A Child in Pain E-Book

Leora Kuttner

• Herausgeber: Crown House Publishing
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 590

Veröffentlichungsjahr: 2010

Beschreibung

This comprehensive book is designed to help pediatric health professionals of all disciplines gain understanding and skill in how to approach and treat children's pain, and how to help children make sense of and deal with their own pain. Pain is the most common reason for children to seek a medical consultation - and sometimes a common reason for avoiding it. Unaddressed fears and anxiety complicate pain management and recovery. A central theme in this book is the examination of children's fears and anxieties that accompany their need for pain relief, and the communication skills and words that can help calm these fears. This book is addressed to all disciplines, in its valuing of the professional-patient relationship and in the language used to allay anxiety, address fears and promote relief and well-being. It is organized into three parts:Part I explores our scientific understanding of pain as a part of children's development. Part II explores pain treatments themselves, their efficacies and how to combine them for therapeutic impact. Part III uses this understanding to help translate knowledge into clinical practice in three domains of pediatric medicine: the physicians' practice, the dental practice, and in the hospital. This volume also includes contributions by Dr. Jonathan Kuttner, on the neuroanatomy and neurophysiology of pain, Dr. Carl von Baeyer on pain assessment, and Drs Stefan Freidrichsdorf and Helen Karl on the pharmacological management of pain.Without doubt, this volume will stand as the "bible" on pediatric pain management for years to come.

Leseprobe

Praise for A Child in Pain

“Applauds to Leora Kuttner! This book should become a “must-have” for all professionals in the field. This informative and entertaining book achieves two goals. First, it provides health professionals from all disciplines with a profound and entertaining overview on the basics of and treatment strategies for relieving pediatric pain. Second, by integrating vivid case examples and easy instructions it enables professionals to integrate these strategies into their clinical practice. This book will help to make the world a bit better for children in pain.”

Dr. Boris Zernikow, Professor of Children’s Pain Therapy and Paediatric Palliative Care, Witten/Herdecke University, Children’s Hospital Datteln, Germany

“In her latest contribution to the well-being of children, Dr. Leora Kuttner has created a gem which is a must read for all child health clinicians. She has masterfully blended her savvy as a scientist, educator, researcher, artist, wife and Mom to create this state of the art and state of the science guide to the understanding and comprehensive management of pain in the lives of young people and their families. From the very first page, Dr. Kuttner’s well-known skill as a masterful communicator comes alive as Part I illustrates with real-life examples, ‘How to Understand, Assess, and Communicate with a Child in Pain.” Through vivid vignettes we are painlessly (!) guided to a variety of ‘right’ ways and best practices in communication around issues of discomfort. In Part II ‘s elucidation of the most up-to-date understanding of treatment of pain, we read not only the current state of the research, but also how it is best implemented and integrated in the comprehensive plan for the patient which is then detailed for us in Part III. Vignettes of actual patient encounters illustrate what really works, and offers not only suggestions, but also hope for greater comfort for both the clinicians and the families they serve.”

Daniel P. Kohen, MD, Director, Developmental-Behavioral Pediatrics Program, Professor, Departments of Pediatrics & Family Medicine and Community Health, and Past-President, American Board of Medical Hypnosis, University of Minnesota

“Dr. Kuttner and her contributors have distilled their rich experience providing integrative care for young people in pain to create an exceptional book that is comprehensive, practical and compassionate. Written with integrity, it speaks to us in the clear voice it would have us use to help children find comfort. This book is profound.”

Laurence I. Sugarman, MD, Clinical Associate Professor in Pediatrics, University of Rochester School of Medicine and Dentistry, President, American Board of Medical Hypnosis

“This is a unique and marvelous book. It addresses all the disciplines that work with children, and is very well organized. Dr. Kuttner not only explains the neurophysiology of pain, the assessment, the pharmacological and psychological management of pain, and the anxiety issues, but she also shows the enormous importance of the words spoken by all professionals, and the simple yet effective ways of ‘making the pain better.’ Throughout the book are numerous case studies, that go a long way in helping the reader understand and put into practice the principles discussed. She also shows how all medical disciplines can collaborate with the child and the family. By reading this book, we can better understand the complexity of pain, and can find numerous ways to improve the pain of a child. This book is a must read for all professionals who work with children, and should be translated into many languages in order to help the children in whatever country they live.”

Chantal Wood, MD, Paediatrician and Pain Care Specialist, Unité d’Evaluation et de Traitement de la Douleur, University Hospital Robert Debré, Paris, France.

“This is a wonderful book full of evidence and practical tips. It is a “must read” for any health professional who works with children.”

Linda Franck, Professor and Chair, Family Health Care Nursing, UCSF School of Nursing

“Like a breath of fresh air, Dr. Kuttner brings clarity, authority, and evidence to this crucially important area of pediatrics. She allows the patient’s voice to be heard, grounds her advice in what is known about best practice, but remains sensitive to the needs of the health professionals, who are only trying to help. Bravo!”

Christopher Eccleston, PhD, Director, Centre for Pain Research, The University of Bath, UK

“Dr. Kuttner has provided simple, clear guidance for health professionals of every discipline, with just the right balance of research made real by countless patient stories that bring it to life. It will be required reading for students and residents rotating through our clinic. There is no other book that fills this niche – easy to read, yet packed with practical advice and strategies that every pediatric clinician can use every day.”

G. Allen Finley, MD, FRCPC FAAP, Professor of Anesthesia and Psychology, Dalhousie University Medical Director, Pediatric Pain, IWK Health Centre, Halifax, Canada

“This splendid book provides practical, clear advice to guide the health professional in working with youth in pain. Dr. Kuttner artfully blends science and evidence with the voices of children to help professionals comprehend state-of-the-art pain care, understand children’s experiences, and acquire language to better communicate with children in pain. This is a must-read! “

Tonya M. Palermo, PhD, Associate Professor of Anesthesiology and Perioperative Medicine, Oregon Health & Science University

A Child in Pain

What Health Professionals Can Do to Help

Leora Kuttner, PhD

Crown House Publishing Limited

www.crownhouse.co.ukwww.crownhousepublishing.com

First published by

Crown House Publishing Ltd

Crown Buildings, Bancyfelin, Carmarthen, Wales, SA33 5ND, UK

www.crownhouse.co.uk

and

Crown House Publishing Company LLC

6 Trowbridge Drive, Suite 5, Bethel, CT 06801, USA

www.crownhousepublishing.com

© Leora Kuttner, 2010

The right of Leora Kuttner to be identified as the author of this work has been asserted by her in accordance with the Copyright, Designs and Patents Act 1988.

