AGES OF USE	INSTRUMENT
4 months to 18 years	Objective Pain Score (OPS) (Hannallah and others, 1987)
1 to 5 years	Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS) (McGrath and others, 1985)
Newborn to 16 years	Nurses Assessment of Pain Inventory (NAPI) (Stevens, 1990)
3 to 36 months	Behavioral Pain Score (BPS) (Robieux and others, 1991)
4 to 6 months	Modified Behavioral Pain Scale (MBPS) (Taddio and others, 1995)
<36 months and children with cerebral palsy	Riley Infant Pain Scale (RIPS) (Schade and others, 1996)
2 months to 7 years	FLACC Postoperative Pain Tool (Merkel and others, 1997)
1 to 7 months	Postoperative Pain Score (POPS) (Attia and others, 1987)
Average gestational age 33.5 weeks	Neonatal Infant Pain Scale (NIPS) (Lawrence and others, 1993)
27 weeks gestational age to full term	Pain Assessment Tool (PAT) (Hodgkinson and others, 1994)
1 to 36 months	Pain Rating Scale (PRS) (Joyce and others, 1994)
32 to 60 weeks gestational age	CRIES (Krechel, Bildner, 1995)
28 to 40 weeks gestational age	Premature Infant Pain Profile (PIPP) (Stevens and others, 1996)
0 to 28 days	Scale for Use in Newborns (SUN) (Blauer, Gerstmann, 1998)
Birth (23 weeks gestational age) and full-term newborns up to 100 days	Neonatal Pain, Agitation, and Sedation Scale (NPASS) (Puchalski, Hummel, 2002)

TABLE 2-2 FLACC Scale ^*

TABLE 2-3 Pain Rating Scales for Children

PAIN SCALE, DESCRIPTION	RECOMMENDED AGE, COMMENTS
FACES Pain Rating Scale (Wong and Baker, 1988) Uses six cartoon faces ranging from smiling face for “no pain” to tearful face for “worst pain”

Children as young as three years. Use original instructions without affect words, such as happy or sad, or brief words resulted in same range of pain rating, probably reflecting child’s rating of pain intensity. For coding purposes, numbers 0,2, 4,6, 8,10 can be substituted for 0-5 system to accommodate 0-10 system.

Provides three scales in one: facial expressions, numbers, and words.

Research supports cultural sensitivity of FACES for Caucasian, African-American, Hispanic, Thai, Chinese, and Japanese children.

Oucher (Beyer, Denyes, and Villarruel, 1992)

Uses six photographs of Caucasian child’s face representing “no hurt” to “biggest hurt you could ever have”; also includes vertical scale with numbers from 0 to 100; scales for African-American and Hispanic children have been developed (Villarruel and Denyes, 1991)

Children 3 to 13 years. Use numeric scale if child can count any 2 numbers, or by tens (Jordan-Marsh and others, 1994).

Determine whether child has cognitive ability to use photographic scale; child should be able to rate 6 geometric shapes from largest to smallest.

Determine which ethnic version of Oucher to use. Allow child to select version of Oucher, or use version that most closely matches physical characteristics of child.

NOTE: Ethnically similar scale may not be preferred by child when given choice of ethnically neutral cartoon scale (Luffy and Grove, 2003).

Poker Chip Tool^† (Hester and others, 1998)

Uses four red poker chips placed horizontally in front of child

Children as young as 4 years. Determine whether child has cognitive ability to use numbers by identifying larger of any 2 numbers.

Word-Graphic Rating Scale^‡ (Tesler and others, 1991)

Uses descriptive words (may vary in other scales) to denote varying intensities of pain

Children 4 to 17 years

Numeric Scale

Uses straight line with end points identified as “no pain” and “worst pain” and sometimes “medium pain” in the middle; divisions along line marked in units from 0-10 (high number may vary)

Children as young as 5 years, as long as they can count and have some concept of numbers and their values in relation to other numbers

Scale may be used horizontally or vertically

Number coding should be same as other scales used in facility

Visual AnalogueScale (VAS) (Cline and others, 1992)

A vertical or horizontal line is drawn to a certain length, such as 10 cm (4 in), and anchored by items that represent extremes of the subjective phenomenon, such as pain, which is measured

Children as young as 4.5 years, preferably 7 years

Vertical or horizontal scale may be used

Research shows that children ages 3 to 18 years least prefer VAS compared with other scales (Luffy and Grove, 2003; Wong and Baker, 1988).

