It’s a common mistake to assume that children and infants experience pain differently from adults. However, the only supporting evidence behind that theory is a lack of evidence – infants cannot properly communicate how they feel, and interpreting an infant’s wants and needs is very difficult. Contrary to this old belief, recent research shows that babies experience pain just as adults do, calling into question many pediatric pain management practices, including the treatment of pain in infants and children over the past few decades.
While the opioid crisis has revealed a problem with the treatment of pain and pain-related illnesses in America, as well as a great problem with the way healthcare is handled in our country, children have ostensibly been even worse off, not receiving the care and attention they need, especially before, during, and after major surgery. In the past, a screaming infant being operated on without prior sedation was ignored on the basis that the neurology of the infant was not ‘advanced enough’ to feel the pain quite the same way and that that person would ‘not even remember it.’
Since then, things have changed. And today, we know better. Babies experience pain in its full breadth as adults do, according to brain imaging. Many people vividly remember traumatizing and painful memories from when they were two years old and younger, including medical treatments such as open-heart surgery or spine surgery. We must be better. It takes a concerted effort to elicit any major change, and thankfully, changes have been taking place over the past few years. But it is not enough.
Children need better post-operative care, including access to non-opioid medication, more individual patient care, more time spent with visitors and other human beings, and most importantly, more time spent asking the patient to rate and describe their pain honestly. The only somewhat accurate way of gauging another person’s pain is to ask them and to ask them often. Pain management for children must, in some cases, also involves the use of opioids. As much as we are investing in a future free from narcotic analgesics, the reality is that nothing combats acute pain like an IV of morphine.
And as unnecessary as it might seem, IV medication is still preferable for children to an intramuscular injection. Many children refuse pain medication if it comes through the other end of a sharp needle, to the point that they would rather pass out in pain than receive a shot (even one that may make them feel better). We have to remember that children are impulsive and react more to short-term consequences than the potential of a long-term reward. It’s difficult to think ahead when you’re younger, and the brain is more likely to draw links and associations, including those that potentiate trauma.
Pain management is, first and foremost, patient-centered and must depend entirely on the communication between a patient and their caregivers. Poorly-managed pain in children can lead to trust issues, chronic pain-related conditions such as hyperalgesia, as well as behavioral problems, and a greater likelihood to underreport a pain that might give doctors a hint at some underlying cause or disease. The same goes for the reckless prescription of opioids, which is just as folly as not prescribing anything for the pain.
Pain Management for Children
Because babies and children feel pain as adults do, their pain must be treated much the same way: through a patient-centric, multimodal approach that considers a child’s mental as well as physical state. Pain management depends heavily on the communication between the patient and the caregiver. Between a nurse or doctor and their pediatric patient, this can be very complicated. Oftentimes, having a parent around is important to authorize certain treatments or help the child feel safer and less frightened by the whole situation.
Children are emotionally volatile and often more reactive, calming them down and soothing them that much more important. An anxious child is much more likely to feel pain than a calm child, and the expectation of pain raises the perception of pain regardless of the stimuli. If a child expects it to hurt, it’ll hurt more. Proper communication, therefore, is critical both to interpreting a child’s pain for therapeutic purposes as well as to help the child cope with their situation and remain calm and less anxious.
Pain Management, Post-Operative Care & the Role of Opioids
Pain management in post-operative care depends on the severity and scope of the operation. While all pain management experts would be against the liberal use of opioids to treat any pain, there are cases of post-operative pain that cannot be treated without narcotic analgesics. However, it’s important to take into account how each individual responds to the medication.
Some do well on little sedation and non-opioid painkillers, while others need something stronger. The trauma of poor pain management and extreme post-operative care is often more damaging than the potential of addiction from a short-term treatment of severe pain with opioids. It’s not a perfect solution, but until better options are available, the first line of defense against severe and acute post-operative pain will be opioids.
Importance of Communication & Complementary Medicine
Children are often not capable of properly speak for themselves. They do, however, respond thoroughly when asked the right questions. In pediatric pain management, every case is individual, so a one-on-one patient-centric approach is critical. With that comes the need for good communication. Nurses and attendants must comfort and question children in pre-and post-operative care, correctly assess pain levels and administer the right form of care.
Sadly, the primary barrier to proper care continues to be the American healthcare system. Many parents can’t afford the right post-operative care for their children, with their only option to buy the prescribed painkillers and hope for the best. In some cases, due to the changes in the way doctors are handling opioid prescriptions, children may be left with little more than a non-steroidal anti-inflammatory to soothe their post-operative pain.
While NSAIDs are enough for most procedures, recovery from major surgery usually requires a stronger, more effective approach. Speaking of effective approaches, ideal pain management is not a one-lane street. Pain management must be multimodal, tackling the patient’s pain from multiple angles through different available therapies. Pharmacological solutions are one thing, but there is a growing body of evidence to support milder postoperative pain, including the use of:
- Physical therapy
- And relaxation techniques
Support from the family is invaluable. Children must know that they’re loved and surrounded by those who care about them and that they’re not alone, left without contact, for hours and hours at a time. The psychological pain of loneliness inflicted on a child after severe surgery can be very damaging, as it is both terrifying and disheartening. Furthermore, it helps to differentiate between pain and harm.
Pain and harm are easily conflated, but most post-operative pain is not harmful and just a side-effect of surgery. This can be complicated for some kids to understand, as they need to report on any unusual or long-lasting pain pointing towards a potential infection or postoperative complication. Nevertheless, knowing that what they’re going through is ultimately going to do them good can feel reassuring in the long run.