Perioperative Pain Management in Newborns Essay

The practice of medicine has become progressively more sophisticated. Facilitating the healing process while simultaneously minimizing or even eliminating pain once thought necessary to achieve healing is now an attainable goal.

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Beliefs of caregivers substantially affect medical intervention to alleviate unnecessary suffering. Before the late 1980s and early 1990s, a common belief was that neonates experienced no pain or less pain than adults, children, or infants who underwent similar surgical procedures

Pain is defined by the International Association for the Study of Pain (IASP) as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage”(1989). Most patients can be asked about their pain and give details that healthcare providers then classify based on the frequency, duration, location, and characteristics of the pain. With these details, the patient can receive treatment and have their pain managed appropriately. Since the patient report is a significant source of information related to their pain, a question of how to handle and treat pain in a population where a vocabulary does not exist becomes difficult. Patients in the neonatal intensive care unit (NICU) are not able to communicate pain in the same way an adult will, so the healthcare providers in this area must find alternate ways to assess this patient population. Fortunately, there are physiologic, behavioral, and hormonal cues that can alert the healthcare provider that pain is present during procedural pain. The goal is to educate the nurse in the NICU to understand the pain response in neonates and intervene with pain relieving measures based on assessment findings.Perioperative Pain Management in Newborns Essay
Literature Review

Neonates are exposed to an assortment of stimuli that generate pain on a daily basis including mechanical ventilation, repeated heel sticks for blood draws, acute medical illnesses, postoperative issues, and even invasive procedures. It has been found that acutely ill neonates in the NICU are subject to between 50 and 132 bedside procedures that can cause pain in a single 24-hour period (Witt, 2016). Nurses, in their nature, strive to make comfort their primary focus. The nurse must strive to alleviate the pain and discomfort of their patients regardless of the ability of the patient to communicate that pain. Sadly, even though there is an abundance of research on pain responses in neonatal populations, this population still falls victim to underestimated and undertreated pain, whether it is related to slowness of changing attitudes, inadequate knowledge, limited assessment tools, or a failure to recognize the response to pain.

One misconception that has been widely proven incorrect is that neonates are unable to feel pain because of their immature central nervous system (Johnston, 2011). Pain management in the neonate has experienced remarkable changes over the past couple of decades. These changes stemmed out from the attempts of health professionals to refute misconceptions regarding pain among neonates. Formerly, the belief was that neonates have limited responses to stimuli, because of the undeveloped nervous system. However, research has demonstrated that the premature nervous system makes neonates more likely to feel pain. Some believe that the neonate may experience hypersensitivity to pain compared to the adult in pain (Smith, 2011). Researchers also suggest that untreated pain among neonate can have long-lasting developmental impacts. These current developments indicate that neonatal pain management must be effective and safe to prevent the negative consequence of untreated pain. Also, reducing pain can improve both short-term and long-term outcomes. These outcomes could be then later used as evidence to guide neonate clinical practice. This paper discusses evidence-based practice in neonate pain management.Perioperative Pain Management in Newborns Essay

Assessing Pain Response in Neonates

Physiological Alterations in Response to Pain

Several known indicators may be measured to assess physiological responses to pain, including heart rate, blood pressure, respiratory rate, blood oxygenation, palmar sweating, vagal tone and intracranial pressure (Johnston, 2011). Other physiological symptoms of pain may include dilation of pupils, changes in skin and body temperature, increased muscle tone, sweating, and increased defecation and urination. While these methods of assessment may shed some light on the pain response, it is essential to look at all the body systems and how they are affected to understand the pain response truly. The nurse should also be mindful that each infant’s response to pain will have variations and may exhibit more or less response based on gestational age and individual factors. It is also important to note that while pain may include these responses, they can also be caused by other factors.Perioperative Pain Management in Newborns Essay

Behavioral Response to Pain

Pain can also be noted through facial expression, body posture, movements, and vigilance. There has been substantial evidence reported in research studies that have linked facial expression of neonates to specific emotions. Longer crying time is also attributed to pain, but these responses need to be observed in context, and the situation as infant crying may signal different needs. Changes in sleep patterns can also be used by the nurse to identify pain among neonate patients.