All rights reserved. Except as permitted under current legislation no part of this work may be photocopied, stored in a retrieval system, published, performed in public, adapted, broadcast, transmitted, recorded or reproduced in any form or by any means, without the prior permission of the copyright owners. Enquiries should be addressed to Crown House Publishing Limited.

British Library of Cataloguing-in-Publication Data

A catalogue entry for this book is available

from the British Library.

10-digit ISBN 1845904362

13-digit ISBN 978-184590436-4eBook ISBN 978-184590455-5

LCCN 2010920343

Printed and bound in the USA

To my beautiful family, both biological and of the heart, who are spread all over the world and remain as close as ever.

Table of Contents

List of Figures and Tables

Acknowledgements

Preface

Foreword

Part I

How to Understand, Assess and Communicate with a Child in Pain

Chapter 1

Pain in Children’s Lives

Chapter 2

How Pain Works (with Jonathan Kuttner, MBBCh, Dip. Sports Med. FACMM)

Chapter 3

Communicating with a Child in Pain

Chapter 4

Assessing and Measuring Pain (with Carl L. von Baeyer, PhD)

Part II

Pain Treatments—Psychological, Physical and Pharmacological

Chapter 5

Psychological Methods to Relieve Pain

Chapter 6

Physical Methods to Relieve Pain

Chapter 7

Pharmacological Methods to Relieve Pain (by Stefan Friedrichsdorf, MD, Leora Kuttner, PhD and Helen Karl, MD)

Part III

Pain and Anxiety Management in Pediatric Practice

Chapter 8

Managing Pain and Anxiety at the Doctor’s Office

Chapter 9

Managing Pain and Anxiety in Dental Practice

Chapter 10

Managing Pain and Anxiety in the Hospital

Afterword

Knowing is Not Enough: Strategies to Improve Pain Management in Healthcare Institutions

References

Index

List of Figures and Tables

Chapter 1

Figure 1.1

The Broad Impact of Chronic Pain

Table 1.1

Common Myths and the Refuting Scientific Evidence

Chapter 2

Figure 2.1

The Historic Model of Pain

Figure 2.2

Central transmission

Figure 2.3

Nerves talking to each other

Figure 2.4

Ascending and Descending Pain Pathways

Figure 2.5

Gate Control Theory of Pain

Figure 2.6

How and Where Medications and Other Common Treatments Work in the Pain System

Figure 2.7

Referred pain

Figure 2.8

The Body-Self Neuromatrix

Chapter 3

Table 3.1

Effective Responses to a Child in Pain

Table 3.2

Considerations in Choosing Language

Table 3.3

Unhelpful Responses to a Child in Pain

Figure 3.1

Biopsychosocial Model of Pain

Chapter 4

Figure 4.1

Neonatal Pain Facial Expression

Table 4.1

Developing a Functional Analysis

Figure 4.2

Body Map

Figure 4.3

Pain Faces Scale – Revised

Figure 4.4

Color Analogue Scale

Figure 4.5

Pain Diary

Table 4.2

The FLACC Scale

Chapter 5

Figure 5.1

The Pain Switch at Work

Table 5.1

Directions to lead a child to use all five senses in imagining

Figure 5.2

“No Pain”

Figure 5.3

“Play and Worry Doctor”

Chapter 6

Figure 6.1

Restless legs

Figure 6.2

Skating within a Maple Leaf

Chapter 7

Figure 7.1

The WHO three-step analgesic ladder

Figure 7.2

The WHO three-step analgesic ladder with pediatric first-line medication

Table 7.1

Opioid analgesics

Figure 7.3

Managing Children in Acute Pain

Chapter 8

Figure 8.1

Migraine with Aura

Chapter 9

Table 9.1

Dental Terms made Child-Friendly

Chapter 10

Figure 10.1

Hospital

Figure 10.2a

“Pane free world”

Figure 10.2b

“No Pain No Shame”

List of Contributors

Stefan J. Friedrichsdorf, MD Medical Director, Pain Medicine & Palliative Care, Children’s Hospitals and Clinics of Minnesota, Minneapolis, MN, USA

Helen W. Karl MD Associate Professor of Anesthesiology University of Washington, School of Medicine Former Director of Pain Medicine Seattle Children’s Hospital, WA, USA

Jonathan Kuttner, MBBCh, Dip. Sports Med. FACMM Musculoskeletal & Pain Specialist Auckland, New Zealand

Carl L. von Baeyer, PhD Professor Emeritus of Psychology & Associate Member in Pediatrics University of Saskatchewan, Saskatoon, Canada

Acknowledgements

My thanks to Mark Tracten at Crown House Publishing for providing me with a legitimate opportunity to take time and immerse myself in the fascinating pain literature—and for his good humour and reliable guidance from inception to completion. This book outgrew the original invitation to “simply update my book A Child in Pain; How to help, what to do (1996), but this time solely for health professionals.” With the astounding advances in the intervening period in pain research and technologically, the process of writing became a rich immersion in this material, and the book matured.

I particularly want to thank Dr. Carl von Baeyer. His resourcefulness, knowledge and decency helped immeasurably with many aspects of this manuscript. I am indebted to my four talented contributors for their enriching collaboration: my brother Jonathan Kuttner, my friends and colleagues Carl von Baeyer, Stefan Friedrichsdorf and Helen Karl for contributing their expertise.

Case studies, which are a significant part of the character of this book, were thoughtfully offered by Acupuncturist, Ruth McCarthy; Dentist, Jane Ronen; and Pain Specialist, Jonathan Kuttner. Material contributed by Dan Kohen, Joanne Eland and Penny Leggott from the first book was incorporated into this one. My thanks once again go to them.

One of the great joys was working with our daughter, Tamar O’Shea as she applied her artistic talents to the physiology drawings and charts, and with our son, Daniel O’Shea who gave freely of his computer prowess. My continuing thanks to Kelly Hayton for her manuscript talents and my editor, Susan Liddicoat for her fine attention to detail and professional guidance along the marathon.

Colleagues and friends read sections of the manuscript and generously provided constructive feedback. For this, I am grateful to: Christine Chambers, Andrea Chapman, Ken Craig, Gill Lauder, Julie Linden, Lori Roth and Bonnie Stevens. Additionally, Susan Tupper read the physical therapy chapter and elucidated the biomechanics of breathing; Joan Fisher and Jonathan Kuttner read the Pharmacological chapter; Jeff Dubin, Bruce Marshall, Jane Ronen & Judith Versloot read and contributed to the Dental Chapter.

