E-DRUG: RFI: paracetamol AND ibuprofen in children? (7)
-------------------------------------------------------
dear E-druggers,
Points made about paracetamol and fever are important.
However, pain is the primary indication for both paracetamol and ibuprofen.
Pain is often not managed in children in the way that it should be -
especially in severe illnesses such as cancer and HIV/AIDS. Follow this link
for a useful article:
http://www.thebody.com/gmhc/issues/julaug97/kidpain.html
(For those without internet, the whole article is cut and pasted below: note
that acetaminophen is the US name for paracetamol, Tylenol is a US brand
name for paracetamol.)
In a number of countries, controls on narcotics (often including codeine)
are very tight and their use for pain control is therefore severely
restricted in practice - the people with pain are most often not located in
the institutions where such drugs are permitted to be used so they do not
get access to opioid analgesics.
In community settings and peripheral health service delivery points, it may
therefore be very necessary to use combinations of NSAIDs such as ibuprofen
along with paracetamol for lack of legal access to stronger agents.
This problem applies to adults as well. The situation needs to change but
until it does, many children and adults have to get by with restricted
treatment possibilities and put up with the pain.
Carolyn Green
--------------------------------------------------------------------------
GMHC Treatment Issues
Volume 11, Number 7/8
July/August 1997
Pain Management in Children with HIV/AIDS
Mary Jo O'Hara, R.N., and Lynn Czarniecki, R.N.,
National Pediatric & Family HIV Resource Center, University of Medicine and
Dentistry of New Jersey
A five-year-old boy enters the hospital and remains curled in a fetal
position, face to the wall, refusing to talk. Medical interventions to treat
the reason for the admission are instituted, but the child remains
withdrawn. Given the stage of illness, a trial of round-the-clock pain
medication is given, and he begins to get up, go to the playroom and enjoy
life again.
A three-year-old girl, finished with the physical exam, chooses an animal
pop-up book to "read" while the phlebotomist prepares to draw blood. Grandma
sits with the child in her lap asking about all the animals, distracting the
child's attention away from the procedure. After a moment's focus upon the
needle "stick," she exhales a deep breath to "blow the hurt away" and the
procedure is over. With a hug from Grandma and the technician, the child
replaces the book and waves good-bye 'til the next visit.
Children with HIV/AIDS experience pain throughout the course of the disease.
Initially, periodic pain associated with procedures may be tantamount, but
as disease progresses and children reach the end of life, pain and pain
management become more complex. Historically, pain in children has been
underrecognized, underreported and undertreated (Schecter, 1991; Eland,
1977). For children living with HIV, history is repeating itself.
There has been little research done in the area of pediatric HIV and pain.
Although there are few reports in the literature, clinicians who have cared
for large numbers of children with HIV recognize pain as a serious problem.
In adults with HIV, pain is a frequently reported symptom during all stages
of disease (O'Neill & Sherrard, 1993; Hewitt, 1997). Patients report
headaches, mouth and throat pain, chest pain, myalgia (muscle ache),
peripheral neuritis, arthralgia (joint pain) and the pain associated with
medical procedures (O'Neill & Sherrard, 1993; Lebovitz, 1989; Singer, 1993).
Like patients with cancer and other diseases, pain in patients with HIV has
been severely undertreated (Breitbart, 1996).
A few studies document that children with HIV also have similar types of
pain. Hirschfeld et al. (1996) reported a pain incidence of 59% in 61
children with HIV infection as compared to an incidence of 47% in children
with cancer. Types of pain experienced by children with HIV include
headache, abdominal pain, oral cavity pain, neuromuscular pain, peripheral
neuropathy, chest pain, earache, odynophagia (pain while swallowing),
myalgia and arthralgia (Czarniecki, 1993).
