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Difficulties in Controlling Pain in Children
Difficulties in Controlling Pain in Children Paolo Busoni, M.D. Why Is It Difficult to Control Pain in Children? There are many ways pain can manifest its presence: acute pain, chronic pain, recurring pain, procedure-related pain, and pain associated with terminal illness. Acute pain can be mathematically measured (linked to a number), which cannot be done for chronic pain. Acute pain follows injury to the body, and generally disappears when the bodily injury heals. Often, but not always, it is associated with objective physical signs of autonomic nervous system activity. To the contrary, chronic pain is rarely accompanied by signs of sympathetic nervous system arousal. The lack of objective signs may prompt the inexperienced clinician to say the patient does not “look” like he or she is in pain. Chronic pain is described better by behavioral measurements, for example in the interest and participation of the child for all that is around him, particularly games. Definitions of pain are important for a full understanding of the problem. To define means “to put limits,” and this is essential for comprehension, which is a word of Latin origin meaning “to close within limits.” In the past, many definitions of pain were unsatisfactory. The most recent definition from the International Association for the Study of Pain, “Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage,” is not immediately clear and probably is still unsatisfactory. Years ago, when I was lecturing on pain at a pediatric meeting, the chairman of the session interrupted me and said, “Make a short story of it: Pain is when it hurts!” So I stopped for a few seconds, and was thinking, “Well . . . if this simple, facile, and probably banal definition is true, we have the weapons to counteract and neutralize the pain. It’s as simple as that.”
From Firenze, Italy. Translated by André van Zundert, M.D., Ph.D., F.R.C.A. Accepted for publication November 27, 2006. Reprint requests: André van Zundert, M.D., Ph.D., F.R.C.A., Catharina Hospital, Michelangelolaan 2, NL-5623 EJ, Eindhoven, The Netherlands. E-mail: [email protected] © 2007 by the American Society of Regional Anesthesia and Pain Medicine. 1098-7339/07/3206-0001$32.00/0 doi:10.1016/j.rapm.2006.11.014
Fig 1. Children remember fearful objects after operations, like scissors, knives, and syringes.
It is probably sufficient to act on pain receptors and chemical mediators as we have some knowledge about N-methyl-D-aspartic acid (NMDA) receptors, which are probably responsible for the development of chronic pain. NMDA is a sort of a silent or sleepy nociceptor that is awakened by continuous and repeated acute pain stimulations. Therefore, to prevent chronic pain, it seems wise and advisable to work against any acute pain, which is apparently easy: We have powerful drugs that have painkiller properties. Or, even better, we can block the pain pathways by
Fig 2. Children often focus on the body part operated upon. Note the red genitalia in the drawing.
Regional Anesthesia and Pain Medicine, Vol 32, No 6 (November–December), 2007: pp 505–509
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Regional Anesthesia and Pain Medicine Vol. 32 No. 6 November–December 2007
Fig 3. Drawings of children’s experiences following operations.
using regional techniques, so that any access to the superior cerebral structures is hampered. This is why at that time we used (and are still using!) central blocks and any kind of peripheral blocks even in the smallest neonates. All the regional techniques used in adult patients can be used in children as well. But
other techniques such as the sacral intervertebral block are unique in children.1,2 The needle in the transsacral block takes an upside-down direction and subsequent insertion of a catheter, tunneled under the skin, follows a cranial emergence without any bending or curve.
Fig 4. Child’s impression after staying 10 days in the intensive care unit.
Difficulties in Controlling Pain in Children
Fig 5. Philoktetes in atrocious pain.
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Busoni
507
Recently Busoni et al. described a new technique for use in children, i.e., the local tumescent analgesia technique.3 This technique allows a separate and distant part of the body surface to be anesthetized and has been shown to be very useful for burn patients and for superficial skin surgery. As such, children enjoy a vast array of techniques and drugs that are efficient for a full control of pain. So . . . if nothing is going wrong, is everything then all right? This question introduces a problem related to monitoring and control of what we were doing. Obviously, we were satisfied. But were the children (and their parents4) equally satisfied? We used a simple method: stimulate the children to produce drawings of what they were able to remember the day after surgery was carried out under a full analgesic covering, e.g., a regional block. We were stunned and astonished by the results of this inquiry. First of all, the pictures demonstrated fear and anxiety, both bed fellows of pain. Surprisingly, we discovered that children are able to remember an incredible number of details: scissors, knives, electrocardiogram electrodes, wires, etc. (Fig 1). Children also pay much attention to the body part which is going to be operated upon (note the red external genitalia in Fig 2). My good friend Claude Saint-Maurice from France sent this to me. It is clear the problem is not typically Italian. Our psychologists were shocked by these drawings (Fig 3). They said they were awful, and that we had to change something . . . but what? This is what one child remembers after 10 days’ experience in our intensive care unit (Fig 4). In summary, we discovered that acute pain is
Fig 6. Painting on preparation room ceilings to reduce preoperative anxiety.