Color Tool (Eland and Banner, 1999) Uses markers for child to construct own scale that is used with body outline Children as young as 4 years, provided they know their colors, are not color blind, and are able to construct the scale if in pain

TABLE 2-4 CRIES Neonatal Postoperative Pain Scale (Krechel and Bildner, 1995)

1. Use nonpharmacologic interventions to supplement, not replace, pharmacologic interventions, and use for mild pain and pain that is reasonably well controlled with analgesics.

2. Form a trusting relationship with child and family. Express concern regarding their reports of pain, and intervene appropriately.

3. Use general guidelines to prepare child for procedure.

4. Prepare child before potentially painful procedures, but avoid “planting” the idea of pain. For example, instead of saying, “This is going to (or may) hurt,” say, “Sometimes this feels like pushing, sticking, or pinching, and sometimes it doesn’t bother people. Tell me what it feels like to you.”

5. Use “nonpain” descriptors when possible (e.g., “It feels like heat” rather than “It’s a burning pain”). This allows for variation in sensory perception, avoids suggesting pain, and gives the child control in describing reactions.

6. Avoid evaluative statements or descriptions (e.g., “This is a terrible procedure” or “It really will hurt a lot”).

7. Stay with child during a painful procedure.

8. Allow parents to stay with child if child and parent desire; encourage parent to talk softly to child and to remain near child’s head.

9. Involve parents in learning specific nonpharmacologic strategies and in assisting child with their use.

10. Educate child about the pain, especially when explanation may lessen anxiety (e.g., that pain may occur after surgery and does not indicate something is wrong); reassure the child that he or she is not responsible for the pain.

11. For long-term pain control, give child a doll, which represents “the patient,” and allow child to do everything to the doll that is done to the child; pain control can be emphasized through the doll by stating, “Dolly feels better after the medicine.”

12. Teach procedures to child and family for later use.

Specific Strategies

1. Distraction

a. Involve parent and child in identifying strong distracters.

b. Involve child in play; use radio, tape recorder, CD player, or computer game; have child sing or use rhythmic breathing.

c. Have child take a deep breath and blow it out until told to stop.

d. Have child blow bubbles to “blow the hurt away.”

e. Have child concentrate on yelling or saying “ouch,” with instructions to “yell as loud or soft as you feel it hurt; that way I know what’s happening.”

f. Have child look through kaleidoscope (type with glitter suspended in fluid-filled tube) and encourage him or her to concentrate by asking, “Do you see the different designs?”

g. Use humor, such as watching cartoons, telling jokes or funny stories, or acting silly with child.

h. Have child read, play games, or visit with friends.

2. Relaxation

a. With an infant or young child:

1. Hold in a comfortable, well-supported position, such as vertically against the chest and shoulder.

2. Rock in a wide, rhythmic arc in a rocking chair or sway back and forth, rather than bouncing child.

b. With a slightly older child:

1. Ask child to take a deep breath and “go limp as a rag doll” while exhaling slowly; then ask child to yawn (demonstrate if needed).

2. Help child assume a comfortable position (e.g., pillow under neck and knees).

3. Begin progressive relaxation: starting with the toes, systematically instruct child to let each body part “go limp” or “feel heavy”; if child has difficulty relaxing, instruct child to tense or tighten each body part and then relax it.

4. Allow child to keep eyes open, since children may respond better if eyes are open rather than closed during relaxation.

3. Guided Imagery

a. Have child identify a highly pleasurable real or imaginary experience.

b. Have child describe details of the event, including as many senses as possible (e.g., “feel the cool breezes,” “see the beautiful colors,” “hear the pleasant music”).

c. Have child write down or tape-record script.

d. Encourage child to concentrate only on the pleasurable event during the painful time; enhance the image by recalling specific details through reading the script or playing the tape.

e. Combine with relaxation and rhythmic breathing.

4. Positive Self-Talk

a. Teach child positive statements to say when in pain (e.g., “I will be feeling better soon,” “When I go home, I will feel better, and we will eat ice cream”).

5. Thought Stopping

a. Identify positive facts about the painful event (e.g., “It does not last long”).

b. Identify reassuring information (e.g., “If I think about something else, it does not hurt as much”).

c. Condense positive and reassuring facts into a set of brief statements, and have child memorize them (e.g., “Short procedure, good veins, little hurt, nice nurse, go home”).

d. Have child repeat the memorized statements whenever thinking about or experiencing the painful event.

