NLE Paediatric Nursing — Paediatric Assessment, Hospitalization & PainStudy Notes

Paediatric physical assessment follows a fundamental developmental principle: perform the least distressing parts first and the most distressing parts last, and build trust before touching. This approach minimises psychological trauma and improves cooperation, aligning with atraumatic care principles central to modern Philippine paediatric nursing practice. **Least-to-Most Invasive Sequencing** The paediatric exam sequence differs from adult assessment. Begin with observation and auscultation (listening to heart, lungs, and abdomen) BEFORE palpation (feeling) and percussion (tapping). This sequencing is critical because crying in infants and young children elevates heart rate and respiratory rate, distorts breath sounds, and makes an accurate assessment impossible. The child's emotional state directly affects vital signs and physical findings, so keep the child calm during early assessment phases. Perform the most distressing parts—ears, mouth, and throat examination—LAST, as these trigger fear and resistance in young children, particularly toddlers and preschoolers. **Position of Comfort and Parental Presence** Examine infants and toddlers on the parent's lap whenever possible; keeping the parent in view provides security and comfort. The caregiver's presence reduces separation anxiety (a major stressor in hospitalised toddlers) and improves the child's cooperation. For toddlers and preschoolers, allow the child to handle assessment equipment (stethoscope, penlight, tongue depressor) before use. This familiarisation reduces fear, allows the child a sense of control, and makes the actual examination less threatening. Keep the child clothed until the specific area needs examination; expose only the body region being assessed to maintain privacy and warmth. **Newborn Assessment Specifics** Newborn assessment requires special attention to vital-sign measurement accuracy. Count the apical heart rate (listening at the apex of the heart with a stethoscope) for a full minute, not just 15 seconds and multiplying—newborn rhythms are irregular, and a short count is inaccurate. Similarly, count respirations for a full minute by observing abdominal movement (newborns are abdominal/diaphragmatic breathers, not chest breathers like adults). Assess primitive reflexes (Moro, rooting, sucking, grasping, stepping, Babinski) according to standard timing. A newborn assessment also includes head-to-toe inspection for birth injuries, skin condition, eye prophylaxis verification, and feeding readiness.

Obtaining accurate vital signs is essential in paediatric nursing. Measurement technique and interpretation vary significantly by age because of developmental and anatomical differences. **Apical Pulse Assessment** The apical pulse (listening directly at the heart's apex with a stethoscope) is the standard method for children under approximately 2 years of age. The radial pulse—reliable in older children and adults—is difficult to palpate accurately in infants because their radial artery is small and mobile, and their irregular cardiac rhythms make a brief count misleading. The apical pulse location changes with growth: in newborns and young infants, the apex is at the 4th intercostal space at the midclavicular line; as the child grows, the apex moves down and medially. Always count the full apical pulse for a complete minute, never for 15 seconds and multiply; newborn rhythms are naturally irregular (called sinus arrhythmia), and a short count will be inaccurate. **Respiration Counting** Infants and young toddlers are obligate abdominal (diaphragmatic) breathers—they breathe using their diaphragm and abdominal muscles, not their chest. Count respirations by observing abdominal rise and fall, not chest movement. Because infants have irregular breathing patterns (periodic breathing with short pauses), always count for a full minute. Counting for only 10 or 15 seconds can miss significant variations. Watch for retractions (inward drawing of skin around ribs, sternum, or clavicle), which indicate respiratory distress, and note the rhythm and depth. A fussy or crying infant will have an elevated respiratory rate, so count when the child is calm if possible. **Blood Pressure Measurement** Blood pressure is routinely measured from approximately 3 years of age onward in Philippine paediatric practice. The key to accurate BP measurement is using a cuff whose bladder (the inflatable part inside the cuff) covers approximately 2/3 of the upper arm circumference from shoulder to elbow. A cuff that is too small falsely elevates the reading (sometimes by 10–20 mmHg); a cuff that is too large falsely lowers it. Many paediatric departments have small, regular, and large cuffs available. With toddlers and young children, obtain BP in a calm, non-threatening manner—let them see and touch the cuff, explain what will happen, and apply the cuff to the arm (not leg, which can be frightening). In some cases, obtaining BP in both arms and legs is necessary (e.g., suspected aortic coarctation, where leg BP is lower than arm BP). If the child is frightened or uncooperative, defer and return; an inaccurate reading is less useful than reassessment after the child settles. **Temperature Measurement** Avoid rectal temperature measurement in young children when possible, despite its historical use. The rectal route carries risks of perforation in infants, is invasive and frightening, and violates dignity. **Axillary (armpit) and tympanic (ear) temperature measurement are preferred** for routine use in paediatric populations. Axillary is considered the safest; hold the thermometer in the axilla for the time recommended by the device (typically 3 minutes for mercury/glass, less for digital). Tympanic thermometry is quick and less invasive but requires proper technique (pulling the pinna up and back in children >3 years, down and back in younger children) and can be unreliable if cerumen impaction is present. Oral temperature is suitable for children who can cooperate (~5 years and older).

