Pain management

The goal of pediatric pain management should be to minimize discomfort while
performing the procedure. The two methods to achieve this goal are psychological
(using the mind) and pharmacological (using drugs). These two methods can be used
together to provide an integrated mind/body approach.
Psychological method
Preparation for every procedure is essential. Unexpected stress is more difficult to
cope with than anticipated stress. If parents and children understand what is going to
happen, where it will happen, who will be there, and what it will feel like, they will
be less anxious and better able to cope. Methods to prepare children are:
• Verbally explain each step in the procedure.
• If possible, meet the person who will perform the procedure.
• Tour the room where the procedure will take place.
• Small children can “play” the procedure on dolls.
• Older children can observe a demonstration on a doll.
• Adolescents may observe a videotape describing the procedure.
• Encourage discussion and answer all questions.
For my child, playing about procedures helped release many feelings.
Parents can buy medical kits at the store or simply stock their own from
clinic castoffs and the pharmacy. We had IV bottles made from empty
shampoo containers, complete with tubing and plastic needles. Several
dolls had accessed ports, and many stuffed animals in our house fell apart
after being speared by the pen during countless spinal taps. Katy’s
younger sister even ran around sometimes with her own pretend port
taped onto her chest. Some suggestions for the child’s medical kit are:
gauze pads, tape, tubing, stethoscope, reflex hammer, pretend needles,
syringes, medical chart, and toy box. Of course, lots of dolls or stuffed
animal patients are required.
• • • • •
My daughter (3 years old) took an old stuffed animal to the clinic with
her. Having the nurse and doctor perform the procedure first on “Bear”
helped her immensely.
Hypnosis is a well-documented method for reducing discomfort during painful pro-
cedures. If performed by a qualified healthcare professional (psychologist, physician,
nurse, social worker, or child life specialist), hypnosis can help your child control
painful sensations, release anxiety, and diminish pain. The professional helps guide
children or teens into an altered state of consciousness that helps to focus or narrow
attention. To locate a qualified practitioner, visit the web page for the American
Society of Clinical Hypnosis at http://www.asch.net/find.htm or call (630) 980-4740.
Imagery is a way to deliberately create a mental image of sights, sounds, tastes, smells,
and feelings. It is an active process that helps children or teens feel as if they are actu-
ally entering the imagined place. Focusing on pleasant images allows the child to shift
attention from the pain. It can also allow the child to actually alter the experience of
pain, which simultaneously gives the child control and diminishes pain. Ask if the
hospital has someone to teach your child this very effective technique.
The following description of using imagery was written by Jennifer Rohloff when she
was 17 years old, and is reprinted from the Free to Be Yourself newsletter of Cancer
Services of Allen County, Indiana.
My Special Place
Many people had a special place when they were young—a special
place that they still remember. This place could be an area that has a
special meaning for them, or a place where they used to go when they
wanted to be alone. My special place location is over the rainbow.
I discovered this place when I was 12 years old, during a relaxation
session. These sessions were designed to reduce pain and stress brought
on by chemotherapy. This was a place that I could visualize in my mind
so that I could go there anytime that I wanted to—not only for pain,
but when I was happy, mad, or sad.
It is surrounded by sand and tall, fanning palm trees everywhere.
The blue sky is always clear, and the bright sun shines every day. It is
usually quiet because I am alone, but often I can hear the sounds of
birds flying by.
Every time I come to this place I like to lie down in the sand. As I lie
there, I can feel the gritty sand beneath me. Once in a while I get up and
go looking for seashells. I usually find some different shapes and sizes.
The ones I like the best are the ones that you can hear the sound of the
ocean in. After a while I get up and start to walk around. As I walk, I can
feel the breeze going right through me, and I can smell the salt water. It
reminds me of being at a beach in Florida. Whenever I start to feel sad
or alone or if I am in pain, I usually go jump in the water because it is
a soothing place for me. I like to float around in the water because it gives
me a refreshing feeling that nobody can hurt me here. I could stay in this
place all day because I do not worry about anything while I am here.
To me this place is like a home away from home. It is like heaven
because you can do anything you want to do here. Even though this place
may seem imaginary or like a fantasy world to some people, it is not to
me. I think it is real because it is a place where I can go and be myself.
Distraction can be used successfully with all age groups, but it should never be used
as a substitute for preparation. Babies can be distracted by colorful, moving objects.
Parents can help distract preschoolers by showing picture books or videos, telling
stories, singing songs, or blowing bubbles. Many youngsters are comforted by hug-
ging a favorite stuffed animal. School-age children can watch videos or TV, or listen
to music. Several institutions use interactive videos to help distract older children or
teens.
My daughter went through her therapy prior to the days when kids
were given any pain medications for procedures. She and I would make
up a schedule of songs for me to sing during the spinal tap or bone
marrow. I would stroke her skin and sing softly to her. She visibly relaxed,
and the staff found it soothing, as well. I’ll never forget the time that the
oncologist, nurse, and I were all quietly singing “Somewhere Over the
Rainbow” during the spinal tap.
Other adjuvant therapies that are used successfully to help deal with medical treat-
ments are relaxation, biofeedback, massage, acupuncture, and accupressure. Ask the
hospital’s child life specialist, psychologist, or nurse to discuss and practice different
methods of pain management with you and your child.
Pharmacological method
Most pediatric oncology clinics offer the choice of sedation and/or anesthesia for pain-
ful procedures or non-painful procedures that require that your child lie completely
still. If you find that your child is distressed by painful procedures (bone marrow aspir-
ation and spinal taps), it is reasonable to explore all available options for pain relief.