6. Behavioral Contracting

a. Informal—May be used with children as young as four or five years of age:

1. Use stars, tokens, or cartoon character stickers as rewards.

2. Give a child who is uncooperative or procrastinating during a procedure a limited time (measured by a visible timer) to complete the procedure.

3. Proceed as needed if child is unable to comply.

4. Reinforce cooperation with a reward if the procedure is accomplished within specified time.

b. Formal—Use written contract, which includes:

1. Realistic (seems possible) goal or desired behavior

2. Measurable behavior (e.g., agrees not to hit anyone during procedures)

3. Contract written, dated, and signed by all persons involved in any of the agreements

4. Identified rewards or consequences that are reinforcing

5. Goals that can be evaluated

6. Commitment and compromise requirements for both parties (e.g., while timer is used, nurse will not nag or prod child to complete procedure)

ROUTES AND METHODS OF ANALGESIC DRUG ADMINISTRATION

Oral

1. Oral route preferred because of convenience, cost, and relatively steady blood levels

2. Higher dosages of oral form of opioids required for equivalent parenteral analgesia

3. Peak drug effect occurs after 1 to 2 hours for most analgesics

4. Delay in onset a disadvantage when rapid control of severe pain or of fluctuating pain is desired

Sublingual, Buccal, or Transmucosal

1. Tablet or liquid placed between cheek and gum (buccal) or under tongue (sublingual)

2. Highly desirable because more rapid onset than oral route

3. Produces less first-pass effect through liver than oral route, which normally reduces analgesia from oral opioids (unless sublingual or buccal form is swallowed, which occurs often in children)

4. Few drugs commercially available in this form

5. Many drugs can be compounded into sublingual troche or lozenge.

a. Actiq—Oral transmucosal fentanyl citrate in hard confection base on a plastic holder; indicated only for management of breakthrough cancer pain in patients with malignancies who are already receiving and are tolerant to opioid therapy, but can be used for preoperative or preprocedural sedation and analgesia

Intravenous (IV) (Bolus)

1. Preferred for rapid control of severe pain

2. Provides most rapid onset of effect, usually in about 5 minutes

3. Advantage for acute pain, procedural pain, and breakthrough pain

4. Needs to be repeated hourly for continuous pain control

5. Drugs with short half-life (morphine, fentanyl, hydromorphone) preferable to avoid toxic accumulation of drug

IV (Continuous)

1. Preferred over bolus and intramuscular injection for maintaining control of pain

2. Provides steady blood levels

3. Easy to titrate dosage

Subcutaneous (SC) (Continuous)

1. Used when oral and IV routes not available

2. Provides equivalent blood levels to continuous IV infusion

Patient-Controlled Analgesia (PCA)

1. Generally refers to self-administration of drugs, regardless of route

2. Typically uses programmable infusion pump (IV, epidural, SC) that permits self-administration of boluses of medication at preset dose and time interval (lockout interval is time between doses)

3. PCA bolus administration often combined with initial bolus and continuous (basal or background) infusion of opioid

4. Optimum lockout interval not known but must be at least as long as time needed for onset of drug

5. Should effectively control pain during movement or procedures

6. Longer lockout provides larger dose.

Nurse-Activated Analgesia

1. Child’s primary nurse designated as primary pain manager and is only person who presses PCA button during that nurse’s shift

2. Guidelines for selecting primary pain manager for family-controlled analgesia also applicable to nurse-activated analgesia

3. May be used in addition to a basal rate to treat breakthrough pain with bolus doses; patients assessed every 30 minutes for the need for a bolus dose

4. May be used without a basal rate as a means of maintaining analgesia with around-the-clock bolus doses

Intramuscular

NOTE: Not recommended for pediatric pain control; not current standard of care

1. Painful administration (hated by children)

2. Some drugs can cause tissue and nerve damage.

3. Wide fluctuation in absorption of drug from muscle

4. Faster absorption from deltoid than from gluteal sites

5. Shorter duration and more expensive than oral drugs

6. Time consuming for staff, and unnecessary delay for child

Intranasal

1. Available commercially as butorphanol (Stadol NS); approved for those older than 18 years of age

2. Should not be used in patient receiving morphine-like drugs because butorphanol is partial antagonist that will reduce analgesia and may cause withdrawal

Intradermal

1. Used primarily for skin anesthesia (e.g., before lumbar puncture, bone marrow aspiration, arterial puncture, skin biopsy)

2. Local anesthetics (e.g., lidocaine) cause stinging, burning sensation.

3. Duration of stinging dependent on type of “caine” used

4. To avoid stinging sensation associated with lidocaine:

a. Buffer the solution by adding 1 part sodium bicarbonate (1 mEq/ml) to 9 to 10 parts 1% or 2% lidocaine with or without epinephrine.

