A Child in Pain

What Health Professionals Can Do to Help

Leora Kuttner

• Publisher: Crown House Publishing
• Year: 2010
• Print ISBN: 9781845904364
• eBook ISBN: 9781845904555
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

This comprehensive book is designed to help pediatric health professionals of all disciplines gain understanding and skill in how to approach and treat children's pain, and how to help children make sense of and deal with their own pain. Pain is the most common reason for children to seek a medical consultation - and sometimes a common reason for avoiding it. Unaddressed fears and anxiety complicate pain management and recovery. A central theme in this book is the examination of children's fears and anxieties that accompany their need for pain relief, and the communication skills and words that can help calm these fears. This book is addressed to all disciplines, in its valuing of the professional-patient relationship and in the language used to allay anxiety, address fears and promote relief and well-being. It is organized into three parts: Part I explores our scientific understanding of pain as a part of children's development. Part II explores pain treatments themselves, their efficacies and how to combine them for therapeutic impact. Part III uses this understanding to help translate knowledge into clinical practice in three domains of pediatric medicine: the physicians' practice, the dental practice, and in the hospital. This volume also includes contributions by Dr. Jonathan Kuttner, on the neuroanatomy and neurophysiology of pain, Dr. Carl von Baeyer on pain assessment, and Drs Stefan Freidrichsdorf and Helen Karl on the pharmacological management of pain.Without doubt, this volume will stand as the "bible" on pediatric pain management for years to come.

Part I

How to Understand, Assess, and Communicate with a Child in Pain

“Pain is the only condition in which
the patient is the diagnostician.”

Unknown

Pain is now regarded not merely as a symptom of a disease, as previously thought, but as a human rights issue (International Association for the Study of Pain, 2004). The relief of pain therefore demands the highest priority. Pain is as important as any disease or illness, deserving of clinical attention and treatment. By definition, pain is a noxious sensation which always has an emotional impact. In assessing and communicating with children and adolescents on their pain, they are the authority on their experience. This is a fundamental principle of pain management in children. Children are to be believed when they say they are in pain.

Pain has its own physiological system. Chapter 1 explores how pain, although unpleasant, can also have a positive function as an intelligent warning system. In its acute form, pain is frequently protective, preventing or stopping further injury. However, in its chronic form, it ceases to protect in any way, and it becomes a problem. Chronic pain is a result of a malfunctioning pain system. Treatment requires a biopsychosocial approach that incorporates appropriate biological, psychological, and social treatments. In the twenty-first century, we need to ensure that misguided messages and myths about pain no longer persist when caring for children in pain.

Carrying out effective pain treatment with children in pain requires a thorough understanding of how the biological, psychological, and social systems interact for pain to be experienced. Chapter 2 takes up the subject of this relationship: how in the pain experience the nerves communicate with one another, the nerve pathways to the brain, the modulation sites, and the brain’s neural networks. We draw on the scientific research and theory, such as the gate control theory, that led to a radical change in the understanding and treatment of pain. We explore the more recent neuromatrix concept in pain medicine (Melzack, 1999) to help understand the complexity of brain function in persistent distressing pain, and explain how persistent pain alters its own neural system.

The most common procedure in a hospital is communication. All professionals need to know how to communicate effectively with children and their parents. There are optimal ways of responding to children in pain, children fearful of anticipated pain, or children wanting to understand why they are in pain. It is fundamental to good practice, and to the child’s short and long-term outcome, that this process be done well. Chapter 3 discusses this and explores the parents’ central role in modeling pain behavior and in helping their child to cope.

Since the 1980s we have seen a burgeoning of well-designed and standardized tools of pain measurement to help assess children’s acute and chronic pain. There are tools for infants and for children with developmental challenges, tools for post-operative pain assessment, and questionnaires for children in chronic pain and their parents. There is a simple measure for young children and pain scales and maps with more sensitivity for older children. Designing reliable and valid measures to assess pain across cultures, countries, and languages has been an emerging strength in the pediatric pain field. The most common and key measures are covered in Chapter 4, including a developmental exploration of how children of different ages understand and express their pain – important facets for a full and adequate assessment.