In a study that assessed facial expression in neonates who underwent heal lance determined that evaluation of pain while assessing eye squeeze, nasolabial furrow, the opening of the mouth, and brow bulging are significant cues that indicate pain in healthy neonates (Rushforth & Levene, 1994). The research revealed ninety-seven percent of term infants and eighty-four percent of preterm infants demonstrated an increase in these behaviors as a response to the heel lance. This assessment should be considered a vital tool because its use could dramatically affect the amount of pain reduction available to the infant when the cues are identified. Equally significant is that this method can be implemented at the bedside and with proper education, will diminish disagreements in differing pain scores from one healthcare provider to the next.Perioperative Pain Management in Newborns Essay

Hormonal/Metabolic Response to Pain

In addition to physical and behavioral responses to pain, there are now resources available that allow the healthcare provider to measure chemical changes as a response to pain in the neonate. Increases in epinephrine and norepinephrine, growth hormone, and endorphins have been noted. This was achieved by measuring levels before, during and after heal lance. Studies have also concluded that insulin secretion is decreased during pain. Furthermore, cortisol, glucagon, and aldosterone levels were increased with noxious stimuli. This finding translates to increased serum glucose, lactate, and ketones, which could then progress the infant to lactic acidosis.Perioperative Pain Management in Newborns Essay

These hormonal changes noted in the neonate can affect their absorption of essential nutrients like fats, proteins, and glucose. Insufficient absorption then has a direct correlation with their healing process and progress, as well as, their growth and development. It has become evident that pain management is so much more than merely keeping the neonate comfortable. When the healthcare team can control their pain, it leads to a decrease in complications.

Assessment: Pain Scales

Self-help reports are the most common instrument for pain assessment, but these tools only apply to patients who can communicate. Since neonates cannot talk, self-help report is not applicable, and the nurse must assess pain using a combination objective signs and subjective observation that are then scored or scaled. However, accurately determining the level of pain among neonates is extremely difficult. Assessment is very complicated given that there are more than 50 different pain scales that are currently in use (Johnson, Ranger & Anand, 2017). These pain scales and pain assessment tools rely on a combination of behavioral observation (such as body posture, tone, and facial expression) and Physiological parameters that include blood pressure, oxygen saturation and heart rate. There are cases when behavioral measures and physiological measures do not correlate. The former may reveal pain specifically while the latter reflects generalized physiologic stress. It has been found that different responses are p
revalent in neonates. Among the most widely used pain assessment scales for neonates include the following: Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS), Neonatal Infant Pain Scale (NIPS), CRIES, and Pain Assessment in Neonates Scale (PAIN).Perioperative Pain Management in Newborns Essay

The Children’s Hospital of Eastern Ontario Pain Scale is a behavioral scale that is widely used to evaluate postoperative pain in children and may also be beneficial in monitor the usefulness of interventions that have been implemented by healthcare providers. It can assist in evaluating effects for reducing the pain and discomfort and is typically applied to children from birth to four years old (Rudd & Kocisko, 2014). This scale bases its assessment of pain on crying, facial expression, verbal cues, assessment of the torso, response to touch and movement of legs. The minimum score is four with a maximum score of 13 (Rudd & Kocisko, 2014). This scale also outlines definitions of each choice in the six parameters, providing further understanding and clarification to decrease variability in rater scores.

