The management of pain can be a complex process. Special populations, such as children or the elderly, can provide additional unique challenges. For example, a child’s developmental stage and age can affect the type, route, and metabolic process of pain medication. The elderly client may have comorbidities that affect what drug is selected, the route of administration, and how the drug is metabolized. Both age groups can be affected by communication difficulties, and both groups of patients may require varied methods of providing comfort, social support, and strategies for pain relief.
PAIN MANAGEMENT IN CHILDREN
It is now well accepted by neuroscientists and pain specialists that the human nervous system is well developed before birth, so children are assumed to be able to experience pain from birth onward (Andrews, & Fitzgerald, 1999). Neonates have the same number of pain nerve endings per square millimeter of skin as adults. They are present in the fetus from the second trimester of pregnancy. Cortical interconnections with the thalamus (the tracts that play a role in the higher perception of pain) are complete by 24 weeks’ gestation, and the central nervous system tracts are completely myelinated by 30 weeks’ gestation (Mathews, 2011).
In fact, infants and children have a more robust inflammatory response than adults and do not have a central inhibitory influence because the descending inhibitory controllers of pain are not fully developed in the neonate. Thus, neonates and young children may actually experience a greater neural response to pain (i.e., more pain sensation and pain-related distress following a noxious stimulus) than adults. The impact of painful experiences on the young nervous system is so significant that long-term effects can occur, including lasting changes to developing somatosensory and pain systems (Schwaller, & Fitzgerald, 2014).
These long-term effects include lowered pain tolerance for several months after a pain-producing experience and negatively affected visual-perceptual abilities in school-aged children (Doesburg, et al., 2013; Mathews, 2011; Palermo, Koh, & Zeltzer, 2011; Taddio, Katz, Hersch & Koren, 1999). Other effects include greater pain and perceptual sensitization to noxious stimulation, reduced brain white matter, reduced subcortical grey matter, delayed corticospinal development, and lower postnatal growth (Schwaller, & Fitzgerald, 2014).
Knowing that neonates and pediatric patients most certainly experience pain, their long history of undertreatment cannot be justified by the lack of easy communication with them (Mathews, 2011; Schechter, 1989). Fortunately for patients and caregivers alike, the way this issue is addressed is changing (Roofthooft, et al., 2014).
Pediatric clients make up a group with very special needs when it comes to pain management. Communication issues, their neurophysiology in relation to their development, the influence and involvement of their parents and families, and ways these patients respond to adverse events make assessment for pain different and more challenging than pain assessment in adults (Palermo, Koh, & Zeltzer, 2011).