Recognising the true extent of a child’s pain is vital, as is selecting the appropriate treatment, and advising on adjunct non-pharmacological treatment strategies
In a pharmacy setting, children experiencing mild, acute pain are most likely to be encountered.
This pain is typically associated with minor injury, infection, such as pain in the ears or throat, or developmental; for example, teething.
Pain in children has many aspects that make it challenging to treat. While we have moved on from the false belief that infants and children do not experience pain in the same way that adults do, it can be difficult to gain an accurate idea of the true level of pain a child is experiencing.
This is particularly so in infants and young children who are unable to verbalise their pain.
“Children can find it difficult to explain how they’re feeling. They often can’t articulate what’s going on inside their body and this can be challenging when it comes to treating pain in children,” explains Eric Chan, head of pharmacy at Blooms The Chemist, Forestville, NSW.
“Most of the time we rely on parents or carers to tell us the symptoms. However, if we have the child in front of us we’ll keep a close eye on their facial expressions.
“For example, if their face is scrunched up it might suggest they’re in quite a bit of pain or discomfort. Also, we might see how playful or active they are.”
Using the right words
Associate Professor Rebekah Moles, lecturer of pharmacy practice at the University of Sydney, agrees that assessing pain in children can be tricky.
She advises, “When questioning a child, try to use their words like ‘ouch’, ‘sore’, and ‘hurt’.
Remember that just because an infant may not be able to communicate doesn’t mean they don’t have pain.
You may need to use more than just questions to find out if there is pain and how severe it is.
“Pain rating scales are very useful tools. Commonly used scales are the numeric scale, where the child is asked to rate their pain on a scale of 1–10 with 10 being the worst pain,” A/Prof Moles says.
These scales can be useful for children that are a little older (than 8 years of age) that can understand number values, she added.
For younger children (3–8 years), the Wong–Baker Faces Scale has been used extensively. This can be accessed online at https://wongbakerfaces.org/
“Parents also need to observe behaviour. Sometimes children in pain will be very withdrawn whereas others may be disruptive, so parents need to note changes from normal,” she said.
Mr Chan adds, “It’s important for pharmacists to tailor their approach so that children feel comfortable attempting to explain their pain, but also so that mum and dad feel at ease.
“It’s certainly easier when you have older children and can discuss pain in terms of a numerical scale. You might ask them how they would rate their pain from one to 10, if 10 were as painful as a tooth being pulled out and one is the pain of a scratch. I find this useful to help quantify a child’s level of pain.
“The real challenge is when you have a child in pain and you don’t know how to help them,” Mr Chan said. “This is usually when it’s outside the scope of the practice and the pharmacist.
“In instances where the child is in pain and non-responsive to analgesia, where there is stomach pain with diarrhoea, prolonged fever, or pain that can’t be explained you would refer to a GP.
“It can leave you feeling helpless, but knowing when to refer is equally as important as being able to treat a patient. The last thing we want to do is delay the correct help for the patient.”
Treating pain in children
In most cases pharmacists would use paracetamol or ibuprofen to treat mild pain, Eric Chan said.
However, he believes community pharmacists are also in an ideal position to take a more holistic approach to pain management.
“We have access to people’s medication records so, if a child gets their prescriptions at the pharmacy, we can check the computer to see what they are taking and ensure they have not been prescribed any other medicines that contain the same ingredients.
“The accessible nature of pharmacists means we are often on a first name basis with our customers; so there’s a good level of trust and familiarity with the family, which can help you provide that holistic care and address any concerns,” he said.
“We often get asked ‘what’s the best way to give medicine to a child’ or ‘what can I do if my child can’t take a tablet’. Pharmacists are in a really good position to discuss dosage forms. We might consider whether or not the child can swallow and, if they can’t take a tablet or capsule, perhaps a soluble tablet or suspension would be preferable.
“Likewise, we might ask if the child likes a particular flavour of liquid, or maybe the parents prefer colour-free forms. This is where the pharmacist can really tailor the child’s treatment, as well as explain the different dosage forms to the parent or carer,” says Mr Chan.
Talking about dosing
“Dosage is something we frequently get asked about,” Mr Chan says.
“You might have a parent who says they only want to give their child up to two doses, rather than the maximum number. In this case I would explain that every child is different and manages pain in a different way. I might suggest they give one dose in the day, another dose in the evening and then come back into the pharmacy in the morning to discuss how the child is feeling and what level of pain they’re experiencing.
