Pain and Children

Susan J. Brillhart MSN, RN, CS, PNP

INTRODUCTION

Pain occurs in every child’s life. The job of the primary care provider is to evaluate actual or anticipated pain, and to apply simple and appropriate pain measures that can help to make visits significantly less painful and frightening for children and their caregivers. This chapter explores recent research findings about pain in children and the broad recommendations for pain assessment, prevention, and management based on those findings. For specific doses and protocols, especially for pediatric conscious sedation, the reader is urged strongly to refer to the annually updated reference and protocol books.

PAIN MYTHS AND REALITIES

Until recently, pain in the pediatric population was neither recognized nor researched, even in the acute care setting. Professionals caring for children have long noted that the effects of pain on children have not been measured, explained, or described sufficiently (McGuire & Dizard, 1982; Richards, Bernal, & Brackbill, 1976; Schechter, 1985). For this reason, health care team members may misunderstand, minimize, or inadequately respond to the level or importance of a child’s pain (Beyer & Byers, 1985; McCaffery, 1977; McGuire & Dizard, 1982). This problem is especially true for young children (Schechter & Allen, 1986). An examination of the literature of the 1970s, 1980s, and early 1990s reveals a frightening ignorance of the level of pain that children experience. Eland (1990) notes that before 1977, only one nursing article appeared in the pediatric pain literature (Schultz, 1971). This was a study describing pain perception in healthy 10- and 11-year-olds. Pediatric pain management was almost nonexistent in medical and nursing textbooks: Ten major pediatric texts totaling more than 12,000 pages contained less than one combined page on the topic (Rana, 1987). Fortunately, the situation has changed, and every current pediatric textbook addresses the issue of pain.

Past Research

Raising the critical question of whether children experience pain, Abu-Saad (1981) reminded readers of the belief, commonly held since the 1930s, that infants do not perceive pain to the same degree as adults because infants lack cortical pathways. Some practitioners still hold this belief; others believe that infants can feel pain but less strongly than adults. Actually, the opposite is true—infants are hypersensitive to pain because of incomplete physiologic development. Researching pain in adults, Melzack and Wall (1965) developed the revolutionary Gate Control Theory of Pain. Melzack (1975) proceeded to develop the widely used McGill Pain Questionnaire but did nothing to dispel longstanding pediatric pain myths or to address pain assessment for children. Swafford and Allan (1968) reported only 2 out of 60 children (3%) on their surgical floor required pain medications. They anecdotally noted, “Pediatric patients seldom need medication for relief of pain. They tolerate discomfort well” (Swafford & Allan, 1968, p. 135). Other researchers reported repeatedly that children received fewer postoperative analgesics than adults (Beyer, DeGood, Ashley, & Russell, 1983; Eland & Anderson, 1977; Schechter & Allen, 1986).

Several comprehensive reviews of pain have appeared in both the earlier medical (Goldman & Lloyd-Thomas, 1991; McGrath, 1990; Schechter, 1984; 1985; 1989) and nursing (Abu-Saad, 1981; Eland, 1990; Ross & Ross, 1988) literature. The First International Symposium on Pediatric Pain was held in 1988. At the National Institute of Health Measurement of Pain Meeting in April 1988, however, the unique and complex problems of pediatric pain were not addressed at all, partially because of the problems of measurement (Loeser, 1990). This occurrence demonstrates that at that time, distinct knowledge about pediatric pain was lacking, especially the pain of children age 12 and younger.

Common Misconceptions

Many myths surround the topic of pediatric pain, most of which lead to inadequate treatment. The first and most serious is that infants do not feel pain. Research has proven that premature infants exposed to repeated heelsticks not only feel pain, but also develop an increased sensitivity to stimulation that outlasts the noxious stimulus by hours or days (Fitzgerald, Millard, & McIntosh, 1989). Because pain inhibitory systems are not fully developed, young infants actually may have an increased stress response to pain, compared with adults. These findings also refute the second serious myth: that children tolerate pain better than adults. Children actually tolerate pain better as they get older because their inhibitory systems become more developed.

