The ethics of pain control in infants and children

In this chapter we will offer a way of framing the ethical balance of competing considerations in pain treatment in infants and children, distinguishing between analyses of harms and benefits, from other more pragmatic, contextual, and cultural considerations. We begin with the ethical foundations behind good pain management for any patient, and especially children: the ethical duty to prevent harm by alleviating pain or suffering, and the importance of assuring equal access to pain treatment. Historically, the driving ethical concern in paediatric pain has been the pervasive undertreatment of pain in children. In the second and main section of the chapter, we offer a detailed analysis of the practical ethical challenges involved in weighing the harms and benefits of pain relief against untreated or undertreated pain. In the third section, we will discuss the more specific concerns of socioeconomic and cultural determinants to paediatric pain treatment. Finally, in the last section, we will address concerns in conducting research on pain interventions in infants and children, as clearly many of the modal methodologies traditionally used for clinical trials in adults (e.g. placebo control designs) pose unjustifiable risk to younger individuals. We will also discuss the importance of considering local context as it impacts standards of care to guide ethical paediatric pain research.

Theory-informed approaches to translating pain evidence into practice

Despite great strides in evidence-based pain assessment and management strategies, infants and children still experience acute pain (including multiple painful procedures) and chronic pain during hospitalization. Translating best evidence on pain assessment and management into clinical practice remains a challenge. The knowledge- or evidence-to-practice gap in pain in children can be addressed by implementing strategies, underpinned by knowledge translation theories, frameworks, and models, to promote and sustain practice change. A range of factors related to the organizational context and individual behaviour play a role in the adoption of new pain assessment and management practices.

Complementary therapy in paediatric pain

There is increasing paediatric use of complementary therapies (CTs), especially for paediatric pain. This chapter reviews the key literature on studies that pertain to CTs that impact pain in children. The research is still in its infancy with few studies that have been well designed and replicated. Likely the strongest of the studies is in hypnotherapy, which will have its own chapter, and in biofeedback for headaches. Acupuncture research is growing but there are few well designed studies in children compared to those in adults. Risks in CTs mostly relate to training of the practitioner and good clinical judgement (e.g. avoiding massage in children aversive to touch). Most are safe when used with clinical judgement.

Hypnosis and relaxation

This chapter discusses the current research literature and clinical practice regarding the use of hypnosis in paediatric pain management, first defining hypnosis and discussing theoretical conceptualizations. Next it presents our current understanding of the mechanisms of hypnotic analgesia, along with the research evidence for the efficacy of hypnosis in the control of acute and chronic paediatric pain; in both sections relevant clinical techniques are discussed. It also includes a description and discussion of different relaxation techniques and the evidence for their efficacy in acute and chronic pain management, and concludes with an attempt to summarize and evaluate the existing literature and make suggestions for future studies and clinical practice.

Cognitive-behavioural interventions

Cognitive-behavioural therapy (CBT) is the most commonly researched and empirically supported psychological treatment for the management of paediatric pain. CBT is a brief, goal-oriented psychotherapy treatment using a hands-on, practical problem-solving approach (Kendall, 2012). It is based on the concept that thoughts, feelings, and behaviours are causally interrelated. This chapter offers an overview of CBT and its application to pain management, describes specific cognitive-behavioural strategies commonly used for paediatric acute and chronic pain problems, presents the empirical evidence supporting these approaches, and highlights key considerations and emerging directions in the use of CBT and related treatments for paediatric pain.

Interventional pain management techniques for chronic pain

As part of multidisciplinary management of paediatric chronic pain, interventional pain management techniques can play an important role when pain is unrelieved by conventional treatment modalities. Many procedures and indications are extrapolated from adult studies, and evidence for long-term efficacy in paediatric populations is limited. Interventions range from injection techniques with local anaesthetic and/or corticosteroids to neuraxial blockade with implanted catheters. Paediatric case series have reported benefit in selected patients with complex regional pain syndrome and cancer-related pain.

Developmental pharmacology of opioids

Recognition of the need for alternative analgesic regimens for managing neonatal and childhood pain has led to a rich literature concerning the ways in which early life pain differs from that at older ages. As in adults, opiates are often considered the gold standard analgesic class of drugs, of which morphine is the prototypical agent. There is a wealth of data detailing clinical observations, measurements, and interventions with regard to the use of opioids in treating pain in children. Studies in the early part of this century have highlighted that, in humans, age is an important factor that influences the morphine requirement of neonates following surgery; and dose requirements are influenced by both pharmacokinetic and pharmacodynamic factors. Laboratory studies have extended our understanding of changes within the peripheral and central nervous systems that underlie alterations in nociception in early life. This chapter will review what is currently known about the actions of opioids upon nociceptive and nociresponsive elements of the nervous system in early life, how they differ from adult responses, and ask whether manipulating endogenous opioid systems in early life may have consequences on neurodevelopment.

Effective management of children’s pain and anxiety in the emergency department

Effective management of children’s pain and anxiety during emergency department (ED) visits facilitates medically necessary care and procedures and increases patient, family, and health care provider satisfaction. This chapter will review evidence-based techniques for achieving this goal. A significant focus is upon non-pharmacological strategies to relieve children’s anxiety because high levels of anxiety exacerbate sensitivity to pain and disrupt coping mechanisms of the child and parent. In addition, advances in techniques for pain relief for specific procedures will be detailed. Aspects of procedural sedation and analgesia that are especially pertinent to the ED will also be reviewed along with two recommended regimens for moderate and deep sedation.

Persisting pain in childhood medical illness

Persisting pain in the context of medical illness has been recognized recently as a global problem by the World Health Organization (WHO, 2012). Whilst the epidemiology of medical illness varies throughout the world, the general principles of pain management are applicable to most medical illnesses in children and are effective. Successful pain management for most children is contingent on the availability of the WHO model list of essential medicines for children (WHO, 2011), although regrettably not all medicines are available in every country in the world.

Chronic pain syndromes in childhood: one trunk, many branches

Although this volume is replete with detailed discussions about specific pain problems, the focus of this chapter is on a discussion of the commonalities in aetiology, associated symptoms, and treatment of many of the frequent chronic pain problems. We will explore in brief the data that demonstrates the co-occurrence of many of the common chronic pain problems in children and the epidemiological similarities that exist between affected individuals. Then we will review the concept of central sensitization and the physiological evidence that supports its presence in many of the functional pain problems. We will briefly review some of the symptoms associated with these entities (orthostatic intolerance, sleep disturbance, depression, anxiety, hypermobility, family distress). Finally, we will discuss briefly a general approach to these problems emphasizing the collection of specific information in the history and physical examination, the critically important presentation of the formulation to the family, and the treatment modalities that appear to be effective for many of these conditions. In-depth discussion of each of these pain problems is available in chapters specifically designated to review them in detail.