Children and pain management

Recognizing pain is one of the biggest gains in kids' health care

In 1985, a grieving mother named Jill Lawson, from the Washington, DC, area, was shocked to learn that her deceased son, Jeffrey, had undergone surgery without anaesthesia.

During the procedure, Jeffrey, a two-week-old preemie, had incisions in either side of his neck, another in his chest, a catheter inserted in his jugular vein, and his chest was cut open from his breastbone around to his back bone. The only substance administered to Jeffrey, apart from oxygen, was Pavulon — a paralyzing agent that has no effect on pain.

The anaesthetist thought Jeffrey’s blood pressure was too low to tolerate anaesthesia (later shown not to be true). But, more importantly, she and numerous other (but not all) medical professionals believed an infant’s central nervous system was too immature to feel pain. And even if he did, he wouldn’t remember it. They were wrong.

Fortunately, this incomprehensible belief has been put to rest. The American Pain Society now gives out an annual award in Jeffrey’s name to honour advocates for children’s pain relief. In the 20 years since Jeffrey’s death, researchers have learned plenty about assessing and treating pain in children of all ages. Here are some of the most important findings:

Pain should not go untreated
This is a no-brainer, but let’s nail down one important point: Not only does untreated pain cause undue stress, it can sensitize a child’s pain pathways, making future bouts of pain worse. Pain can be a useful alert that something is wrong. But there’s no benefit from ongoing suffering.

Pain assessment is key to good pain management
Assessing pain in young children is not as easy as people think, so researchers have developed better methods. With babies and non-verbal children, doctors and nurses use physiological markers such as heart rate, breathing, colour, clenched fists and facial expression. With young children, they use visual scales to help kids rate their own pain.

Assessing your child’s pain is more difficult than you think
“Research shows that when parents and children both rate a child’s pain, the parents tend to rate it lower than the child,” says Fiona Campbell, an anaesthesiologist and consultant in pain management at Toronto’s Hospital for Sick Children. While the differences are not always huge, the take-home message is this: If you think you might be exaggerating your child’s suffering, you’re probably wrong.

Vicki Baerg, of Surrey, BC, was surprised to learn how difficult it was to determine her son’s level of pain during his recovery from heart surgery. Baerg’s son Christopher, now nine, was born with a cluster of heart defects known as Tetralogy of Fallot. He had open-heart surgery at five months and then again at age three. After the second surgery, Christopher didn’t react the way Baerg expected. “He’d lie quietly and look sad, but he didn’t really complain,” Baerg says. “The doctor asked how he was doing. I said, ‘I guess he’s OK. He’s not crying.’” At that point, Christopher was still hooked up to the heart monitor. The doctor noticed his heart rate was up and that he was sweating — both signs of pain — and topped up the medication. “When the medication kicked in, his heart rate went back to normal, he looked less pale and he stopped sweating,” Baerg says. “I had assumed that his colour and the sweating were related to his heart functioning, but it turned out to be pain.”
Good pain management has three components
Campbell refers the three P’s of pain management. The first P stands for pharmacological (drugs), but Campbell says the best approach also uses the other two P’s: psychological and physical. Medication can’t always take away all of the pain. Psychological and physical strategies seldom bring significant relief on their own. But non-drug strategies can reduce distress and help kids relax and focus on something other than how much it hurts.

Psychological techniques for pain management include distraction (playing with toys or video games, reading, drawing) and relaxation techniques, such as deep breathing or progressive muscle relaxation.

Physical treatments include simple techniques such as hot or cold compresses or massage. In some cases, physiotherapists use acupuncture or TENS (transcutaneous electrical nerve stimulation), a technology that uses electrical impulses to activate touch pathways, which can decrease the pain messages to the spinal cord.

Psychological pain is no different from physical pain
Some pain is thought to be caused mainly by psychological rather than physical factors. But apart from differences in treatment, experts no longer make a big distinction between the two. “In terms of what happens in the brain, there is no difference between pain that has a medically identified cause and pain thought to be psychological in origin,” says psychologist Patrick McGrath, a professor at Dalhousie University. “People used to say that psychosomatic pain was all in your head. All pain is in your head.”