“It’s about acknowledging the parent’s concerns and educating them, so they can make the best decision for their child. We’re also there to offer them support and reassurance. We have to take the time to understand each person’s individual circumstance.”
When it comes to guidance on administering the correct doses, pharmacists can play a vital role.
They can explain that weight-based, rather than age-based, is the preferred method of dosing for paracetamol or ibuprofen in children, according to advice from leading paediatric hospitals.
This method allows for more accuracy. For example, a petite child might need a dose that would often be associated with younger children. Similarly, a larger child might need a dose that’s associated with an older child.
Pharmacists can also remind parents and carers to always check the dosing chart on the bottle or pack, as paracetamol and ibuprofen come in different strengths and brand names.
As such, the dosing might vary.
Additionally, both medicines have different dosing intervals, so it’s important to advise on how often the dose can be given. Paracetamol can be given every 4–6 hours, but not more than four times in 24 hours.
Ibuprofen can be given every 6–8 hours, but no more than three times in 24 hours.
Incorporating adjunct and non-pharmacological treatments
Mr Chan says, “If you have a child whose pain is associated with teething, then there are a range of teething gels available to help soothe the gums. You might also deal with skin pain as a result of insect bites or sunburn. In this case, I might recommend a soothing cream or gel as well as an analgesic to ease the pain.
“It can be useful to consider adjunct treatments. For example, if you have a child with stomach ache you might give paracetamol but also suggest the use of a heat pack to help relieve the pain.”
There are many non-pharmacological treatments that can be useful when treating children’s pain.
According to the Royal Children’s Hospital Melbourne, the aim of non-pharmacological interventions is to make the pain more bearable, to help the child feel in control and to teach coping strategies, which may come in useful in later years.
Easy-to-implement non-pharmacological pain management techniques include:
- deep breathing
- use of heat or cold
- swaddling, feeding or skin-to-skin contact for babies
- distraction therapy such as music, bubbles or storytelling.
Mr Chan adds, “Certainly, there are some parents who want to avoid giving medicine to their children.
It’s important to understand peoples’ concerns and beliefs around medication. Showing genuine, authentic care is essential”.
Talking to parents about fever
Pain and fever often go hand in hand. For example, the two can present as a result of an ear infection, teething, or following a vaccination.
However, many parents have an exaggerated fear of fever in children and a limited understanding of its valuable role in recovery. As such, pharmacists and their staff can help alleviate some of the worry and educate parents and carers.
“With regards to fever in children, it’s good to understand what exactly fever is. It’s the body’s natural defense mechanism. It raises the body’s temperature to kill something off and to offer protection,” says Eric Chan.
Dianne Crellin, research associate at Murdoch Children’s Research Institute, advises, “It’s important to relay what constitutes a fever; a temperature above 38°C is considered a fever. However, fever in kids is a common symptom and in most circumstances it goes hand in hand with a fairly benign illness.
“I believe much of parents’ concern stems from potential complications, such as febrile convulsion. Pharmacists can help alleviate some of these concerns by advising that only approximately 2% of kids experience febrile convulsion as a result of fever and, despite being scary for the family, there are no lasting ramifications.
“Children lose more fluids when they’re hot, so pharmacists can advise parents to make sure their child is well hydrated and comfortable.
“Pharmacists are certainly part of a team that can promote a better understanding of what should and shouldn’t alarm parents when it comes to the health of their children.”
She says a parent’s observation of their child is much more meaningful than the temperature on the thermometer. For example, if the child is pale and inactive, appears particularly unwell, or if they don’t know what’s causing the fever, this would warrant a visit to the GP.
Key points to remind parents and carers include:
- Fever is common in children and usually associated with a viral infection.
- Fever is a natural response to an infection.
- Paracetamol and ibuprofen can be used to help reduce a fever.
- Children with fever need to keep their fluid intake up.
The Royal Children’s Hospital Melbourne. Fact Sheets: Pain relief for children—paracetamol and ibuprofen. Reviewed July 2020. Accessed online via: https://www.rch.org.au/kidsinfo/fact_sheets/Pain_relief_for_children/
Children’s Health Queensland Hospital and Health Service. Paediatric Fact Sheet—Fever in children. Accessed online via: https://www.childrens.health.qld.gov.au/fact-sheet-fever-in-children/