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1. ACUTE PAIN MANAGEMENT

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INTRODUCTION

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The treatment and alleviation of pain constitute a basic human right that exists regardless of age.1,2 Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage.3 Previous experience and management of pain, even from very early stages in life, alter the responses and behavior toward further “painful” experiences and events. Hence, no two people experience pain the same way, which adds to the complexity of the management of pain.

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Unfortunately, even when pain is obvious, children frequently receive no or inadequate treatment for pain and painful procedures. The newborn and critically ill child are especially vulnerable to receiving no treatment or undertreatment.4,5 The conventional notion that children neither respond to nor remember painful experiences to the same degree that adults do is inaccurate. Many of the nerve pathways essential for the transmission and perception of pain are present and functioning by 24–29 weeks of gestation.6,7 Research in newborn animals has revealed that failure to provide analgesia for pain results in “rewiring” of the nerve pathways responsible for pain transmission in the dorsal horn of the spinal cord, resulting in increased pain perception of future painful insults. This confirms human newborn research that found that the failure to provide anesthesia or analgesia for newborn circumcision resulted not only in short-term physiologic perturbations but also in longer-term behavioral changes.8,9

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Nurses are traditionally taught or cautioned to be wary of physicians’ orders and patients’ requests for pain management, as well. The most common prescription order for potent analgesics, “to give as needed” (pro re nata, PRN), in reality means “to give as infrequently as possible.” The PRN order also means that either the patient must know or remember to ask for pain medication or the nurse must be able to identify when a patient is in pain. Neither requirement may be met by children in pain. Children less than 3 years of age and critically ill children may be unable to adequately verbalize when they are in pain or where they hurt. Moreover, they may be afraid to report their pain. Several studies have documented the inability of nurses, physicians, and parents/guardians to correctly identify and treat pain, even in postoperative pediatric patients.

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Societal fears of opioid addiction and lack of advocacy are also causal factors in the undertreatment of pediatric pain. Unlike adult patients, pain management in children is often dependent on the ability of parents/guardians to recognize and assess pain and on their decision whether to treat or not. Parental misconceptions concerning pain assessment and pain management may therefore also result in inadequate pain treatment. Even in hospitalized patients, most of the pain that children experience is managed by their parents/guardians. Parents/guardians may fail to report pain either because they are unable to assess ...

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