Reassurance is not helpful
“Parents tend to think reassurance will help children with pain, but in a situation of momentary acute pain, like a needle, distraction is more helpful,” says Ron Blount, a psychology professor at the University of Georgia. It’s not that parents should never reassure kids, it’s a question of how and when. “Whatever you focus the child’s attention on tends to be magnified,” he says. Some common parental strategies, such as apologizing (“I’m sorry — I know this is hard”), empathizing or criticizing (“Don’t make such a fuss”), direct a child’s attention towards his distress. By the way, lying about imminent pain doesn’t help, either. “Tell your child the truth in an age-appropriate way, but let him know that you will help him deal with it,” says Blount.

What helps?
Distraction. Try to focus your child’s attention on something else. Clinicians and parents have tried everything from humour to having children blow bubbles, look at books or play video games to get their mind on something else.

Baerg used distraction when Christopher had to have some post-surgical drainage tubes removed from his chest. Morphine was added to his drip, but she was told that the procedure would still hurt quite a bit. “I told Christopher he had to keep really still and I gently held his head, kept my face down close to his and distracted him,” says Baerg. She felt Christopher tense up when the tubes were pulled out. “His face flinched, but he didn’t move or cry very much.”

Pre-emptive pain management. Some doctors recommend giving young children acetaminophen before an immunization. It may ease the sting of a needle, but, more importantly, the medicine is at work before the post-needle local soreness takes hold. If your child really can’t handle needles, use EMLA cream or topical anaesthetic patches to numb the prick.

Other research has shown that standard infant comfort measures, such as breastfeeding or swaddling premature babies skin to skin, has an analgesic effect on procedural pain, like needles.

Whatever technique you try, the unfortunate truth is that pain is part of life. Watching your own child suffer is one of the most unpleasant aspects of being a parent. And though nothing we do can take away all of a child’s pain, at least now we have a much better idea of how to make it more bearable and short-lived.
Managing Chronic Pain
Matthew Solomon didn’t stand up straight for three months. He stayed doubled over because of the pain in his side. The 13-year-old was afraid something awful would happen if he stood up straight.

Lots of children experience recurrent abdominal pain at some point in their lives, but Matthew’s symptoms were atypical and worse than usual. It kept him from participating in normal activities and sometimes woke him at night. It would be six months before he could go back to school regularly,” says Matthew’s mother, Marlene Solomon, of Toronto.

In the end it got better, but no medical cause was ever determined. To some extent, focusing on the cause got in the way because it reinforced an “I am sick” mindset, says Solomon. “We were all really focused on why he was in pain. But once we were confident that the doctors were monitoring his health and taking his condition seriously, we had the confidence to start helping Matthew learn to live with and manage the pain.”

A psychologist suggested they treat it like a disability. That was the turning point. Solomon and her husband learned ways to help Matthew cope using relaxation (swimming or long baths) and distraction (video games, drawing, puzzles). “It was a long slow road with many ups and downs. It took him a year and a half to get back his physical health, and six months after that to get his emotional health back, but he’s fine now.”

Solomon’s advice to parents of children with this kind of chronic pain is to keep looking for the cause, but don’t fixate on it. “Whether the cause is physical or psychological isn’t that important,” she says. “Monitor your child’s health, but put most of your energy into helping him manage the pain and maintain as normal a life as possible. But whatever you do, it’s essential that you believe your child.”

This experience mirrors the findings of Carrie Hicks, a pain researcher in Prince Albert, Sask. Hicks’ Ph.D. thesis involved an experimental distance project, called Help Yourself Online, where kids with chronic headaches and stomach pain learned pain management techniques via computer, email and one-on-one telephone counselling. Hicks compared two groups of children with chronic problems. One was on a treatment waiting list, while the other had access to Help Yourself Online.

Kids with chronic pain tend to have a lot of catastrophic thoughts along the lines of “Oh my God, here comes the pain again. Something really bad must be wrong with me!” That kind of thinking is understandable, but it makes the pain worse. Hicks taught children to replace negative thinking with coping thoughts, such as “I’ve had stomach pain before and I know that when I do my deep breathing, it helps.” After three months, almost three-quarters of the treatment group reported a 50 percent or better pain reduction. Only 14 percent in the control group reported a similar improvement. “The key for the treatment group was having something constructive to do when things went wrong rather than focusing on the pain without doing something about it,” says Hicks.

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