These chapters provide you with the foundation for understanding the role of pain in children’s growth and development; the basic physiology of how pain works in the human body, and how to share this knowledge with children – communicating with them when they hurt and are suffering so that they feel heard and helped; and then how to further assess and measure their pain.

Chapter 1

Pain in Children’s Lives

“Pain is when it hurts.”

5-year-old boy

As children and teens grow and explore the world, they experience many falls, illnesses, and hurts of one kind or another. They turn to their parents to find relief from pain. Too often parents feel anxiety and fear, not knowing what to do in the face of their children’s pain, and turn to pediatric professionals for the expertise and guidance to provide their child with sufficient relief. Pediatric health professionals at all levels of care need to know how to provide this necessary help.

Fortunately today many breakthroughs in scientific research have increased our understanding and treatment of childhood pain. The goal of this book is to make this information easily accessible to those working directly with children. With a knowledge of the most effective therapies and treatment combinations in conventional and complementary medicine, professionals can help children and their parents to better manage minor and major pain from injuries and illness. Instead of minimizing, misunderstanding, or dismissing a child’s pain, a skilled professional can provide prompt pain relief and empower the child to cope. This requires a combination of helping the child to understand and interpret the pain sensations and to develop coping skills, as well as being aware of the treatment options to ease the pain.

Pain is part of growing up. Young children frequently fall and scrape themselves as they learn to walk, run, climb, and ride a bicycle. This is a time of developing co-ordination and skill and, as a consequence, learning about pain and suffering. Research has shown that preschool children during play, experience an average of one ‘owie’ or ‘boo-boo’ every three hours (Fearon, McGrath, & Achat, 1996). Children encounter accidents at home, in parks, in cars, and on the playground at school. They may experience pain when they get a tooth filled at the dentist’s office or when they have an injection at the doctor’s office. Some children and adolescents struggle for years with painful diseases and hospital treatments.

This chapter discusses the role that pain plays in the human body, the relationship between pain and the brain, and types of pain. A few widely held attitudes or misconceptions about pain have prevented parents and health care providers from dealing promptly and appropriately with children’s pain. At the end of this chapter I review and debunk misconceptions about pain.

The Protective Value of Pain

Pain is protective. It provides vital information to guide us in the use of our body, informs us about its condition, and helps us survive and remain intact. As health care professionals, part of our responsibility towards children is teaching them to respect pain signals and to learn how to interpret and cope with them. We know from interview studies on children’s concepts of pain that they seldom mention any beneficial aspects of pain, such as pain’s diagnostic value, its warning function, or its role in determining whether treatment is effective (Abu-Saad, 1984a,b,c; Ross & Ross, 1984a,b; Savedra, Gibbons, Tesler, Ward, & Wegner 1982). Children need to know that pain is their personal safety-alarm system, interpreted by the brain in a highly rapid and sophisticated way. Pain messages quickly tell us if there is something wrong with our organs, muscles, bones, ligaments, and tissues, all of which are interwoven with nerve fibers and pain mediators that rapidly carry pain messages to, from, and within our brain. Children need to be informed that part of the sophistication of pain is that memory, emotions, previous learning, beliefs, stress, endocrine and immunological processes, as well as the current meaning of pain, all factor into how the pain message is experienced.

In its healthiest form, short-term acute pain is protective, alerting and preventing damage to one’s body. As David, aged four and a half, discovered: “You’ve got to listen to your stomach when it’s hurting, ’cause if you don’t, your stomach will get upset!” David knew this firsthand; for five days he had had stomach pains and gastric spasms and had been throwing up. The pain signals had taught him that if he continued eating the tuna sandwich his well-intentioned mother had given him, his stomach might send it back again. Recovering from a gastrointestinal virus, David had come to respect the signals he was receiving from his stomach: to eat only what his stomach could handle and when to stop. Because his actions helped settle his pain and nausea, and because he was being listened to – although he was only four and a half – he learned to manage his own recovery, and set the stage for dealing effectively with the experience of pain in the future.