The Neonatal Infant Pain Scale is a six-item scale that was developed based on a survey of 43 neonatal nurses who were asked to identify behaviors associated with pain in patients they cared for in the NICU. The six categories identified were facial expressions, crying, breathing pattern, arm movement, leg movement, and infant arousal states. The total score range is 0-7. This scale was used to score 38 term infants’ pain two minutes before, during needle insertion, and three minutes after the procedure in order to test its validity for assessing pain in infants (Lawrence, et al., 1993). These researchers determined the NIPS was a successful tool and its use became common to determine the need for pain management in neonates.Perioperative Pain Management in Newborns Essay

The CRIES scale is another simple validated tool that allows assessment of pain through physiological and behavioral function. It was developed at the University of Missouri at Columbia as a method to evaluate pain in the postoperative period. This tool assesses crying, need for oxygen therapy, increased vital signs, facial expression, and infant sleep state by assigning a value of 0-2 to each category. This scale was an improvement on the NIPS scale because it provided a greater range of score. However, the assessment of the blood pressure is seen as a procedure that could be painful to the neonate, likely resulting in unnecessary distress and could have an effect on the observes scoring (Bildner & Krechel, 1996).

The Pain Assessment in Neonates Scale was developed in response to a study seeking to improve the effectiveness of rating neonatal pain by combining the NIPS and CRIES scales and addressing the downfalls that the researchers experienced with the two. A group of researchers, seeking to validate pain scales within their organization, designed a study to compare the results of the NIPS and CRIES on the NICU floor and a Step-Down Unit (SDU). The nurses that were involved with this research survey stated worries that the NIPS gave more weight to body movements by assigning it two categories while the rest of the behavioral cues were assigned to as single category (Hudson-Barr, et al. 2002). Additionally, it is common for neonates to be swaddled for comfort creating a dilemma. Do the nurses disturb the baby to assess movement or assume that if they are not moving then they are not in pain. On the other hand, the CRIES assessment requires checking blood pressure which is considered a painful procedure that could cause stress to the infant (Hudson-Barr, et al. 2002). The PAIN scale combined extremity movements into one category, eliminating the uneven weight of bodily movements, and eliminated blood pressure from the assessment creating less distress on the infant.Perioperative Pain Management in Newborns Essay

Long-Term Effects of Unmanaged or Poorly Managed Pain

Neonates experience a multitude of procedures that can cause them to experience pain. Studies have shown that neonates undergo about 750 procedures during their hospital stay (Fitzgerald, 2009). Since infants cannot communicate their pain, it is likely that it will go unnoticed. Untreated pain can have adverse long-term effects on the development of the child. When the pain goes unmanaged, this results in prolonged suppression of the immune system, placing the patient at an increased risk for multiple complications (Pasero & McCaffery, 2011). The brain of neonates is still developing, and untreated pain causes changing levels of neural activity. The central nervous system responds to the pain and may create neural pathways. This persistent sensitization of pain can alter the healthy development of the brain or can have damaging effects on the entire central nervous system.

Neonatal surgery is linked to changes in future pain response. Neonates that undergo circumcision without analgesia were found to have enhanced behavioral response to immunization several months later. Following neonatal circumcision without analgesia, the behavioral response to immunization many months later is also enhanced (Tadio, 2008). Children that were exposed to neonatal intensive care as infants were found to have persistent changes in sensory processing (Hermann & Holdmeister, 2006) and the degree of change was more intense among children who have undergone surgery as a neonate. Animal studies found that injury during the neonatal stage may occur because enhancement is a somatosensory response and this could be true among humans.Perioperative Pain Management in Newborns Essay

Pharmacological Pain management

Opioids are effective pain management medication, but there are dosage requirements which are much lower among neonate than among children and infants. Opioids are given based on body weight, and since neonates have the lowest body weight, there is a decreased clearance in neonates. In procedures that require surgery, however, opioids are used as part of pain management. Recent studies have shown that opioids are safe. Protocols vary and may include intermittent bolus doses, continuous infusions, or nurse-controlled analgesia (Lago, 2013). Respiratory depression is one of the side effects of opioids, and the fear of side effects is a contributing factor to the inadequate use of opioids in neonates.

