CHILDREN'S HEALTH * SANTE INFANTILE ET JUVENILE
Pediatric pain and polar bears David Helwig A n imaginary polar bear and a 3-year-old cancer patient who dreaded lumbar punctures were among the reasons psychologist Patricia McGrath of London, Ont., established Canada's first pediatric pain-management program. The oncology patient, Jennifer, was one of six patients at the Children's Hospital of Western Ontario (CHWO) in the early 1 980s who taught McGrath the importance of understanding pain from a child's perspective. For example, the children corrected McGrath's false assumption that the worst part of a lumbar puncture was when the needle entered the spinal cord. "What I learned is that [the needle] didn't bother children at all", she recalls. "What bothered them were factors that we now know are really powerful modifiers of
pain." For Jennifer, and many other children, the most disturbing aspect of the procedure was found to be the preinsertion application of ethyl chloride spray. Enter the polar bear. "In working with Jennifer, we talked about what is cold and wet, akin to this spray", McGrath told CMAJ. "We tried to make a game of it, to invent something that would feel cold and wet, and maybe prick her, but that wouldn't frighten her during the procedure. I don't know David Helwig is a freelance writer living in St. Thomas, Ont. 130
CAN MED ASSOC J 1990; 143 (2)
whether it was Jennifer or me who thought of a big wet kiss from a polar bear. He has a jagged tooth, and when he pulls away he nips your back. "The very next procedure, she was calm throughout. She didn't react to the spray, or the prick [of the local infiltration], or the needle insertion. She didn't find it at all difficult. At the end, she said it was a piece of cake." Jennifer died about 3 years ago but her photograph still holds a prominent spot on McGrath's desk, and the lessons learned from her and other early patients have become integral components of CHWO's pediatric pain program. "I think what they taught me is that the answer to understanding a child's pain comes from the children themselves, not from us blindly applying adult perceptions to their world", McGrath says. Indeed, she thinks the proper management of pain in both children and adults has been hindered by major misperceptions that have been corrected only during the past 15 years. One such impediment was the long-standing belief that the sensory system for pain consisted of fixed nerve routes. Descartes, for example, proposed in his 1664 Treatise on Man that burning pain was caused by tiny particles of fire that activated nerves that in turn transmitted energy to the brain along clear-cut pathways. This direct-path theory, however, implied that pain must be directly proportional to the nature
and extent of tissue damage. It did not explain why some people experience excruciating pain without any noticeable injury, or why athletes are sometimes seriously injured during competition but fail to notice until later. "It is now commonly accepted that the sensory system for pain is complex and that there are many places in the nociceptive system where the signals initiated by a noxious stimulus can be modified to alter pain perception", McGrath and CHWO colleague Loretta Hillier wrote last year in a paper published in Pediatrician (1989; 16: 6-15). "There are endogenous opioid systems that can be activated by environmental and psychological factors to suppress pain." McGrath's research suggests that simple, nonpharmacologic
pain-suppression techniques employing these factors are especially powerful when used on children. After all, youngsters tend to be less sceptical about nondrug interventions than adults. "They have all experienced the pain relief provided by a parental hug or kiss after an injury, so they understand that their pain can be truly modified by nondrug techniques", McGrath writes in her book, Pain in Children: Nature, Assessment, and Treatment. It was published this year by Guilford Press. McGrath came to London in 1979 from the National Institutes of Health in Bethesda, Maryland. It was supposed to have been only a 2-year visit to study dental pain,
but her interest in pediatrics led to an invitation from Dr. Barrie de Veber to work with some of his cancer patients. "Those kids led me to decide I wanted to devote myself pretty much full time to pediatrics", McGrath says. In 1983, she established CHWO's pioneering pediatric pain program. "As far as I know, we were the first in North America. "There's been a proliferation of pain clinics in the last 3 years.... As far as I know, we still are one of the few that is multidisciplinary, in that we're not sponsored by a particular discipline within medicine." Children are referred to the CHWO program because of chronic pain that has a psychologic basis, recurrent pain syndromes including abdominal, limb and head pain, and acute pain caused by disease, injury or medical procedures. The program's chief goals are to increase the patient's understanding and control. Jennifer, for instance, was instructed at a preschool level about the intent and technicalities of her lumbar punctures and taught some simple methods of pain reduction. Instead of dwelling on her fears concerning the procedure, she was encouraged to describe ethyl chloride's true, not-so-unpleasant sensations. Pediatric pain associated with medical procedures is often exacerbated by a perceived lack of control. Well-meaning parents can worsen the situation by intentionally neglecting to tell a child about a lumbar puncture ahead of time, depriving him of an opportunity to prepare. "In general, children will experience less pain when they are prepared in an age-appropriate manner for a potentially pain-inducing stimulus", McGrath says. Proper pain management begins, she says, with adequate analgesia selected according to the
Children are less sceptical about nondrug interventions than adults.