The third myth is that infants and young children do not remember pain. Although this idea may be very soothing to the caregiver of a child in pain, it is untrue. Research of circumcised males during their 4- to 6-month vaccinations showed they had greater stress responses than uncircumcised males. In the same study, male infants who received a local anesthetic (EMLA in this case) for circumcision had a lower stress response than those who did not (Taddio, Katz, Ilerisich, & Koren, 1997). Although children may have no active memory of pain, a pain experience may have lasting effects on how individuals respond to future episodes throughout their childhood and possibly adulthood. Even the unremembered effects of pain should not be dismissed, as any family member of a person who has had surgery and sedation can attest. Disturbed sleep and behavior patterns are not uncommon in children and adults, even when surgical pain was “well controlled” (Orenstein, Manning, & Pelphrey, 1999).

Another myth is that children always tell the truth about pain. If they believe that admitting to pain will cause something more painful (especially an injection), children may be
untruthful. For this reason, intramuscular (IM) injections should be a last resort for pain management in children. Children also may not really be aware of how much pain they have (slow-building chronic pain) or may assume that the provider knows how they feel. Physical indicators or mood changes may be the key to assessment in these children.

The fifth myth is that pain “builds character.” It is not uncommon to hear caregivers make such comments to their children, especially older children and adolescents. The provider needs to remind parents that the pain is real. The clinician should tell all involved of the measures that he or she will use to decrease pain and measures that the family can continue at home to suppress pain. Adolescents may receive three to four booster vaccinations at once, some of which can be immediately extremely painful, with soreness lasting 7 to 10 days. Caregivers need to recognize this interruption in tissue integrity as an injury (even though a medical provider inflicted it) and treat the child’s pain appropriately.

Another myth is that crying most often stems from fear rather than pain. While the older infant and toddler will greatly dislike being restrained, providers and parents should treat a procedure that is known to be painful as such. They should not lightly brush off a child’s cries because the child is upset about being restrained. Children who have repeated painful procedures are not just fearful of being restrained; they have increased sensitivity to pain and should be assessed very carefully.

The seventh myth is that children cannot tell exactly where or how much they hurt. Children as young as 4 years can localize pain and can point to it on themselves or on drawings. Children as young as 3 years can effectively use the FACES rating scale (see discussion later in this chapter; Wong & Baker, 1988).

The eighth myth is that caregivers and health care providers can properly assess the child’s pain. Children in chronic pain have different pain behaviors and may be in severe pain but may not “show” any pain response at all. Providers may then assume that the child has no pain and that pain reports are just attempts to gain attention. Multiple studies, recent and old, show that almost everyone, in every field of health care, underrates children’s pain. Home caregivers also were found to underrate pain. Disappointingly, very little change has been made in this critical area of pain control. The message is to believe what the child says regarding the pain’s severity, length, and so forth. Otherwise, chronic pain may lead to depression, anxiety, and low self-esteem (Zeltzer, Bush, Chen, & Riveral, 1997). The only way to treat pain appropriately is to listen to what children say about it.

The ninth myth is that all sedating or paralyzing drugs have an analgesic effect. In fact, many drugs used for sedation and paralyzation have no analgesic effect at all. The provider must remember to give analgesia, sedation, or a paralytic when needed, ensuring that each separate and necessary element is kept at the appropriate level. An active paralytic without sedation or analgesia can have disastrous psychological and physiologic effects. A sedated and paralyzed child in pain who does not receive analgesia will still display a change in vital signs and other physiologic effects, which can be potentially dangerous in the unstable patient.

The 10th myth, perpetuated by caregivers and health care professionals, is that children and adolescents will become addicted to narcotics if they are used. Providers should explain the difference between addiction (a voluntary psychological or behavioral response characterized by a compulsive drug-seeking behavior), tolerance (an involuntary physiologic need for larger doses to maintain the original analgesic effect), and physical dependence (displayed by involuntary physiologic withdrawal symptoms when delivered narcotics are suddenly stopped or reversed). Everyone should understand that a child in pain does not become addicted when narcotics are used for pain control. Caregivers also should understand that a child who needs narcotics for weeks to months probably will develop tolerance or dependence. These children will be weaned slowly and successfully from those narcotics. Such weaning is a routine and expected part of discharge protocol in most major pediatric intensive care units.

