CHILDREN HAVE PAIN, TOO

G. Allen Finley, MD FRCPC FAAPProfessor of Anesthesia & Psychology, Dalhousie University

Dr. Stewart Wenning Chair in Pediatric Pain, IWK Health CentreHalifax, NS

Just over 20 years ago, a little girl taught me about pain. At 4 years old, she was dying from cancer. When I first met her, she was curled up under the blankets, looking like a wet dishrag. She wouldnʼt talk to anyone, and wouldnʼt let her mother hold her. We started a simple treatment with intravenous morphine, and she began laughing, joking, singing songs, and drawing pictures. Her parents had 6 weeks of the child they knew and loved, before she quietly and comfortably passed away. She changed my life.

Imagine being the parent of a child with cancer who wonʼt even let you hug her because it hurts too much. Imagine being a teenager with chronic pain who nobody believes. Imagine being too young to find the words to say when it hurts. We do a better job with children like Caitlyn these days, but children all over the world still suffer severe pain from surgery, arthritis, injuries, burns and hospital needle pokes, even though doctors and nurses know how to prevent or treat most pain. This pain also hurts their parents, their loved ones, and those who care for them.

Did you know that some premature babies have up to 25 needle pokes and skin-breaking procedures on their first day of life? Thatʼs no way to spend your birthday! When premature and newborn babies suffer untreated pain, there are permanent changes to the nervous system that can affect their whole lives.

Children suffer many types of pain, but perhaps the worst are the pains that we inflict as health care professionals, under the guise of investigation or treatment. Although children seem to recover quickly after surgery, that doesnʼt mean that they donʼt have the same amount of pain for the initial recovery period as an adult would, yet they frequently get less medication for their size than adults.

On the other hand, they often donʼt complain, because they are afraid the pain treatment might be worse than the pain itself, or they are just trying to “be brave”. Children have lots of good reasons not to tell you about their pain.

Children with neurological impairments like cerebral palsy are even more disadvantaged. They undergo many more operations and procedures than the average child, but because they canʼt communicate as well, their pain often isnʼt recognized.

Pain has a purpose – itʼs there help us prevent further damage in case of injury. Children with the rare genetic inability to feel pain have continuous problems with burns, infections, and injuries. However, chronic pain that continues after the injury has healed or occurs without tissue damage serves no useful purpose – it is a disease in its own right.

Six to 8% of children in the community suffer “intense and frequent pain” that interferes with their lives. If a 40 year old misses a year or two of work due to pain, then there are economic implications, but our society has resources that step in, like Workmenʼs Compensation. What happens if you miss grades 11 and 12 due to pain? What are the long term consequences for the individual and for society?

Why don't we do more to prevent suffering in the most vulnerable members of our society? What are the barriers to providing better pain relief for children? We know parents want their childrenʼs pain treated.

There are even international agreements that Canada is a signatory to, such as the United Nations Convention on Rights of the Child, that mandate better care for children than is presently provided.

Even in Canadaʼs foremost teaching hospitals there is an unacceptable burden of pain and suffering inflicted on children, and in other healthcare settings the situation is even worse.

We are moving forward with initiatives to improve childrenʼs pain prevention

and treatment around the world. We need more research, but we need to focus less on how to treat pain, which drugs to give, and more on how to ensure pain is assessed and treated in every child. The challenges are greater in health service delivery than in pharmacology; in making sure that every physician, nurse, physiotherapist, psychologist, lab technician, and administrator recognizes the importance of pain to children, their families, and their caregivers.

We need a commitment to research, service, and advocacy. This can be accomplished by implementing the principles of ChildKind International, an innovative initiative of the IASP Special Interest Group on Pain in Childhood to designate hospitals that take steps to prevent and treat pain.

The World Health Organization has just published basic guidelines for managing childrenʼs pain, and these need to be implemented world-wide.

By reaching out to clinicians and hospitals with a national strategy, we can prevent much acute pain from occurring, and from developing into chronic pain syndromes that stop children from attending school, playing, learning, and developing. By developing an institutional and clinical culture that recognizes the importance of pain prevention, we can ensure that every member of every hospital staff considers it part of their daily job to prevent and relieve suffering.

We know what we have to do. Letʼs get together and make it happen!