Children learn about their bodies when we encourage and teach them to pay attention to their body’s messages and sensations. They learn to interpret the different pain signals and determine what gives the best form of relief. This learning is refined over a lifetime. Even very young children can be taught to share their pain sensations so that we can determine what is going on, their severity, and what will be most effective in helping the pain to go and stay away.

The value of pain is poignantly evident when we encounter children born with one of the rare conditions of insensitivity or indifference to pain (Nagasako, Oaklander, & Dworkin, 2003). Throughout their lives, these children are at great risk of damaging their bodies, particularly their eyes, hands, fingers, joints, and feet. Pain is disabled by their genetic condition and does not protect them. It does not alert them to stop an action that will cause injury, or prompt them to call for help when they experience the early pain signals of a medical crisis such as appendicitis. These children continue to walk on sprained ankles and damage the tips of their fingers and their legs; frequently they require artificial protection such as braces and guards. By school age, these children have already sustained significant and often irreparable damage to their limbs.

Pain in the Body and the Brain

David Morris (1991), a Professor of Bioethics, writes about the outdated belief that pain can be divided into physical and mental pain. He calls this ‘the Myth of Two Pains.’ According to this myth, there are two entirely separate types of pain: physical and mental. Morris elaborates: “You feel physical pain if your arm breaks, and you feel mental pain if your heart breaks. Between these two different events we seem to imagine a gulf so wide and deep that it might as well be filled by a sea that is impossible to navigate.” (p. 9)

This concept, that pain is either in the body or the mind, goes back to the 17th-century philosophy of René Descartes, who argued that the body and mind were separate. He also maintained that there was a one-to-one relationship between the injury and the amount of pain felt – a theory now debunked. Today’s scientific evidence is that there is continual interaction in the nervous system between our physical and mental functions such that any division between them is an artificial construct.

One of the earliest medical practitioners to publicly question this mind-body split was Dr. H. Beecher, a Boston surgeon who traveled to Europe with U.S. troops during World War II. In 1956 he published a paper which described how soldiers who had very similar wounds to the civilians he had treated at home, required significantly less pain medication (Beecher, 1956). In talking with these men, he realized that the meaning of their pain was very different from that for civilians. Pain to these soldiers meant they were alive and were out of active warfare. War wounds were a ticket home. Beecher’s reports challenged the thinking of the day and importantly showed that the amount of tissue damage often bore little correspondence to the level of felt pain, and there was no validity in a mind-body dichotomy These conclusions are now widely accepted in clinical practice. We now know that the meaning of a person’s pain is subjective, highly personal, and variable from one situation to another, and that this meaning will influence how the pain is experienced. Mental pain can be physically experienced and physical pain mentally experienced. Mind and body are integrated systems.

Definition of Pain

That pain is subjective in no way detracts from the validity of the physical origins of the pain. Pain signals travel through the limbic system, the part of the brain most involved in emotion and motivation (see Chapter 2). When in pain, we are affected emotionally and our feelings can range from distressed, anxious, vulnerable, weepy, to depressed. These emotional or affective correlates are well documented in the literature. The official definition of pain by the International Association for the Study of Pain (IASP) acknowledges this: “Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Pain is always subjective. Each individual learns the application of the word through experiences related to injury in early life.” (1979, p. 249)

Pain is experienced as emotional and mental suffering, as well as a distressing physical sensation. Above all it is subjectively experienced and so is private and entirely personal. Consider the instructive words o...

Table of contents

• Cover
• Praise for A Child in Pain
• Title Page
• Copyright
• Dedication
• Table of Contents
• List of Figures and Tables
• Acknowledgements
• Preface
• Foreword
• Part I How to Understand, Assess and Communicate with a Child in Pain
• Part II Pain Treatments—Psychological, Physical and Pharmacological
• Part III Pain and Anxiety Management in Pediatric Practice
• Afterword Knowing is Not Enough: Strategies to Improve Pain Management in Healthcare Institutions
• References
• Index