,IM for OPD Caution in neonates, IV can produce severe hypotension,apnea Dose of syrup 0.5-1mg/kg 4 hrly orally or IM. As a suppository: 1mg/kg 4 hourly Needs conversion to active component Morphine This enzymatic activity is <10% of adults

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Dexmedetomidine : intraop infusion of (2 μg / kg over 10 min , followed by 0.7 μg / kg/h ) combined with inhalation anesthetics –reduces postop opioid requirement Ondansetron for nausia,vomitting: 100mcg/kg

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‘If a child can play video games, can learn to use PCA’. To use PCA, the child must understand the relationships between a stimulus (pain), a response (pushing the button), and a delayed result (pain relief). Use ‘apnea monitors’ and pulse oximeters if opioids are being used in infants < 6 mths , or in children with resp dysfunction etc. PCA Drug Bolus (mcg/kg) Continuous (mcg/kg/hour) 4 hour limit (mcg/kg) Morphine 20 4-10 300 Fentanyl 0.25 0.15 4 Lockout interval = 5 to 7 min.

Regional Analgesia :

Regional Analgesia Increasingly used Single-dose caudal administration of LA, Plexus blockade, femoral, brachial plexus, fascia iliaca, lumbar plexus, and sciatic blockade Neuraxial catheter placement for continuous pain control after surgery

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The Sacred Canal caudal and lumbar approach are the most popular concerns about soilage of caudal catheters not problem. meticulous care, occlusive dressings. When placing a catheter using LOR technique use saline, microdrip USG enhances,success rate and the safety Epidural Analgesia

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bupivacaine, levobupivacaine , and ropivacaine Single bolus injection Max dosage Neonates 2 mg /kg Children _ 2.5 mg /kg Continuous postopinfusion Max infusion rate Neonates 0.2 mg / kg/hr Children 0.4 mg / kg/hr Adjuncts S(+)- ketamine (1 mg /kg) more prolongation than clonidine Clonidine 1-2 mcg/kg doubles duration For continuous 0.2mcg/kg/hr Guidance by Association of Paediatric Anaesthetists of Great Britain & Ireland

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Ropivacaine 0.2% or Levobupivacaine 0.25% 0.2 mg/kg/h(<1yr)- 0.4 mg/kg/h(>1yr) continuous epidural levobupivacaine, 0.0625% optimal for lower abdominal or urological surgery Clonidine added as 3 μg/kg/h adjuvant The esterase systems are mature in early life, and amethocaine (tetracaine) , 2-chloroprocaine can be used

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Respiratory Depression -likelihood with A) additional systemic narcotics B) high catheters C) age less than 6 months D) preemies < 60weeks gestational age

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Other approaches SC Nasal, P.R., P.O opioids Transdermal fentanyl 12.5-100mcg/hr Regional techniques : Penile block Ilioinguinal Iliohypogastric block: Fascia iliaca block : Fentanyl: 2-3 ug /kg (comes in 50 ug /ml) ½ in each nostril Others:intranasal ketorolac Ketamine 0.5mg/k g

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Continuous intercostal block Fractured ribs and upper abdominal or thoracic surgery. Extra pleural analgesia : Catheter placed by surgeon with chest open, medial and superior to posterior edge of incision , dorsal to parietal pleura.Tip at posterio-medial, a few cm lateral to spine. Lignocaine limited to 4-6 mg/kg Bupivacaine 0.3-0.4 mg/kg/hr.

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For IV cannulation and lumbar puncture. Not recommended for IM injection or heel prick in neonates Mixture of 2.5% lidocaine and 2.5% prilocaine in a cream base. The specific concentration gradient promote penetration of intact skin Application with occlusive dressing. Depth of anesthesia ranges from 3mm after 60 min (onset to pick effect), to 5 mm after 90 EMLA Skin applications

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Tetracaine 4% gel (Ametop) more rapid and prolonged surface anaesthesia than EMLA in mucosa-adhesive polymer film for pain of oral lesions due to radiation and antineoplastic therapy. Liposome-encapsulated tetracaine available LAT (LET) 4% lidocaine, 0.1% adrenaline+0.5% tetracaine in a gel -surface anaesthetic to lacerations of skin especially face,scalp Liposomal lidocaine (ELA-max): dispersed in liposomes, massaged into the skin without occlusion Skin applications…..