Topical or Transdermal

1. EMLA (eutectic mixture of local anesthetics [lidocaine and prilocaine]) cream and anesthetic disk or LMX4 (4% lidocaine cream)

a. Eliminates or reduces pain from most procedures involving skin puncture

b. Must be placed on intact skin over puncture site and covered by occlusive dressing or applied as anesthetic disc for 1 hour or more before procedure

2. LAT (lidocaine-adrenaline-tetracaine) or tetracainephenylephrine (tetraphen)

a. Provides skin anesthesia about 15 minutes after application on nonintact skin

b. Gel (preferable) or liquid placed on wounds for suturing

c. Adrenaline not for use on end arterioles (fingers, toes, tip of nose, penis, earlobes) because of vasoconstriction

3. Numby Stuff

a. Uses iontophoresis to transport lidocaine 2% and epinephrine 1:100,000 (Iontocaine) into the skin

b. Current delivered by small battery-powered device that has an electrode with Iontocaine and a ground electrode

c. Produces local dermal anesthesia in about 10 minutes to a depth of approximately 10 mm at maximum setting

d. May be frightening to young children when they see the device and feel the current

e. Child should be observed during iontophoresis, and all metal, such as jewelry, should be removed from application site to prevent burns.

4. Transdermal fentanyl (Duragesic)

a. Available as patch for continuous pain control

b. Safety and efficacy not established in children younger than 12 years of age

c. Not appropriate for initial relief of acute pain because of long interval to peak effect (12 to 24 hours); for rapid onset of pain relief, give an immediate-release opioid

d. Orders for “rescue doses” of an immediate-release opioid recommended for breakthrough pain, a flare of severe pain that breaks through the medication being administered at regular intervals for persistent pain

e. Has duration of up to 72 hours for prolonged pain relief

f. If respiratory depression occurs, possible need for several doses of naloxone

5. Vapocoolant

a. Use of prescription spray coolant, such as Fluori-Methane or ethyl chloride (Pain-Ease); applied to the skin for 10 to 15 seconds immediately before the needle puncture; anesthesia lasts about 15 seconds

b. Cold disliked by some children; may be less uncomfortable to spray coolant on a cotton ball and then apply this to the skin

c. Application of ice to the skin for 30 seconds found to be ineffective

Rectal

1. Alternative to oral or parenteral routes

2. Variable absorption rate

3. Generally disliked by children

4. Many drugs able to be compounded into rectal suppositories *

Regional Nerve Block

1. Use of long-acting local anesthetic (bupivacaine or ropivacaine) injected into nerves to block pain at site

2. Provides prolonged analgesia postoperatively, such as after inguinal herniorrhaphy

3. May be used to provide local anesthesia for surgery, such as dorsal penile nerve block for circumcision or for reduction of fractures

Inhalation

1. Use of anesthetics, such as nitrous oxide, to produce partial or complete analgesia for painful procedures

2. Side effects (e.g., headache) possible from occupational exposure to high levels of nitrous oxide

Epidural or Intrathecal

1. Involves catheter placed into epidural, caudal, or intrathecal space for continuous infusion or single or intermittent administration of opioid with or without a long-acting local anesthetic (e.g., bupivacaine, ropivacaine)

2. Analgesia primarily from drug’s direct effect on opioid receptors in spinal cord

3. Respiratory depression rare but may have slow and delayed onset; can be prevented by checking level of sedation and respiratory rate and depth hourly for initial 24 hours and decreasing dose when excessive sedation is detected

4. Nausea, itching, and urinary retention are common doserelated side effects from the epidural opioid.

5. Mild hypotension, urinary retention, and temporary motor or sensory deficits are common unwanted effects of epidural local anesthetic.

6. Catheter for urinary retention inserted during surgery to decrease trauma to child; if inserted when child is awake, anesthetize urethra with lidocaine.

