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Pain: Our Children Are Not ImmuneJennifer was 13 years old. She wore glitter eye shadow and was looking forward to attending an 'N Sync concert with her sister that weekend. She was admitted to the hospital for intravenous antibiotics to treat a simple skin infection. All I needed to do was place an IV and order her antibiotics. I planned to use an anesthetic cream for the IV placement. A downside of the cream is that it can cause constriction of the veins, making the IV harder to place, but Jennifer was old enough to have big veins. I wasn't worried. The anesthetic worked well, and she didn't flinch as I made my first attempt at the IV. The second time she cried a little, but more out of fear than anything else. I wasn't willing to try more than three times, and I called in backup. The ICU nurses tried and then the ER nurses tried. I discussed alternatives to IV therapy with Jennifer's parents and her primary physician, but they preferred that we keep trying. I finally placed an IV on the thirteenth attempt in a spot without the anesthetic cream. It was one of my worst IV experiences. The next day, Jennifer's parents brought Godiva chocolate in appreciation of the excellent care we had provided for their daughter. Misunderstanding PainUndertreatment of pain is a chronic problem in hospitals and is a particularly acute and underrecognized problem in pediatric hospitals. We routinely perform painful procedures on children who cannot understand why they need them. For children too young to appreciate time, "It will only take a minute" is the same as an eternity. Adults can understand why a blood draw is necessary and tolerate the minimal discomfort. For a child, the same blood draw is torture."Put it on! Put it on!" begged a 3-year-old who needed chronic blood transfusions. Her mother explained that she was asking for a Band-Aid, her signal that the blood draw was over. It breaks my heart every time. In a toddler—for whom a stranger's touch is intolerable during even routine exams—IV placements, lumbar punctures, and stitches are terrifying. They don't yet have the verbal ability to understand our explanations or the words to describe the pain and fear they feel. Even with good pain control, we often have to restrain the children to keep them still during procedures. There have been many historical barriers to achieving good pain control in pediatric patients, especially infants and young children. Their pain is easy to dismiss. They can't tell us that it hurts, and we assure ourselves that they won't remember the pain later. Until even 15 years ago, newborns were thought to be incapable of experiencing pain because their nerve fibers are not fully developed at the time of birth. There was also the fear of causing addiction. Anesthetics were dangerous, especially for infants and children. Using these arguments even as late as the 1980s, some surgeons operated with medications to immobilize newborns but without using any medicine to control their pain. Everyone HurtsSince then, all of these arguments have been proven untrue. Despite the underdeveloped pain nerve fibers present at birth, newborns have physiologic changes telling us they experience pain every bit as acutely as older children. Infants who underwent surgery without pain control were shown to have hormonal changes of extreme physiologic stress and more difficult recovery than children who received adequate pain treatment. Furthermore, they seem to remember the pain we so casually dismiss. Infants have been shown to have behavior changes lasting days after painful procedures performed without anesthetic, including circumcision.Pediatricians are not oblivious to pain. There has been a nationwide program to routinely record pain as another vital sign along with heart rate, respiratory rate, temperature, blood pressure, and oxygen saturation. There are many other initiatives at the individual hospital level. Our ideas about pediatric pain have metamorphosed, and our behavior is catching up. I think I am sensitive to issues of pain control, yet I know I have left many patients untreated and undertreated. It was important to observe the pain long enough to diagnose the problem, or the parents didn't report the pain, or I wasn't sure the child was in pain, or it took me time to order the medication and for the nurses to administer it. Recently, a mother's teary eyes widened as I explained the routine blood and urine tests and the lumbar puncture her newborn daughter would need. "But will it hurt?" she asked. I reassured her as best I could. Her daughter needed these tests. I would try to minimize the hurt. But looking at this mother, I knew I couldn't take away the pain. —Ellen Rothman, HMS '98, a third-year resident in pediatrics at Children's Hospital in Boston |