Vital signs change significantly with age as the child's cardiovascular, respiratory, and thermoregulatory systems mature. **Heart rate and respiratory rate DECREASE, and blood pressure INCREASES, as the child grows.** This developmental trend is essential to remember: a newborn's normal heart rate of 110–160 bpm would indicate serious tachycardia in an adolescent (whose normal is 60–100 bpm). Conversely, an adolescent's normal HR of 70 bpm might indicate bradycardia in a newborn. **Memorise Approximate Ranges** (awake, resting state): **Newborn (0–1 month):** HR 110–160 bpm (up to ~180 when crying); RR 30–60 breaths/min; Systolic BP approximately 60–90 mmHg. Newborns can have significant heart rate variation with state (sleeping, feeding, crying); this is normal. Respirations are irregular due to periodic breathing (short periods of apnoea followed by rapid breathing) — this is not pathological if the newborn is well. **Infant (1–12 months):** HR 90–160 bpm; RR 30–53 breaths/min; Systolic BP approximately 70–100 mmHg. Heart rate remains elevated but begins to slow. Respirations remain rapid and may still show irregular patterns. **Toddler (1–3 years):** HR 80–140 bpm; RR 22–37 breaths/min; Systolic BP approximately 80–110 mmHg. Separation anxiety peaks in this group; vital signs may be elevated due to distress. **Preschool (3–5 years):** HR 80–120 bpm; RR 20–28 breaths/min; Systolic BP approximately 80–110 mmHg. Further slowing of HR and RR; child is more cooperative with assessment. **School-age (6–12 years):** HR 70–120 bpm; RR 18–25 breaths/min; Systolic BP approximately 85–120 mmHg. Continued approach toward adult ranges; vital signs more stable with emotion. **Adolescent (13–18 years):** HR 60–100 bpm; RR 12–20 breaths/min; Systolic BP approximately 95–120 mmHg. Vital signs approach adult ranges; assessment technique and communication similar to adult. **Important Clinical Principles:** **Fever and Vital Signs:** Fever raises both heart rate and respiratory rate (approximately 10 bpm increase per 1°C elevation). Always consider this when interpreting tachycardia or tachypnoea in a febrile child. **Shock and Vital Signs in Children:** Children compensate remarkably well for shock through tachycardia—the body increases heart rate to maintain cardiac output (CO = Heart Rate × Stroke Volume). **Tachycardia is the earliest sign of shock in children.** Hypotension is a LATE and ominous sign, appearing only after the child has decompensated significantly. An infant or child with low blood pressure and tachycardia is in decompensated shock and requires immediate intervention. Never reassure a parent that "the blood pressure is only slightly low" in a tachycardic child—this is a danger sign. **Breath-Holding Spells:** Toddlers may hold their breath during crying or frustration, leading to cyanosis and brief syncope. This is self-limited and not life-threatening, though frightening to witnesses. Reassure parents; the child will resume breathing reflexively.

Effective communication and age-appropriate preparation significantly reduce fear, improve cooperation, and support the child's emotional wellbeing during hospitalisation and procedures. Every stage of childhood has distinct cognitive abilities, fears, and communication needs. Philippine paediatric nurses must tailor their approach to match each developmental level, using language and strategies that the child can understand and that address their specific concerns. **Infant (0–12 months)** Infants communicate through crying and body movements—they have no understanding of language beyond tone and rhythm. Infants respond to a **soft voice, holding, rocking, and consistent touch.** The **primary caregiver's presence is essential**; infants develop attachment to their caregivers and separation from them causes distress. *Nursing strategies:* Keep the primary caregiver present and visible whenever possible. Use consistent caregivers (assign the same nurse when feasible) to build familiarity. Speak softly and calmly; your tone conveys safety or anxiety. Hold the infant securely; this communicates comfort and safety. Allow non-nutritive sucking (a pacifier or clean finger) and offer oral sucrose solution for procedural pain in very young infants (0–6 months). Do not separate the infant from the caregiver for procedures unless absolutely necessary; whenever possible, the parent can be present. **Toddler (1–3 years)** Toddlers have limited language and think concretely—they do not yet understand cause and effect, time, or abstract concepts. They live in the present moment and have no sense of future ("tomorrow" or "next week" has no meaning). Toddlers fear separation from their primary caregiver (the major stressor of hospitalisation), fear loss of control, and experience regression when stressed. *Nursing strategies:* **Prepare the toddler just before a procedure**, not hours ahead (their sense of time is too short; early preparation only prolongs anxiety). Use **simple, concrete words** that relate to their senses: instead of "We'll take a blood test," say "A nurse will poke your finger and a tiny drop of blood will come out." Use concrete, sensory language: "You will feel a small pinch," not "It will hurt a little." Allow the toddler **choices that actually exist**: "Do you want the medicine in the cup or the spoon?" is a real choice. Do NOT offer "Do you want your medicine?" when it is not optional. Toddlers need some sense of control; offering genuine, limited choices gives them this. **Tolerate and support rituals and comfort objects**—a special blanket, stuffed animal, or favourite toy provides enormous comfort. Expect **regression** (bed-wetting, thumb-sucking, wanting a bottle, baby talk) and **negativism** (saying "no" to everything). These are normal responses to stress; reassure parents that regression is temporary and will resolve when the child is discharged. Do not shame or punish regressive behaviour. Allow the toddler to handle equipment, express feelings (including anger and fear), and participate in self-care as able (e.g., holding the bandage, pressing the IV dressing). **Preschooler (3–5 years)** Preschoolers engage in **magical thinking** — they believe in magic, that thoughts can cause events, and that illness or hospitalisation is a punishment for being "bad." They **fear bodily harm and mutilation** (fear that if the skin is broken, their "insides will leak out"). They interpret procedures and illness in concrete, literal terms and can be easily frightened by adult language. *Nursing strategies:* Use **simple, concrete, non-threatening words**. Avoid words like "shot" (sounds violent), "cut," "take," or "die." Instead: "The needle will help the medicine go in," "We will gently open your throat to look inside," "We will take your temperature to find out how warm you are." **Reassure that the illness or procedure is NOT a punishment**—explicitly tell the child "You didn't do anything wrong; this isn't your fault; being sick is not because you were bad." Preschoolers interpret magical thinking literally; they may believe the hospitalisation happened because they had a bad thought or said something mean. **Use bandages generously**—applying a bandage after a procedure reassures the preschooler that nothing is "leaking out." Allow **medical play** with dolls, toy stethoscopes, and syringes so the child can act out procedures, process fears, and feel some control. Praise cooperation afterward: "You were so brave; you held very still." This builds confidence. Be **honest** about whether something will hurt. Preschoolers know the difference between a gentle touch and a painful procedure. Saying "It won't hurt" when they feel pain damages trust. Instead, say "This will be uncomfortable/sting for a moment, but I will be right here with you." **School-age Child (6–12 years)** School-age children want **explanations and reasons**. They are developing logical thinking and want to understand how things work. They respect authority and honesty, value privacy and modesty, and are beginning to separate their identity from their family. *Nursing strategies:* Give **honest, factual information**. Explain not just what you will do, but WHY—"We need to listen to your heart and lungs to make sure they are healthy." School-age children ask many questions; encourage questions and answer them honestly and thoroughly. **Respect privacy and modesty**—knock before entering, close the curtain, and cover the body appropriately. Allow the child to wear underwear and expose only the body part being examined. This becomes increasingly important as they approach adolescence. **Involve the child in care decisions** when possible: "After we get you dressed, do you want to walk to the clinic or use the wheelchair?" School-age children enjoy understanding procedures and may want to see equipment, ask how it works, and participate in simple self-care tasks. **Minimise separations** from parents; allow parental presence during procedures and hospitalisation (rooming-in). However, school-age children often welcome some independence—time alone with peers, engaging activities, and involvement in their own care. **Adolescent (13–18 years)** Adolescents are developing identity, independence, and abstract thinking. They are deeply concerned with peer acceptance and privacy. They