The final myth is that children are more susceptible to opioid-induced respiratory depression than are adults. Multiple studies have shown narcotics to be as safe for children older than 3 months (and possibly younger) as they are for adults. As children increase their tolerance to the drug, they also increase their tolerance to respiratory depression. Pain is a natural antagonist to the action of opioids, so the more intense the pain, the more drug the child can receive safely. Respiratory depression also is rare in appropriate long-term opioid therapy, even if delivered in seemingly high doses (cancer pain).

Infant Pain Myths

The misperceptions about pain and infants are varied and far-reaching. This short section explores recent discoveries concerning the effects of pain on infants and potential long-term concerns.

Premature and full-term infants have a functional nervous system capable of perceiving pain and, when exposed to noxious stimuli, can experience changes in their physiologic status, biochemistry, behavioral state, cry features, and facial expression. Acute changes in physiologic status can be extremely dangerous for very premature or unstable infants. Increasing intracranial pressure can precipitate intraventricular hemorrhage (IVH). A state of hypermetabolism and catabolism ultimately may cause morbidity and mortality. In blinded, randomized trials (Anand, 1999), intravenous morphine reduced pain responses, stabilized vital signs, and decreased the incidence of poor neurologic outcomes (defined as death, grade III or IV IVH, or cystic periventricular leukomalacia). Treatment with the topical anesthetic EMLA (a eutectic mixture of 2.5% lidocaine and 2.5% prilocaine) has been found to reverse the hypersensitivity threshold for neonates with repeated heelsticks and to decrease the pain response for future vaccinations in circumcised male infants.

Individuals researching memory in very young infants have discovered interesting information. On their first breast-feeding, newborns chose the breast that was wiped with their own amniotic fluid over the breast that was wiped with a clean cloth. One-day-old infants respond differently to an odor once it has been paired with a reinforcing tactile stimulus. With these findings, it is no surprise that by age 6 months, infants show anticipatory fear when facing a previously painful stimulus (Porter, Grunau, & Anand, 1999).

PAIN ASSESSMENT

The assessment of pain in children is a much discussed and debated topic. The most important part of pain assessment in children is to believe whatever the child is saying. The World Health Organization has adopted McCaffery’s (1977) definition
of pain: Pain is whatever the experiencing person says it is, existing whenever the person says it does. Children “say” they have pain in different ways, verbal and nonverbal. The provider must understand what his or her beliefs are concerning pediatric pain and how those beliefs could influence practice.

Purpose and Goals of Assessment

Accepting that pain is multidimensional, the assessment of pain in children should accomplish several functions. Zeltzer et al. (1997) list multiple key functions for providers. All these suggestions should assist in developing pain management strategies optimally suited to each individual child.

First, determine how best to communicate with a child about pain, which may be a prerequisite to any other element of pain assessment. Evaluation of a child’s developmental status and ability to understand pain, illness, and medical procedures is important.

Second, assess the intensity, quality, and characteristics of the child’s pain experience; determine the child’s pain management needs; and evaluate the effectiveness of ongoing pain-management strategies. Neglected or inexpert use of pain assessment is a major reason why children’s pain often is undermanaged.

Third, review the psychosocial aspects of pain. Identifying the child’s coping style, personality, and family factors will help target dysfunctional beliefs, attitudes, and coping skills. Then identify significant maladjustment or traumatic responses to pain (including depression and withdrawal) that may cause serious sequelae or encourage the development of dysfunctional attitiudes and beliefs regarding pain, illness, and medical care.

Fourth, understand anxiety or behavioral stress in response to illness or procedures that may further exacerbate pain and make accurate estimation difficult.

Baker and Wong (1987) developed an overall approach called QUESTT that should be used for all pain assessments:

Question the child.
Use pain rating scales.
Evaluate behavior and physiologic changes.
Secure parents’ involvement.
Take cause of pain into account.
Take action, and evaluate results.

Questioning the child is the most important factor in pain assessment. The provider should ask the child questions using terminology familiar to that child. Hester and Barcus (1986) have developed an excellent pain experience history questionnaire that specifies questions for the child and for the caregiver. Their answers provide the basis for an effective plan of pain prevention. Caregiver involvement is crucial; children may deny pain to strangers yet admit it to a trusted caregiver. Children also may deny pain if they believe that admitting it will result in an injection or if they believe that they deserve the pain. Some children believe that they have been “bad” and are responsible for causing other negative events in their lives (eg, parents’ divorce, illness of a sibling). This may lead them to believe they deserve any pain that they have.

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