Doctors are waking up to the fact that children facing an operation need anesthetics and painkillers just as much as adults
Published: The Globe and Mail, January 11, 1992, FOCUS
By Deborah Jones, Halifax
WHEN anesthetist Allen Finley met the small cancer patient two years ago, she was curled in the fetal position and pushed everyone away, including members of her family. Dr. Finley decided to give her morphine, an unusual prescription for such a small child, even though the drug is routinely administered to dying adults.
"Overnight she became awake and alert. We were able to keep her like that until she died six weeks later," recalls Dr. Finley, a staff anesthetist at the Izaak Walton Killam Children's Hospital in Halifax, which today routinely administers painkillers to its young patients. "It was a gift of six weeks to her and her family."
Because of this experience, Dr. Finley, who also teaches at Dalhousie University's medical school, became committed to researching and finding treatments for young children in pain, a subject he says lags five years behind pain management for adults.
Until recently, it was commonly believed that children either didn't experience pain or felt it less than older people. Indeed, until about five years ago, major operations like heart surgery, tumour removal and limb amputation were sometimes performed on premature babies and newborns with only muscle relaxants to immobilize them. They were given few or no painkillers.
Today, especially in light of studies in Boston during the 1980s, doctors are recognizing that the recovery of very young children is hindered by the pain they suffer during and after an operation. Anesthetics are now routinely used for major surgery on babies in virtually all Canadian hospitals.
But, for less invasive treatments, there is still a long way to go. Last year, for example, Dr. Finley published a study on safe, effective ways to ease children's pain from bone-marrow aspirations. Most Canadian youngsters still undergo the procedure - in which marrow is drawn from the hip bone using a thick needle - while conscious, with just a local anesthetic and sedative to ease the discomfort. Dr. Finley recommends that powerful drugs, administered by an anesthetist and in a ward, be given to the children so they are tranquillized for a brief time. The doses would diminish their pain but not drug them as deeply as general anesthetics used in operating rooms.
Dr. Finley also notes that another minor operation, circumcision, is performed without painkillers on baby boys. Usually the once-routine procedure is done at a maternity hospital nursery, "and (anesthetists) are not invited."
Meanwhile, there is a wide variety of hospital policies on managing pain in children recovering from operations or dying in palliative-care units. The use of strong painkillers such as morphine on dying children remains controversial. Some people fear the young patients will become addicts; often the children themselves balk at receiving what anti-drug campaigns have taught them are narcotics.
"Parents need to be aware that cancer pain can be controlled relatively safely and easily, and that most other types of pain can also be controlled," says Dr. Finley. "There is no need for children to suffer after surgery or with other conditions."
Adults' reluctance to acknowledge children's pain, he says, is "an unconscious defence mechanism." Since no physician or nurse wants to cause pain, "it's easier to believe it's not there than to believe it's there and you're not doing anything about it."
He and psychologist Patrick McGrath of Dalhousie University in Halifax have several research projects under way, including preparing a guide to pain management for parents of young cancer patients, to be published early this year.
Dr. McGrath is the co-author, with Anita Unruh, of Pain in Children and Adolescents. Published in 1987, it was one of the first texts on childhood pain. Dr. McGrath had become interested in children's pain several years ago when he was staff psychologist at the Children's Hospital of Eastern Ontario in Ottawa.
Among his contentions is that pain in children is unfairly and incorrectly diagnosed as psychosomatic. His patients have included youngsters with recurrent abdominal pain, a condition thought to be caused by emotional problems. But usually, he found, the persistent aches did not have an underlying emotional cause, and a subsequent study showed that increasing dietary fibre helped about half the patients. "We think a good proportion of kids with recurrent abdominal pain are just constipated. It's just that their gut needs more fibre. Instead of psychotherapy, give them some bran - it's a lot cheaper and it works," says Dr. McGrath.
The desire to believe in psychosomatic underpinnings to children's pain is widespread. "It's the trash heap on which you throw everything you don't understand," he says. "If a child says (he's) hurting, you should take it seriously. On the other hand, most children have so many bumps and scrapes you don't want to overreact. The problem is, we don't know what overreaction is."
To find out, researchers at Dalhousie have launched a study of pain in healthy kids. "We're looking at 'owies' or 'bo bos,' and trying to understand how day-care kids understand pain," says Dr. McGrath.
A few wrong-headed notions have already been shot down. One fallacy has been that children complain a lot about pain, and that asking children if they hurt draws attention to their pain and makes them hurt more. But as he makes his rounds at the Izaak Walton Killam Children's Hospital, Dr. Finley says he has found that children are more likely not to mention their condition.
"If a five-year-old hurts, it doesn't take him long to realize if a nurse asks if it hurts and he says 'yes,' she comes back with a needle. He's smart enough to learn to keep his mouth shut."
As any parent of a colicky baby knows, babies and young children show they are in pain but offer few clues to its source. Dr. Finley says nurses and doctors must try hard to communicate with them. He notes that they may be helped by recent research at the University of British Columbia in Vancouver that tracks infant facial expressions in response to pain.
And he says anesthetists have found that, contrary to customary practice, small children usually require more painkilling drugs for their body weight than older people.
Ultimately, researchers are discovering their work complicated by an old tradition: Many adults suffer pain silently in the belief that it's honourable to be stoic - and they expect their children to do the same. Deborah Jones is a regular contributor to The Globe and Mail.
Copyright Deborah Jones 1992
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