question authority, want respect, and can think about hypothetical situations and consequences. *Nursing strategies:* **Treat with respect and honesty**. Adolescents quickly detect condescension; speak to them as you would to a young adult, not a child. Provide **privacy and confidentiality**—interview the adolescent **separately from parents** when discussing sensitive topics (sexual health, substance use, mental health, abuse). Build trust by demonstrating confidentiality; tell the adolescent what information you must share with parents (safety concerns, abuse) and what information you can keep private. **Allow control and participation in decisions** about their care: "What time would you prefer to do the dressing change?" "Are you comfortable with your parents present during this discussion?" Adolescents need to feel they have a say in what happens to their body. **Ensure privacy**—provide a screen during examination, allow the adolescent to keep underwear on during procedures, and avoid unnecessary exposure. **Peers are very important**; hospitalisation often means separation from friends, which is a significant stressor. Allow visits from peers, phone/internet contact with friends, and engagement in age-appropriate activities. Be aware that adolescents may not disclose health concerns (e.g., substance use, depression, sexual activity) to parents; create a safe environment for honest discussion and connect them with confidential resources. **General Communication Principles Across All Ages** **Never lie.** If a procedure will hurt, say so. "It will sting for a moment" is honest; "It won't hurt at all" is a lie that damages trust. If the child doesn't trust you, cooperation becomes impossible. **Be at eye level.** Kneel or sit so you are at the child's height, not towering over them. This is less threatening and shows respect. **Use the child's name.** Personalised communication is warm and respectful. **Prepare according to age.** The younger the child, the closer to the event you prepare them. An infant needs no advance preparation; a toddler needs preparation 5–10 minutes before; a preschooler can handle preparation 30 minutes before; a school-age child or adolescent can prepare hours or even a day before.

Hospitalisation is a stressful experience for children and families. The greatest stressors vary by developmental stage: **separation from primary caregiver** (major stressor for toddlers), **loss of control** (affects all ages, especially toddlers and adolescents), and **fear of bodily injury and pain** (preschoolers). Understanding the child's likely response enables nurses to provide targeted, developmentally appropriate support aligned with atraumatic care principles. **Separation Anxiety in Toddlers — A Classic NLE Theme** Separation anxiety is the **major stressor for toddlers (ages 1–3 years)** during hospitalisation. Toddlers have formed strong attachment to their primary caregiver and cannot understand why the parent is not present. They lack the cognitive ability to understand that the parent will return; they only know the parent is gone. Separation anxiety progresses through three distinct stages: **Stage 1: Protest (Hours to Days)** The toddler cries loudly, screams, clings to the parent, searches for the parent, resists strangers, and refuses comfort from anyone except the parent. The child may also refuse to eat, play, or cooperate with care. **This is a healthy response**—it shows that the child has formed a secure attachment to the caregiver. Parents should be reassured that this behaviour is normal and indicates good bonding. **Stage 2: Despair (Days to Weeks)** As the toddler realises the parent will not return (in the toddler's understanding), the child withdraws emotionally. The toddler becomes sad, quiet, apathetic, and uninterested in play, food, or interaction. The child may rock back and forth, suck thumb intensely, or engage in self-soothing behaviours. Parents often interpret this as "the child has adjusted," but it is actually a sign of depression and emotional shutdown. The nurse must reassure parents that this is a concerning sign that requires increased attention, not a sign of improvement. **Stage 3: Detachment (Denial) — Most Serious (Weeks)** If separation continues, the toddler may appear to have "adjusted"—the child becomes superficially friendly with staff, smiles, plays, and shows little emotional reaction to the parent's visits. **This appearance of adjustment is deceptive and represents the most serious stage.** The child has given up hope that the parent will return and has emotionally detached as a defence mechanism. This resignation can result in lasting psychological harm and difficulty with bonding even after discharge. Reunion with the parent may be difficult because the child has "protected" themselves by detaching. **Nursing Management of Separation Anxiety** The goal is to prevent progression through these stages and maintain the child-parent bond. Philippine paediatric practice increasingly supports family-centred care principles: **Encourage Rooming-In (Parent Stays Overnight):** This is the most effective prevention of separation anxiety. When the parent stays in the hospital room or on the unit, the toddler does not experience separation. Many Philippine hospitals now provide cots or recliners for parents. Rooming-in allows the parent to participate in care, provide comfort, and maintain the child's routine—all of which reduce stress for both child and parent. **Liberal Parental Visiting and Unrestricted Access:** If rooming-in is not possible, allow parents to visit at any time, without restriction. Some older paediatric practice limited visiting hours; this is no longer recommended and contradicts atraumatic care principles. Parents should be encouraged to visit as often as possible, participate in care (feeding, bathing, play), and be present during procedures when appropriate. **Maintain Transitional Objects and Comfort Items:** Ensure the child's comfort object (blanket, stuffed animal, favourite toy, or family photo) is at the bedside at all times. These objects provide security and a connection to home. If the child becomes upset during procedures, allowing the child to hold the comfort object can significantly reduce distress. **Maintain Home Routines and Rituals:** Hospitalised children benefit enormously from maintaining familiar routines. Ask the parents about the child's normal bedtime routine, favourite foods, nap schedule, and daily rituals. Replicate these in the hospital as much as possible. If the child normally has a bath and bedtime story at home, try to provide this in the hospital. Familiar routines reduce anxiety and help the child feel less disoriented in an unfamiliar environment. **Assign Consistent Caregivers:** When possible, assign the same nurse to care for the child over multiple shifts or days. Consistency reduces the need for the child to adapt to multiple strangers and builds a therapeutic relationship. The child learns to trust this caregiver, which partially compensates for the parent's absence. **Encourage Parental Participation in Care:** Invite parents to participate in feeding, bathing, dressing, and play activities. This maintains the parent-child relationship, gives parents a sense of control and purpose, and allows the child to remain with the parent. During procedures, the parent can be a comforter (not the restrainer); the nurse performs the procedure while the parent holds and soothes the child. This preserves the parent as a source of comfort, not authority or pain. **Communication with Parents:** Explain to parents that toddler responses to hospitalisation are age-appropriate and predictable. Reassure them that separation anxiety, regression, and even anger or rejection after the parent's visit are normal and do not indicate poor parenting. Many parents feel guilty; reassurance and education reduce this guilt and help parents understand their role in supporting their child. **Loss of Control and Regression** Beyond separation, hospitalised children experience **loss of control**—their environment is unfamiliar, routines are disrupted, strangers perform intimate procedures, and the child has little say in what happens. This loss of control is a significant stressor for all ages, particularly toddlers and adolescents. **Regression** — reversion to earlier developmental behaviours — is a normal response to stress in hospitalised children. A toilet-trained toddler may wet or soil; a child who has outgrown the bottle may want it again; a child who stopped thumb-sucking may resume it; older children may use baby talk or want to be held like an infant. **Reassure parents that regression is temporary and will resolve**; do not shame or punish the child for regressive behaviour. Instead, meet the child's emotional needs for comfort and security; once the child feels safe again, development will resume. **Preserve Control** through genuine choices, involvement in care decisions, and predictability. Allow the child to choose which arm for the blood pressure cuff, when to take medication (morning or afternoon), what to wear from options available, and whether to walk or use a wheelchair. Maintain routines; tell the child truthfully what will happen and when. Small sense of control can dramatically reduce anxiety.