child's pain level and the circumstances in which pain is experienced. Then, the factors affecting the child's perception of pain must be identified and modified. McGrath advises against relying on a single pain-control method. Instead, she recommends teaching each child numerous techniques. The following are some sample strategies: * relax using biofeedback, deep breathing, soothing music, progressive relaxation, or breathing imaginary "magic sparklies"; * divert attention with stories, songs, counting, conversation, games, or by allowing the patient to help with the procedure; * deep, continuous rubbing; * imagine numbness, or that the pain does not disturb; * "move" the pain; * imagine a favourite television superhero; * hypnosis; * squeeze the hand of an adult in proportion to pain intensity; * exercise; * acupuncture; * instruct family members to treat the child normally on days of painful procedures. Instead of hushed voices and darkened rooms, allow the patient to play in
the waiting area or play room. Many of these techniques, of course, are not new. Relaxing by exercise or quiet music, or distraction with some engrossing activity, were all recognized as paincontrol measures by Avicenna, the Persian physician and Islamic philosopher, in the 10th century AD. Such simple methods can nonetheless be highly effective. For example, a CHWO study found that the mean number of distress behaviours among nine boys and five girls undergoing lumbar punctures fell from 3.6 per child to 1.3 - the maximum number possible was 5 - after a pain-management program. Pain-control measures often can be undertaken without prolonging treatment. In cases in which the procedure does take longer, subsequent treatments often take less time as patients become more cooperative and less fearful. Nonetheless, clinical application is lagging far behind scientific advances in the pediatric-pain field. Despite growing evidence that infants may experience pain during circumcision, McGrath's hospital continues to perform the procedure using only a little rye whisky for analgesia. "Some people feel whisky is a placebo for people performing the circumcision, but doesn't do anything for the child", she points out. Others argue that circumcision performed by a skilled physician causes less pain than an injection, but McGrath suspects better pain management is possible. "I would almost like to see us move toward giving local infiltrations until somebody can prove that not to give them causes less pain. "I think the pendulum is swinging. We've been at one end of providing inadequate pain management. I think we're swinging towards providing very good pain-control techniques to infants and children."m CAN MED ASSOC J 1990; 143 (2)
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Pediatric pain and polar bears David Helwig A n imaginary polar bear and a 3-year-old cancer patient who dreaded lumbar punctures were among the reasons psychologist Patricia McGrath of London, Ont., established Canada's first pediatric pain-management program. The oncology patient, Jennifer, was one of six patients at the Children's Hospital of Western Ontario (CHWO) in the early 1 980s who taught McGrath the importance of understanding pain from a child's perspective. For example, the children corrected McGrath's false assumption that the worst part of a lumbar puncture was when the needle entered the spinal cord. "What I learned is that [the needle] didn't bother children at all", she recalls. "What bothered them were factors that we now know are really powerful modifiers of
pain." For Jennifer, and many other children, the most disturbing aspect of the procedure was found to be the preinsertion application of ethyl chloride spray. Enter the polar bear. "In working with Jennifer, we talked about what is cold and wet, akin to this spray", McGrath told CMAJ. "We tried to make a game of it, to invent something that would feel cold and wet, and maybe prick her, but that wouldn't frighten her during the procedure. I don't know David Helwig is a freelance writer living in St. Thomas, Ont. 130
CAN MED ASSOC J 1990; 143 (2)
whether it was Jennifer or me who thought of a big wet kiss from a polar bear. He has a jagged tooth, and when he pulls away he nips your back. "The very next procedure, she was calm throughout. She didn't react to the spray, or the prick [of the local infiltration], or the needle insertion. She didn't find it at all difficult. At the end, she said it was a piece of cake." Jennifer died about 3 years ago but her photograph still holds a prominent spot on McGrath's desk, and the lessons learned from her and other early patients have become integral components of CHWO's pediatric pain program. "I think what they taught me is that the answer to understanding a child's pain comes from the children themselves, not from us blindly applying adult perceptions to their world", McGrath says. Indeed, she thinks the proper management of pain in both children and adults has been hindered by major misperceptions that have been corrected only during the past 15 years. One such impediment was the long-standing belief that the sensory system for pain consisted of fixed nerve routes. Descartes, for example, proposed in his 1664 Treatise on Man that burning pain was caused by tiny particles of fire that activated nerves that in turn transmitted energy to the brain along clear-cut pathways. This direct-path theory, however, implied that pain must be directly proportional to the nature