Yet barriers to recognition and treatment of pain are considerable. Despite
increasing research to the contrary (Anand, 1987), myths regarding
children's pain persist. Some clinicians continue to believe that children
do not experience pain. The belief that nerve cell myelination was
incomplete in infants and young children has resulted in the erroneous
assumption that children do not experience the same kind or intensity of
pain as adults, and therefore do not need the same pain prevention
(anesthesia) or pain relief (analgesia). A second myth is that children do
not remember painful experiences. "The sooner we get this over with, the
sooner he'll forget" is a common attitude when performing painful
procedures. Anyone who has witnessed a three year old begin to cry at the
sight of the hospital entrance knows that children do remember and associate
their pain.
A third myth is that children cannot tell where it hurts. It is true that
children may not have the same vocabulary, and much of what is communicated
may be nonverbal, but using reliable pain assessment tools (such as the
Eland coloring tool) allows children to communicate the location, frequency
and intensity of their discomfort. As children, clinicians and family
members become increasingly familiar and competent in the use of such tools,
a better understanding and subsequent management of children's pain can be
expected. Pain assessment should be as routine a component of data
collection as vital signs.
The assumption that children who watch TV, play or sleep must not be in pain
is also a myth. As with adults who distract themselves from noxious stimuli,
so do children find a way to focus attention away from the pain. Sleep,
unfortunately, is a too common remedy used by children to escape from pain.
Managing Pain
The effective treatment of pain in children with HIV/AIDS can be
challenging. Developing an appropriate pain management strategy may include
pharmacologic and nonpharmacologic (complementary) therapies tailored to a
child's age, development, culture, type of pain and past experience.
Specific barriers can sometimes hinder clinicians. Children may be nonverbal
because of age or neurologic complications, and cannot self-report their
pain. But even when the children do express themselves, parents and health
care professionals may deny a child's pain because it represents progression
of disease. Also, families who have a history of substance abuse may be very
resistant to the use of opioid analgesics for fear of addiction.
Effective pain management requires several essential components. First, pain
must be recognized. Pain is whatever the child says it is and wherever the
child says it hurts. When there is a reason to suspect pain, but the child
is unable to communicate due to age or cognition, a trial of pain management
should be offered. Using the example of the five-year-old boy, it is clear
that the responsibility for considering pain as the source for signs of
depression is the clinician's. Children express pain in a number of
different ways. Besides crying, grimacing or thrashing about, children with
chronic pain may simply become withdrawn, quiet, depressed, inactive and
anorectic.
Secondly, pain should be treated even as the underlying cause is being
determined. Reluctance or refusal to medicate a child in acute pain for fear
of "masking the symptoms" is neither ethically acceptable nor medically
indicated. The family of a child doubled over with acute abdominal pain
should expect that a correct diagnosis will be based upon appropriate
medical and laboratory evaluations and not solely on a pain assessment. Even
when a specific diagnosis for pain is elusive, which is not uncommon for
children with HIV, pain relief is essential.
Lastly, the backbone of good pain management is the appropriate use of
analgesics according to a pain ladder (Pediatric Supportive Care/Quality of
Life Committee, 1995). The following is based upon the World Health
Organization guidelines.
Mild pain: acetaminophen or nonsteroidal anti-inflammatory drugs
(NSAIDs such as ibuprofen or naproxen).
Moderate pain: continue NSAIDs or acetaminophen and add a mild
opioid such as codeine.
Severe pain: continue NSAIDs or acetaminophen and add a strong
opioid such as morphine, oxycodone or fentanyl.
The dose of opioids to achieve pain relief can go very high. Longer-acting
opioids such as liquid methadone or time-released morphine can be used once
the correct dose is determined by using short-acting morphine. The fentanyl
patch, a transdermal system that provides timed-released fentanyl over three
days, has been extremely helpful for opioid-experienced patients who cannot
tolerate oral medications. Whenever a long-acting agent is administered, the
patient must also be given prescriptions for a short-acting opioid for
breakthrough pain. As tolerance develops, the clinician can calculate the
24-hour requirement for short-acting medication and adjust upward the
long-acting opioid.
Certain adjuvant medications such as anticonvulsants and antidepressants
have been found useful for neuropathic pain. Hydroxyzine, which can help
with nausea, also has an analgesic affect and can reduce the amount of
opioid required. Side effects of opioids such as nausea, constipation,
itching and drowsiness should be anticipated and treated aggressively.
