'This won't hurt a bit'

In an often-cited 1997 study in The Lancet (Vol. 349, No. 9052: 599–603), researchers found that infants who were circumcised without appropriate pain management reacted to subsequent vaccinations with more pain than their uncircumcised counterparts. But increased sensitivity isn’t the only potential problem that pain in medical settings can cause.

“Having pain — or perceiving your child experience pain — can be a trigger for ongoing traumatic stress in children and their parents,” says Anne E. Kazak, PhD, director of the department of psychology and the Center for Pediatric Traumatic Stress at the Children’s Hospital of Philadelphia (CHOP). Medical traumatic stress responses, she explains, are associated with life-threatening disease or treatment-related experiences in children. Pain can be part of these potentially traumatic experiences, leading to flashbacks, hyper-arousal and avoidance.

Traumatic stress reactions can make children — and their parents — reluctant to face the risk of more pain. As these children grow up, for example, some may be more inclined to avoid seeking optimal or needed health care. “They may become more avoidant of the health-care system,” says Kazak.

Fortunately, psychologists and others are developing interventions that health-care professionals, parents and children themselves can use to lessen both acute and chronic pain.

Kazak and her colleagues, for example, have developed tools health-care professionals can use when children face painful procedures, hospital visits or other potential sources of medical traumatic stress. The evidence-based tools, available at the center’s www.healthcaretoolbox.org, include hand-outs for children and parents on coping with illness, injury, hospitalization and more; instruments for assessing pain, stress, coping and psychosocial support; and educational materials for health-care professionals, including a pocket card for assessing patients’ needs after injuries and a pocket card with brief screening and intervention recommendations.

“In medicine, you have the ABCs: airway, breathing and circulation,” says Kazak. “Our main message to healthcare providers is to then add DEF: reduce distress, promote emotional support and remember the family.”

Reducing procedural pain

Psychologists are also seeking ways to reduce the pain associated with particular procedures, such as vaccinations.

“Vaccinations are a hot topic now, with the H1N1 vaccine,” says Christine T. Chambers, PhD, research chair in pain and child health at Dalhousie University in Halifax, Canada, and recipient of the 1999 APF Lizette Peterson Homer grant for research on injury to children. She and colleagues are working to make sure practitioners have easy access to the science on pain reduction.

In a 2009 review of the literature on immunization pain published in Clinical Therapeutics (Vol. 31, Supp. B: S77–103), Chambers and colleagues found that several psychological interventions significantly reduce children’s pain. The most effective were breathing exercises, such as blowing bubbles or blowing on pinwheels; child- or nurse-led distractions, such as watching a DVD; and strategies that combined approaches, such as relaxation and distraction.

What didn’t work, the review found, was suggestion — saying that a vaccination won’t hurt, for example. “There was no evidence that that works,” says Chambers. “And it can really undermine the relationships children have with parents or health professionals.”

Chambers and the rest of the group — led by Anna Taddio, PhD, of the Leslie Dan Faculty of Pharmacy at the University of Toronto — are now summarizing their findings in clinical practice guidelines that synthesize the evidence in favor of psychological as well as various pharmacological and physical interventions. These guidelines will be distributed to pediatricians, family physicians and public health officials across North America.

In the meantime, Chambers and colleague Patrick J. McGrath, PhD, are bringing that knowledge about what’s effective directly to children and their parents via two DVDs designed for use in emergency rooms. With one targeting preschoolers and the other older children, the videos use puppets to teach children and parents how to use effective pain reduction techniques.

“There’s often a lot of down time while families wait for blood work and so on,” says Chambers, explaining that families can use that time to watch the DVDs. Although she and McGrath are still analyzing the results of this randomized trial, participants have been enthusiastic.