My warm appreciation to Lonnie Zeltzer for writing the Foreword and to Neil Schechter for writing the Afterword to this book.

And my ongoing love and gratitude to Tom my husband, partner and companion in all, who thoughout this process was his divinely humoured supportive self – and to the children, parents and siblings who contributed their experiences, their poignant drawings and their guidance on how to help them manage their pain, fear and worries.

Preface

A Child in Pain: What Health Professionals Can Do to Help is designed to help pediatric health professionals of all disciplines gain understanding and skill in how to approach and treat children’s pain, and how to help children make sense of and deal with their own pain. Pain is the most common reason for children to seek a medical consultation—and sometimes a common reason for avoiding it. Unaddressed fears and anxiety complicate pain management and recovery. A central theme in this book is the examination of children’s fears and anxieties that accompany their need for pain relief, and the communication skills and words that will allay these fears.

Pain is now recognized as a major health problem in its own right. Pain, however, has a history of being one of the least understood and one of the most neglected domains of health care, particularly for children. In this book I have placed a strong emphasis on children’s experience of pain and pain treatment, and on their self-expression of their concerns. Wherever possible, children are quoted in the book so that we gain a more nuanced appreciation of their needs. The quotes are from children in my practice or in my documentaries. If the former, their names and identifying factors have been changed to protect their identity. Throughout the book the term children includes teenagers, and covers ages three to nineteen. As well, in pediatric medicine today, parents have gained their rightful place as an integral part of their child’s care (the term parent includes carer). This book also demonstrates how health professionals can guide parents to help their child through acute pain, procedures, or chronic pain.

As a clinical psychologist with more than 30 years experience in pediatric pain management, I want to sharpen the focus on behavioral, emotional, and relational aspects of pain management, while simultaneously working with the essential and traditional contributions of physical and pharmacological treatments in our health care system. Affectionately termed the “3Ps,” the integration of all three aspects of treatment forms a fundamental principle in this book. The integration of psychological, physical, and pharmacological methods goes hand in hand with our prevailing a biopsychosocial model of care. Today a child’s pain (particularly the more complex and chronic pains of childhood) cannot be properly appreciated or treated without applying a biopsychosocial model that incorporates all aspects of the child’s world. Dealing with only one aspect of pain and neglecting the other contributing stressors would now be regarded as providing sub-standard care. Explaining why pain may be occurring, how the brain is “the mastermind” of the pain system, what the child can do to manage or resolve the pain, and how medication and the child’s efforts can provide comfort, is now part of state of the art care. With this as a central tenet, I provide examples of, and discussion on, how to navigate this biopsychosocial spectrum of care with greater facility. As fourteen-year-old Jeremy says in the book, “A mind is a terrible thing to waste!”

Today, in the first part of the 21st century, there is still a great deal that we need to do to address and relieve children’s pain and suffering. To meet this I’ve drawn from evidence-based literature to provide direction. Our challenge is to bridge the gap between knowing and doing. This book is another in a series of efforts that our international pediatric community has made to close the gap between what we know and what we do.

Our knowledge in pain medicine has mushroomed over the last three decades. On many fronts remarkable progress has been achieved in understanding and developing capacities to assess, treat and relieve children’s pain and suffering. This includes basic science research on nerve and brain functioning, technological advances in imaging, and new delivery systems for medications. We have developed new analgesics and anesthetics, and there has been a burgeoning of research into determining the efficacy of psychological, physical, and pharmacological approaches to treating pain. Studies and meta-reviews have examined efficacy with recommendations on how best to apply treatments to relieve different types of pain. Pain services in children’s hospital are proliferating, and there is growing collaboration between the many disciplines within the hospitals to develop standards of care and protocols to manage acute, procedural, and chronic pain. Pain management has become a collective pursuit across disciplines—and this is welcomed.

A Child in Pain: What Health Professionals Can Do to Help is addressed to all disciplines, in its valuing of the professional-patient relationship and in the language used to allay anxiety, address fears and promote relief and well-being. The book is organized into three parts: Part I explores our scientific understanding of pain as a part of children’s development. It addresses the physiological processing of pain, how to assess it, and how to explain it to children who are fearful, anxious, and in pain. Part II explores pain treatments themselves, their efficacies and how to combine them for therapeutic impact. Part III uses this understanding to help translate knowledge into clinical practice in three domains of pediatric medicine: the physicians’ practice, the dental practice, and in the hospital. Within the extensive References at the back of the book, key resources are identified with an asterisk.

I have found it a rewarding and extraordinary privilege to belong to a vigorous, dynamic, resourceful, and generous international pediatric pain community. We’ve shared, learned from each other, collaborated, and inspired each other. We have worked together, critiqued each other’s endeavors, and matured as practitioners and researchers. My hope is that this book supports and benefits those of you entering and participating in this deeply meaningful and worthwhile field.

Foreword

For all of you who are about to read this book, you are in for a real treat! Dr Leora Kuttner is an experienced pain clinician extraordinaire and her clinical knowledge and sensitivity emanate from each page of this book. Even as an experienced children’s pain clinician myself, I found reading this book not only informative but joyful to read as well. I will explain what sets this book apart from many others and makes it a “must read” for any primary care clinician and, in fact, for clinicians across many disciplines who treat children.

First the book is well written, devoid of much medical jargon, and tells an interesting story. I think that Leora’s experiences and background as a film maker is apparent throughout the book. She not only explains a phenomenon but shows the reader exactly what she means, as if the reader were viewing the story on the screen. This way of writing is evident in each chapter. She provides a “how to” that makes the book ecologically sound and clinically useful. Further, she then gives clinical examples to demonstrate what she has just described.

There are many unique aspects of this book that have been touched on by other authors of children’s pain books but not in the depth that is presented here. For example, two themes intertwine throughout the book that help connect the chapters together—the importance of observation and language. Leora shows how close observation of a child’s non-verbal behavior, including body movement and position, facial expression, eye contact, tone of voice, cry, muscle tension, and even what is not said provides important information about a child’s pain experience and perceptions of ability to cope with the pain. Observation of the environment is noted to be equally important. For example, she describes the importance of noting context (e.g. are parents present in the treatment room but do not know what to do to help their child, or is a child not crying because peers are present?), as well as parental interactions with their child in pain or in anticipation of pain (e.g. the example provided of parents whose toddler daughter developed diabetes, a condition that required parents to perform multiple finger pricks during the day).

