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Pain and Pain Management

The diagnosis and treatment of various kinds of pain; ethical issues involved in providing, or more commonly, withholding such treatment.

In 1994, the New England Journal of Medicine published a forum on ethical questions concerning pain management in children. The forum began its discussion by acknowledging that the medical community at large fails to provide effective pain relief for children and infants. The forum cited recent studies which found that "pain can be relieved effectively in 90 percent of patients but is not relieved effectively in 80 percent of patients." In children the failure to relieve pain is even more pronounced. Forum participants cited a study which found that postoperative analgesics were administered to children far more infrequently, or in lower doses, than to adults—even when both had undergone the same operation.

The forum considered several issues regarding the medical establishment's reluctance to provide pain relief for children and arrived at some interesting conclusions. For one, it stated that "Denial of relief from pain that is proportionate to the expressed need for such relief must be judged an unjustified harm, unless such deprivation serves a substantially greater good." It characterized as "undocumented lore" the belief among practitioners that giving narcotic painkillers to children could lead to a life of drug addiction. The forum implored pediatricians to rely instead on empirical data, none of which has found a link between opioid treatment of pain and drug addiction. Finally, acknowledging that research published in journals often has little impact on actual doctor practices, participants in the forum concluded their discussion with a call for "specific administrative interventions" to eradicate the currently inadequate standards of pain management for infants and children. The authors encourage "pressure from parents" to force doctors to take a child's expressions of pain as seriously as they would an adult's.

Infancy

By the time a fetus is 30 weeks old, the central nervous system has developed sufficiently to process and transmit pain messages. Infants have the internal networks to process pain, but they can feel more intense pain since the pain inhibiting mechanisms of their bodies have not fully developed. Infants are also more likely to suffer from unrelieved pain simply because they are unable to communicate their distress. A further complication is that many doctors believe children either don't feel pain as intensely as adults or won't remember having experienced it, and as such will only suffer in the instant. As Jane Brody pointed out a 1995 New York Times column, this belief accounts for the common procedure of simply restraining infants and young children about to undergo a painful procedure. Also, until recently, premature infants who needed surgical procedures were given only minimal anesthesia. Recent studies, however, have changed these practices, and medical personnel hotly debate how much and in what instances infants should be medicated against pain.

Discerning the level of pain experienced by infants is, of course, very difficult since they are unable to verbally communicate their distress. Bernadette Carter, in her book Child and Infant Pain, discusses several strategies for pain measurement in infants based on behavioral and physiological data. Behavioral data for measuring infant pain include measuring facial expressions, body movements/rigidity, and levels of crying. Sociologists and anthropologists have long known that facial expressions have universal significance. Several researchers have used this knowledge to devise facial expression coding systems to assist doctors in measuring pain. Two of the most common are the Neonatal Facial Coding System and the Facial Action Coding System. These systems have slightly varying conclusions as to how infant facial expressions relate to specific levels of pain, but both concluded that tightly closed eyes and open mouths can be regarded as good indications of infant pain. Crying is difficult to relate to a level of pain, since an infant's cry can mean several things, but research has found that adults tend to be able to discern hunger and other cries from cries of pain. Research into body movement has also shown some promise for pain measurement, finding that rapid foot movement is a fairly reliable indication of suffering.

The use of pain-killing drugs in infants is controversial, and many doctors are reluctant to prescribe opioids for fear of provoking respiratory depression, especially in very young infants. Recent research, however, has suggested that with the types of pain that call for opioid intervention in children older than two months, reasonable use of opioids is usually medically safe. However, there can be side effects, and pediatric nurses should watch for their onset. Among non-opioid pain relievers, aspirin is to be avoided because of the risk of Reye's syndrome. Acetaminophen is the most popular non-opioid, anti-in flammatory analgesic for children. It is widely used, generally considered safe, and is available in a variety of formulations. Non-drug pain management techniques are also available and vary, depending on the degree and duration of pain, from the simple use of pacifiers and reassuring touch to such non-traditional methods as acupuncture and aromatherapy—although the latter have seldom been used with infants.

