This last week has been hard on all of us. And very very confusing.
Our poor baby cut his first teeth. You know how when you read an article about teething it mentions all these associated symptoms like diarrhea and diaper rash and fussiness and even potentially low grade fever? Then it usually goes on to say that those symptoms may not be associated with teething at all so check with your doctor because there may be something else going on?
Clearly, there were teeth cutting through the gum. I could feel and see them. I could also see (and feel) an increase in drool production. I thought the more frequent loose stools were related to that. They weren’t really watery. Then there was the diaper rash. Our first ever. We felt like bad parents. It wasn’t just red…it was blistering. We cringed ever time we looked at it or had to clean it. But clearly the diaper rash was from pooping 10 times a day, right? And our son didn’t feel like eating because his gums hurt, right? And those little red bumps on his hands were from chewing them, right?
It’s now become obvious that he has hand, foot and mouth disease. HFMD is going around his daycare right now so it seems a safe bet. Rashes in the genital region are common in HFMD which alleviates some of our diaper-rash guilt.
The treatment for HFMD is symptomatic and supportive: hydration, pain and fever management and time. But this begs the question…
How can you tell if your pre-verbal child is in pain?
Contrary to my UT post, I have been treating my son with over-the-counter analgesics for the last few days. I am an anesthesiologist. Taking away pain is a huge part of my identity and when I think about my son being in pain and unable to tell me about it, I feel physically ill.
Pain – The Fifth Vital Sign
In 1995, the president of the American Pain Society, Dr James Campbell, described pain as “the fifth vital sign.” Pain is the number one reason why people seek medical care and yet it is often overlooked and poorly treated. When nursing was just starting to develop as a profession, it was realized that regular measurement of patients’ vital signs (heart rate, respiratory rate, blood pressure and temperature and, once it was available in the ’80s, pulse oximetry reading) was able to identify patients whose condition was deteriorating before they, well, collapsed. Dr Campbell felt that if pain was formally assessed in a standardized manner every time the vitals were assessed, then we would be well on our way to identifying pain in a timely manner and be able to treat it appropriately. If you’ve ever been a patient in a hospital, you might have experienced this. After having your vitals taken, the nurse asks you to rate your pain from 0-10 (a simple numeric scale). Your rating is charted on a special pain assessment form. If you rate > 4 in my hospital, the nurse is obligated to offer you some pain medication. Whether or not you take it is up to you.
When I was in medical school, I was taught that children younger than 4 couldn’t be relied on to tell you where it hurt, not even by pointing. At young ages many of them just aren’t able to use words to express what they are feeling. Often they will point to their tummy. Everything is a tummy ache. An ear infection is a tummy ache. A sore throat is a tummy ache. Appendicitis is a tummy ache. A headache is a tummy ache.
However, children as young as 3 or 4 can use developmentally appropriate self-reporting pain tools. They may be able to “colour the pain” on a picture of a person to show you where it hurts even if they can’t express it in words.
In children this age, we commonly use the Faces scale or a simple visual-analog scale (VAS) (easy to find using google), both of which can also be used at home
Preschoolers and young children in pain may view it as a punishment. They need lots of verbal and physical reassurance as well as analgesics when they are in pain.
Developmentally, toddlers and infants don’t yet have the tools to “tell” us when they are in pain or to rate its severity for us. We have to rely on their behaviours and, in the hospital, vital signs. Toddlers in pain may have trouble sleeping. They may “guard” the painful body part. They may exhibit aggressive or regressive, withdrawn behaviour. They may scream and cry. Infants cry and may be inconsolable. They may be hypersensitive or irritable. They often flail, arch their backs or appear rigid. They may draw their knees up to their chest. They also have difficulty sleeping. They may refuse to eat.
In the hospital we use the FLACC or RILEY pain scales which have been validated for young children for both medical and surgical pain (again, I suggest google if you want details).
When my son was in the throes of HFMD he easily scored a 5 or 6 on the FLACC scale and a 6 on the Riley scale. A dose of baby acetaminophen later and he scored zero.
Now I have HFMD and, based on what I am feeling, I am very very glad that I gave my son some simple over-the-counter analgesics!