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Regional Anesthesia and Pain Medicine Vol. 32 No. 6 November–December 2007
Fig 7. Paintings to distract children’s attention.
not only when it hurts, but that there are more relevant players: anxiety, fear, angst, apprehension to lose control of important parts of the body . . . . All of these feelings play an important role, and cannot be controlled by drugs or blocks. In Homerus it is written that “. . . Philoktetes was lying in atrocious pain in the Island of Lemnos . . . for he had been bitten by a poisonous water snake. There he lay sick and sorry” (Fig 5). Therefore, he was abandoned by the Greek warriors going to the Trojan war. Philoktetes’ foot is a typical example of neuropathic chronic pain. He was lamenting, his foot smelled horrible, and he was abandoned. This episode underlines the social implications of chronic pain. These patients are difficult, the therapeutic results often frustrating, and there is a tendency to abandon these difficult patients. Therefore, we made an inquiry among our children and their parents . . . the simple question was: “What do you fear most in this hospital?” The answers we got back were not only related to pain, but also fear of instruments and a hostile environment full of alarms, disagreeable odors, and unpleasant sounds. We discovered that not only the operating theater was fear and pain inspiring, but the whole hospital environment. After informing the hospital directors, we were fortunate to receive some private funding and started an ambitious project to transform, whenever it was possible, the hospital environment. We put colors everywhere. No more white walls, but pictures and colors. As you see here, pictures on the ceiling of an operating theater, to be more exact on the ceiling of the preparation rooms (Fig 6). Young artists were pleased to show their paintings in the corridors of the
hospital (Fig 7). Clowns, musicians, pet therapy (favorite dog or cat), etc. . . .even in the preoperative rooms, proved to be very useful in alleviating fear and anxiety, not only for the children, but for their parents as well.5,6 These artists were selected to cope with the peculiar hospital environment children can be confronted with in different situations: ambulatory or clinical, radiological or other technical investigations; emergency department; operating theaters; . . .following the child step-by-step through the hospital. In fact, pain is everywhere and not only in the operating theater. However, we should not only control pain, but also the well-being of children to make them feel better. Unfortunately, after initial enthusiasm, soon
Fig 8. Clowns alleviate fear and anxiety in children and their parents.
Difficulties in Controlling Pain in Children
•
Busoni
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Fig 9. Socrates condemned to death by an Athenian court in 399 BC. (“The Death of Socrates” by Jacques Louis David.)
criticism and disapproval appeared. What kind of music should one use? Lullaby and classic music are boring for some of our children. Some of these songs are judged inappropriate and unfit according to the parents and boring for the personnel. Musicians have to be accepted by the nurses and the medical staff, and not perceived as an intrusion.7 Applause from 1 side, criticism from the other. Clowns are extremely useful in mitigating pain and anxiety in children before induction of anesthesia (Fig 8). However, they can deeply disrupt the work of the personnel of the operating theater.5 So, solving 1 problem creates another problem. This seems to be in accordance with the second thermodynamic principle: if you put order in one place, disorder in another appears. In the year 399 B.C., Socrates was condemned to death by an Athenian court that had found him guilty of impiety and corrupting Athenian youth through his teaching (Fig 9). He chose to die by drinking hemlock. The jailer took off his chains, and Socrates, sitting up on the couch, began to bend and rub his leg, saying, as he rubbed: “How singular is the thing called pleasure, and how curiously related to pain, which might be thought to be the opposite of it; for they are never present to a man at the same instant, and yet he who pursues either is generally compelled to take the other; their bodies are two, but they are joined by a single head.” And he invented a myth and said: “If Aesop had remembered them, he would have made a fable about God trying to reconcile their strife, and how, when he could not, he fastened their heads together; and this is the reason why when one comes the other follows, as I know by my own experience now, when after
the pain in my leg which was caused by the chain pleasure appears to succeed.”8 I think this story explains very well, much better than what I tried to say, why it is difficult, according to my experience, to achieve complete pain control in children. I even presume in adults as well.