Data primarily from American Pain Society: Principles of analgesic use in the treatment of acute pain and chronic cancer pain, ed 4, Skokie, Ill, 1999, The Society; and McCaffery M, Pasero C: Pain: a clinical manual, ed 2, St Louis, 1999, Mosby.

SIDE EFFECTS OF OPIOIDS

Signs of Tolerance

1. Decreasing pain relief

2. Decreasing duration of pain relief

Signs of Withdrawal Syndrome in Patients with Physical Dependence

TABLE 2-5 Nonsteroidal Antiinflammatory Drugs (NSAIDs) Approved for Children ^*

DRUG	DOSAGE	COMMENTS
Acetaminophen (Tylenol)	10-15 mg/kg/dose every 4-6 hours, not to exceed 5 doses in 24 hours or 75 mg/kg/day, orally	Available in numerous preparations Nonprescription Higher dosage range may provide increased analgesia

Choline magnesium trisalicylate (Trilisate)

Children <37 kg (81.5 lb): 50 mg/kg/day divided into 2 doses

Children >37 kg (81.5 lb): 2250 mg/day divided into 2 doses

Available in suspension, 500 mg/5 ml Prescription Ibuprofent (Children’s Motrin, Children’s Advil) Children <6 months: 5-10 mg/kg/dose every 6-8 hours, not to exceed 40 mg/kg/day

Available in numerous preparations

Available in suspension, 100 mg/5 ml, and drops, Nonprescription 100 mg/2.5 ml

Naproxen (Naprosyn) Children >2 years: 10 mg/kg/day divided into 2 doses

Available in suspension, 125 mg/5 ml, and several different dosages for tablets

Prescription

Tolmetin (Tolectin) Children >2 yr: 20 g/kg/day divided into 3-4 doses Available in 200-mg, 400-mg, and 600-mg tablets Prescription

NOTE: Newer formulations of NSAIDs selectively inhibit one of the enzymes of cyclooxygenase (COX-2, which is responsible for pain transmission) but do not inhibit the other (COX-1). Inhibition of COX-1 decreases prostaglandin production, which is necessary for normal organ function. For example, prostaglandins help maintain gastric mucosal blood flow and barrier protection, regulate blood flow to the liver and kidneys, and facilitate platelet aggregation and clot formation. Theoretically, the COX-2 NSAIDs provide similar analgesic and antiinflammatory benefits with fewer gastric and platelet side effects than the nonselective agents. COX-2 NSAIDs are approved for use in patients older than 18 years of age.

^* All NSAIDs in this table (except acetaminophen) have significant antiinflammatory, antipyretic, and analgesic actions. Acetaminophen has a weak antiinflammatory action, and its classification as an NSAID is controversial. Patients respond differently to various NSAIDs; therefore changing from one drug to another may be necessary for maximum benefit.
Acetylsalicylic acid (aspirin) is also an NSAID but is not recommended for children because of its possible association with Reye’s syndrome. The NSAIDs in this table have no known association with Reye’s syndrome. However, caution should be exercised in prescribing any salicylate-containing drug (e.g., Trilisate) for children with known or suspected viral infection.
Side effects of ibuprofen, naproxen, and tolmetin include nausea, vomiting, diarrhea, constipation, gastric ulceration, bleeding nephritis, and fluid retention. Acetaminophen and choline magnesium trisalicylate are well tolerated in the gastrointestinal tract and do not interfere with platelet function. NSAIDs (except acetaminophen) should not be given to patients with allergic reactions to salicylates. All NSAIDs should be used cautiously in patients with renal impairment.

Data from Olin BR and others: Drug facts and comparisons, St Louis, 2002, Facts and Comparisons.