Paracetamol is also given to neonates, usually in combination with other drugs, as a form of pain management. Its analgesic efficacy is influenced by dose, route of administration, and type of pain stimulus. It may be administered orally and intravenously. Paracetamol may benefit neonates because it can lead to reduced general anesthetic and opioid requirements. There is also evidence that paracetamol use can lead to a reduction in the need for postoperative mechanical ventilation. It is also advisable to neonates that are susceptible to respiratory complications (Walker, 2014). Additionally, it has also meager complication rates.Perioperative Pain Management in Newborns Essay

Acetaminophen and NSAIDs inhibit prostaglandin formation and have minimal risk of causing respiratory depression. They are not used as sole agents for severe or moderate pain but are instead used to assist opioid analgesia, which can then lead to a reduction of the dose of opioids. The use of this combination limits the adverse effects of opioid use. The commonly used IV NSAID for analgesia in neonates is Ketorolac, which has been found to be safe and effective, though evidence of safety is mostly anecdotal and retrospective. Acetaminophen is found to be an attractive agent for pain management in neonates, but dosing should be based on gestational age, and strict attention to dosing must be provided to prevent toxicity. Acetaminophen is used as an adjunct to opioid analgesia to reduce the adverse effects of opioids. One adverse effect of NSAID is bleeding, and if provided to neonates there should be close observation for clinical signs of bleeding. Future clinical trials are needed for NSAID use.

Non-Pharmacological Forms of Pain Management

Non-pharmacologic method for pain management includes
oral sucrose or glucose, breast or bottle feeding, skin-to-skin care Kangaroo Care (also known as skin to skin care). Growing interest has developed in this area of pain management due to the significant amount of painful procedures neonates are subjected to due to their status as preterm. Because there are many adverse effects associated with pharmacological interventions, there is a desire to step outside of that realm and explore new methods to decrease painful stimuli in the neonate. Nonpharmacological methods are extremely desirable to the healthcare community because they have proven to be effective and work in two different ways. These methods are believed to block nociceptive transmission, activate descending inhibitory pathways, and activate the attention and arousal systems that modulate pain. Indirectly, they reduce the amount of total noxious stimuli.Perioperative Pain Management in Newborns Essay

Oral sucrose is administered to infants because it causes the body to released natural opioids through an unknown mechanism (Walker 2014). Stevens (2012) conducted a systematic review of the oral sucrose method among neonate population and found that it significantly reduced the pain associated with procedures. Neonate patients who receive sucrose exhibited a significant decreased in behavioral and physiologic indicators of pain. It also showed improvement in various validated pain scores. In clinical experiments, vital signs were found to be more stable when compared to a placebo. Oral sucrose is safe and has limited side effects. The recommended dosage ranges from 12 to 120 mg (24 % sucrose solution or 20–30 % glucose solution). Sucrose therapy, however, is not recommended to infants after three months of age because its efficacy is reduced.

Breastfeeding or Breastmilk

Breastfeeding is an alternative to sucrose use for pain therapy of the neonate. Breastfeeding was found to have an advantage for one-time painful procedures (Shah, 2006). Breastfeeding the neonate after a one-time painful procedure such as heel stick procedure or venipuncture demonstrated a decrease in the variability of physiologic response associated with pain (Witt, 2016). It showed a reduced duration of total crying time, a lower increase in heart rate, and decreased scores in standardized pain assessment tools such as the neonatal infant pain scale (NIPS), and neonatal facial coding system (NFCS) (Witt, 2016). Another study conducted in Taiwan revealed that the use of breastmilk or sucrose in combination with tucking showed a significant decrease in pain recovery after heel stick compared to no intervention at all (Peng, et al., 2018). This evidence further points to the effectiveness of using multiple non-pharmacological interventions to relieve pain.Perioperative Pain Management in Newborns Essay

The Premature Infant Pain Profile (PIPP)
It is a 7-indicator composite measure that was developed at the University of Toronto and McGill University to assess acute pain in preterm and term neonates. It has been validated in studies using synchronized videotaping of infants undergoing painful procedures [14, 21]. The indicators include (1) gestational age, (2) behavioral state before painful stimulus, (3) change in heart rate during stimulus, (4) change in oxygen saturation, (5) brow bulge during painful stimulus, (6) eye squeeze during stimulus, and (7) nasolabial furrow during painful stimulus [14]. Gestational age is taken into consideration. Scoring is initially done before the painful procedure. The infant is observed for 15 seconds and vital signs recorded. Infants are then observed for 30 seconds during the procedure where physiological and facial changes are recorded and scored. The score ranges from 0–21, with the higher score indicating more pain [14]. The PIPP is however burdensome and time consuming for clinical purposes, especially in the emergency department, and its use for intubated neonates remains questionable” [21].Perioperative Pain Management in Newborns Essay

