Pain Management in Pediatric Patient

Pain Management in Pediatric Patient in Emergency Departments

This work will address the issue of pediatric pain management in emergency departments, through a review of two academic articles that are based upon quantitative research of the issue. Among one of the more serious problems in pediatric nursing is the under-medication of very young children, with known extremely painful injuries presenting to emergency departments.

There seems to be a pervasive occurrence of the administration of analgesic pain medication in the very young in emergency departments.(Chan, Russel, & Roback, 1998, pp. 620-623) (Jylli & Olsson, 1995, pp. 1403-1408) it is assumed that much of the reluctance on the part of emergency room physicians to administer pain medications to small children is associated with fear of adverse reactions in children, and the idea that very young children perceive pain in a different way than do adults.

For many years, a pervasive assumption in the medical community has been that infants are incapable of perceiving pain. One consequence of this widespread perspective, according to K.J.S. Anand and P.R. Hickey, is that "newborns are frequently not given analgesic or anesthetic agents during invasive procedures, including surgery" (New England Journal of Medicine 317:21 [November 19, 1987], 1322-29). Recently, however, parents and pediatric nurses have moved to the forefront in challenging such clinical practices and their underlying rationale. Their concerns over the infliction of unnecessary pain on newborns have been supported not only by practitioners, but also by professional organizations such as the American Academy of Pediatrics and the American Society of Anesthesiologists. Anand and Hickey's comprehensive analysis offers the empirical support of facts and data to what had previously been a largely theoretical argument. (Campbell, 1988)

One additional idea is that the preschool child's inability to effectively communicate through language their need for pain relief can alter a physicians' reaction to a need for pain medication. As most children are not capable of developing full sentence language skills until they are greater than two years old. Another spoken idea with regard to pediatric pain management is the idea that very small children will not remember the pain sensations that occur and therefore it should not be treated with medication. To some experts the idea of conducting surgery on an infant without analgesia is abhorrent but it seems to occur frequently and especially on newborns. (Huston, 2002, pg. 61) the general impression from reading several qualitative and quantitative studies on the pediatric pain management is that children are being neglected based on myths that are pervasive, despite the recognition of the problem more than a decade ago.

Electronic Research Tactics

To conduct this review, a search was done on the medial electronic resources at the university library for major search terms, linked together "pediatric pain management" "pediatric under medication" "infant pain perception" and "language development children."

Overview of Research Findings

There were at least 15 good hits for each search term but many of the articles are found only in specialized journals that are not all subscribed to by the library. This last statement was the only real obstacle to finding the information needed for this review. The articles chosen, established key information about both prevalence and reasons of under medication of small children in emergency departments as well as providing sound qualitative data to guide the research question. In the two research works that are carefully scrutinized in this review, there is continuing evidence of the pervasive under-medication of small children, as apposed to school aged children.

Article I

The first article I will analyze is Underuse of Analgesia in Very Young Pediatric Patients With Isolated Painful Injuries published in the Annals of Emergency Medicine in 2003 and written by J. Alexander and M. Manno. The work is relative to a greater understanding of the under utilization of pain medications in the very young in triage situations. The work details a population of infants aged 6-24 (96) months and compares them retrospectively to a group of school aged children ages 6-10 (84). The work is a qualitative retrospective study that identifies several aspects of treatment, including the type of injury the child presented with, only isolated and known painful injuries (burns and fractures) were studied and compares the data to information from patient charts of a group of comparable number of school aged children 6-10 years of age. The work indicates that through retrospective qualitative study the infants where more likely to receive no pain medication upon treatment in the emergency department, despite similarly known painful isolated injuries to the older group and were also more likely to receive over the counter analgesics rather than narcotic-based drugs when analgesics were administered. The study also compared other factors in the treatment charts of these children, attempting to discount the possible clinical reasons why the children did not receive medication, one being if there were noted complications from drugs that were given in either group, and there was no significant data to suggest this in the statistical analysis, though this is often a concern noted by physicians when analgesic medications are not administered to children. The work was conducted in a hospital where there is a specialized pediatric ED and this could limit the generalizability of the research findings, though it also shows that even in specialized care there are problems with pediatric pain management. A better understanding of the myths that have pervasively left children under medicated for pain in the triage situations is foundational to better nursing practice, and especially better pediatric pain management for acute pain upon injury.

Article II

The second article. Factors Affecting Emergency Department Assessment and Management of Pain in Children written in 2005, by Probst, Lyons, Leonard & Esposito is a larger study (933 charts) but with a similar retrospective qualitative design, with several key differences apart from the size of the study. The work detailed three basic groups (0-1) (2-5) (6-15) through the process, assessed the charts for the utilization of pain assessment scale tools and determined that the youngest group (0-1 yrs) was least likely to receive pain medication and/or be assessed using the scales provided in the emergency departments throughout the state of Illinois. The article is very timely and relevant as it is conducted on a large scale and provides countless details about the utilization of pain assessment tools and also pain management failures in pediatric treatment in non-specialized Eds. The general results indicate that the older the child, in addition to the utilization of pain scales the more likely they were to receive pain medications, despite the similarity in the severity of injuries among all patients assessed in the chart survey. Another additional difference within this work is that it is being utilized as a quality assessment tool by a state organization, while the previous study is being utilized simply to further research with regard to under medication of young children in emergency rooms. The limitation of this study are lessor than those of the previous study as the retrospective review was conducted on a larger group and identified patients in three age groups rather than two. Though the retrospective style of the work, as in the previous work, leaves much of the reasoning behind the decision to administer medication and what kind or not to administer analgesics to a child can only be a point of conjecture.