Language is also a powerful tool as noted through the many clinical examples that Leora has provided. The salience of language is especially noted in the chapter on psychological interventions for children’s pain (Chapter 5), one component of what Leora calls the “3Ps” (psychological, physical, and pharmacological) of children’s pain treatment. In this chapter, she describes in more detail and clarity the concepts of hypnosis and the use of imagery with children than I have read anywhere else. She provides many lovely elucidating clinical case examples to illustrate what she means. Throughout this section, she highlights the importance of language. That is, how what is said to a child and when, can have a profound impact on that child’s experience of pain and pain-related distress as well as having the ability to enhance or subvert a child’s ability to cope with the pain. As a simplistic example, think of giving morphine to a child who has just had surgery. There might be three ways to administer the morphine. One is to simply give it and not say anything. Another is to give it and say “we can try to lower your pain with this medicine.” Yet another way is to say, “I am going to give you some really powerful magic medicine that will likely not only make the hurt better but may even make you feel silly and laugh!” How would you rather receive your analgesia? Leora provides beautiful examples of the power of words and language.

In the chapter on psychological interventions (Chapter 5), Leora also includes biofeedback and presents newer theories related to cognitive behavioral therapies called ACT (acceptance and commitment therapy). Within her description of ACT she also discusses the importance of mindful awareness. That is, the importance of being present, noticing thoughts, sensations, and emotions but not becoming absorbed in or attached to them. In this chapter, she also discusses other creative sensory pathways to help children cope with pain, including music, art, and play.

The chapter on physical strategies (Chapter 6) for pain management in children is just as stellar. Leora provides detailed explanations about self-directed strategies such as breathing with the creative use of bubbles, pranayama breathing and other breathing techniques. She discusses massage, and even provides descriptions of how parents can massage their stressed child. She covers the value of touching, including body to body contact as in kangaroo carrying for newborns and infants and talks about swaddling, rocking, and sucrose for infants. In addition she covers yoga, acupuncture and acupressure in addition to the usually described physical therapy, TENS, heat and cold. However, for each physical strategy, Leora provides specific “how to” details and gives clinical examples to illustrate what she means.

The book also has sections on how to examine a child in pain and how to help a child receive dental care without pain and stress. It describes how to manage children’s pain in the hospital setting and how to manage the hospital setting to reduce the likelihood of hospitalized children experiencing pain and distress. It also provides a practical guide to minimize painful experiences in childhood and to reduce the likelihood that early pain experiences will create painful memories that can lay a template for the development of adult chronic pain.

Leora has also brought in some key contributors with added expertise in the neuroanatomy and neurophysiology of pain (her brother, Dr. Jonathan Kuttner, a musculoskeletal and pain specialist), in pain assessment (Dr. Carl von Baeyer) and in the pharmacological management of pain (physicians Drs. Stefan Freidrichsdorf and Helen Karl). She has even solicited a patient, a young girl, to bring together in narrative form a summary of what the book imparts. I applaud Leora in this outstanding book and encourage readers to enjoy.

Lonnie Zeltzer, MD Director, UCLA Pediatric Pain Program Professor of Pediatrics, Anesthesiology, Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA

Part I

How to Understand, Assess, and Communicate with a Child in Pain

“Pain is the only condition in which the patient is the diagnostician.”

Unknown

Pain is now regarded not merely as a symptom of a disease, as previously thought, but as a human rights issue (International Association for the Study of Pain, 2004). The relief of pain therefore demands the highest priority. Pain is as important as any disease or illness, deserving of clinical attention and treatment. By definition, pain is a noxious sensation which always has an emotional impact. In assessing and communicating with children and adolescents on their pain, they are the authority on their experience. This is a fundamental principle of pain management in children. Children are to be believed when they say they are in pain.

Pain has its own physiological system. Chapter 1 explores how pain, although unpleasant, can also have a positive function as an intelligent warning system. In its acute form, pain is frequently protective, preventing or stopping further injury. However, in its chronic form, it ceases to protect in any way, and it becomes a problem. Chronic pain is a result of a malfunctioning pain system. Treatment requires a biopsychosocial approach that incorporates appropriate biological, psychological, and social treatments. In the twenty-first century, we need to ensure that misguided messages and myths about pain no longer persist when caring for children in pain.

Carrying out effective pain treatment with children in pain requires a thorough understanding of how the biological, psychological, and social systems interact for pain to be experienced. Chapter 2takes up the subject of this relationship: how in the pain experience the nerves communicate with one another, the nerve pathways to the brain, the modulation sites, and the brain’s neural networks. We draw on the scientific research and theory, such as the gate control theory, that led to a radical change in the understanding and treatment of pain. We explore the more recent neuromatrix concept in pain medicine (Melzack, 1999) to help understand the complexity of brain function in persistent distressing pain, and explain how persistent pain alters its own neural system.

The most common procedure in a hospital is communication. All professionals need to know how to communicate effectively with children and their parents. There are optimal ways of responding to children in pain, children fearful of anticipated pain, or children wanting to understand why they are in pain. It is fundamental to good practice, and to the child’s short and long-term outcome, that this process be done well. Chapter 3 discusses this and explores the parents’ central role in modeling pain behavior and in helping their child to cope.

Since the 1980s we have seen a burgeoning of well-designed and standardized tools of pain measurement to help assess children’s acute and chronic pain. There are tools for infants and for children with developmental challenges, tools for post-operative pain assessment, and questionnaires for children in chronic pain and their parents. There is a simple measure for young children and pain scales and maps with more sensitivity for older children. Designing reliable and valid measures to assess pain across cultures, countries, and languages has been an emerging strength in the pediatric pain field. The most common and key measures are covered in Chapter 4, including a developmental exploration of how children of different ages understand and express their pain – important facets for a full and adequate assessment.

These chapters provide you with the foundation for understanding the role of pain in children’s growth and development; the basic physiology of how pain works in the human body, and how to share this knowledge with children – communicating with them when they hurt and are suffering so that they feel heard and helped; and then how to further assess and measure their pain.

Chapter 1

Pain in Children’s Lives

“Pain is when it hurts.”

5-year-old boy

As children and teens grow and explore the world, they experience many falls, illnesses, and hurts of one kind or another. They turn to their parents to find relief from pain. Too often parents feel anxiety and fear, not knowing what to do in the face of their children’s pain, and turn to pediatric professionals for the expertise and guidance to provide their child with sufficient relief. Pediatric health professionals at all levels of care need to know how to provide this necessary help.