Crying Requires Increased Vital Signs Expression Sleeplessness (CRIES)
It is an acronym of five physiological and behavioral variables proven to indicate neonatal pain. It is commonly used in neonates in the first month of life [15]. The scale was developed at the University of Missouri and may be recorded over time to monitor the infant’s recovery or response to different interventions [22]. CRIES looks at five parameters: (1) crying, where a high pitched cry is usually associated with pain, (2) increased oxygen requirements, as neonates in pain show decrease oxygen saturation, (3) facial expression where grimacing is the expression most associated with pain, (4) vitals signs, which are usually assessed last as to not awaken or disturb the child, and (5) sleeping patterns where increased sleeplessness is associated with pain [15]. Indicators are scored from 0–2 with the maximum possible score of 10, a higher score indicating a higher pain expression [15].Perioperative Pain Management in Newborns Essay

Maximally Discriminate Facial Movement Coding System (MAX)
It is used for infants to assess emotions associated with facial expression. It looks at brow, eye, and mouth movements [16, 23]. MAX provides a system for measuring emotional signals, and identifies nine fundamental emotions: interest, joy, surprise, sadness, anger, disgust, contempt, fear, and physical distress or pain. The scoring entails 68 MAX number codes, each representing a different facial expression. The description of the expression of each number code is based on the anatomically possible movements of the facial muscles and is a description of what the face looks like when the movements have taken place [16]. Critical studies argue that MAX only includes measurements that are said to correspond with emotions and does not differentiate between anatomically distinct facial movements (inner and outer brow raise) [24, 25].

2.2. Toddlers
In toddlers, verbal skills remain limited and quite inconsistent. Pain-related behaviors are still the main indicator for assessments in this age group. Nonverbal behaviors, such as facial expression, limb movement, grasping, holding, and crying, are considered more reliable and objective, measures of pain than self-reports [26]. Most children of this age however are capable of voluntarily producing displays of distress, with older children displaying fewer pain behaviors (e.g., they cry, moan, and groan less often). Most two-year-old children can report the incidence and location of pain, but do not have the adequate cognitive skills to describe its severity [27]. Three-year-old children, however, can start to differentiate the severity of pain, and are able to use a three-level pain intensity scale with simple terms like “no pain, little pain or a lot” [27]. Children in this age group are usually able to participate in simple dialogue and state whether they feel pain and “how bad it is” [27]. The following section describes common scales used for this age group.Perioperative Pain Management in Newborns Essay

The Children’s Hospital of Eastern Ontario Pain Scales (CHEOPS)
It is one of the earliest tools used to assess and document pain behaviors in young children [28]. It used to assess the efficacy of interventions used in alleviating pain. It includes six categories of behavior: cry, facial, child verbal, torso, touch, and legs. Each is scored separately (ranging from 0–2 or 1–3) and calculated for a pain score ranging from 4–13 [28]. Its length and changeable scoring system among categories makes it complicated and impractical to use compared to other observational scales.

The Faces Legs Activity Cry Consolability Scale (FLACC)
It is a behavioral scale for measuring the intensity of postprocedural pain in young children [29]. It includes five indicators (face, legs, activity, cry, and consolability) with each item ranking on a three point scale (0–2) for severity by behavioral descriptions resulting in a total score between 0–10 [29]. FLACC is an easy and practical scale to use in evaluating and measuring pain especially in pre-verbal children from 2 months to 7 years. Numerous studies have proven its validity and reliability [30].Perioperative Pain Management in Newborns Essay

It is a behavioral scale used to measure distress in critically ill unconscious and ventilated infants, children, and adolescents [31, 32]. This scale is composed of 8 indicators: alertness, calmness/agitation, respiratory response, physical movement, blood pressure, heart rate, muscle tone, and facial tension. Each indicator is given a score between 1 and 5 depending on behaviors displayed by the child and the total score is gathered by adding all indicators (range from 8–40). Patients are monitored for two minutes. The COMFORT scale has been proven to be clinically useful to determine if a child is adequately sedated [32].

