An 18-month-old girl splits her lip badly while climbing on an icy jungle gym at her day care center. Her parents are contacted and they rush her to the local emergency room,
where the attending physician confirms that her lip will need three or four stitches. He explains that he can use a local anesthetic to numb the area, but advises the parents that
this, too, will be painful for their daughter. He suggests that they get the procedure over as quickly as possible without the use of local anesthesia. The father agrees to restrain his daughter while her lip is sutured.
The above story—which is based on an actual event—is not meant to imply that children are being cruelly subjected to torturous medical procedures. Rather, it raises questions
concerning commonly held attitudes and beliefs about pediatric pain. Is a child’s experience of pain different from an adult’s experience of pain? Would the ER physician
have dismissed the use of a local anesthetic had the patient been an adult?
The tendency toward under medication is far more pronounced in children than in adults. Studies reveal that children receive much less postoperative analgesia than adults who have
the same diagnoses and have undergone the same procedures. And children younger than 2 years of age are less likely to be treated than older children.
Reasons for these disparities are rooted in
- Myths about children’s experience of pain
- Fears held by patients’ parents and healthcare providers about opioid addiction and adverse side affects of pain medication
- Inadequate knowledge of pain assessment and state-of-the-art treatment options.
The following are examples of widely held myths:
Myth: Young infants do not feel pain. Children tolerate pain better than adults because their nervous systems are immature.
Fact: Neuroanatomical studies show that cortical and subcortical centers responsible
for perceiving pain, as well as neurologic pain transmission pathways, are well-developed by 29 weeks of gestation. Moreover, current
research indicates that infants and children most likely experience more pain than adults as a result of a vigorous inflammatory response
to pain combined with reduced central inhibitory influence.
Myth: Children have no memory of their early years and therefore experience no long-term effects of pain.
Fact: It is now known that pain and distress do indeed endure in memory and may exaggerate behavioral and affective responses during subsequent painful events.
Preliminary research data suggest that early painful experiences may actually change the function and structure of nociceptive neural pathways, causing increased sensitivity to pain.
Nociceptive pain results from the activation of nociceptors by noxious stimuli; causes of nociceptive pain include bone fractures, inflammation, burns and sprains.
Myth: Children become addicted to narcotics easily.
Fact: Less than 1% of children treated with opioids develop an addiction. When appropriately administered, opioids are no more dangerous for children than they are for adults.
Myth: The use of opioids in children will result in respiratory depression.
Fact: While respiratory depression is a serious and well-known side effect of opioids, it rarely occurs in children. Safe and effective use of opioids in children, without increased risk
of respiratory depression, has been documented.
Indeed, with adequate monitoring and adherence to appropriate guidelines for dosages, respiratory depression should be a rare event in children. Also, because agents are available to reverse
the effects of opioids, the condition can be treated if it occurs.
Healthcare providers who have attitudinal biases regarding pediatric pain relief, inadequate pain assessment skills and limited knowledge of treatment options are at risk for legal claims
of unnecessary physical and emotional distress.
Myths, fears and lack of adequate knowledge explain—but do not excuse—the suffering that children experience as a result of under medication. The current availability of safe,
low-cost pediatric pain management technology raises this basic question: Is the apparent under treatment of pain in children ethically justifiable?
Fortunately, medical specialty organizations such as the American Academy of Pediatrics and the American Pain Society are working diligently to transform pediatric pain research into clinical practice,
and excellent resources and guidelines exist for delivering safe, quality and compassionate pain care to children.
If the fundamental principle of responsible medical care is “do no harm,” pediatric clinicians must consider the potential “harm” of pain and decide whether failure to use all possible means of relieving pain is ethical.
As seen in recent lawsuit decisions, physicians are increasingly being held accountable for failure to adequately treat pain. Pressure from parents is also playing a part in the evolution of new pediatric treatment protocols.
In examining current practices and identifying needed changes, pediatric physicians are encouraged to utilize new pain management standards and guidelines, online resources, research data and risk managers.
