Neonates and Children
63. M.M., a 2-day-old, 3-kg girl, has just had bowel surgery for congenital bowel atresia. How should pain management be approached for M.M.?
Many misconceptions exist about the management of pain in the pediatric population. Historically, infants and children have been undertreated for pain and painful procedures. This is partly because of difficulty in communicating with, and evaluating pain, in children, particularly those who are nonverbal. It was also believed that children did not experience pain in the same way as adults do. Significant advances have been made in the understanding of children's pain perception, and assessment tools designed for different stages of development and communication abilities are available.216,217 Nevertheless, misconceptions still exist, ranging from the amount of pain a child should experience after a painful procedure to the fear of addiction. Inadequately treated pain can interfere with the healing process, increase heart and respiratory rates, reduce oxygen saturation, and induce hyperglycemia and metabolic acidosis. Increased morbidity and mortality associated with unrelieved pain has been documented in neonates undergoing cardiac surgery.218 The reality is that infants and children experience pain just as adults do and should receive appropriate medication and doses to treat their pain.
64. What would be a rational pain management plan for M.M.?
Because M.M. has had significant GI surgery, severe pain should be anticipated and prevented. Therefore, use of opiates, such as morphine or fentanyl, would be appropriate in this situation. Children appear to mature very early with respect to morphine metabolism. Infants as young as 5 months of age show very similar pharmacokinetic parameters as adults; however, morphine concentrations in patients younger than 2.4 months are five times higher than in older patients because of slower metabolic clearance and a lower central compartment volume of distribution.219 The dosing of morphine in children is similar to adults on a milligram-per-kilogram basis, but children <5 months of age may require less-frequent dosing. The use of opiates in infants and children does not lead to addiction. Critically ill children who are receiving opiates for long periods of time develop tolerance and physical dependence and exhibit signs and symptoms of withdrawal if opiates are weaned too quickly, which however, should not preclude pediatric patients from receiving opiates.
An appropriate initial dosing regimen for M.M. would be fentanyl 1 mcg/kg IV every 4 hours with 1 mcg/kg every 2 hours as needed for breakthrough pain. When using parenteral morphine preparations in infants, close attention should be given to the preparation used and the age of the infant. Parenteral morphine preparations are available with and without preservatives. Infants <3 months of age are more susceptible to respiratory depression caused by an allergic reaction to the sulfites or to CNS irritation induced by benzyl alcohol. Thus, neonates and infants <3 months of age should receive only preservative-free morphine. When choosing a route of administration, attention should be given to the patient's clinical condition. Although oral routes are preferred, they may not be appropriate immediately following surgery. Opiates are frequently administered IM; however, IM administration offers no advantage over IV and causes much more pain and distress. Children receiving repeated IM injections often deny the presence of pain to avoid the injection.217 Therefore, IV administration is the preferred parenteral route in pediatric patients.
Assessment of pain and relief in M.M. is more challenging because she is unable to verbalize specific information. Careful attention to behavioral responses, such as crying characteristics, crying duration, facial expressions, visual tracking, response to stimuli, and body movement, will be most useful in assessing pain and relief in M.M.216,217 Heart rate, respiratory rate, blood pressure, and presence of diaphoresis can provide useful clues to M.M.'s level of pain or comfort and can alert the clinician to potential side effects. Careful monitoring, together with adjustments to the dose and frequency of administration, provides optimal therapy.
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