The Observational Scale of Behavioral Distress (OSBD)
It remains the most frequently used measurement in procedure-related distress studies [33]. It consists of 11 distress behaviors identified by specialists to be associated with paediatric procedure-related distress, anxiety, and pain. Scores are calculated from summing up all 11 distress behaviors. The behaviors are usually organized into categories of growing intensity, considering their level of interference with medical procedures (e.g., moaning, flinching, and disruption of medical materials) [34]. The validity and reliability of the OSBD has been widely reported [35, 36]. Limitations of the OSBD are noted, where the explanations of the different phases of the procedure: anticipatory (when the child is waiting for the procedure), procedural (distress while the procedure is taking place), and recovery (postprocedural distress) are interchangeable among studies [35, 36]. In instances where procedural phases are constant, differences arise in initiating the procedure (e.g., venipunctures) which are frequently independent of the child’s behavior, and affect the duration of the procedure and the number of observation intervals. This ultimately increases or decreases the scores [37].Perioperative Pain Management in Newborns Essay

Observational Pain Scale (OPS)
It is intended to measure pain in children aged 1 to 4 years, and is used to assess pain of short or long duration [38]. The scale was primarily produced at the University of Amsterdam in the Netherlands. The scale measures 7 parameters: facial expression, cry, breathing, torso, arms and fingers, legs and toes, and states of arousal [38]. The OPS has a simple scoring system which makes it easy to use by all healthcare professionals to obtain valid and reliable results [39]. The indicators are rated from 0-1 with a maximum score of 7, where the higher score indicates greater discomfort [38].

The Toddler-Preschooler Postoperative Pain Scale (TPPPS)
It is used to assess pain in young children during and after a medical or surgical procedure. It is most commonly used for children aged 1–5 years [40]. In order to observe verbal, facial, and bodily movement, the child needs to be awake. This scale relies on behavioral observations, but also includes a self report element. The TPPPS includes seven indicators divided into three pain behavior groups: vocal pain expression, (verbal complaint, cry, moan) facial pain expression (open mouth, squinted eyes, brow bulging and furrowed forehead) and bodily pain expression (restlessness, rubbing touching painful area) [41]. It is a useful tool for evaluating the effectiveness of medication administration in children, but does not measure pain intensity [42]. If a behavior is present during a 5-minute observation period, a score if 1 is given whereas a score of 0 is given if the behavior was not present. The maximum score obtained is 7, which indicates a high pain intensity [40].Perioperative Pain Management in Newborns Essay

2.3. Preschoolers
By the age of four years, most children are usually able to use 4-5 item pain discrimination scales [43]. Their ability to recognize the influence of pain appears around the age of five years when they are able to rate the intensity of pain [44]. Facial expression scales are most commonly used with this age group to obtain self-reports of pain. These scales require children to point to the face that represents how they feel or the amount of pain they are experiencing [45]. The following section describes scales commonly used with this age group.

The Child Facial Coding System (CFCS)
It is adapted from the neonatal facial coding system and developed for use with preschool children (aged 2–5 years). It consists of 13 facial actions: brow lower, squint, eye squeeze, blink, flared nostril, nose wrinkle, nasolabial furrow, cheek raiser, open lips, upper lip raise, lip corner puller, vertical mouth stretch, and horizontal mouth stretch [46]. The CFCS has been useful with acute short-duration procedural pain [47].Perioperative Pain Management in Newborns Essay

Poker Chip Tool
It is a tool that was developed for pre-schoolers to assess “pieces of hurt” [48]. The tool uses four poker chips, where one chip symbolizes “a little hurt” and four chips “the most hurt you could experience”. The tool is used to assess pain intensity. Health care professionals align the chips in front of the child on a flat surface, and explain, using simple terms, that the chips are “pieces of hurt”. The child is asked “how many pieces of hurt do you have right now?” [49] Although most studies focus on using it in children four to thirteen years old, adolescents have used it successfully as well [50].