Families must be educated about the difference between physical dependence
and addiction. The clinician needs to explore with the patient and family
the meaning of pain to them and their previous experience with pain and pain
medications. In families where substance abuse exists, the issue must be
discussed directly with them and there must be mutual understanding and
agreement about the giving of opioid prescriptions.
Anticipating and preventing pain, rather than alleviating existing pain is
the goal of appropriate pain management. "Round-the-clock" as opposed to PRN
(as needed) dosing maintains a constant analgesic level. The goal is to
attain maximum pain relief with minimum side effects. Once pain relief has
been attained, it is essential that the schedule be continued and not
reduced because the child is now pain-free.
Coping Techniques
Pain is more than a physiologic response to a noxious experience. If we
again consider the three-year-old who bursts into tears at the sight of the
hospital, it is clear that the discomfort is more than the moment of the
needle stick associated with a blood draw. Recognizing that anticipatory
anxiety has a profound impact on the child's quality of life, appropriate
interventions to decrease the fear associated with the painful procedure
should be instituted.
Strategies to meet this need are primarily based upon the child's
developmental level. Infants and young children respond to distraction
techniques such as bubbles, pop-up books or pinwheels. As children become
older, visualization techniques such as imagining the pain controlled by a
switch which the child can "turn down" may assist in coping with chronic
pain. Visualizing the sights, sounds and smells of a visit to Grandma's
house may allow the child to relax, thereby decreasing the muscle tension
associated with acute pain. More sophisticated interventions, such as
altering the level of consciousness and attaining a deep state of relaxation
through hypnosis require professional training but can make a significant
impact on pain control, particularly for children with chronic pain.
Nonpharmacologic interventions can be enormously successful but should never
be used in place of appropriate pharmacologic pain management. The use of a
topical anesthetic, such as EMLA cream, 2.5 grams applied to the
venipuncture site 45 to 60 minutes before the painful procedure (as in the
example of the three-year-old) will avoid the development of anticipatory
anxiety since the pain will be eliminated. In the meantime stress management
techniques can be applied to return control of the experience to the child.
Recognizing, assessing and treating the acute and chronic pain associated
with HIV disease in children is frustrating and time-consuming. But
successful interventions are both possible and necessary and offer
incalculable rewards.
References
Anand KJS, Hickey PR. The New England Journal of Medicine. November 19,
1987; 317(21):1321-9.
Breitbart W et al. Pain. May-June 1996; 65(2-3):243-9.
Czarniecki L et al. PAAC Notes. 1993; 5:492-5.
Czarniecki L et al. Pain in HIV/AIDS (48-52). Washington, D.C., France-USA
Pain Association.
Eland JM, Anderson JE. The experience of pain in children. Pain: a
Sourcebook for Nurses and Other Health Professionals. Boston, Little, Brown,
1977.
Hewitt DJ et al. Pain. April 1997; 70(2-3):117-23.
Hirschfeld S et al. Pediatrics. September 1996; 98(3 Pt 1):449-56.
Lebovitz A et al. Clinical Journal of Pain. September 1989; 5(3):245-8.
O'Neill W, Sherrard J. Pain. July 1993; 54(1):3-14.
Pediatric Supportive Care/Quality of Life Committee of the NIAID's Pediatric
ACTG, (1995). "Enhancing supportive care and promoting quality of life:
clinical practice guidelines. Pediatric AIDS and HIV Infection: Fetus to
Adolescent," 6, 187-203.
Schecter N. Pediatric Clinics of North America. August 1989; 36(4):781-4.
Singer BJ et al. Pain. July 1993; 54(1):15-9.
--
To send a message to E-Drug, write to: e-drug@healthnet.org
To subscribe or unsubscribe, write to: majordomo@healthnet.org
in the body of the message type: subscribe e-drug OR unsubscribe e-drug
To contact a person, send a message to: e-drug-help@healthnet.org
Information and archives: http://www.essentialdrugs.org/edrug