One father, a doctor just completing his anesthesia residency, explained:
That first bone marrow was horrible. To have my little 3-year-old
look up at me with tears in her eyes and ask, “What else are you going
to let them do to me, Daddy?” was just too much. It was the worst day
of my life.
His wife, a nurse, said:
We really made waves by insisting that Meagan be sedated for her
spinal taps and bone marrows. It was mostly a logistical problem, but
we held firm, and now it has become much more routine for many
other kids as well.
The ideal pain relief drug for children should be easy to administer, be predictable in
effect, provide adequate pain relief, have a short duration, and have minimal side
effects. There are three topical anesthetics in wide use for pediatric procedures. EMLA
cream is put on the skin one to two hours prior to the painful procedure. Numby
Stuff also uses a cream anesthetic, but a mild electrical current helps it penetrate the
skin in just a few minutes. Ethyl chloride spray is used immediately before the proce-
dure to anesthetize the surface of the skin. Additionally, lidocaine may be injected
under the skin to numb the skin and tissue under it. For more information, see
Chapter 10, Chemotherapy.
Drugs for sedation and/or general anesthesia are given intravenously. Some facilities
take the child into the operating room (OR) for the procedure; others use a preoper-
ating area or clinic sedation room and allow the parent to be present the entire time.
Drugs used for pediatric anesthesia during procedures include:
• Valium or Versed plus morphine or fentanyl. Valium and Versed are sedatives
that are used with pain relievers such as morphine or fentanyl. These drugs can
be given in the clinic, but the possibility of slowed breathing requires expert
monitoring and the availability of emergency equipment. The combination of a
sedative and a pain reliever will result in your child’s being awake but sedated.
The child may move or cry, but will not remember the procedure. Often, EMLA
or lidocaine is also used to ensure that the procedure is pain-free.
Joel was treated from ages 14 to 17. During his spinal taps he would
get Versed once he was positioned on the table. I would always sit at his
head and keep his shoulders forward while his head rested on my arm
(kind of a hug). As the versed took effect, he would look up at me with
huge eyes and give me a grin a mile wide, then he would say something
off the wall. He had to spend an hour flat after the LP. He’d be groggy
the whole time, constantly asking me what time it was and how soon
we could leave. He’d forget he asked and ask me again five minutes later.
This continued for the whole hour. Later, we’d laugh about it. He never
remembered anything from the LPs.
• Propofol. A milky liquid given by IV, propofol has rapid onset with a rapid
recovery. Administration and monitoring by an anesthesiologist (doctor who
specializes in giving anesthetics) are required. Propofol, a general anesthetic, will
cause your child to lose consciousness. At low doses, propofol prevents memory
of the procedure but may not relieve all pain, so it is often used with EMLA or
lidocaine.
Patrick (12 years old) hates the lack of control involved when having
a procedure and getting propofol. He attempts to regain some control by
verbally explaining to the doctors just exactly how he wants it done each
time. He has his own little routine—tells them jokes, sings “I Want to Be
Sedated” (you know, the Ramones song), etc. Patrick’s biggest problem is
the taste from the propofol. We have tried so many different things when
he wakes up to mask the taste—Skittles, gum, Gatorade. We now have
a supply of atomic fireballs. I give him one as soon as they bring him out
and he says that really helps cover the taste.
• Ketamine. Ketamine needs expert monitoring. It has a much longer recovery
time than the drugs listed above, and upon awakening, up to 30 percent of chil-
dren may become confused and/or hallucinate. For these reasons, ketamine is no
longer in wide use for pediatric sedation for procedures.
There are many types of drugs and several methods used to administer them, from
very temporary (ten minutes) mild sedation to full general anesthesia in the operat-
ing room. Discuss with your oncologist and anesthesiologist which method will work
best for your child.
Let’s face it, kids don’t care about blasts, lab work, or protocols, they
just want to know if they are going to be hurt again. I think that one of
our most important jobs is to advocate, strongly if necessary, for adequate
pain control. If the dose doesn’t work and the doctor just shrugs her
shoulders, say you want a different dosage or drug used. If you encounter
resistance, ask that an anesthesiologist be consulted. Remember that good
pain control and/or amnesia will make a big difference in your child’s
state of mind during treatment.
Emotions may run high after a difficult procedure. Rather than engage in a lengthy
dissection of what went wrong, schedule an appointment time with your physician
well in advance of the next scheduled procedure to air your concerns and problem-
solve.
Because children with leukemia are treated for years, some children build up a
tolerance for sedatives and pain relievers. Often, over time, doses may need to be
increased or drugs changed. If your child remembers the procedure, advocate for a
change in drug and/or dosage. It is reasonable to request that an anesthesiologist be
present to ensure adequate pain relief.
My job as an oral surgery assistant required me to be very familiar
with different types of sedation. From the first day of Stephan’s diagnosis,
I quietly insisted on versed for bone marrows and spinal taps. We have
been in treatment for two years, and they still fight me every time, saying
that it’s just not necessary. When I make the appointment I tell them we
want Stephan sedated, and then I call and remind them so that all will
go smoothly.All types of sedation require that your child not eat or drink for a number of hours
prior to the procedure. After the procedure, your child may eat or drink when she is
alert and able to swallow. Sedation can result in complications, primarily to the airway.
It is imperative that sedation be carried out under the care of trained, experienced
personnel and that the child be monitored until fully recovered from the anesthesia.