Faces Pain Scale
It was developed by Wong and Baker and is recommended for children ages 3 and older [51]. The scale requires health care professionals to point to each face and describe the pain intensity associated with it, and then ask the child to choose the face that most accurately describes his or her pain level [51]. Most pain rating scales using faces that portray degrees of distress are divided into two categories: those starting with neutral face as the “no pain” indicator and those with a smiling face. Results showed that children exposed to smiling scale had considerably higher pain scores in the no pain categories and lower scores for positive pain than children who used the neutral faces scale [52]. A study by Chambers and colleagues indicated that children’s pain ratings differ depending on the types of faces scale used, and that faces scales with smiling faces may confuse emotional states with pain ratings [52]. The revised pain scale (FPS-R) is a simplified 6 face adaption of Bieri’s validated faces pain scale. It does not contain smiling faces or tears thus avoiding the confounding of affect and pain intensity [45].Perioperative Pain Management in Newborns Essay

The OUCHER Scale
It was developed by Beyer in 1980 [53]. It is an ethnically based self-report scale, which has three versions: Caucasian, African-American, and Hispanic [54, 55]. Even though it covers a wide array of patients, it still has limits. For example, females are not represented, as well as other cultures. It is used for children older than 5 years [55]. The tool has two separate scales: the numeric scale (i.e., 0–100) and the photographic scale usually used for younger children. The photographic scale entails six different pictures of one child, portraying expressions of “no hurt” to “the biggest hurt you can ever have” [56]. Children are asked to choose the picture or number that closely corresponds to the amount of pain they feel [56].

2.4. School-Aged Children
Health care professionals depend more comfortably on self-reports from school-aged children. Although children at this age understand pain, their use of language to report it is different from adults. At roughly 7 to 8 years of age children, begin to understand the quality of pain [57]. Self-report visual analogue and numerical scales are effective in this age group. A few pain questionnaires have also proven effective for this age such as the pediatric pain questionnaire and the adolescent pediatric pain tool [58, 59]. A brief discussion of these tools is presented here.Perioperative Pain Management in Newborns Essay

Visual Analogue Scale (VAS)
It is a horizontal line, 100 mm in length, attached to word descriptions at each end, “not hurting” or “no pain” to “hurting a whole lot” or “severe pain”. The children are asked to mark on the line the point that they feel represents their pain at this moment [60]. A color analogue scale can also be used, where darker more intense colors (i.e., red) represent more pain [61].

Paediatric Pain Questionnaire
It is a self-report measure to assess children and adolescents coping abilities using 8 subscales “information seeking, problem solving, seeking social support, positive self-statements, behavioral distraction, cognitive distraction, externalizing and internalizing as well as three more complex scales (approach, distraction, and emotion-focused avoidance) [58]. It contains 39 items in total, with scores ranging from 1 (“never”) to 5 (“very often”). Children or adolescents are requested to state how often they “say, do, or think” certain items when they hurt or in pain. The questionnaire usually takes about 10–15 minutes to complete [62].Perioperative Pain Management in Newborns Essay

Adolescent Pediatric Pain Tool (APPT)
It is a valid all encompassing pain assessment tool used for individual pain assessments and measures intensity, location, and quality of pain in children older than 8 years of age [63]. The APPT is most useful with children and adolescents who are experiencing complex, difficult to manage pain [59]. It consists of a body map drawing to allow children to point to the location of pain on their body and a word graphic scale to measure pain intensity. The word graphic rating scale is a 67 word list describing the different dimension of pain and a horizontal line with words attached that range from “no,” “little,” “medium,” “large,” to “worst” possible pain [59, 64–66].