Fortunately today many breakthroughs in scientific research have increased our understanding and treatment of childhood pain. The goal of this book is to make this information easily accessible to those working directly with children. With a knowledge of the most effective therapies and treatment combinations in conventional and complementary medicine, professionals can help children and their parents to better manage minor and major pain from injuries and illness. Instead of minimizing, misunderstanding, or dismissing a child’s pain, a skilled professional can provide prompt pain relief and empower the child to cope. This requires a combination of helping the child to understand and interpret the pain sensations and to develop coping skills, as well as being aware of the treatment options to ease the pain.

Pain is part of growing up. Young children frequently fall and scrape themselves as they learn to walk, run, climb, and ride a bicycle. This is a time of developing co-ordination and skill and, as a consequence, learning about pain and suffering. Research has shown that preschool children during play, experience an average of one ‘owie’ or ‘boo-boo’ every three hours (Fearon, McGrath, & Achat, 1996). Children encounter accidents at home, in parks, in cars, and on the playground at school. They may experience pain when they get a tooth filled at the dentist’s office or when they have an injection at the doctor’s office. Some children and adolescents struggle for years with painful diseases and hospital treatments.

This chapter discusses the role that pain plays in the human body, the relationship between pain and the brain, and types of pain. A few widely held attitudes or misconceptions about pain have prevented parents and health care providers from dealing promptly and appropriately with children’s pain. At the end of this chapter I review and debunk misconceptions about pain.

The Protective Value of Pain

Pain is protective. It provides vital information to guide us in the use of our body, informs us about its condition, and helps us survive and remain intact. As health care professionals, part of our responsibility towards children is teaching them to respect pain signals and to learn how to interpret and cope with them. We know from interview studies on children’s concepts of pain that they seldom mention any beneficial aspects of pain, such as pain’s diagnostic value, its warning function, or its role in determining whether treatment is effective (Abu-Saad, 1984a,b,c; Ross & Ross, 1984a,b; Savedra, Gibbons, Tesler, Ward, & Wegner 1982). Children need to know that pain is their personal safety-alarm system, interpreted by the brain in a highly rapid and sophisticated way. Pain messages quickly tell us if there is something wrong with our organs, muscles, bones, ligaments, and tissues, all of which are interwoven with nerve fibers and pain mediators that rapidly carry pain messages to, from, and within our brain. Children need to be informed that part of the sophistication of pain is that memory, emotions, previous learning, beliefs, stress, endocrine and immunological processes, as well as the current meaning of pain, all factor into how the pain message is experienced.

In its healthiest form, short-term acute pain is protective, alerting and preventing damage to one’s body. As David, aged four and a half, discovered: “You’ve got to listen to your stomach when it’s hurting, ’cause if you don’t, your stomach will get upset!” David knew this firsthand; for five days he had had stomach pains and gastric spasms and had been throwing up. The pain signals had taught him that if he continued eating the tuna sandwich his well-intentioned mother had given him, his stomach might send it back again. Recovering from a gastrointestinal virus, David had come to respect the signals he was receiving from his stomach: to eat only what his stomach could handle and when to stop. Because his actions helped settle his pain and nausea, and because he was being listened to – although he was only four and a half – he learned to manage his own recovery, and set the stage for dealing effectively with the experience of pain in the future.

Children learn about their bodies when we encourage and teach them to pay attention to their body’s messages and sensations. They learn to interpret the different pain signals and determine what gives the best form of relief. This learning is refined over a lifetime. Even very young children can be taught to share their pain sensations so that we can determine what is going on, their severity, and what will be most effective in helping the pain to go and stay away.

The value of pain is poignantly evident when we encounter children born with one of the rare conditions of insensitivity or indifference to pain (Nagasako, Oaklander, & Dworkin, 2003). Throughout their lives, these children are at great risk of damaging their bodies, particularly their eyes, hands, fingers, joints, and feet. Pain is disabled by their genetic condition and does not protect them. It does not alert them to stop an action that will cause injury, or prompt them to call for help when they experience the early pain signals of a medical crisis such as appendicitis. These children continue to walk on sprained ankles and damage the tips of their fingers and their legs; frequently they require artificial protection such as braces and guards. By school age, these children have already sustained significant and often irreparable damage to their limbs.

Pain in the Body and the Brain

David Morris (1991), a Professor of Bioethics, writes about the outdated belief that pain can be divided into physical and mental pain. He calls this ‘the Myth of Two Pains.’ According to this myth, there are two entirely separate types of pain: physical and mental. Morris elaborates: “You feel physical pain if your arm breaks, and you feel mental pain if your heart breaks. Between these two different events we seem to imagine a gulf so wide and deep that it might as well be filled by a sea that is impossible to navigate.” (p. 9)

This concept, that pain is either in the body or the mind, goes back to the 17th-century philosophy of René Descartes, who argued that the body and mind were separate. He also maintained that there was a one-to-one relationship between the injury and the amount of pain felt – a theory now debunked. Today’s scientific evidence is that there is continual interaction in the nervous system between our physical and mental functions such that any division between them is an artificial construct.

One of the earliest medical practitioners to publicly question this mind-body split was Dr. H. Beecher, a Boston surgeon who traveled to Europe with U.S. troops during World War II. In 1956 he published a paper which described how soldiers who had very similar wounds to the civilians he had treated at home, required significantly less pain medication (Beecher, 1956). In talking with these men, he realized that the meaning of their pain was very different from that for civilians. Pain to these soldiers meant they were alive and were out of active warfare. War wounds were a ticket home. Beecher’s reports challenged the thinking of the day and importantly showed that the amount of tissue damage often bore little correspondence to the level of felt pain, and there was no validity in a mind-body dichotomy These conclusions are now widely accepted in clinical practice. We now know that the meaning of a person’s pain is subjective, highly personal, and variable from one situation to another, and that this meaning will influence how the pain is experienced. Mental pain can be physically experienced and physical pain mentally experienced. Mind and body are integrated systems.

Definition of Pain

That pain is subjective in no way detracts from the validity of the physical origins of the pain. Pain signals travel through the limbic system, the part of the brain most involved in emotion and motivation (see Chapter 2). When in pain, we are affected emotionally and our feelings can range from distressed, anxious, vulnerable, weepy, to depressed. These emotional or affective correlates are well documented in the literature. The official definition of pain by the International Association for the Study of Pain (IASP) acknowledges this: “Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Pain is always subjective. Each individual learns the application of the word through experiences related to injury in early life.” (1979, p. 249)

Pain is experienced as emotional and mental suffering, as well as a distressing physical sensation. Above all it is subjectively experienced and so is private and entirely personal. Consider the instructive words of sixteen-year-old Jodi, who coped for five years with severe pain from Guillain-Barré, a neuromuscular syndrome:

Pain is something that no one can analyze. How can you feel someone else’s pain? You can’t look at someone and say they are at an eight or a ten out of ten level of pain! How can you do that? It is internal. It’s within that person. Only that person can say what level of pain they are in!