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Local measures Dressing perfusion by applying dilute local anaesthetic onto a foam layer applied to skin graft donor sites is also simple, very effective and safe provided the maximum dosage limits are strictly adhered to. These sites can otherwise be extremely distressing to the child for a period up to 48 h

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orally and repeated in neonates. Doses of 2-3 mL into the oral cavity with syringe or pacifier dipped in the solution and inserted into mouth. It can be prepared by using 1 packet of table sugar dissolved in 5 mL of water. Others, dextrose and glucose, have no effect . Sucrose 25%

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How does sucrose work? Thought to be 2 mechanisms: Sweet taste ,Release of endogenous opioids: Peak effects at around 2 minutes Not effective if given Narcan, as Narcan competes for the same receptor sites Sucrose.....

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Nonpharmacologic interventions Pacifiers, sucrose, hand-to-mouth, non-nutritive sucking Whiskey nipple* Swaddling, nesting, holding Position changes, correct positioning for procedures Decrease environmental stimuli (light, noise, abrupt movements) Decreased handling with rest periods between procedures Comfort measures noted to be effective with individual neonate Soothing vocalizations, recorded intrauterine sounds

Kangaroo care:

Kangaroo care And breast feeds

Different procedures and Strategies:

Different procedures and Strategies Procedure Strategy Myringotomy Preop oral paracetamol or NSAID Tonsillectomy Opioids Regular paracetamol and NSAID LA Antiemetics Tramadol Mastoid and middle ear Great auricular nerve block opioids antiemetics Strabismus LA blocks ( subtenon or peribulbar ) NSAID Vitreoretinal surgery NSAID Peribulbar block Dental Procedures Intraoperative LA infiltration NSAIDS Subumbilical Surgery , inguinal hernia LA, ilio -inguinal block ,caudal analgesia Circumcision Caudal epidural and dorsal nerve block Neonatal Circumcision LA,Sucrose,paracetamol Hypospadias Repair, Orchidopexy Caudal reduces opiods need Abdominal surgery Multimodal - parenteral opioids NCA,PCA or EA (may add clonidine ) , NSAIDs and paracetamol Association of Paediatric Anaesthetists: Good Practice in Postoperative and Procedural Pain

Different procedures and Strategies……….:

Different procedures and Strategies………. Procedure Strategy Appendicectomy Infiltration, and multimodal, PCA with NSAID Fundoplication Epidural LA + opioid , opioids-NSAID,paracetamol Laparoscopic Infiltration+multimodal,24hrs crucial Lower Limb Short term NSAID, EA,PCRA, paracetamol,continuous N block Upper Limb Br.plex block Spinal surgery Short term NSAIDs,consult surgens for EA timing, intrathecal opioids act 18-24hrs, Dual cath EA cleft lip repair Infraorbital nerve block early postop Cardiac Surgery (sternotomy) EA,Intra theacal,infiltration , meagre data regarding complications Thoracotomy Multimodal,infiltration,paracetamol , NSAID, opioid,oral opioid Neurosurgery Team coop. reg assessment, rest as above.

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Do not discharge from PACU until satisfactory pain control Clear instructions for home care Pain most severe in the first 24-72 hrs,may persist for several days or weeks.

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Male child16 yr, 35kg, electric burns . Operated for debridement . post op pain scale 10 . Morphine bolus IV total 60mcg/kg i.e. 2mg. pain down to 3. Continuous iv infusion 8mg with 175 mcg dexmedit in 40ml NS at rate 0.5 ml / hr. + Paracet 500mg tds oral The pain scores remained <3. Case 1

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2 yrs, 7mth 8kg - Herniotomy Caudal Block (Bupivacaine 0.25 mg, 5cc + Lignocaine with adr 1% 3cc + Clonidine 10 mcg.) +honey sucking Case 2 ½ 1 2 3 4 5 6 7 8

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Pain management in children -inadequate Pain is less intense in neonates & children Potent analgesics are dangerous Explanations to child and parents -helpful. Individualised, child centred and multimodal approach Anticipate, observe, assess the pain(proper scale) ,patients response to treatment. Document management. Address fear and anxiety Route of administration depends upon severity Avoid IM injections Ensure staff have appropriate training, experience and on-going practice Summary

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