Pain is recognised as the **fifth vital sign** in paediatric nursing. However, children — especially the very young — often **cannot verbalise pain**, so the nurse must choose an **age-appropriate assessment tool**, observe behaviour, and monitor physiologic indicators. Accurate pain assessment is essential because unmanaged pain has serious physiologic consequences (increased heart rate, blood pressure, and respiratory rate; delayed healing; increased infection risk; psychological trauma). **Principles of Paediatric Pain Assessment** **Infants and young children cannot reliably report pain verbally;** they lack the language skills and the understanding that pain is a separate concept they can describe. A crying infant is not necessarily in pain—the infant may be hungry, tired, uncomfortable, or frightened. Similarly, a child who is quiet may be in significant pain (or in shock). The nurse must use **behavioural observation, physiologic parameters, and context** to assess pain. **Behavioural Cues of Pain in Children:** - Crying (though not all pain causes crying; deep pain may cause silent withdrawal) - Facial grimacing, brow furrowing, lip biting - Body rigidity, muscle tension, guarding of the painful area - Resistance to movement, reluctance to use an extremity (holding an injured arm, not weight-bearing on an injured leg) - Restlessness, agitation, or conversely, stillness and withdrawal - Sleep disturbance, refusal to eat - Regression (baby talk, thumb-sucking, clinginess in an older child) **Physiologic Indicators of Pain:** - Elevated heart rate (tachycardia) - Elevated blood pressure - Elevated respiratory rate - Pale or flushed skin - Sweating - Dilated pupils **Important:** These physiologic signs may diminish over time as the child adapts to chronic pain; absence of elevated vital signs does not mean the child is not in pain. Similarly, a sleeping child may be in pain; assess carefully before and after procedures. **Age-Appropriate Pain Assessment Tools** The choice of tool depends on the child's age, developmental stage, and ability to communicate. **FLACC Scale (Faces, Legs, Activity, Cry, Consolability)** - **Appropriate age:** Infants from approximately 2 months through 7 years (especially useful for non-verbal or developmentally delayed children) - **How it works:** The nurse observes five categories: (1) **Facial expression** (0=relaxed to 2=grimacing), (2) **Leg muscle tone** (0=relaxed to 2=rigid/kicking), (3) **Activity level** (0=normal/lying quiet to 2=thrashing/arching), (4) **Cry** (0=no cry to 2=high-pitched, screaming), (5) **Consolability** (0=calm/content to 2=inconsolable). Each category is scored 0, 1, or 2; total score 0–10. A score of **0 = no pain**; **1–3 = mild pain**; **4–6 = moderate pain**; **7–10 = severe pain**. - **Advantage:** Does not require the child to understand or communicate pain verbally; purely observational. Useful for infants, developmentally delayed children, sedated children, and those with communication barriers. **FACES (Wong-Baker Faces Pain Rating Scale)** - **Appropriate age:** Approximately 3 years and older - **How it works:** Shows the child a series of faces ranging from very happy ("no hurt") to very sad and crying ("worst hurt possible"). The child points to the face that best matches how they feel. Faces are numbered 0–5 or 0–10. - **Advantage:** Requires minimal language; visual and concrete. Many children this age can identify and point to their pain level. Used widely in Philippine paediatric practice. - **Limitation:** Assumes the child can identify with facial expressions and understand the correlation with their own pain. **Numeric Rating Scale (0–10)** - **Appropriate age:** Approximately 7–8 years and older - **How it works:** The child rates pain on a scale of 0 (no pain) to 10 (worst pain possible). The nurse explains: "0 means you have no pain at all, 10 means the worst pain you could imagine, and 5 is medium pain. Where would you say your pain is?" - **Advantage:** Simple, quick, and widely used in older children and adults. Allows precise quantification of pain and tracking of pain changes over time. - **Limitation:** Requires understanding of numbers and abstract scales; not suitable for children who cannot count or understand magnitude. **NIPS and CRIES Scales (Neonatal Intensive Care Pain Assessment Tools)** - **Appropriate age:** Neonates and young infants (0–3 months) - **How they work:** These are behavioural and physiologic scales specifically designed for neonates, who cannot cry loudly or show facial expressions clearly. They assess parameters like facial expression, breathing pattern, arm and leg tone, state of arousal, and physiologic variables (heart rate, oxygen saturation). - **Example:** NIPS assesses facial expression, cry quality, breathing pattern, arm and leg tone, and state of consciousness; total score 0–7. - **Advantage:** Specifically validated for non-verbal neonates; accounts for the neonatal inability to cry strongly or move expressively. **Using Pain Tools Effectively** - **Establish a baseline pain score** when the child is calm and not in acute pain, so you have a reference point. - **Use the same tool consistently** for a given child; this allows you to track pain changes accurately. - **Reassess pain frequently** — after medication administration, after procedures, and at least every few hours. Many Philippine paediatric protocols recommend pain reassessment within 30 minutes of analgesic administration to assess effectiveness. - **Believe the child's pain report.** If a child says they have pain (using words, pointing to a face, or giving a numeric rating), accept it as true and intervene. Do not dismiss pain because "the child doesn't look like they're in pain" — a child who has adapted to chronic pain may show few behavioural signs. - **Document pain scores.** Pain assessment and management should be documented in the child's nursing notes and medical record, just as vital signs are recorded. **Special Consideration: Untreated Pain in Infants** For many decades, it was mistakenly believed that infants did not feel pain or that pain was not as important in infants as in older children. **This is FALSE.** Infants clearly demonstrate pain responses and suffer serious consequences of untreated pain, including physiologic stress, delayed healing, and altered pain responses later in life. Current evidence shows that infants who undergo repeated painful procedures without analgesia may develop altered pain sensitivity and heightened pain responses. All infants deserve pain assessment and management, including analgesia and non-pharmacologic comfort measures.