She speaks the truth! The primary way of knowing what is going on is to ask each child about his or her experience of pain and its impact on daily life, feelings, and friendships.

How Thought and Imagination Influence Pain

As pointed out previously, in every pain situation, there is an interplay of thoughts, beliefs, emotions, and attitudes with bodily sensations that creates the experience of pain. It is this interaction that enables us to change – increase or decrease – the pain experience. When a child appreciates the impact of these different and personal aspects, it becomes a vital part of success in the treatment process.

Eight-year-old Seana tells what she does to reduce her painful intravenous needles during cancer treatment:

I learned to use my imagination and go to a place I love, Candyland. I concentrate on what’s happening there so I don’t even know there’s a needle in my arm! It’s funny how it happens.

(Kuttner, 1986)

Not all children can attain the level of concentration to turn off pain entirely, but many can find some relief, and with regular practice can improve their outcome. Seana found relying on her imagination so helpful that even when out of hospital, she reported practicing.

In contrast, 12-year-old Josh, a dramatic, highly imaginative young man, who detested coming into hospital for cardiac check-ups, focused his thoughts on all the awful things that could happen. As a result, when Josh experienced a small pain, it quickly escalated into an overwhelming one. He concluded that if he imagined the worst scenario for himself, he would be prepared for any eventuality in hospital. So he imagined that he might die and worked himself up into such a heightened state of anxiety that his routine blood collection became a horrendous and painful experience for him, his family, and the staff. Josh’s dramatic reaction is an example of ‘catastrophizing,’ a cognitive reaction to pain to be discussed in Chapter 3. The instructions his mind gave his body were not, “Shut down on the pain; it is an OK pain,” but “MAYDAY! This is the end!”

Our mind and body also interact through the production and release of endorphins – one of the body’s own painkillers, an opioid (morphine-like) chemical produced by the body that serves to suppress pain. Endorphins, first discovered in 1975, are manufactured not as first thought only in the brain and spinal cord, but throughout the entire body. We now know that every major internal organ has its own opioid receptors. This means that every organ, including the gut lining, is designed to receive information in the form of neuro-chemical transmitters from the brain, including the naturally occurring opioids for pain relief. These internal pain relievers can be released through physical exercise, and possibly through relaxation, deep breathing, and meditation. Seana probably released enough endorphins to block the sensation of the needle in her arm, whereas Josh released large amounts of adrenaline to boost his panic and terror that heightened his experience of pain. This is the power of our thoughts and beliefs. Pain is after all, a function of a conscious brain.

Types of Pain

As an ‘intelligent’ signal, pain comes in many different forms. Pain has been divided into acute (protective) pain, recurrent pain, or chronic (often non-protective) pain. Protective pain sensations are referred to as ‘nociceptive’ or normal, sensory pain. Non-protective pain sensations are referred to as ‘neuropathic’ or abnormal pain. While the length of time of the pain and its normality or abnormality are aspects used to categorize these types of pain, it is now postulated that acute, recurrent, and chronic pain may be part of a continuum (Cervero & Laird, 1991). Acute severe pain may have some abnormal nerve patterns characteristic of chronic pain, and chronic pain may begin as and have some acute pain episodes (for a full explanation, see Chapter 2). With this potential continuum of protective to non-protective pain in mind, here is an overview of the characteristics of pain in the acute, recurrent, and chronic states.

Acute Pain

Acute pain indicates an episode of tissue injury, potential tissue damage, or inflammation. Examples are pain caused by surgery, a burn, a fracture, or a cut. Acute pain provides continuous, second-by-second sensory information. The pain begins suddenly and follows a predictable trajectory: first warning that tissue has been damaged and over time lessening as the tissue heals and inflammation subsides. Acute pain can be mild to severe. Most of these conditions are readily diagnosed and the source of the pain is fairly easy to determine. The American Pain Society’s position statement of children’s acute pain (2001) explains:

Acute pain is one of the most common adverse stimuli experienced by children, occurring as a result of injury, illness, and necessary medical procedures. It is associated with increased anxiety, avoidance, somatic symptoms, and increased parent distress. Despite the magnitude of effects that acute pain can have on a child, it is often inadequately assessed and treated.

With acute pain a host of physiological and psychological responses are mobilized, as different chemical substances, neurotransmitters, are released. The brain immediately receives these pain signals from the injury site, then releases substances such as adrenaline and noradrenaline. Prompt action to relieve the pain, such as removing a body part from danger or stopping an action to minimize further harm, enables the body to return to some equilibrium. These actions occur reflexively and almost without thought. Pain shocks us into being protective. It’s a marvelously sophisticated internal survival system that is highly effective – most of the time.

If children with acute pain are provided with adequate treatment and taught to address their pain and distress promptly, relief will be more rapid. Describing the pain can lead to faster relief. “Is that a sting or a tingling feeling, an ache or a sharp pain? Is it a big owie or a pinch?” With guidance, children can describe their pain, clarifying what causes the pain, and learn which treatment might be helpful. Children learn that an ache such as muscle fatigue can be relieved with heat, a rub, rest, or analgesic. A burning or stinging pain may indicate inflammation as well as nerve injury, and often feels better when an ice pack or a cool pack is applied and analgesic medication taken. A sharp pain is a signal of more acute tissue damage, or it may indicate muscle spasm, such as the classic ‘stitch’ in one’s side while running. Relaxing the muscles by bending over from the waist and taking deep breaths will ease this pain. A dull, gnawing pain may indicate a more persistent pain, associated with visceral pain, ligament, or tendon injury. Rehabilitation therapy or wearing a splint to restrain movement will ease ligament or tendon type of pain, giving the tissue time to stabilize and heal.

Acute pain commands attention, causes anxiety, and drains energy. Blood pressure can increase with acute pain, and after an initial drop, the heart rate also can increase. Discomfort and distress continue until this pain is adequately and effectively addressed. When the pain eases, the intervention has been successful. Generally, acute pain will diminish over a period of days or weeks, becoming less intense as time progresses. It is short-term and unlikely to return. Even though acute pain disappears, it does produce changes that linger in the body’s nervous system. The brain remembers this pain. If not properly treated, the injury continues to signal and pain will persist, becoming intermittently recurrent or chronic. It is incumbent on health care professionals to provide this necessary relief promptly, to prevent further harm (Walco, Cassidy, & Schechter, 1994).