References 1. Busoni P, Sarti A. Sacral inervertebral epidural block. Anesthesiology 1987;67:993-995. 2. Busoni P, Messeri A, Sarti A. The lumbosacral epidural block: a modified Taylor approach for abdominal urologic surgery in children. Anaesth Intensive Care 1991;19:325-328. 3. Bussolin L, Busoni P, Giorgi L, Crescioli M, Messeri A. Tumescent local anesthesia for the surgical treatment of burns and postburn sequelae in pediatric patients. Anesthesiology 2003;99:1371-1375. 4. Messeri A, Caprilli S, Busoni P. Anaesthesia induction in children: a psychological evaluation of the efficiency of parents’ presence. Paediatr Anaesth 2004;14:551-556. 5. Vagnoli L, Caprilli S, Robiglio A, Messeri A. Clown doctors as a treatment for preoperative anxiety in children: A randomized, prospective study. Pediatrics 2005;116:563-567. 6. Caprilli S, Messeri A. Animal assisted activity at A. Meyer Children’s Hospital. A pilot study. Evid Based Complement Alternat Med 2006;3:379-383. 7. Robiglio A, Caprilli S, Messeri A. Is it possible to heal with sounds? The impact of music at “A. Meyer” Children’s Hospital. The Suffering Child 2004;4:12-14. 8. Plato. Phaedo. Written 360 B.C.E. Translated by Benjamin Jowett.
From Firenze, Italy. Translated by André van Zundert, M.D., Ph.D., F.R.C.A. Accepted for publication November 27, 2006. Reprint requests: André van Zundert, M.D., Ph.D., F.R.C.A., Catharina Hospital, Michelangelolaan 2, NL-5623 EJ, Eindhoven, The Netherlands. E-mail: [email protected] © 2007 by the American Society of Regional Anesthesia and Pain Medicine. 1098-7339/07/3206-0001$32.00/0 doi:10.1016/j.rapm.2006.11.014
Fig 1. Children remember fearful objects after operations, like scissors, knives, and syringes.
It is probably sufficient to act on pain receptors and chemical mediators as we have some knowledge about N-methyl-D-aspartic acid (NMDA) receptors, which are probably responsible for the development of chronic pain. NMDA is a sort of a silent or sleepy nociceptor that is awakened by continuous and repeated acute pain stimulations. Therefore, to prevent chronic pain, it seems wise and advisable to work against any acute pain, which is apparently easy: We have powerful drugs that have painkiller properties. Or, even better, we can block the pain pathways by
Fig 2. Children often focus on the body part operated upon. Note the red genitalia in the drawing.
Regional Anesthesia and Pain Medicine, Vol 32, No 6 (November–December), 2007: pp 505–509
505
506
Regional Anesthesia and Pain Medicine Vol. 32 No. 6 November–December 2007
Fig 3. Drawings of children’s experiences following operations.
using regional techniques, so that any access to the superior cerebral structures is hampered. This is why at that time we used (and are still using!) central blocks and any kind of peripheral blocks even in the smallest neonates. All the regional techniques used in adult patients can be used in children as well. But
other techniques such as the sacral intervertebral block are unique in children.1,2 The needle in the transsacral block takes an upside-down direction and subsequent insertion of a catheter, tunneled under the skin, follows a cranial emergence without any bending or curve.
Fig 4. Child’s impression after staying 10 days in the intensive care unit.
Difficulties in Controlling Pain in Children
Fig 5. Philoktetes in atrocious pain.
•
Busoni
507
Recently Busoni et al. described a new technique for use in children, i.e., the local tumescent analgesia technique.3 This technique allows a separate and distant part of the body surface to be anesthetized and has been shown to be very useful for burn patients and for superficial skin surgery. As such, children enjoy a vast array of techniques and drugs that are efficient for a full control of pain. So . . . if nothing is going wrong, is everything then all right? This question introduces a problem related to monitoring and control of what we were doing. Obviously, we were satisfied. But were the children (and their parents4) equally satisfied? We used a simple method: stimulate the children to produce drawings of what they were able to remember the day after surgery was carried out under a full analgesic covering, e.g., a regional block. We were stunned and astonished by the results of this inquiry. First of all, the pictures demonstrated fear and anxiety, both bed fellows of pain. Surprisingly, we discovered that children are able to remember an incredible number of details: scissors, knives, electrocardiogram electrodes, wires, etc. (Fig 1). Children also pay much attention to the body part which is going to be operated upon (note the red external genitalia in Fig 2). My good friend Claude Saint-Maurice from France sent this to me. It is clear the problem is not typically Italian. Our psychologists were shocked by these drawings (Fig 3). They said they were awful, and that we had to change something . . . but what? This is what one child remembers after 10 days’ experience in our intensive care unit (Fig 4). In summary, we discovered that acute pain is
Fig 6. Painting on preparation room ceilings to reduce preoperative anxiety.
