Current trends in the management of common painful conditions of preschool children in United States pediatric emergency departments

Pain management of musculoskeletal injuries in children: current state and future directions

BACKGROUND

Pain is the most common reason for seeking health care in the Western world and is a contributing factor in up to 80% of all emergency department (ED) visits. In the pediatric emergency setting, musculoskeletal injuries are one of the most common painful presentations. Inadequate pain management during medical care, especially among very young children, can have numerous detrimental effects. No standard of care exists for the management of acute musculoskeletal injury-related pain in children. Within the ED setting, pain from such injuries has been repeatedly shown to be undertreated.

OBJECTIVES

Upon completion of this CME article, the reader should be better able to (1) distinguish multiple nonpharmacological techniques for minimizing and treating pain and anxiety in children with musculoskeletal injuries, (2) apply recent medical literature in deciding pharmacological strategies for the treatment of children with musculoskeletal injuries, and (3) interpret the basic principles of pharmacogenomics and how they relate to analgesic efficacy.

RESULTS

Pediatric musculoskeletal injuries are both common and painful. There is growing evidence that, in addition to pharmacological therapy, nonpharmacological methods can be introduced to improve analgesia in the ED and after discharge. Traditionally, acetaminophen with codeine has been used to treat moderate orthopedic injury-related pain in children. Other oral opioids (hydrocodone, oxycodone) are gaining popularity, as well. Current data suggest that ibuprofen is at least as effective as acetaminophen-codeine and codeine alone. Medication compliance might be improved if adverse effects were minimized, and ibuprofen has been shown to have a similar or better adverse effect profile than the oral opioids to which it has been compared. Pharmacogenomic data show that nearly 50% of individuals have at least 1 reduced functioning allele resulting in suboptimal conversion of codeine to active analgesic, so it is not surprising that codeine analgesic efficacy is not optimal. At the same time, nonpharmacological therapies are emerging as commonly used treatment options by parents and adjuncts to analgesic medication. The efficacy and role of techniques (massage, music therapy, transcutaneous electrical nerve stimulation), although promising, require further clarification in the treatment of orthopedic injury pain.

CONCLUSIONS

There is a need to optimize the measurement, documentation, and treatment of pain in children. There is growing evidence that nonpharmacological methods can be introduced to improve analgesia in the ED, and efforts to help parents implement these methods at home might be advantageous to optimize outpatient treatment plans. In pharmacotherapy, ibuprofen has emerged as an appropriate first-line choice for mild-moderate orthopedic pain. Other oral opioids (hydrocodone, oxycodone) are gaining popularity over codeine, because of the current understanding of the pharmacogenomics of such medications.

Efficacy of ShotBlocker in reducing pediatric pain associated with intramuscular injections

OBJECTIVE

The aim of the study was to determine the efficacy of ShotBlocker (Bionix, Toledo, Ohio) in reducing pediatric pain with intramuscular (IM) injections.

METHODS

A prospective randomized controlled trial was conducted in children aged 2 months to 17 years who required an IM injection. Children were randomized to the no-intervention group or the ShotBlocker group. Demographic data and the number of IM injections were recorded. Perceived pain scores were obtained from nurses and caregivers using a 6-point Likert-type scale. Baker Wong Faces scale was used in children 36 months or older. Difficulty using the device was also rated by nurses on a 6-point scale.

RESULTS

One hundred sixty-five children were enrolled with 80 in the no-intervention arm and 85 in the ShotBlocker arm. The mean age of children was 45 months and 56% were male. Perceived pain scores by nurses were higher for the no-intervention group (2.6 vs 1.8, P < .001) as well as by caregivers (2.6 vs 2.1, P = .04). Children aged 36 months and older (n = 64) did not report a difference in pain scores (1.5 vs 1.3, P = .6); however, in a subgroup of children 72 months or older, pain scores trended higher in the no-intervention group (1.3 vs 0.5, P = .051). Nurse-perceived difficulty of ShotBlocker use was low 1.39 (+/-1.1).

CONCLUSIONS

Nurses and caregivers noted lower pain scores in children assigned to the ShotBlocker group. These differences were not as evident when children rated their own pain.

Nonoperative management of pediatric burn injuries

There are an estimated 1.2 million burn injuries per year in the United States, one third of which occur in children. Most of these injuries will be treated nonoperatively, frequently in an outpatient setting. This article aims to provide the practitioner with a understanding of the pathophysiology of burn injuries, a guide to the initial assessment of the patient, and management recommendations for nonoperative treatment of the burned pediatric patient.