2.5. Adolescents
Adolescents tend to minimize or deny pain, especially in front of friends, so it is important to provide them with privacy and choice. For example, they may or may not choose to have parents present. They expect developmentally appropriate information about procedures and accompanying sensations. Some adolescents regress in behavior under stress [3]. They also need to feel able to accept or refuse strategies and medications to make procedures more tolerable. To assess pain and, specifically chronic pain, the adolescent pediatric pain tool (see above section) or the McGill pain questionnaire are helpful.Perioperative Pain Management in Newborns Essay

The McGill Pain Questionnaire (MPQ)
It was developed by Melzack in 1971 [67]. It is an assessment tool that combines a list of questions about the nature and frequency of pain with a body-map diagram to pinpoint its location [68]. The questionnaire uses word lists separated into 4 classes to assess the total pain experience. The categories are (1) sensory, which contains words describing pain in terms of time, space, pressure, heat, and brightness, (2) affective category which describes pain in terms of tension, fear, and autonomic properties, (3) evaluative, and (4) miscellaneous. After the patient is done rating their pain words, the administrator allocates a numerical score, called the “Pain Rating Index” [69]. Scores vary from 0–78 with the higher score indicating greater pain [68].

3. Minimizing Pain during Procedures: Nonpharmacologic Methods
Pain is one of the most frequent complaints presented in paediatric emergency settings. The emergency department itself is a very stressful place for children. Thus it is important for health care providers to follow a child centered or individual approach in their assessment and management of pain and painful procedures [70]. This approach promotes the right of the child to be fully involved in the procedure, to choose, associate, and communicate. It allows freedom for children to think, experience, explore, question, and search for answers, and allows them to feel proud for doing things for themselves. It is essential to focus on the child rather than the procedure and avoid statements such as “let’s just get it over with” [70]. The child and family should be active participants in the procedure. In fact, allowing parents or family members to act as positive assistants rather than negative restraints helps to reduce stress in both children and parents and minimizes the pain experience [70]. It is also essential to ensure that all procedures are truly necessary, and can be performed safely by experienced personnel. Ideally procedures should be done in a child-friendly environment, using appropriate pharmacologic and nonpharmacologic interventions with routine pain assessment and reassessment [70].Perioperative Pain Management in Newborns Essay

Distraction is the most frequent intervention used in the emergency department to guide children’s attention away from the painful stimuli and reduce pain and anxiety. It is most effective when adapted to the developmental level of the child [71]. Distraction techniques are often provided by nurses, parents or child life specialists. Current research has shown that distraction can lead to the reduction in procedure times, and the number of staff required for the procedure [72]. Distraction has also proven to be more economical than using certain analgesics [73]. Distraction is divided into two main categories: passive distraction, which calls for the child to remain quiet while the health care professional is actively distracting the child (i.e., by singing, talking, or reading a book) [74]. Active distraction, on the other hand, encourages the child’s participation in the activities during the procedures [74]. Interventions used to minimise pain are classified into three main categories (cognitive, behavioral, or combined) [75].Perioperative Pain Management in Newborns Essay

Cognitive Interventions
They are mostly used with older children to direct attention away from procedure-related pain (e.g., counting, listening to music, non procedure-related talk) [76]. The following are a few examples of cognitive interventions:
(1) Imagery. The child is asked to imagine an enjoyable item or experience (e.g., playing on the beach) [77].
(2) Preparation/Education/Information. The procedure and feelings associated with the procedure are explained to child in an age appropriate manner. The child is provided with instructions about what he/she will need to do during the procedure to help them understand what to expect [78, 79].
(3) Coping statements. The child is taught to repeat a set of positive thoughts (e.g., “I can do this” or “this will be over soon”) [80].
(4) Parental training. The parents or family members are taught one of the above interventions to decrease their stress, as decreasing the parent’s distress will often lead to a decrease in the child’s distress [77].
(5) Video games and television. These may be used to distract children from thwborns Essay

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