Kahsay
Curr Pediatr Res 2017 Volume 21 Issue 1
152
surgical visit for patients and their families is important to
develop their perception towards pain management [40].
A study by Lm Zhu et al. in Canadian pediatric teaching
hospitals indicated that out of the 55 (83.3%) children
who take pain management intervention, six of them
received a physical treatment and five children received a
psychological intervention [14].
General the following interventions are considered as non-
pharmacological treatment of pain based on the recent and
numerous studies.
Sucrose
Concentrated sucrose solutions (2 ml of 24% solution)
may be used as a pain relief measure in preterm and term
newborns up to 1 month of age as its analgesic effect lasts
approximately 3 to 5 min. It promotes natural pain relief
by activating endogenous opioids in contact with the oral
mucosa. The effectiveness of sucrose solution enhanced
by allowing the infant to continue sucking on a pacifier
or breastfeed [41]. A randomized controlled clinical
trial found that a single dose oral sucrose is effective
and safe for minimizing physiological response to a
painful stimulus and behavioral expressions in preterm
infants [37]. The proposed hypothesis initiated from the
endogenous opioid release can cause by taking oral 20-
30% glucose through unknown mechanism. Therefore,
Several studies recommended to considered oral sucrose
as one of the non-pharmacological interventions of pain
[30,31,37].
Distraction
Distraction involves engaging a child in a wide variety of
pleasant activities that help focus attention on something
other than pain and the anxiety. Examples of distraction
activities are listening to music, singing a song, blowing
bubbles, playing a game, watching television or a video,
and focusing on a picture while counting. Guided imagery
and breathing techniques may be forms of distraction for
school-age children and adolescents [42]. A randomized
control trial suggested that a virtual reality games were
found to be effective distraction for children with acute
burn injuries [43].
Breast Feeding
Breast milk is the best alternative to no intervention or
to the use of sucrose in patient suffering with a single
painful procedure. During venipunctures and heel stick
procedures, neonates who were breastfed showed a
substantial decrease in the variability of physiologic
response as compared to other non-pharmacological
interventions [30,39,44].
Skin-to-Skin Contact
Skin to skin contact demonstrated as effective non-
pharmacological intervention in reduction of pain
especially when used as adjunctive therapy to breastfeeding
or other sweet solutions. Canadian medical association
demonstrated that skin-to-skin contact principally
Kangaroo care plays its own role in reducing and caring
their children as the care giver and the baby have a direct
physical contact [4,30].
Pharmacological Management of Pain
The current pharmacologic treatment protocol of pain for
children is primarily extrapolated from adult intervention
without any evidence of value in children [32]. High-
quality pediatric experimental researches are needed
to demonstrate efficacy and safety of analgesics for
innumerable pain conditions in children to avoid continued
use of analgesics empirically [8]. The development of age-
appropriate pain assessment tools leads to improvement
in the management of pain in children in the last two
decades. Depending on the severity of pain, non-opioids
and opioids are the most common analgesic agents used
a “step-wise” approach in management of pain in both
children and adults [19,24,28]. It is important that pain be
reassessed soon after any pharmacological intervention to
guide further interventions and to ensure the achievement
of pain relief ensured by reassessment of pain regularly
after any pharmacological intervention. Multimodal
analgesia practice should be considered in patients with
pain by concomitant use of the opioids, NSAIDs and other
adjuvant therapies [14].
Generally, World Health Organization (WHO)
demonstrated three-step analgesic ladder for treatment of
pain (Figure 3) [45].
Non-Opioids Used for Management of Pain in Pediatrics
Acetaminophen
:
It
is the most frequently used pain-
relieving agent in pediatric patients. It has lack of
significant side effects and excellent safety profile with
benefit to all levels of pain in children [39]. In common to
the guideline of different institutions (Table 4), initially a
loading dose of 30 mg/kg should be given, then 10-15 mg/
kg every four to six hours as maintenance with maximum
dose of 90 mg/kg/day for children. But, for term neonates
of less than ten days 60 mg/kg and 45 mg/kg for premature
infants. Neonates have a slower clearance rate so the drug
must be given less frequently. Acetaminophen is manly
used for mild to moderate pain independently and in
combination of opioids for patients with severe pain for
example
acetaminophen with codeine) [24,37,45]. Rectal
preparations of this analgesics used for infants and toddlers
who are unable or unwilling to take orally. However,
several studies have confirmed that rectal absorption
comparatively inefficient and slow. Hepatotoxicity is
not associated with single rectal doses of 30 to 45 mg/kg
produced plasma concentrations that were generally in the
effective range [46].
In relative to oral doses rectal doses are slowly decline in
plasma concentrations. Based on a day pharmacokinetic
study, the dosing interval for rectal dose extended to at
least 6 h [29]. Acetaminophen toxicity can result when the
