As recently as a decade ago, most doctors believed that newborn infants had immature nervous systems that prevented them from feeling pain, and that even older children did not remember pain. Doctors also hesitated to use narcotics in children because they feared the drugs would cause respiratory problems and addiction.

Recent research has shown just the opposite, however. It is now known that babies have a mature nervous system able to feel pain—which is unfortunately coupled with an immature ability to produce neurochemicals that can inhibit pain.

And even when older children cannot remember the actual experience of pain, it seems to get permanently recorded at a biological level. According to a study published in the Archives of Pediatrics & Adolescent Medicine, children who received painful bone marrow aspiration treatments without pain medication suffered more during later procedures even when they were done with painkillers.

In fact, insufficiently treated pain early in life can cause lasting—perhaps lifelong—emotional and physiological damage. Younger children especially lack the experiences and mental abilities that help older children and adults mitigate incoming pain; for example, the knowledge that the pain after an injection is not serious and will soon pass.

Assessing Pain in Children

The measurement of pain in children is a major challenge because they often cannot effectively communicate the pain they are experiencing. “Self-report” has long been considered the standard tool in pain assessment. 

A variety of assessment tools are available. However, in a study of 150 hospitalized children ranging from 3 to 18 years, the Faces Scale was clearly the most preferred scale for all age groups. This scale consists of 6 cartoon faces ranging from a very happy, smiling face depicting "no pain" to a tearful, sad face depicting "worst pain". 

The Faces Scale has been developed into a practical, laminated version.

 

Wong-Baker FACES Pain Rating Scale

From Wong D.L., Hockenberry-Eaton M., Wilson D., Winkelstein M.L., Schwartz P.: Wong's Essentials of Pediatric Nursing, ed. 6, St. Louis, 2001, p. 1301. Copyrighted by Mosby, Inc. Reprinted by permission.

The Oucher Scale  consists of a vertical numerical scale (10-100) for children who can count to 100, and a vertical photographic scale of a Caucasian child with expressions of no hurt to worst hurt. Since its development, a Hispanic and African-American version have been created.

The Color Scale is used by asking the child to select a color (using markers or crayons), that is like their "worst or most hurt", then a color that is like "a little less hurt", then a color for even less hurt and lastly, a color for "no hurt". A numeric value can be placed on each color. Asking the child to select a color that is most like the pain that they are currently experiencing can then assess the pain intensity.

Yet another method of assessing a child's pain using poker chips is offered by Nancy Hester of the School of Nursing in Denver, Colorado:

• Use four red poker chips.
• Align the chips horizontally in front of the child on the bedside table, a clipboard or other firm surface.
• Tell the child, "These are pieces of hurt." Beginning at the chip nearest the child's left side and ending at the one nearest the right side, point to the chips and say, "This (the first chip) is a little bit of hurt and this (the fourth chip) is the most hurt you could ever have."
  For a young child or for any child who does not comprehend the instructions, clarify by saying, "That means this (the first chip) is just a little hurt; this (the second chip) is a little more hurt; this (the third chip) is more hurt; and this (the fourth chip) is the most hurt you could ever have."
• Ask the child, "How many pieces of hurt do you have right now?" Children without pain will say they don't have any.
• Clarify the child's answer by words such as "Oh, you have a little hurt? Tell me about the hurt." (Use the Pain Interview.)
• Record the number of chips selected on the bedside flow sheet.

Assessing pain is especially challenging in children who are too upset to be capable of rating their pain. In addition, some children may be too frightened to report their pain for fear that equally painful treatments (such as shots) would be forthcoming.

In the absence of a child’s accurate self-report, doctors must rely on behavioral and other measures for assessing their pain. These might include noting changes in normal behavior or analyzing cries and facial expressions. However, it has only been within the past 5-10 years that there have been any meaningful attempts to systematically detail such measures.

The Parent’s Role

Communicating a child’s pain is often the responsibility of the child's parents, especially if he is too young to communicate his own pain effectively. In general, the following age-related abilities regarding pain communication apply:

Infants – Parents can usually tell the difference between cries from hunger or a wet diaper versus cries due to more serious distress. Especially at this age, a parent’s perception is invaluable.

3-4 years of age – Children at this age may become very quiet and inactive while in pain, or conversely may become extremely agitated and almost hyper. Words they may use for their pain may include “hurt” or “feel bad.” Often parents know they are in pain because they are not acting like they normally do.

School age and older – Children over 4 years of age can often tell you more about pain, even using units of measure (e.g., 0 for “no pain,” up to 5 for “very bad pain”). They can also now show parents and doctors where they hurt.

Adolescents – Older children can explain pain more clearly because they understand more of what is taking place. The specific words a child uses at this age are also important. For example, “shooting” or “stabbing” often refer to pain caused when a nerve is involved.

Experts offer the following general suggestions for helping a child cope with pain:

• Be honest, but be reassuring.

• Look for distractions from the pain, such as a favorite book, or conjure up pleasant images.

• If a painful treatment is forthcoming, tell your child what is about to happen. Just like with adults, children don’t like medical surprises.

• Always offer hope that the child’s doctor will try hard to find a way to ease the pain.

• And above all, when children say they are in pain, believe them. Pain is a complex interplay of emotion, attitude, and physical sensation, and children should not have to fight to be heard.

Partners in Pain

Having a parent or other loved one present may be the best treatment of all for a child’s pain. Children feel much more secure when their parents are involved, especially during emotional, distressing or frightening times.

Children need simple accurate information about what is going to happen. Don’t lie to children about painful procedures; tell them what will happen and what it will feel like. Explain things slowly in small bits, and repeat as often as needed. Let the child know that you understand how he or she feels.

Children should be helped to ask questions and express feelings. It is okay for children to show that they are afraid. Also, giving a child some control over treatment may be helpful, even if it is only deciding which chair to sit in or which arm to use for an injection.

For chronic pain from cancer, the same types of medications used by adults are often available for children, but in smaller, more controlled doses. Many parents fear that a child who takes a “narcotic” will become addicted or learn to rely on drugs. And some parents are afraid that a medicine will not work later if it is given too early. These concerns are not supported by facts and should not interfere with pain management. Narcotics or opioids are safe if used under a doctor’s direction. And, quite simply, strong pain requires strong medicine.

Beyond treating pain in kids with drugs, experts are now calling for more nonmedicinal approaches which seem to work better in children. These include such techniques as distraction, hypnosis, meditation, controlled breathing and fantasy to ease pain during medical procedures. Children can enter a relaxed, imaginary state of consciousness far more easily than adults, say researchers, especially at younger ages.

Finally, parents must be sure to take care of themselves. Many pediatric pain centers offer psychological counseling to parents as well as children, and support groups such as Candlelighters International (for parents of children with cancer) often have local chapters.

A parent who is emotionally well equipped to calmly help a child work through pain may be the child’s best tool for recovery.

SOURCES:

• Archives of Pediatrics & Adolescent Medicine, 1998; http://archpedi.ama-assn.org)

• U.S. News & World Report, June 12, 2000

• Candlelighters (www.candlelighters.ca)

• Making Cancer Less Painful: A Handbook for Parents, by Patrick J. McGrath, Ph.D., G. Allen Finley, MD, Catherine J. Turner, RN

• The Pediatric Pain Research Lab (http://pedspain.nursing.uiowa.edu)

• The Wong-Baker Faces Pain Rating Scale on the web.