Infant pain is distressing not only for the child, but also for parents and carers. However, pharmacists play an important role in relieving symptoms.

Over a normal day in the pharmacy, you will typically have someone, be it an adult or a concerned parent with their child or toddler, present at the counter complaining of some sort of pain or ache. In the vast majority of cases, asking a few contextual questions, such as ‘where is the pain?’ or ‘on a scale of 1-to-10, how painful is it?’ will quickly establish the nature of the complaint and may offer a lead as to a possible cause to enable you to follow a suitable course of remedial action, perhaps an over-the-counter solution, or, depending on the severity or nature of the pain, you might recommend a visit to the GP or hospital.

In the case above, the outcome reached is based on a fundamental tenet of ‘diagnosis 101’ — two-way communication. You ask a question, you get a verbal response, which leads to another question, then response, and so on. In most cases, even with the very young, they are also able to point or show you where the pain is. Training and experience as a health professional means that through educated open and closed questioning of the patient (could be the adult or both the parent and child), along with other non-verbal signposting, you will consider or eliminate possible causes almost immediately, helping you arrive at the most likely cause and appropriate next step.

Consider, therefore, the difficulty presented when a parent arrives at the pharmacy with an infant, two-to-12 months old, concerned that their child is in pain and seeking assistance. The normal route, the verbal-based technique outlined above, is now not an option. Of course, you can question the parent as regards symptoms or signs that have led them to their conclusion.

However, without the input from the person experiencing the pain, the infant, establishing any type of diagnosis could prove challenging. In the case of a first-time parent, they may be quite distressed, as they ‘don’t know what they don’t know’, making their expectation of getting help more acute and immediate, which can bring an added level of pressure to the situation.

With pharmacy being actively promoted as a ‘first port of call’ regarding general healthcare, it’s increasingly likely that you will encounter this difficult scenario at your pharmacy. The purpose of this article therefore is to provide some background information regarding ‘infant pain’ and to help you develop more educated questions and observations that can establish likely causes and subsequent action, or at least allay the immediate fears of a worried parent.

The nature of infant pain

Due to the simple fact that infants can’t tell us about the pain they’re experiencing, establishing the nature of infant pain is notoriously difficult. In fact, prior to the last 30 years or so, whether infants, due to their underdeveloped brain and neural pathways, actually experienced ‘pain’ at all was still a genuine question.

In recent decades however, with the advent of technology, it has been proven beyond doubt that infants do experience pain in the same way that adults do. Clinical tests with various stimuli allied to realtime MRI and neuro scanning techniques have shown that sensory receptors in infants ‘light-up’ to a similar extent to those of adults exposed to the same stimuli.

This ongoing research, aimed at improving and measuring infant response to pain medication, along with other research in the field, clearly dispels any suggestion that infants do not feel pain.

You might think, ‘how can I help?’ The problem you have is like that faced by every health professional in this area, be it neonatal nurse, paediatrician, consultant — ‘I can’t ask the patient the question’. In much the same way as a farmer can spot that ‘something’s not right’ in one animal in a group of hundreds — because they know the animal and what is ‘normal behaviour’ — the parents of the infant also know what their infant’s ‘normal’ signs are in terms of feeding, sleeping, movement, mood, etc, and are therefore best placed to recognise changes in these areas that can help clinicians identify/eliminate possible causes of infant pain.

Behavioural changes

could be the first

indication of a

potential problem

Warning signs

The most common causes of infant pain are:

Teething.

Infections (especially ear).

Colic (most often up to four months).


Pain through colds, flu transmitted at home, through contact with others or toys, etc, if there are other children in the house.

As the infant is unable to describe their symptoms, there are signs to look for in several key areas outlined below, some knowledge of which can help you ask relevant questions that can help identify the problem. Behavioural changes could be the first indication of a potential problem and are most likely to be recognised by the parents.

Crying

As with the farmer above, parents soon come to learn a ‘normal’ cry. It is the infant’s only way of communicating a variety of needs. Through time, they can distinguish subtle differences in crying that represent being hungry or tired. Maybe it’s discomfort, requiring a nappy change, or just needing a cuddle! If an infant is in pain, their cry may (not always) become more high-pitched and extended in duration and will certainly sound different than normal.

