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DEVELOPMENT
OF PEDIATRIC PAIN Introduction Pain is a signal, developed through the evolutionary process, to protect the body from further stress or injury. If prolonged, particularly in the young, it can cause distress, anxiety, and suffering. It is surprising, therefore, that prior to the 1960's, few studies or articles addressed the nature of pain in children. In fact, recent studies in the 1990's revealed that children in pain are still often under treated. Reasons for this inadequacy may be due to current myths on pediatric pain and pain management. For example, some believe that young children do not experience pain because of neurologic immaturity. However, studies have shown that pain pathways as well as cortical and subcortical centers necessary for pain perception are developed by 30 weeks of gestation. Children not only experience pain, but also often have changes in behavior, eating and sleeping patterns, following painful medical procedures. Misunderstandings in the use of narcotics affect the role of pediatric pain management. Although there are concerns regarding the respiratory depressant effects of narcotics due to slower metabolisms than adults, and the possibility of addiction, studies have indicated that children older than the age of 6 months demonstrate adult-like pharmocokinetics and, when weaned over a period of time, have rare occurrences of addiction. Over the past three years, St. Mary's Healthcare System for Children has developed a pediatric pain management program to address the need for pain management in post acute rehabilitation settings. The facility has documented this ongoing process in the format of this handbook that we hope will be useful for other institutions interested in undertaking a similar endeavor. Pediatric Pain Management Most pediatric pain management programs are located in academic medical centers and often focus on acute pain, particularly in the inpatient setting. Outpatient clinic settings are often arranged to help children suffering from chronic pain. However, in post-acute rehabilitation settings, pediatric inpatients experience both chronic and acute pain. Pain management is particularly important in providing accurate pain assessment and consistent care for both communicative and non-communicative patients in post-acute settings. Treating children with pain involves a balance of pharmacological and adjuvant therapies. When using drugs, it is important to clarify the difference between addiction and physical dependence. Addiction is drug-seeking behavior due to psychological dependence. Physical dependence, on the other hand, is exhibited by the signs and symptoms of withdrawal and can be treated by gradually weaning the patient from the drug. In addition to pharmacotherapy, adjuvant therapies are also recommended in pain management. They include psychotherapy and complementary (alternative) medicine treatments, such as acupuncture and acupressure. Pain management is a common reason for patients to pursue complementary medicine modalities. Our Facility St. Mary's Healthcare System for Children is a post-acute rehabilitation facility that provides care to children often with illness that are chronic in nature. The care if provided both on an inpatient as well as home care basis. Our inpatient capacity consists of a 97-bed facility in Bayside, New York, and a 44-bed facility in Ossining, New York. Our home care program includes over 1600 families in the greater New York area. At St. Mary's, prior to the establishment of a pain management program, pain was treated on an as needed basis. Although treatment was instituted following a patient's complaint of pain, the treatment often varied from practitioner to practitioner. We also realized that assessment is often difficult in children, particularly in children who are unable to communicate. Due to these observations, we embarked on a pain management program to create an "ouchless" environment in both of our facilities by proactively assessing the presence of pain before patients complained of pain. Goals For Our Programs In 1997, our goal to establish a pain free facility in our institution was made possible through the generosity and support of The Mayday Fund. We began the development and implementation of a pain management program that would utilize the available resources of our post-acute setting and deliver treatment that would adequately relieve pain in children. In addition, we decided to record this process in the form of a handbook to act as a blueprint for any other organization that would be interested in implementing a pain management program at its facility. In designing the pain management program at St. Mary's, we determined that the program would involve the following team members:
This pain management program utilized not only the traditional tools for pain management such as pharmacology, but also tools from complementary medicine. These would include imagery, biofeedback, hypnosis, massage therapy, music therapy, acupressure, and acupuncture. Specialists (such as an anesthesiologist) would also be available for consultation on an as needed basis. Implementation of the pain management program involved two steps: the first was to develop a model appropriate for the inpatient setting, and the second was the adaptation of the model for the pediatric home care setting.
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