Effective pain management in children combines **non-pharmacologic measures** (first-line, always used) and **pharmacologic interventions** (medications, chosen based on pain severity and type). The goal is to minimise pain and suffering, support healing, and reduce psychological trauma. Philippine paediatric practice follows the WHO analgesic ladder: non-opioid analgesics for mild pain, opioids for moderate-severe pain, used with adjunctive measures. **Non-Pharmacologic Pain Management — First-Line** Non-pharmacologic measures are always used, even when medication is also given. They carry no medication risks, reinforce the nurse's presence and support, and are often more effective when combined with medication. **Distraction and Environmental Modification** - **Music, singing, stories, or age-appropriate videos** during procedures reduce pain perception by engaging the child's attention elsewhere. Many Philippine paediatric units play soft music during procedures. - **Imagery or guided visualisation** (especially for older children): "Imagine you're at the beach; feel the warm sand..." helps the child mentally "escape" from the procedure. - **Counting games, breathing exercises** ("Blow out the candles" for deep breathing) give the child something to focus on and control. - **Reduce environmental stimuli:** Dim bright lights, lower noise, maintain calm atmosphere. The hospital environment is inherently anxiety-provoking; reducing additional stimuli helps. **Positioning and Comfort Measures** - **Hold and cuddle the child.** Physical comfort from the nurse or parent is powerful analgesia. The child feels secure and less alone. - **Swaddling infants** (wrapping snugly in a blanket) reduces movement, prevents startling, and provides a sense of security. Swaddling + sucking + skin-to-skin contact are effective for procedural pain in newborns. - **Non-nutritive sucking:** A pacifier, clean thumb, or parent's clean finger in the infant's mouth during procedures reduces pain perception and distress. Combined with oral sucrose, this is very effective for newborn pain. - **Avoid restraint.** Use positions of comfort (child upright, held securely by parent or nurse) rather than forced supine or prone restraint, which increases fear and pain perception. If restraint is necessary for safety (e.g., to prevent movement during a critical procedure), use the least restrictive method and release/reposition frequently. **Topical Anaesthesia** - **EMLA cream (eutectic mixture of local anaesthetics: lidocaine 2.5% + prilocaine 2.5%)** applied to skin **60 minutes before** needle sticks (IV insertion, blood draw, vaccination) significantly reduces procedural pain. Apply EMLA under a clear occlusive dressing to a small area; the child will feel numbing. EMLA is contraindicated in infants under 3 months (rare risk of methemoglobinemia with prilocaine) but widely used in older infants and children. - **Numbing sprays** (e.g., ethyl chloride) produce rapid, brief numbing (seconds) and are useful when EMLA application time is not available, though the spray sensation can be startling. - **Topical anaesthetic is standard of care for needle sticks in children** — it is inexpensive, safe, effective, and humane. **Oral Sucrose Solution for Infants** - **Oral sucrose solution (24% concentration, 2 mL per kg body weight, maximum 2–3 mL)** administered 2–5 minutes before a procedure reduces pain responses in neonates and infants up to approximately 6–12 months. The mechanism is not fully understood but may involve endogenous opioid release. - **Sucrose is used for procedural pain only** (brief painful events), not chronic pain. - **Combine sucrose with non-nutritive sucking and gentle handling** for maximum effect. - **Example:** A 3-kg newborn receives 2 mL of 24% sucrose orally (using a syringe or dropper, slowly to prevent aspiration) 3 minutes before a heel-stick; simultaneously, a clean finger or pacifier is offered for sucking, and the infant is held securely. Pain response is notably reduced compared to heel-stick without these measures. **Pharmacologic Pain Management** **Principles of Medication Administration in Children** - **All doses are weight-based** and calculated in mg/kg. The child's most recent weight in **kilograms** (not pounds) is essential. Always double-check weight-based calculations, particularly for high-alert medications (opioids, sedatives). - **Verify the dose before administration.** For safety-critical drugs, two nurses or another qualified practitioner should verify the calculated dose independently. - **Use age-appropriate formulations.** Infants and young children cannot swallow tablets; use liquid formulations, crushed tablets (if appropriate), or age-adjusted dosing. - **Consider hepatic and renal function.