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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 |
![[wong faces scale]](../pain/images/wong_faces.gif) |
|
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:
This page was last
edited on 05/30/2002
Written by Richard
Zmuda, senior writer, cancerpage.com
Edited by Rachael Myers Lowe, cancerpage.com
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