Pain relief for your child after surgery

An anaesthetist (a doctor who cares for your child while they are under anaesthetic- a substance that stops pain or makes people go to sleep during surgery) will see your child before their operation; they will talk to you about the anaesthetic and about the pain relief suitable for your child during and after the operation or procedure.

If your child has had treatment before, it can be helpful to tell the anaesthetist which ways of managing your child’s pain have worked well previously and any side-effects they may have experienced.

The anaesthetist will give your child some pain relief medicine during the operation or procedure so that they will be comfortable when they come back onto the ward. The anaesthetist may use a combination of different types of pain-relieving medications including paracetamol, Non-Steroidal Anti-Inflammatories, and opioids.

Some children may be given an injection of local anaesthetic into or around the site of the operation or a nerve nearby (this is called a nerve block). Different pain medicines work in different ways and also work well when more than one type is used together at the same time. The anaesthetist will select the most appropriate regime for each child or young person. The different types of pain-relieving medications are discussed more later in this webpage.

How do I tell if my child is in pain?

If your child is old enough, either you or the nurse caring for your child can ask them about their pain, using a pain assessment tool. These tools help a child or young person to give an indication of the severity of their pain using numerical scales or images. In younger children or those unable to tell you about their pain, a behavioural pain assessment tool can be used by the nurses and you to indicate how much pain your child has. These tools look at a range of typical pain behaviours such as facial expressions, a child or young person’s level of activity, their cry and how easy they are to comfort. Being able to understand the intensity of a child or young person’s pain will help guide the nurses in the best ways to manage it. These are available on the wards so please do ask your nurse to explain which tool they are using.

It’s very important that you are part of the assessment and management of your child’s pain as you know them best and will be able to help them nurses interpret any pain behaviours.

Pain assessment after you have gone home can also help you manage your child’s pain effectively and guide your use of pain relief.

There are different pain relief medicines that might be given to your child when back on the ward and you can give at home, including:

Paracetamol:

This is a mild pain-relieving medicine that is widely used in both children and adults for pain relief and reducing a high temperature. The effects of paracetamol last between 4 to 6 hours so it should be given regularly while your child is uncomfortable. Paracetamol is available as oral liquid as well tablets; it may also be given intravenously (into a vein) if your child is not yet eating and drinking.

Side effects of paracetamol are uncommon, but on rare occasions a child might develop a rash or other reaction. If a rash develops, please inform a nurse or doctor immediately.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs):

NSAIDs are another group of pain-relieving medications and include ibuprofen, diclofenac and parecoxib. They are useful in relieving pain and inflammation (swelling) and can also bring down a high temperature. They can be given 3 to 4 times a day, that is, every 6 to 8 hours. NSAIDs can be given as tablets or liquids or intravenously (into a vein) if your child is not yet eating or drinking.

Some children with kidney problems, blood clotting problems, heart problems or asthma, may not be allowed to take this type of medicine. Your child’s doctor will explain if they are unsuitable and possible alternatives.

NSAIDs can sometimes cause irritation to the stomach, leading to indigestion or feeling sick (nausea). Therefore, it is usually recommended that a child has something to eat before taking them. If your child is taking them for more than a few days your child’s doctor can prescribe something to protect the stomach. Other side effects include mild diarrhoea or tummy ache.

Opioids:

Opioids are a group of strong pain-relieving medications including oral morphine and tramadol. They are used to manage moderate to severe pain. Once given these medications take about 30 minutes to work and last for about 4 -6 hours. They are available in tablet and oral liquid forms. They are useful for managing short-term pain following surgery. They can be given as required or regularly.

These medications can sometimes make your child sleepy, feel sick (nausea) and /or constipated. The dose can be adjusted to manage the sleepiness and other medications can be given to manage the nausea/constipation if needed.

Your child may receive one or more of these medications. These medications relieve pain in different ways so a combination can give your child the best possible pain relief. The types of medication your child receives will depend on the operation or procedure they have had and their medical condition.

After some operations or procedures, children may require other types or routes of pain relief. This is because some operations or procedures can be more painful so require stronger pain relief, or because your child may not be allowed to have medicines by mouth for a few days afterwards.

There are four main ways that children may receive these types of pain relief:

• Patient Controlled Analgesia (PCA) – intravenous (into a vein) opioid medications with the patient able to decide when they receive pain medication by pressing a button.
• Nurse Controlled Analgesia (NCA) – a technique for nurses to give intravenous (into a vein) opioid medications.
• Epidural – an injection in the patient’s back which administers local anaesthetic continuously for a few days.
• Wound infiltration catheters – a technique of giving local anaesthetic continuously for a few days into the wound site.

A suitable method of pain management will have been chosen for your child, depending on their age, type of operation or procedure and medical condition. If your child requires one of these techniques, the anaesthetist will discuss this with you before the operation. Further information leaflets are available on these techniques – please ask your nurse for a copy or you can also access this information on the GOSH website.

What is a nerve block?