** Young infants have immature metabolism; some drugs are metabolised more slowly. Dosing intervals may differ from older children. **Paracetamol (Acetaminophen)** - **Dose:** 10–15 mg/kg/dose orally or rectally every 4–6 hours, **not exceeding approximately 75 mg/kg/day** total and a single-dose adult ceiling of approximately 1,000 mg. - **Route:** Oral (preferred), rectal, or IV (rarely, in hospital settings). - **Onset:** 30–60 minutes orally; 1–2 hours rectally. - **Duration:** 4–6 hours. - **Advantages:** **Safest first-line antipyretic**; **no anti-inflammatory effect** (so it reduces fever and pain, but not inflammation); **no GI bleeding risk**, unlike NSAIDs; **well-tolerated**; available in many formulations (liquid, syrup, suppository, tablet). Suitable for all ages from newborn onward. - **Limitations:** Not anti-inflammatory; slower onset than NSAIDs; less effective for inflammatory pain (e.g., arthritis). - **Special caution:** Avoid in severe hepatic impairment; ensure single doses don't exceed ceiling; educate parents not to exceed maximum daily dose (risk of hepatotoxicity with chronic overdose). **Ibuprofen (NSAIDs)** - **Dose:** 5–10 mg/kg/dose orally every 6–8 hours, **age ≥6 months**. - **Onset:** 30–60 minutes. - **Duration:** 6–8 hours (longer than paracetamol). - **Advantages:** **Anti-inflammatory**, making it superior for inflammatory conditions (otitis media, arthritis, inflammatory bowel disease); **more potent analgesic than paracetamol for inflammatory pain**; longer duration means fewer doses/day. - **Important:** **Always give with food** to reduce gastric irritation. - **Limitations:** **Avoid in dehydration, GI bleeding/ulcer disease, or renal impairment**. Monitor for GI upset, bruising, or prolonged bleeding. Not suitable for NSAIDs-induced asthma exacerbation. - **Precaution:** In Filipino children with viral illness (varicella, influenza), use paracetamol preferentially; NSAIDs carry some theoretical increased risk of severe secondary infection, though this is debated. **Aspirin — CONTRAINDICATED in Viral Illness** - **NEVER give aspirin to a child with a viral illness** (varicella/chickenpox, influenza). Risk of **Reye's syndrome — a rare but life-threatening acute encephalopathy with hepatic dysfunction and cerebral oedema.** Current evidence suggests the risk is small, but avoidance is standard in paediatric practice. - **Aspirin can be used** for certain chronic conditions (e.g., post-Kawasaki disease), but in acute viral illness, use paracetamol or ibuprofen instead. **Opioid Analgesics (for Moderate-Severe Pain)** - **Morphine** is the standard opioid for moderate-severe pain in children. **Dosing is weight-based and titrated to effect.** - **Initial dose (opioid-naive):** approximately 0.05–0.1 mg/kg IV/IM every 2–4 hours; titrate by increasing dose or decreasing interval based on pain response and side effects. - **Oral morphine:** approximately 0.25–0.5 mg/kg every 4 hours. - **IV continuous infusion:** used for severe pain; dosing varies widely based on age and clinical context. - **Other opioids:** Codeine (less commonly used now due to variable metabolism and risk of overdose in ultra-rapid metabolisers), meperidine, hydromorphone, fentanyl (especially for procedural sedation). Each has specific dosing; always reference a paediatric drug guide. - **Monitoring opioid side effects is essential:** - **Respiratory depression:** Monitor respiratory rate and oxygen saturation closely, especially with IV opioids. Have naloxone (opioid antagonist) available. Teach the child/family to report difficulty breathing. - **Sedation:** Expected and often desirable for comfort; however, excessive sedation affecting consciousness requires evaluation. - **Constipation:** A major side effect, especially with chronic opioid use. Administer stool softeners and osmotic laxatives (e.g., polyethylene glycol, lactulose) concurrently. Encourage fluids and activity as tolerated. - **Nausea/vomiting:** May occur; manage with antiemetics (e.g., ondansetron) if needed. - **Pruritus (itching):** Less common but can occur; usually managed with antihistamines or opioid rotation. - **Opioids are appropriate and necessary for moderate-severe pain;** fear of addiction is unfounded in acute pain management. Respiratory depression is managed by appropriate dosing and monitoring. **Combination Approach (Non-Pharmacologic + Pharmacologic)** Best pain management combines strategies: e.g., a child undergoing a procedure receives EMLA 60 minutes before, oral sucrose 2 minutes before, distraction during, pain medication if pain is expected, and parent presence and reassurance throughout. This multimodal approach is more effective than any single intervention. **Pain Reassessment** - **Reassess pain within 30 minutes of administering analgesia** to determine effectiveness. If pain is not adequately controlled, increase the dose (within safe limits) or change the medication. - **Document pain scores before and after intervention**, response to medication, and any side effects. Pain documentation should be as thorough as vital signs documentation. - **For chronic pain or ongoing hospitalisation, establish a pain management plan** with the child, family, and team, including medications, non-pharmacologic measures, and pain goals (e.g., "pain 0–2/10 during procedures, 2–4/10 at rest").