If this crying cannot be eased by addressing the usual needs, ie, feed, change, etc, this may be a reason to investigate further. Colic is a painful intestinal issue, the cause of which is not known. Up to four months old, this prolonged (up to three hours per day), intense crying, especially if it occurs at roughly the same time each day, may be a sign of colic. If the infant is drawing their legs into the tummy at the same time, this may also indicate colic.

Changes in appetitie

If the infant has a ‘healthy’ appetite, (ie, feeds regularly and well, is gaining weight), then instances where food is refused, or feeds missed completely in the case of breast or bottle feeding, this may be a sign of underlying illness/pain which requires monitoring. Other signs may be that sucking (bottles) has become weaker, or a good latch not achieved while breastfeeding. Irregularity in feeding routines, fewer soiled or wet nappies, leading to slower weight gain or weight loss, may be a further indication of underlying illness/pain

Fever

Colds, flu, ear infections and stomach bugs, along with viral or bacterial infections, can all cause fever and pain in infants. They are particularly susceptible, as their immune systems are under-developed. If fever is suspected, check the temperature. Normal temperature should be 37.8°C, however if the temperature is 38°C or above (<12wks old) or above 38.3°C (3-6mths), the doctor should be contacted immediately.

Lethargy

Infants by their general nature are active, bright, inquisitive, alert, and attentive. Any signs of sluggishness, drowsiness or sleeping for longer than usual may be a sign of infection or another underlying condition and should be monitored.

What can be done to help?

If pain is suspected, there are several steps, both medicinal and non-medicinal, that can be taken to help alleviate symptoms.

Consider advising any of the following:

Non-medical

There is significant evidence to indicate that a variety of physical and environmental interactions can help soothe an infant experiencing pain or distress. These can also help the parent who may be experiencing feelings of helplessness in caring for their child.

Skin-to-skin contact (‘Kangaroo care’) between the parent and child can have a pain-relieving effect and can also help reduce stress levels of the parent.

Breastfeeding — this promotes skinto-skin contact, with the added proven pain-relieving qualities offered by breast milk. In a clinical setting, for those unable to breastfeed, a 24 per cent sucrose solution administered via dropper onto the tongue also offer pain relief.

Massaging the infant’s tummy can help relieve tummy pain (not after feeding).

Holding the infant and moving with a slow, steady, rhythmic rocking movement can help reduce or relieve pain and stress.

Using distractions such as music, singing, reading stories aloud can help.

Changing the infant’s immediate environment to something more secure and nest-like can help them feel more contained, warm, and comforted.

Medical

Due to the difficulty in diagnosing pain in infants — especially outside of a hospital neonatal ICU environment — there is only a limited amount that can be offered to a concerned parent by way of medicinal relief over the counter.

In Summary

As mentioned at the outset, it is increasingly likely that you may encounter infant pain issues at the counter. Hopefully this short article has given you some context to develop the right questions to ask. Within the first 12 months, most mothers and infants are still under the umbrella of GP and post-natal care, so it is likely anything serious would be caught early within that framework.

Almost all infant fevers and pain are non-threatening in nature and will pass in a few days. Some points below would necessitate immediate referral to GP:

Temperature levels outside of those indicated earlier (<3mths — 38°C or above — 38.3°C or above). 

Vomiting. 

Stiff neck. 

Skin discolouration, rash. 

Pain or sickness that’s been going on for more than a couple of days. 

Any difficulty breathing due to coughing or wheezing

References on request

CONTRIBUTOR INFORMATION

Written and researched by
Eamonn Brady (MPSI), owner of
Whelehans Pharmacies in Mullingar
Tel 04493 34591 (Pearse St) or
04493 10266 (Clonmore). www.
whelehans.inet. Eamonn specialises in
the supply of medicines and training
needs of nursing homes throughout
Ireland. Email ebrady@whelehans.ie