TABLE 2-6 Dosage of Selected Opioids for Children

TABLE 2-7 Management of Opioid Side Effects

SIDE EFFECT	ADJUVANT DRUGS	NONPHARMACOLOGIC TECHNIQUES
Constipation	Senna and docusate sodium Tablet: 2 to 6 years: Start with ½ tablet once a day; maximum: 1 tablet twice a day 6 to 12 years: Start with 1 tablet once a day; maximum: 2 tablets twice a day >12 yr: Start with 2 tablets once a day; maximum: 4 tablets twice a day Liquid: 1 month to 1 year: 1.25-5 ml q hs 1 to 5 years: 2.5-5 ml q hs 5 to 15 years: 5-10 ml q hs >15 years: 10-25 ml q hs Casanthranol and docusate sodium Liquid: 5-15 ml q hs Capsules: 1 cap PO q hs Bisacodyl: PO or PR 3 to 12 years: 5 mg/dose/day >12 years: 10-15 mg/dose/day Lactulose 7.5 ml/day after breakfast Adult: 15-30 ml/day PO Mineral oil: 1-2 tsp/dayPO Magnesium citrate <6 years: 2-4 ml/kg PO once 6 to 12 years: 100-150 ml PO once >12 years: 150-300 ml PO once Milk of Magnesia <2 years: 0.5 ml/kg/dose PO once 2 to 5 years: 5-15 ml/day PO 6 to 12 years: 15-30 ml PO once >12 years: 30-60 ml PO once	Increase water intake Prune juice, bran cereal, vegetables
Sedation	Caffeine: single dose of 1-1.5 mg PO Dextroamphetamine: 2.5-5 mg PO in AM and early afternoon Methylphenidate: 2.5-5 mg PO in AM and early afternoon Consider opioid switch if sedation is persistent	Caffeinated drinks (e.g., Mountain Dew, cola drinks)
Nausea, vomiting	Promethazine: 0.5 mg/kg q 4-6 hr; maximum: 25 mg/dose Ondansetron: 0.1-0.15 mg/kg IV or PO q 4 hr; maximum: 8 mg/dose Granisetron: 10-40 mcg/kg q 2-4 hr; maximum: 1 mg/dose Droperidol: 0.05-0.06 mg/kg IV q 4-6 hr; can be very sedating	Imagery, relaxation Deep, slow breathing
Pruritus	Diphenhydramine: 1 mg/kg IV or PO q 4-6 hr prn; max: 25 mg/dose Hydroxyzine: 0.6 mg/kg/dose PO q 6 hr; maximum: 50 mg/dose Naloxone: 0.5 mcg/kg q 2 min until pruritus improves (diluted in solution of 0.1 mg of naloxone per 10 ml of saline) Butorphanol: 0.3-0.5 mg/kg IV (use cautiously in opioid-tolerant children; may cause withdrawal symptoms); maximum: 2 mg/dose because mixed agonist-antagonist	Oatmeal baths, good hygiene Exclude other causes of itching Change opioids
Respiratoy depression: mild to moderate	Hold dose of opioid Reduce subsequent doses by 25%	Arouse gently, give oxygen, encourage to deep breathe
Respirator depression: severe	Naloxone During disease pain management: 0.5 mcg/kg in 2-min increments until breathing improves (American Pain Society, 1999; McCaffery and Pasero, 1999) Reduce opioid dose if possible Consider opioid switch During sedation for procedures: 5-10 mcg/kg until breathing improves (Yaster, 1997) Reduce opioid dose if possible Consider opioid switch	Oxygen, bag and mask if indicated
Dysphoria, confusion, hallucinations	Evaluate medications, eliminate adjuvant medications with central nervous system effects as symptoms allow Consider opioid switch if possible Haloperidol (Haldol): 0.05-0.15 mg/kg/day divided in 2-3 doses; maximum: 2-4 mg/day	Rule out other physiologic causes
Urinary retention	Evaluate medications, eliminate adjuvant medications with anticholinergic effects (e.g., antihistamines, tricyclic antidepressants) Occurs with spinal analgesia more frequently than with systemic opioid use Oxybutynin 1 year: 1 mg tid 1 to 2 years: 2 mg tid 1 to 3 years: 3 mg tid 1 to 5 years: 4 mg tid >5 years: 5 mg tid	Rule out other physiologic causes In/out or indwelling urinary catheter

hs. At bedtime; IV, intravenous; PO, by mouth; PR, by rectum; prn, as needed; q, every; tid, three times a day

^* For further information about compounding drugs in troche or suppository form, contact Professional Compounding Centers of America (PCCA), 9901 S. Wilcrest Drive, Houston, TX 77009; (800) 331-2498; www.pccarx.com.

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DEVELOPMENTAL CHARACTERISTICS OF CHILDREN’S RESPONSES TO PAIN

Preterm Infant

Young Infant

Older Infant

Young Child

School-Age Child

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NONPHARMACOLOGIC STRATEGIES FOR PAIN MANAGEMENT

General Strategies