Lindsey L. Cohen, PhD, an associate psychology professor at Georgia State University in Atlanta, believes a combined approach is the best solution to procedural pain in children. “Various things work a little bit, but nothing so far has eliminated children’s procedural pain and anxiety,” says Cohen, who reviewed the literature on needle-related anxiety and pain management in a 2008 study in Pediatrics (Vol. 122: s1134–s139). “There’s no gold standard.”

A reusable bee-shaped device called Buzzy exemplifies a combined approach Cohen advocates. Invented by pediatrician Amy Baxter, MD, of Pediatric Emergency Medicine Associates in Atlanta, the device — pressed against the skin during a shot — combines distraction, a cold pack and vibration to relieve needle-related pain in children. “If you bang your elbow, you typically rub it,” says Cohen, adding that the literature on pain relief supports both cold and distraction as effective strategies.

Cohen and Baxter are studying Buzzy’s effectiveness, with funding from the National Institutes of Health. In a randomized controlled trial presented at the 2009 American Academy of Pediatrics annual meeting, they found that Buzzy decreased pain significantly more than the standard option of vapocoolant spray among 4- to 18-year-olds undergoing venipuncture.

Coping with chronic pain

Children who suffer from chronic pain can be an especially tough — but rewarding — group to treat, says Jessica W. Guite, PhD, a psychologist in the pain management service at CHOP. The most common chronic pain conditions, she says, are headaches, abdominal pain and musculoskeletal pain. A major challenge is helping families understand there’s often no quick fix for chronic pain, says Guite, who’s also an assistant professor of anesthesiology and critical care at the University of Pennsylvania School of Medicine. An important aspect of this is helping children and parents understand the differences between acute and chronic pain and the different approaches to treating them.

Treatment for chronic pain is often counterintuitive, since components like physical therapy may initially increase pain. Although parents do the best they can to provide support in this very difficult situation, emphasizes Guite, efforts to protect a child with chronic pain can backfire.

“If someone has pain from an acute injury, it may not be appropriate for them to initially get up, exercise or go to school until sufficient healing occurs,” she says. “However, when pain becomes chronic, it becomes essential for kids and families to figure out ways to help the child or adolescent get back into activities they may have put on the sidelines.” In research funded by the National Institute of Child Health and Human Development, Guite is studying ways that families’ beliefs about pain and expectations for treatment affect outcomes for adolescents with chronic pain.

“We need a better understanding of how we can communicate with families to help them get to a place where they see the merits of treatments that emphasize improving the child’s functioning — treatments that parents may initially see as at odds with a desire to protect their child from further discomfort,” she says.

Psychologist Tonya Palermo, PhD, chief of the division of clinical research in pain and regional anesthesia at the Oregon Health and Science University in Portland, is tackling another challenge when it comes to children’s chronic pain: the dearth of health-care professionals trained to treat it.

“In the whole United States, there are maybe 30 pediatric pain clinics,” she says. “For most children who don’t live in major urban areas, it’s actually quite hard to get care.” Palermo has come up with a solution: an Internet-based intervention for children and parents.

“Children engage really well with this form of treatment delivery,” she says. “And it’s such a flexible way of delivering treatment.”

Based in cognitive-behavioral therapy, the intervention educates children about chronic pain, teaches them relaxation skills and lifestyle modifications, and urges them to use cognitive strategies, such as focusing anew on normal activities. For parents, the emphasis is on recognizing stress in their children, rewarding good coping behaviors and modeling healthy responses to their own pain. The intervention also includes tips for parent-child communication.

In an NIH-funded randomized, controlled trial published in 2009 in Pain (Vol. 146, No. 1–2: 205–13), Palermo and colleagues found significantly greater reduction in pain intensity and activity limitations for the Internet treatment group than for the control group at a three-month follow-up.

“This technology can be used in a real cost-effective manner to reach a large number of patients,” says Palermo. “Our findings suggest that there might be ways we can consider less intensive treatments online but administered to a bigger population and then reserve in-person services for those kids who need more intensive treatment.”

Rebecca A. Clay is a writer in Washington, D.C.