New Standard of Care to Ease Pain in Kids

A new joint policy statement from the American Academy of Pediatrics and the American Pain Society addresses the need for healthcare professionals to eliminate or ease pain suffered by children whenever possible. The statement says ample knowledge about pain exists for physicians to treat children humanely and effectively, but it is not universally applied.

Joseph F. Hagan, Jr., MD, a pediatrician, is a Fellow of the American Academy of Pediatrics and Chair of the Committee on Psycho-social Aspects of Child and Family Health that authored the new standards on children's pain. He joined the Early Show to explain the new policy.

The most common type of pain children experience is acute--or short-lived--pain caused by injury, illness, or medical procedures. Pain has sensory, emotional, cognitive, and behavioral components that go well beyond that of a simple sensory experience. But according to the statement, there are many barriers to treating acute pain in children, including:

The myth that children, especially infants, don't feel pain the way adults do.

A lack of assessment and reassessment for pain.

Fears about side effects of pain medications, including respiratory problems and addiction.

The belief by some healthcare workers that pain builds character in children.

The AAP and APS feel that most acute pain experienced in medical settings can be prevented or substantially relieved. To accomplish this, physicians need to expand their knowledge about pediatric pain management principles, provide a calm environment for painful procedures, use appropriate assessment tools and techniques, anticipate painful experiences, and involve families in creating solutions for their child's pain.

In addition, the statement recommends that pediatricians advocate for child-specific research in pain management and Food and Drug Administration evaluation of painkillers for children, which are commonly only tested in adults.

Hagan personally feels strongly that this was an important topic that needed to be written as a standard of care. Given the advances over the years in our understanding and treatment of pain, our practice of pain management for children ought to be better.

The new standard of care, as described by Hagan, recognizes that infants and children have pain, that we know how to measure it, and that even in children who can't talk yet there are ways to test it. There are no advantages to pain, and there are disadvantages to pain, says Hagan. We need to treat pain in children and treat it well.

Hagan was trained in the 70s in an oncology clinic, and although it was a caring place with good care, pain management was much different for kids back then. For painful procedures like a spinal tap or bone marrow aspiration, kids did not get the same kinds of pain relief as today.

Today, local anesthetic can be combined with an antianxiety drug to make you forget ow troubling the experience was. Even with minor procedures like circumcision, Hagan says it used to be the standard of care that boys received no local anesthetic during circumcision. Now we need to make sure everyone is doing that. As early as 5 or 6 years ago there were contradictory standards of treatment and topical creams were debated, but now we know injectable lidocaine is the gold standard. We need to make sure everyone is aware of that, says Hagan.

Part of the problem is that doctors and the medical profession at large take time to completely absorb new developments in pain management, and old beliefs are hard to overturn. But many of those beliefs are outdated.

Hagan believes the main disadvantage to pain is that it hurts. There is really no need to go any further than that. All the other reasons that are marshalled in defense of not administering pain relief are secondary.

But one outdated idea is that children experience pain differently than adults. Whe it comes to the long-term effects of pain on children, the old view is that when it's over, it's done and they forget about it. Now we think about the complex ways pain affects our bodies and our brain. When you have a response to pain, we always knew you get an immediate unpleasant sensation to protect yourself and take yourself away from the source of the pain. But now we think there is more: There is an association made with mood, anxiety, and there is a memory, which is not a good memory because adults and children recall painful or anxiety-producing situations.

Not to pick on dentists, but lots of older people have a negative association with dentists because of pain. Now that dentistry is so advanced in pain management there is not as much recollection in younger patients.

Also, the notion that painkillers cause respiratory problems and addiction in children is not relevant if the medication is prescribed appropriately, says Hagan. There is a very wide margin of safety between good pain management and side effects of drugs these days. When you treat pain to the level of pain relief, you don't induce addiction. You are simply treating pain. In his experience, Hagan says it's not that hard to wean a child off a chemical addiction that occurs if the pain is prolonged due to the nature of the injury or illness. Psychological addiction in the presence of pain is rare.

The old-fashioned notion that pain builds character hopefully doesn't exist anymore, although it's been a part of Western culture to believe it. Withstanding pain has traditionally been reflective of a strong character--and definitely part of the problem when it comes to administering proper pain relief in kids.

As far as the solution to these problems, Hagan says we need to teach doctors and healthcare workers that pain is the fifth vital sign. Part of what we can fix is health providers' attitudes and make sure they understand these pediatric pain management issues, anticpate painful experiences, and take pain into account when practicing medicine.

Parents can get into the act by also understanding the issues. They can ask good questions before their children go in for potentially painful procedures. For example, ask how pain is going to be gauged, what preparations are made in advance, and what medications can be used once you get the child home.

Different parents have different techniques for calming their children, and different children have different coping skills. Whatever can be done to increase comfort in terms of favorite toys, foods, or people should be thought out beforehand and plans should be prepared in advance. Hagan encourages families to visit hospitals in advance to reduce anxiety and get used to doctors in potentially scary scrubs and gloves. Many hospitals provide child counselors to help out with these efforts.

Hagan also says that since most of the studies of pain management with the newer drugs prior to releasing the drugs are adult studies, we need more studies on pain medications for kids.

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