**Atraumatic care** is a foundational concept in paediatric nursing, defined as the provision of care using approaches that minimise physical and psychological distress to children and families. Every procedure, every interaction, every moment of hospitalisation should be guided by the principle of reducing trauma. This aligns with Philippine paediatric nursing standards and the principle of "do no harm" central to RA 9173. **Core Principles of Atraumatic Care** 1. **Prevent/Minimise Separation from Family** - Encourage rooming-in and liberal parental visiting. - Allow parents to participate in care and procedures (as comforters, not restrainers). - Use consistent caregivers to build therapeutic relationships. - Maintain communication with family about routines, concerns, and progress. 2. **Promote a Sense of Control** - Offer genuine choices (not false choices): "Do you want the medicine in the cup or the spoon?" is a choice. "Do you want your medicine?" (when it's mandatory) is not. - Involve the child in care planning and decision-making at their developmental level. - Maintain familiar routines and rituals. - Allow the child to express feelings, including anger and fear, without judgment. 3. **Minimise Pain and Discomfort** - Assess and manage pain proactively using age-appropriate tools. - Use non-pharmacologic measures (comfort, distraction, swaddling, sucrose). - Apply topical anaesthesia before procedures. - Cluster care (group procedures together) to reduce cumulative distress. - Use positions of comfort and avoid restraint when possible. **Procedural Environment and Location** **Perform painful procedures in a dedicated treatment room, NOT in the child's bed or the playroom.** This principle is crucial: - **The child's bed must remain a "safe space"** where care is gentle, routines are established, and the child feels secure. If procedures are done in the bed, the child loses this sense of safety and may refuse to stay in or sleep in the bed. - **The playroom must be "safe"** — a place for play, learning, and normalcy. If procedures happen in the playroom, children will avoid it, lose developmental benefits of play, and become anxious when in the playroom. - **A treatment room** (a separate room for procedures) preserves the bed and playroom as safe spaces. The child comes to expect that procedures happen in the treatment room, not the bedroom, which provides some psychological control and predictability. **Restraint and Holding** **Therapeutic Holding (Position of Comfort)** Therapeutic holding is appropriate holding for comfort and safety during procedures. The child is in a position of comfort (e.g., upright, held by a parent, feeling secure) rather than a position of restraint. Example: During a blood draw, the parent holds the child upright on the lap, the parent's arm gently around the child to keep the child still, while the nurse performs the draw. The parent is a comforter. This is NOT restraint; it is supportive holding. **Restraint (Physical Restraint)** Restraint—forcing the child into a fixed position against their will—should be **a last resort, used only when necessary for safety or when the procedure absolutely requires immobility and cannot be deferred.** Examples of necessary restraint: holding a child's head still during eye drops to prevent eye injury; immobilising an arm to prevent contamination of a surgical field. **Important principles:** - **Restraint requires a physician/healthcare provider order.** Nurses cannot restrain a child arbitrarily. - **Use the least restrictive method.** If gentle holding suffices, do not escalate to formal restraint. If one person can hold the child securely, do not use three people. - **Check circulation and comfort frequently.** Never restrain a limb tightly; ensure distal circulation is intact (check colour, warmth, capillary refill of fingers/toes distal to restraint). A child in significant distress may experience shock; monitor vital signs. - **Never tie a restraint to a movable bed part** (e.g., bedrail, which the child can pull, or the bed frame, which moves with the bed). Restraints must be secured to an immobile part of the environment. - **Remove or reposition restraints frequently** (at least every 1–2 hours) to prevent skin irritation, improve circulation, and allow movement. Restrained children develop skin breakdown, contractures, and psychological distress if restrained for prolonged periods. - **Document restraint use:** note the type of restraint, the reason (safety/procedure), time applied, time released, circulation check, child's response, and behaviour. Restraint use is a serious intervention and must be thoroughly documented. **Mummy (Papoose) Restraint** The mummy or papoose restraint is a brief, specific restraint used to immobilise an infant or young child for procedures requiring a still head or face. A soft sheet or special restraint blanket is wrapped snugly around the child's body and limbs, leaving the specific area (e.g., head for scalp IV, face for eye drops) exposed. This restraint: - Is used **for short periods only** (minutes, not hours). - Is applied when the child is calm if possible (wrap the already-calm child, not a struggling child). - Requires explanation to the family; the nurse assures them it is temporary and for safety. - Must be released as soon as the procedure is complete. Example: A 6-month-old requires a scalp-vein IV insertion. The nurse wraps the infant in a mummy restraint, exposing only the scalp. The IV is placed quickly by an experienced nurse; the restraint is removed immediately after. This restraint provides immobility while preventing injury from movement. **Preparation and Truthfulness** **Tell the Truth.** Never say "it won't hurt" if it will. The child will feel pain and will lose trust in you. Instead, be honest: "This will sting for a moment, but I will do it quickly, and then it will feel better." Honesty builds trust, which improves cooperation far more than false reassurance. **Prepare According to Developmental Stage.** Young children should not be prepared long in advance (increases anxiety); older children and adolescents appreciate more time to prepare and ask questions. **Avoid Negative Language.** Avoid words like "shot," "cut," "take away," "hurt," or "sick." Use concrete, neutral language: "The needle will go in and the medicine will go in too," not "the shot will hurt." For surgery: "We will be asleep and the doctor will fix your belly," not "the doctor will cut you open." **Praise and Reassurance After Procedures.** After a difficult procedure, praise the child for cooperation: "You did such a good job holding still!" or "You were very brave." This builds confidence and makes future procedures easier. Never shame: "You cried like a baby" or "You didn't cooperate." The child did the best they could with their developmental abilities. **Children's Bill of Rights (Adapted for Atraumatic Care)** Many paediatric units in the Philippines adopt principles aligned with the Children's Bill of Rights, including: - The right to informed assent/consent (age-appropriate explanation and agreement) - The right to freedom from unnecessary procedures and pain - The right to privacy and dignity - The right to parental presence and involvement - The right to play and normalcy - The right to truthful information - The right to refuse treatment (within medical/ethical boundaries) **Atraumatic Care as Standard Practice** Atraumatic care is not a "nice to have" — it is a standard of professional nursing practice. The American Academy of Pediatrics, the Association of Paediatric Nurses, and international guidelines emphasise atraumatic care. In the Philippine context, RA 9173 and the Nursing Code of Ethics require nurses to minimise harm and promote wellbeing. Every procedure, every interaction should reflect atraumatic principles.