Toddlerhood to school-aged children

Pain assessment in toddlers, preschoolers, and school-aged children faces some of the same problems associated with infants, but is made considerably easier by the children's increasing communicative sophistication. Several methods of assessment have been developed, including facial expression scales (like those for infants) as well as other techniques that allow the child to report his or her level of pain. These methods include questionnaires, diaries, games, diagrams, and several types of scales.

Pain management strategies for toddlers need not involve drugs. Recent studies have explored the possibility of using children's imagination and playfulness to help them relieve their own pain. These strategies work best when the pain is short-lived (like getting an injection or having a bandage removed) or low-level, such as the pain associated with common childhood illnesses. To alleviate short-lived pain, parents can tell their children that they have the power to make the pain go away by simply turning it off in their minds, just like they would turn off a light. Or, it has been suggested, children can be given a specific task to perform, like blowing as hard as they can when the doctor is about to inject them. The blowing directs their attention away from the pain and fear of the needle. There are a variety of such techniques which play on the high level of suggestibility in young children. In 1994, a study was conducted in which 77 children aged four to seven were told to pretend they were blowing bubbles while being given an injection. The study found that they reported experiencing significantly less pain than the control group.

There are also ways to incorporate play into pain management. Children can be given the opportunity to play doctor before receiving an injection. Another method is to allow children to see a procedure performed on another child, on video, before it is performed on them. In many cases, this latter strategy dramatically relieves anxiety about a procedure, such as a cast removal, which generally causes little, if any, pain aside from the child's fear. Parents also should not show their own apprehension of medical procedures in front of their children; like everything else, a child models much of her behavior from her parents'. As Dr. Gina French, a fellow in behavioral pediatrics at the Ohio State University College of Medicine told Prevention magazine, "Most kids don't have a lot of experience with shots, and much of their anticipated fear has been taught to them."

Surprisingly little research has been done in the area of pain relievers specifically designed for children. This again goes back to the medical community's long-standing reluctance to administer narcotic pain relievers to children. Drug companies are unlikely to devote the large amounts of money needed to develop new drugs for children if doctors are not willing to use them. However, in recent years some companies have begun to produce childhood pain relievers. One of the first was Anesta Corporation, which in the early 1990s began production of an opiate called fentanyl (marketed under the brand name Oralet). It was the first narcotic ever tested and approved specifically for children and was sold as a lollipop. This marketing strategy, despite the protest it provoked, was intended to make the drug more palatable to children, who are often resistant to orally administered liquids delivered in a medical setting. Many doctors, relying on the "undocumented lore" decried by the New England Journal of Medicine, suggested that linking candy and opiates in the mind of a child was dubious. Another recently developed drug, EMLA Cream, is a topical anesthetic that can be applied to a child's skin. It deadens nerve endings, making the insertion of IVs or more difficult procedures, such as spinal taps or bone marrow aspiration, significantly less painful. Midazolam (Versed) is also commonly used in a diluted form to calm and sedate children before a procedure, although it is not technically approved for such use. Over-the-counter analgesics, such as acetaminophen and ibuprofen, are also commonly used.

For Further Study

Books

Carter, Bernadette. Child and Infant Pain: Principles of Nursing Care and Management. London: Chapman and Hall, 1994.

Periodicals

Brody, Jane. "Personal Health Column." New York Times, October 25, 1995, and November 1, 1995 (two-part article), pp. B7 & C13.

Muson, Marty. "Save the Wails." Prevention, December 1994, p. 38.

Stevens, Bonnie, and C. Celeste Johnson. "Pain in the Infant: Theoretical and Conceptual Issues." Maternal-Child Nursing Journal, January-March 1993, pp. 3-13.

Walso, Gary, et al. "Pain, Hurt, and Harm: The Ethics of Pain Control in Infants and Children." New England Journal of Medicine, August 25, 1994, pp. 541-44.

Williams, Rebecca D. "Calming Fears, Easing Pain." FDA Consumer, October 1994, p. 16.