and extent of tissue damage. It did not explain why some people experience excruciating pain without any noticeable injury, or why athletes are sometimes seriously injured during competition but fail to notice until later. "It is now commonly accepted that the sensory system for pain is complex and that there are many places in the nociceptive system where the signals initiated by a noxious stimulus can be modified to alter pain perception", McGrath and CHWO colleague Loretta Hillier wrote last year in a paper published in Pediatrician (1989; 16: 6-15). "There are endogenous opioid systems that can be activated by environmental and psychological factors to suppress pain." McGrath's research suggests that simple, nonpharmacologic
pain-suppression techniques employing these factors are especially powerful when used on children. After all, youngsters tend to be less sceptical about nondrug interventions than adults. "They have all experienced the pain relief provided by a parental hug or kiss after an injury, so they understand that their pain can be truly modified by nondrug techniques", McGrath writes in her book, Pain in Children: Nature, Assessment, and Treatment. It was published this year by Guilford Press. McGrath came to London in 1979 from the National Institutes of Health in Bethesda, Maryland. It was supposed to have been only a 2-year visit to study dental pain,
but her interest in pediatrics led to an invitation from Dr. Barrie de Veber to work with some of his cancer patients. "Those kids led me to decide I wanted to devote myself pretty much full time to pediatrics", McGrath says. In 1983, she established CHWO's pioneering pediatric pain program. "As far as I know, we were the first in North America. "There's been a proliferation of pain clinics in the last 3 years.... As far as I know, we still are one of the few that is multidisciplinary, in that we're not sponsored by a particular discipline within medicine." Children are referred to the CHWO program because of chronic pain that has a psychologic basis, recurrent pain syndromes including abdominal, limb and head pain, and acute pain caused by disease, injury or medical procedures. The program's chief goals are to increase the patient's understanding and control. Jennifer, for instance, was instructed at a preschool level about the intent and technicalities of her lumbar punctures and taught some simple methods of pain reduction. Instead of dwelling on her fears concerning the procedure, she was encouraged to describe ethyl chloride's true, not-so-unpleasant sensations. Pediatric pain associated with medical procedures is often exacerbated by a perceived lack of control. Well-meaning parents can worsen the situation by intentionally neglecting to tell a child about a lumbar puncture ahead of time, depriving him of an opportunity to prepare. "In general, children will experience less pain when they are prepared in an age-appropriate manner for a potentially pain-inducing stimulus", McGrath says. Proper pain management begins, she says, with adequate analgesia selected according to the
Children are less sceptical about nondrug interventions than adults.
child's pain level and the circumstances in which pain is experienced. Then, the factors affecting the child's perception of pain must be identified and modified. McGrath advises against relying on a single pain-control method. Instead, she recommends teaching each child numerous techniques. The following are some sample strategies: * relax using biofeedback, deep breathing, soothing music, progressive relaxation, or breathing imaginary "magic sparklies"; * divert attention with stories, songs, counting, conversation, games, or by allowing the patient to help with the procedure; * deep, continuous rubbing; * imagine numbness, or that the pain does not disturb; * "move" the pain; * imagine a favourite television superhero; * hypnosis; * squeeze the hand of an adult in proportion to pain intensity; * exercise; * acupuncture; * instruct family members to treat the child normally on days of painful procedures. Instead of hushed voices and darkened rooms, allow the patient to play in
the waiting area or play room. Many of these techniques, of course, are not new. Relaxing by exercise or quiet music, or distraction with some engrossing activity, were all recognized as paincontrol measures by Avicenna, the Persian physician and Islamic philosopher, in the 10th century AD. Such simple methods can nonetheless be highly effective. For example, a CHWO study found that the mean number of distress behaviours among nine boys and five girls undergoing lumbar punctures fell from 3.6 per child to 1.3 - the maximum number possible was 5 - after a pain-management program. Pain-control measures often can be undertaken without prolonging treatment. In cases in which the procedure does take longer, subsequent treatments often take less time as patients become more cooperative and less fearful. Nonetheless, clinical application is lagging far behind scientific advances in the pediatric-pain field. Despite growing evidence that infants may experience pain during circumcision, McGrath's hospital continues to perform the procedure using only a little rye whisky for analgesia. "Some people feel whisky is a placebo for people performing the circumcision, but doesn't do anything for the child", she points out. Others argue that circumcision performed by a skilled physician causes less pain than an injection, but McGrath suspects better pain management is possible. "I would almost like to see us move toward giving local infiltrations until somebody can prove that not to give them causes less pain. "I think the pendulum is swinging. We've been at one end of providing inadequate pain management. I think we're swinging towards providing very good pain-control techniques to infants and children."m CAN MED ASSOC J 1990; 143 (2)
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