Recurrent Pain

Recurrent pain is pain that alternates with pain-free periods, during which there is commonly complete recovery with no residual pain or disability. Recurrent pains are far more common in children than are chronic pains. Prevalence estimates of recurrent pain can range from one out of three young school children once a week (Petersen, Brulin, & Bergström, 2006) to 45% of adolescents (Fichtel & Larsson, 2002).

Common types of recurrent pain include headaches (tension, migraine, and mixed types), abdominal pain, irritable bowel syndrome, back pain, and limb pains. While most children cope well with recurrent pain, for some children it accounts for many missed days of school, and if a comprehensive treatment program is not quickly implemented, it can result in disruptions in the school and social life of these otherwise healthy children. Like the treatment for chronic pain, recurrent pain treatment requires the child’s active participation in developing coping methods for their pain assessment and management. The school nurse or counselor is often helpful with the child’s re-entry by supporting the use of pain management at school. Treatment combines Psychological, Physical, and Pharmacological methods – which I refer to as the 3Ps – with each component synergistically empowering the others to improve the overall treatment.

Chronic Pain

Chronic pain has no apparent protective purpose. It is pain that persists long beyond its initial useful, protective, and informative function. It often is a consequence of damaged, abnormally functioning nerves (neuropathic pain). Pain is considered chronic when it lasts longer than three to six months. Examples of such pain are rheumatoid arthritic pain, complex regional pain syndrome, hypersensitivity in a limb following trauma, and diseases causing pain, like Crohn’s disease. Children with physical disability from a disease or trauma will often have accompanying chronic pain which affects and limits all aspects of their lives. The American Pain Society’s position statement on chronic pain (2005), which includes recurrent pain, further elaborates:

Chronic pain is a significant problem in the pediatric population, conservatively estimated to affect 15% to 20% of children (Goodman & McGrath, 1991). Children and their families experience significant emotional and social consequences as a result of pain and disability. The financial costs of childhood pain also may be significant in terms of healthcare utilization as well as other indirect costs, such as lost wages due to time off work to care for the child (Li & Balint, 2000). In addition, the physical and psychological sequelae associated with chronic pain may have an impact on overall health and may predispose for the development of adult chronic pain (Campo et al., 1999; Walker, Garber, Van Slyke, & Greene, 1995).

Chronic pain persists often due to physiological and chemical changes to nerve fibers, which alter the way pain works. In conditions that have not had adequate pain relief, the involved nerves become highly sensitive to touch and pressure. These nerve pathways often do not respond in a predictable way to conventional medication or treatment. Because chronic, persisting pain changes the way the pain system works, it unfortunately often leads to more pain, and may impede the healing and repair process. Our understanding for this comes from animal pain studies that found long-lasting increases in the excitability of the pain-integrating neurons, known as central sensitization (Schwartzman, Grothusen, Kiefer, & Rohr, 2001). Evidence now suggests that long-term plastic changes in the peripheral nervous system and the brain-spinal cord network may represent the mechanisms underlying the persistence of chronic pain. Chronic pain may be a consequence of long-term physiological changes which, in turn, may further generate abnormal nerve impulses (Schwartzman et al., 2001).

These detrimental long-term neurological effects provide a compelling reason why children’s pain in the acute stage must be promptly and adequately treated and controlled to prevent the development of chronic and more complex pain. Experiencing chronic pain is wearing and draining for children (see Figure 1.1). The nature of the pain can be constant, with some variation and few pain-free periods. Consequently, chronic pain becomes part of the child’s life, changing how the child moves or participates in activities, school, and friendships (Bursch, Walco, & Zeltzer, 1998). The child is likely to lose hope that it will ever go away. Without comprehensive treatment and therapy, children living with chronic pain often feel that there is nothing that will provide relief. This hopelessness compounds with the pain and can lead to depression, isolation, and despair. Reviving and sustaining children’s hope, while pursuing multi-pronged 3P treatment (psychological, physical, and pharmacological) is central to successful chronic pain treatment.

Figure 1.1. The Broad Impact of Children’s Chronic Pain.

Living with persisting pain impacts the social, psychological as well as physical areas of a child’s life, and all need to be understood and addressed in treatment.

We learn so much from children with chronic pain. Earlier I introduced sixteen-year-old Jodi, who has struggled for five years with the debilitating Guillain-Barré syndrome. She experienced many kinds of pain in the course of her very slow recovery and became an authority on her condition. Cued to these different body sensations, she paid close attention to the pain signals’ distinctive characteristics as they indicated important changes in her condition and could guide her treatment. Over the years she became a skilled and patient teacher of the doctors who would come onto the ward. When asked, “Do you have any pain?” Jodi explained that in fact she had three types of pain:

I have nerve pain, which is a shooting, sharp kind of sensation that comes sporadically and is not there all the time. Then I have muscle pain – I can’t call it an ache, because an ache is something that you can put up with. It’s more like someone has beaten you internally – it’s a severe ache. My joint pain is like an arthritic pain, an osteoporosis kind of pain. (Kuttner, 1990)

After Jodi had described in impressive detail the quality, intensity, frequency, and the subtle differences of pain from different origins in the body, she added, “The hard part was people not believing me!”

We need to let children know that we hear them when they are in pain and that we know they are suffering – whether or not the child’s behavior accords with what we conceive of as pain. Remember that when children have had persisting pain, they may no longer ‘wear the pain on their sleeve’ and may have adjusted to it so that they have a life. In other words, the overt behavioral signs of chronic pain tend to habituate or dissipate as time passes, despite continued self-reported pain (von Baeyer & Spagrud, 2007).

When a child suffers from chronic pain, the entire family must accommodate to the child’s increased needs, and this exacts an enormous toll in suffering and disruption for the child, parents, and siblings. For all these reasons, children with chronic pain require a specialized long-term and intensive pain management program that involves changes in lifestyle, psychological treatment, physical therapy, and medication (Krane & Mitchell, 2005; Zeltzer & Schlank, 2005).

Misguided Messages about Pain

There are mixed messages in our world about how to deal with pain, such as, pain requires a battle, or pain is good for you as it builds character! These conflicting messages often confuse while influencing our attitudes toward pain.

Pain Requires a Battle!

