NYTimes: Why Aren’t We Managing Children’s Pain?

Why Aren’t We Managing Children’s Pain?
By Rachel Rabkin Peachman
June 27, 2016 2:36 pm
It began with a simple roller­skating accident three years ago. Taylor
Aschenbrenner, then 8 years old, lost her balance amid a jumble of classmates,
tumbled to the floor and felt someone else’s skate roll over her left foot. The searing
pain hit her immediately.
The diagnosis, however, would take much longer. An X­ray, M.R.I.s, a CT scan
and blood tests over several months revealed no evidence of a break, sprain or other
significant problem. Taylor’s primary symptom was pain — so severe that she could
not put weight on the foot.
“Our family doctor first told us to give it some time,” said Taylor’s mother, Jodi
Aschenbrenner, of Hudson, Wis.
But time didn’t heal the pain. After about a month, an orthopedist
recommended physical therapy. That didn’t end the problem, either. “I couldn’t walk
or play outside or do anything,” Taylor said.
After she had spent a year and a half on crutches, her orthopedist suggested she
see Dr. Stefan Friedrichsdorf, the medical director ofpain medicine, palliative care
and integrative medicine at Children’s Hospitals and Clinics of Minnesota. He and
his team promptly recognized Taylor’s condition as complex regional pain
syndrome, a misfiring within the peripheral and central nervous systems that causes
pain signals to go into overdrive and stay turned on even after an initial injury or
trauma has healed.
He came up with a treatment plan for Taylor that included cognitive behavioral
therapy, physical therapy, mind­body techniques, stress­reduction strategies, topical
pain­relief patches and a focus on returning to her normal life and sleep routine,
among other things.
“That turned things around so fast, if I didn’t see it myself, I wouldn’t have
believed it,” Mrs. Aschenbrenner said. “I thought, ‘finally, someone understands
what this is, has experience with it, and knows how to fix it!’”
But why did it take so long for a child in unbearable pain to find relief? Experts
say children’s pain is, for the most part, grossly underrecognized and undertreated.
“Unfortunately, in 2016 pain management in the United States and all Western
countries is still abysmal,” said Dr. Friedrichsdorf, who noted that pediatric pain
receives the least attention. “Data shows that adults with the same underlying
condition will get two to three times as many pain medication doses as children. We
also know that the younger a child is, the less likely it is that he or she will get proper
pain management in the hospital.”
There are effective treatments for pediatric pain. But pediatricians, specialists
and even parents have been slow to turn to them because pain in children has long
been misunderstood and medical training in pain management is scant. Veterinary
schools require “at least five times more education on how to handle pain” than
medical schools, Nora D. Volkow, the director of theNational Institute on Drug
Abuse, said earlier this year in testimony before a Senate committee.
As recently as the 1980s, babies would routinely undergo invasive medical
procedures, including open­heart surgery, without anesthesia or analgesics because
physicians believed that infants’ brains were not developed enough to feel the pain.
And it was thought that even if babies did feel pain, it wouldn’t ultimately matter
because they wouldn’t remember it later on.
The emphasis in Western medicine has traditionally been on “addressing the
underlying condition at hand, saving lives and executing medical procedures
effectively, while pain has been pushed way down on the priority list,” said Christine
Chambers, a professor of pediatrics, psychology, neuroscience and pain
management at Dalhousie University in Halifax, Nova Scotia.
Many doctors and parents also fear that pain medications, whether or not they
are warranted, will have dangerous side effects on children, such as developmental
problems and addiction. Current scientific evidence, however, supports a different
conclusion.
“Research shows that poorly managed pain exposures early in life can actually
change the wiring in the brain and prime children to be more sensitive to it later on,
putting them at risk for developing chronic pain in childhood and adulthood,” said
Anna C. Wilson, a child psychologist and assistant professor of anesthesiology at the
Pediatric Pain Management Center at Oregon Health & Science University. And
while babies or young children may not consciously remember it later in life, their
nervous systems will.
But there is reason for optimism. Contrary to previous conventional thinking,
the effective use of pain medication for children does not hinder brain development,
according to several studies. “We know that giving strong pain medications to very
young children does not interfere with their neurodevelopment later on,” Dr.
Friedrichsdorf said.
Research has also shown that the appropriate medical use of prescription pain
medications, such as opioids, when properly monitored, does not lead to addiction
in young children and adolescents, Dr. Friedrichsdorf added.
A host of other behavioral interventions have been shown to prevent and treat
pain as well. Pain experts say these can and should be used even during seemingly
minor medical procedures, such as vaccinations. Parents can hold their children
during the procedure, breast­feed or give them a sweet solution (or a lollipop for
older children) to suck on, distract them with a song or breathing exercises, and use
a topical numbing cream if needed.
One recent study also found that a parent’s behavior and approach to their
children’s vaccinations can affect a child’s response to needles.
“That vaccination at age 5 might not seem like a big deal to you, but if it goes
wrong and causes a lot of pain, then the child becomes fearful, and the parent might
not take them back for subsequent vaccinations,” Dr. Chambers said. “The child may
then escalate a response when they require blood work for some other condition,
and then they will get pinned down,” which can perpetuate a cycle of fear and pain
over medical care.
She has started a social media campaign called “It Doesn’t Have to Hurt” that
aims to educate parents about resources that can ease children’s pain. Organizations
like ChildKind International are approaching the issue through clinicians. ChildKind
has developed an accreditation available to hospitals that make pain management in
children a priority.
“One of the best ways to address the epidemic of chronic pain in this country is
to stop it before it starts,” said Dr. Wilson at Oregon Health & Science University. “If
we could reduce painful experiences and problems in childhood, we might be able to
reduce chronic pain in the next generation.”