508
Regional Anesthesia and Pain Medicine Vol. 32 No. 6 November–December 2007
Fig 7. Paintings to distract children’s attention.
not only when it hurts, but that there are more relevant players: anxiety, fear, angst, apprehension to lose control of important parts of the body . . . . All of these feelings play an important role, and cannot be controlled by drugs or blocks. In Homerus it is written that “. . . Philoktetes was lying in atrocious pain in the Island of Lemnos . . . for he had been bitten by a poisonous water snake. There he lay sick and sorry” (Fig 5). Therefore, he was abandoned by the Greek warriors going to the Trojan war. Philoktetes’ foot is a typical example of neuropathic chronic pain. He was lamenting, his foot smelled horrible, and he was abandoned. This episode underlines the social implications of chronic pain. These patients are difficult, the therapeutic results often frustrating, and there is a tendency to abandon these difficult patients. Therefore, we made an inquiry among our children and their parents . . . the simple question was: “What do you fear most in this hospital?” The answers we got back were not only related to pain, but also fear of instruments and a hostile environment full of alarms, disagreeable odors, and unpleasant sounds. We discovered that not only the operating theater was fear and pain inspiring, but the whole hospital environment. After informing the hospital directors, we were fortunate to receive some private funding and started an ambitious project to transform, whenever it was possible, the hospital environment. We put colors everywhere. No more white walls, but pictures and colors. As you see here, pictures on the ceiling of an operating theater, to be more exact on the ceiling of the preparation rooms (Fig 6). Young artists were pleased to show their paintings in the corridors of the
hospital (Fig 7). Clowns, musicians, pet therapy (favorite dog or cat), etc. . . .even in the preoperative rooms, proved to be very useful in alleviating fear and anxiety, not only for the children, but for their parents as well.5,6 These artists were selected to cope with the peculiar hospital environment children can be confronted with in different situations: ambulatory or clinical, radiological or other technical investigations; emergency department; operating theaters; . . .following the child step-by-step through the hospital. In fact, pain is everywhere and not only in the operating theater. However, we should not only control pain, but also the well-being of children to make them feel better. Unfortunately, after initial enthusiasm, soon
Fig 8. Clowns alleviate fear and anxiety in children and their parents.
Difficulties in Controlling Pain in Children
•
Busoni
509
Fig 9. Socrates condemned to death by an Athenian court in 399 BC. (“The Death of Socrates” by Jacques Louis David.)
criticism and disapproval appeared. What kind of music should one use? Lullaby and classic music are boring for some of our children. Some of these songs are judged inappropriate and unfit according to the parents and boring for the personnel. Musicians have to be accepted by the nurses and the medical staff, and not perceived as an intrusion.7 Applause from 1 side, criticism from the other. Clowns are extremely useful in mitigating pain and anxiety in children before induction of anesthesia (Fig 8). However, they can deeply disrupt the work of the personnel of the operating theater.5 So, solving 1 problem creates another problem. This seems to be in accordance with the second thermodynamic principle: if you put order in one place, disorder in another appears. In the year 399 B.C., Socrates was condemned to death by an Athenian court that had found him guilty of impiety and corrupting Athenian youth through his teaching (Fig 9). He chose to die by drinking hemlock. The jailer took off his chains, and Socrates, sitting up on the couch, began to bend and rub his leg, saying, as he rubbed: “How singular is the thing called pleasure, and how curiously related to pain, which might be thought to be the opposite of it; for they are never present to a man at the same instant, and yet he who pursues either is generally compelled to take the other; their bodies are two, but they are joined by a single head.” And he invented a myth and said: “If Aesop had remembered them, he would have made a fable about God trying to reconcile their strife, and how, when he could not, he fastened their heads together; and this is the reason why when one comes the other follows, as I know by my own experience now, when after
the pain in my leg which was caused by the chain pleasure appears to succeed.”8 I think this story explains very well, much better than what I tried to say, why it is difficult, according to my experience, to achieve complete pain control in children. I even presume in adults as well.
References 1. Busoni P, Sarti A. Sacral inervertebral epidural block. Anesthesiology 1987;67:993-995. 2. Busoni P, Messeri A, Sarti A. The lumbosacral epidural block: a modified Taylor approach for abdominal urologic surgery in children. Anaesth Intensive Care 1991;19:325-328. 3. Bussolin L, Busoni P, Giorgi L, Crescioli M, Messeri A. Tumescent local anesthesia for the surgical treatment of burns and postburn sequelae in pediatric patients. Anesthesiology 2003;99:1371-1375. 4. Messeri A, Caprilli S, Busoni P. Anaesthesia induction in children: a psychological evaluation of the efficiency of parents’ presence. Paediatr Anaesth 2004;14:551-556. 5. Vagnoli L, Caprilli S, Robiglio A, Messeri A. Clown doctors as a treatment for preoperative anxiety in children: A randomized, prospective study. Pediatrics 2005;116:563-567. 6. Caprilli S, Messeri A. Animal assisted activity at A. Meyer Children’s Hospital. A pilot study. Evid Based Complement Alternat Med 2006;3:379-383. 7. Robiglio A, Caprilli S, Messeri A. Is it possible to heal with sounds? The impact of music at “A. Meyer” Children’s Hospital. The Suffering Child 2004;4:12-14. 8. Plato. Phaedo. Written 360 B.C.E. Translated by Benjamin Jowett.