A nerve block is where local anaesthetic is injected into or around the site of an operation or a nerve nearby. Local anaesthetics stop the nerves in that part of your body sending signals to your brain making the area feel numb and decreasing the pain in that area of your child’s body. Your child will be asleep when the injection is given. The anaesthetist will discuss the type of injection or nerve block that will be given and advise you how long the numbness may last. How long the pain-relieving effect lasts may vary. As the local anaesthetic wears off your child might start to feel some pain so your child will need to continue to have the other pain relief medicines to reduce any pain.

Other things that are not medications can also help to reduce pain. You can help by taking your child’s mind off their pain through distraction, by playing a game or reading a book together. Further information can be found on our website.

Hot packs can help relax muscles; however please take advice from your nurse or doctor about where these can be placed as they should not be used directly over the surgical wound. Cold packs can also be helpful to reduce inflammation and thus pain. The wards should have some reusable gel hot/cold packs that can be frozen or heated in the microwave; if not, then the Pain Service can be contacted for one. Please ensure all instructions for use are followed carefully.

The pain service can also be contacted for a TENS machine. TENS (Transcutaneous electrical nerve stimulation) is a safe, easy to use, drug-free method of managing pain. A very low-level electrical current is applied to areas of the body using soft gel pads that stick to the skin and are attached to a small battery-operated device. The low-level electrical current stimulates nerves in the body that help to reduce pain.

Please do not use TENS without first taking advice from your nurse or doctor on the ward.

This is a specialist team of nurses and doctors who can help the ward nurses and doctors manage your child’s pain. The team provides advice on different methods of pain relief and will also visit some children on the wards if required.

If you have any questions about your child’s pain please ask the nurses on the ward, your child’s doctor, anaesthetist, pharmacist or a member of the Pain Control Service.

Family members or carers play a very important part in helping us to manage their children’s pain. As you know your child best, ways you can help include:

• Telling us what has helped or not in the past.
• Letting us know how well you think the current pain relief is working.
• If you are worried that your child is in pain, please let the nurses know.
• Encourage your child to tell you or the nurse if things are painful.
• We also know that persuading your child to take medicines can be difficult, so we might need your help with this.

Every child is different, so the length of time pain relief is needed will vary. It also depends on the type of operation or procedure your child has had. They may need to carry on taking pain relief medicines after you have left the hospital but usually only for a few days.

We will recommend that your child takes one or more pain relief medicines when they go home. Different types of pain relief medicines work well together so it is possible to give paracetamol and ibuprofen at the same time if the pain is bad. Paracetamol and ibuprofen can be purchased in your local supermarket or pharmacy, these are not normally provided upon discharge from the ward.

It is important to make sure you don’t give different brands of the same medicine at the same time for example paracetamol is found in Calpol©, Paraped© and other cough and cold remedies. Ibuprofen is found in brands such as Nurofen©, Calprofen©, and Anadin©. If you are not sure you can ask your local pharmacist for advice.

The nurses will explain any medication you are going home with and let you know when the last dose of pain relief was given. For any concerns regarding Pain Management when at home please contact the ward in the first instance.

It can be useful at home to keep a record of what was given when so you know what medication is due when.

• Always give the medications according to the instructions on the bottle or packet, as advised by your Doctor, Nurse or Pharmacist.
• Never give more than the recommended number of daily doses of pain relief medicines for your child.
• Use a pain assessment tool to help you decide if your child is in pain.
• If the pain is bad give pain relief medications regularly, otherwise just dose when needed.
• Do not wait for the pain to worsen before giving a dose of medicine.
• If your child is still in pain or you are worried that the medicines are not working, please contact the ward for advice.
• In general, continue giving your child pain relief for as long as they complain they are in pain.

You can use the same methods as the nurses used on the ward. There are a few pain rating scales you can use.

Numerical Rating scale (6-17yrs approx.):

If your child is old enough to rate their pain using a Numerical Rating scale you can ask them to score their pain- 0 being no pain, 10 being the worst pain imaginable.

Wong-Baker FACES® Pain Rating scale (3-18 years approx.):

Explain to your child that each face represents a person who has no pain, some pain or a lot of pain. If your child does not use the word ‘hurt’ then use a word they understand. Explain that face 0 doesn’t hurt at all, face 2 hurts a little bit, face 4 hurts a little more, face 6 hurts even more, face 8 hurts a whole lot and face 10 hurts as much as you can imagine, although you don’t have to be crying to get the worst pain.

If you child reports a pain score of four or more on either scale, we would recommend giving some pain relief.

The Parents Postoperative Pain Measure (PPPM) (two-17 years approx.):

Mark your child either ‘yes’ or ‘no’ for each point below, then add up the ‘yes’. If you have more than 3 'yes' then we recommend giving pain relief.

• Whine or complain more than usual?
• Play less than usual?
• Not doing things they usually like?
• Act more worried than normal?
• Act more quiet than normal?
• Have less energy than usual?
• Eat less than usual?
• Holds sore part of their body?
• Groan more than usual?
• Want to be close to you more than usual?