Medication administration in children differs significantly from adults in terms of route selection, dose calculation, formulation, and technique. Paediatric medication administration requires special attention to safety, especially in infants and young children who cannot communicate adverse effects verbally. **Weight-Based Dosing and Calculation** **All paediatric medication doses are calculated based on the child's weight in kilograms, NOT pounds or age.** This is critical because of vast weight variation among children of the same age. A 2-year-old might weigh 12 kg or 20 kg; dosing based on age alone would be dangerously inaccurate. **Calculation formula:** Dose (mg) = Dose per kilogram (mg/kg) × Child's weight (kg) **Example:** A 3-year-old weighing 16 kg requires paracetamol 10–15 mg/kg for fever. - Calculated dose: 15 mg/kg × 16 kg = 240 mg - Safe dose range: 10–15 mg/kg = 160–240 mg. A dose of 240 mg is safe. **Critical Safety Measures:** - **Always verify the child's most recent weight** — weights change; do not assume a weight from a previous visit. Weigh the child at each visit/admission. - **Double-check calculations.** For high-alert medications (opioids, sedatives, chemotherapy), have a second nurse or qualified person verify the calculation independently before administration. - **Use a paediatric drug reference** to verify the dose is within safe limits for the child's age and weight. Never estimate; always reference an authoritative source. - **Be aware of maximum daily dose limits.** Even if a single dose is safe, ensure the total daily dose does not exceed safe maximums. Example: Paracetamol maximum daily dose is ~75 mg/kg/day; if the child receives 6 doses in 24 hours, ensure total does not exceed this. **Intramuscular (IM) Injection Sites** **Vastus Lateralis (Anterolateral Thigh) — PREFERRED Site for Infants and Young Children** The vastus lateralis is the **preferred and safest IM injection site for infants and children up to approximately 2–3 years (or until walking well).** This large thigh muscle: - Has the largest muscle mass in infants, providing a safe target. - Contains no major nerves or blood vessels in the safe injection zone. - Is easily accessed; the child is positioned supine or on the parent's lap, and the outer thigh is exposed. - Is less painful than gluteal injections and allows good technique. **Technique:** Identify the injection site by dividing the thigh into thirds; inject in the **middle third of the outer (lateral) thigh**, midway between the hip and knee. The needle enters at a 90-degree angle to the skin. Safe volume: up to 1 mL for infants, up to 1.5 mL for toddlers (though most paediatric injections are <1 mL). **Ventrogluteal (Gluteal) Site — Safe Once the Child Walks Well** The ventrogluteal site (deep gluteal muscle) becomes safe once the child is walking well and the muscle is developed, typically around 2–3 years of age. This site: - Has adequate muscle mass in walking children. - Contains no major nerves or vessels when injected correctly (in the centre of the muscle belly, not near the sciatic nerve). - Is more private (buttocks) and can be used in older children and adolescents. **Deltoid Site — Small Volumes, Older Children, Vaccines** The deltoid (shoulder) muscle is used **only for small-volume vaccines or injections** (<0.5 mL) in older children and adolescents. The deltoid is small and poorly developed in young children; the axillary nerve is close and risk of nerve injury is higher. This site is NOT recommended for infants and toddlers. **Dorsogluteal Site — AVOID in Young Children** The dorsogluteal (deep buttock) site is **avoided in children under ~3 years or until walking well** because: - The muscle is underdeveloped and small. - The sciatic nerve is large and close; risk of injury is significant. - Safer alternatives (vastus lateralis) are available. Once the child is walking well and the buttock muscle is developed (3+ years), the dorsogluteal site becomes safer, though the ventrogluteal is still preferred. **Oral Medication Administration** **Use a Calibrated Oral Syringe or Dropper** - Never use a kitchen teaspoon; household spoons vary widely in volume (a "teaspoon" might be 2–7 mL). Use a **syringe (without needle) or calibrated dropper** provided with the medication or available in the pharmacy. - Draw the medication into the syringe; the barrel shows exact volume. **Technique for Infants and Young Children** - **Position the child upright or semi-upright** (NOT flat); this prevents aspiration. - **Direct the syringe or dropper toward the side and back of the cheek** (buccal area), NOT directly at the back of the throat (risk of gagging/aspiration). - **Administer slowly.** Allow the child time to swallow; squirting medication quickly overwhelms the child and increases aspiration risk. - **Do NOT restrain the child's head.** Allow the child to move their head; the child's swallowing reflex protects the airway. - **Praise and comfort after.** The child may dislike the taste; provide a drink of water afterward if allowed. **Liquid Medication Hiding — WRONG** - **Do NOT hide medication in a full bottle of formula or essential food.** If the child does not finish the bottle (common with infants), the full dose is not received. Additionally, if done repeatedly, the child may develop an aversion to the formula/food. - **Acceptable exception:** A small amount of medication mixed with a small amount of food (not the child's entire formula/food) that the child will definitely finish. Example: Mix an oral antibiotic (5 mL) with 1 teaspoon of applesauce that the child quickly finishes, then offer the regular bottle. This is acceptable because the small amount of food is consumed entirely. - **Always tell parents/guardians:** "The medicine tastes bad; mix it with a small bite of applesauce and give it right away so the child finishes it all. Then offer a drink." **IV Medication Administration in Children** **IV access in children is typically via peripheral vein (antecubital, hand, foot) or, for longer-term access, a central line (PICC, central venous catheter).** **Peripheral IV:** - **Smaller gauge needles** (22–24 G) are used compared to adults (18–20 G). - **Veins:** scalp veins are used in infants (surprising to adults, but scalp veins are accessible and safe); larger veins (antecubital, hand) are used in older children. - **Fluid rate:** carefully controlled, especially in infants, to prevent fluid overload. Infusion pumps with low-volume accuracy are essential. - **Flushing:** IV lines in children are flushed regularly (every 4–8 hours or per protocol) with saline to maintain patency. Medications must be thoroughly flushed through. **Safety for IV Medications:** - **Verify the IV is patent** before administering; ensure fluids infuse easily and the insertion site shows no signs of infiltration (swelling, coolness, blanching). - **Use appropriate concentrations.** Some medications come in adult concentrations and must be diluted for children to prevent toxicity from overdose. - **Administer at appropriate rates.** IV push medications (given quickly) and IV infusions (given over minutes or hours) have different rates. Follow medication guidelines carefully. - **Monitor for infiltration or extravasation.** If the needle dislodges and fluid enters the tissue (infiltration), pain, swelling, and tissue damage result. Stop the infusion and restart the IV. Some medications (chemotherapy, vesicants) cause severe tissue damage if extravasated; immediate action is required. **High-Alert Medications and Double-Checking** **High-alert medications** include opioids, sedatives, chemotherapy, insulin, cardiac drugs, and others. For these medications: - **Two nurses or a nurse + physician verify** the calculated dose, medication, concentration, and route independently before administration. - **Dose is verified against the physician's order and the child's weight.** - **A pediatric drug reference is consulted** to ensure the dose is within safe limits. - **After administration, monitoring is intensified** (vital signs, side effects, efficacy). **Example High-Alert Scenario:** A 20-kg child is prescribed morphine for post-operative pain. The nurse calculates: 0.1 mg/kg × 20 kg = 2 mg IV. Before giving, the nurse calls a second nurse or the charge nurse: "I calculated 2 mg of morphine IV for this 20-kg child. Can you verify the dose from the order and check our drug reference?" The second nurse verifies. Only then is the medication drawn and administered. After administration, vital signs and respiratory rate are monitored closely.