Advertisements on TV or in magazines advocate that to find relief, pain needs to be battled down! “Is this pain killing you?” Often the weapon of choice is a certain medication, which is promoted with happy music behind the softly announced stream of sideeffects. Such injunctions promote an adversarial relationship with the pain inside our bodies. The unhelpful, underlying rationale is:

Pain is our enemy and must be beaten. Guard and fight against pain, against this invader that doesn’t intrinsically belong in the body. Tighten and tense up against these inner sensations.

With pain defined as the enemy, fear comes out and panic can reign. In the battle to kill the pain within our own bodies, brain is pitted against body. Acceptance and commitment therapy (discussed in chapter 5) is a recent development to effectively counter this misinformed attitude.

Using the language of war, we lose the concept of pain as an intelligent guide and messenger helping us live more harmoniously within our body. Believing that pain is an invader and an enemy, relief against pain comes in the form of ‘shots’. Shots come from guns. They wound and hurt. No wonder children don’t want anything to do with them! In our hospital we teach the use of the word ‘injection’ or ‘needle’ instead.

In a hospital clinic parents have been heard to use the threat of a needle to force obedience from a child, “If you don’t behave yourself, the doctor will give you a shot!” Health care professionals can promptly counter, “No! We’re here to help you to feel better and to manage!” Unfortunately, the child has already had fear instilled and will remain distrustful until the health professional’s hard work of building trust breaks through. This is part of our cultural legacy of war, fear, and threats.

There is a further insidious message found on television and in magazines and newspapers. In the battle against pain, the only means to arm yourself is to rely on something outside of your body – a bottle of pills. Faces smiling with relief in advertisements try to convince us that reaching for a pill is the only option. Rarely are other options revealed. Pharmaceutical companies do not make a profit by teaching pain sufferers that actively using their inner resources, such as imagery or relaxation, together with a pain medication, will control pain and reduce discomfort. However, in pain clinics throughout the world, these brain-body techniques are now a key part of pain programs – one of the three Ps of pain treatment: psychological, the ‘top-down’ treatment approach.

Pain Builds Character

Another common misconception is that being stoic when in pain is admirable, as if pain is good for you. Pain builds strength and character. “Pain will make a man out of you!” “No pain, no gain” reflects this stiff upper-lip attitude toward pain. The truth is very different. Suppressing one’s pain adds considerably to the strain of experiencing pain and depletes energy, joy, and vitality. When pain is present, efforts need to be made to relieve it. Pain especially has no place in the lives of growing children. It is not needed for character, growth, or achievement.

This stoic position further suggests that pain medication should not be used, or that we should feel shame or defeat when we ‘give in’ and use it. Taking medication means weakness, as if it weakens character. This attitude obstructs successful pain management. Medications appropriately given to a child in acute or persistent pain by a knowledgeable health professional will go promptly to the source of the pain and provide relief. Analgesics are, without question, the method to use when pain overwhelms and drains, as when a fractured bone is being set in a cast. Pain medication will help break a continuous cycle of pain, as when a child has a migraine headache. Medication provides relief and a chance to sleep and heal. When pain is reduced, the analgesic can be gradually withdrawn and other pain-reduction methods such as physiotherapy, heat pads, or hypnosis can come into play to further the child’s recovery. Controlling pain promptly and keeping it well controlled until it abates is the fundamental principle of effective pain management.

Neither the belief that pain is a battleground in which fear reigns and medication is the only help, nor that pain builds character and taking medication is a weakness, is true. Like life, the truth is more complex, and a lot more interesting! When pain is kept under control with adequate, regular doses of pain medication, the child can develop inner resources using imagery and self-regulation to better manage the pain so that less medication is then required.

Debunking Myths About Children and Pain

The belief that children don’t experience pain pervaded medical and nursing teaching and practice until the 1980s. If children expressed pain, it was ignored or underestimated and undertreated. “It’s not really that bad. It can’t be hurting that much!” These attitudes harmed children in pain. The following case study shows the long-term consequences of practices that neglected babies and children in pain:

Rod is highly respected 46-year-old police officer. He is decisive, physically tough, and capable on the job. Few people knew that vigorous Rod was born prematurely. He spent the first four months of his life in an incubator in a neonatal intensive care unit (NICU). He had many painful medical procedures to aerate his lungs, feed him, draw blood, and check blood oxygen levels. After leaving the NICU and over the next five years, he had regular check-ups, which included many blood tests. He has no clear memory of these early experiences, just his parents’ stories. But Rod has one serious problem: he cannot stay in a room where there is a needle. Since the age of 12, he has never allowed blood to be taken. He can’t tolerate any invasive medical procedure. Try holding down a 230-pound man, let alone a man trained to fight! No blood technician, physician, or nurse had taken on the challenge.

Health difficulties forced Rod to consult a doctor, who required a series of tests for a diagnosis. Suddenly faced with a serious health issue and medical tests, he needed help. Rod’s terror was visceral and overwhelming: “I feel like such a wimp. I can face and wrestle an armed man to the ground. But when a pint-sized nurse comes toward me with a needle, I clear out of the room! It’s irrational. It’s crazy!” No, it’s not crazy at all. At a very early age Rod had become sensitized to pain. In those early years he probably had not been given analgesics to control the pain before invasive medical treatments, since it was believed then that newborn infants did not feel pain. As an infant he experienced that there was nothing he or others could do to stop the pain. Now any medical procedure caused terror to overwhelm his six foot three inch frame, and without knowing why, he would flee to safety.

Rod came for a consultation to conquer his deep, reflexive fear. He was ashamed, and he wanted to learn how to desensitize himself to needles, manage that pain, and overcome this Achilles heel. Highly motivated, he became skilled in using deep-breathing methods and self-hypnosis. After six weeks of cognitive-behavior therapy and coping techniques with graduated experiences with needles, Rod learned to regulate and lessen his own anxiety and to exercise his coping skills. He then calmly had his blood drawn – a triumph!

If Rod’s pain in infancy had been recognized and better controlled, he might not have developed this understandable, so-called ‘irrational’ terror. (See chapter 8 for further discussion about the amygdala in the limbic system and our built-in survival responses.) If over the next five years, during regular check-ups, his fear had been noted and discussed, giving him more control, he would not have felt ashamed or powerless. There was much that his parents and the various health care professionals could have done during those early years to alleviate his pain by supporting him to learn coping skills and to develop confidence, and thus prevent his 45-year-old phobic response to medical interventions.

There are a number of myths about children and pain that scientific evidence has now proven wrong. These myths and their refutations are summarized in