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Archive for November 22nd, 2013

A Rational Approach to Managing Acute Pain in Children

Pain is one of the most common reasons for a parent or caregiver to seek medical attention for their child. Children experience pain for a wide variety of reasons, many that are similar to if not exactly the same as causes of adult pain, but historically pediatric patients have been grossly undertreated. I am 37-years-old and, sadly, if I had undergone a surgical procedure as an infant there would have been a significant chance that I would have received no analgesia at all. Things are better now, but there remains a large gap between what is recommended and how pediatric pain management is practiced in the real world.

The appropriate management of a child’s pain is a vital aspect of compassionate and high quality care, and it is simply the right thing to do. Failing to treat pain effectively is ethically no different than purposefully causing pain in a child, and it can have serious repercussions. Poorly controlled pain can interfere with a child’s recovery because of the negative impact of catecholamine surges and other stress-related chemicals, and impair the ability to take part in physical or occupational therapy. It can also make future encounters with health care professionals more challenging because of anxiety and mistrust.

Untreated pain can interfere with deep breathing, potentially leading to prolonged need for supplemental oxygen and increased risk of pneumonia. It can prevent restful sleep, which has myriad health consequences beyond just cognitive impairment. Pain can interfere with the family unit by significantly increasing parental or caregiver anxiety, which can lead to neglect, abuse, and increased utilization of healthcare resources. Poorly-managed acute pain can increase the likelihood of a patient, even a child, developing chronic pain. There is even good evidence in neonates (my next post I think), that poorly managed acute pain can lead to increased sensitivity and an increased pain response to future occurrences of procedural pain, such as routine immunizations.

Multiple reports throughout the 1970′s and 1980′s revealed that pediatric patients received substantially less pain treatment compared to adults for equivalent conditions, such as broken bones and hernia repair. Despite steady improvement in pain management in kids over the past few decades, we still have a long way to go. Though appropriate anesthesia is now standard of care in children of all ages, many physicians are uncomfortable with evaluating and treating acute pain (chronic pain is another topic) in children. And many parents are resistant to the use of safe and effective pain medications.

Even with physicians that might profess their comfort with recognizing and treating pediatric pain, my admittedly personal experience is that many still allow kids to be in pain at times for a variety of reasons. However, it isn’t that these physicians and caregivers are heartless or enjoy watching their patients, or their children if it is a parent putting up a roadblock, suffer. Even knowing a child is in pain can sometimes be challenging. And there are many misconceptions regarding pain in children that interfere with appropriate treatment. The bulk of these misconceptions involve the use of opioids. All of these misconceptions and false beliefs should be amenable to education and increased awareness of science-based guidelines.

Pediatric pain is a challenging entity. So much so that many institutions have pediatric pain teams. My wife is an expert on pediatric pain and spends her days, and often nights, as a palliative care pediatrician helping to manage pain and other symptoms in children who are approaching the end of life. Her insights and expertise on this topic have been invaluable in my own encounters with pain as a pediatric hospitalist. Her experience, like mine, is that even at major academic institutions pain management is regularly not approached systematically, nor based on the best available evidence.

So what is pain exactly, and how is it assessed in kids?
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Posted in: Science and Medicine

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