Managing Children’s Pain After Surgery

By | January 7, 2019

Pain control in infants and children has come a long way over the past few decades. Experts know how to provide appropriate anesthesia when children need surgery and understand the ways that even very young children express distress when they’re hurting afterward. There is a lot of evidence about reducing the pain and anxiety that can accompany immunizations and blood draws, and there is increasing expertise about helping children who struggle with chronic pain.

But today’s parents may be shocked to learn that was not always the case. As recently as the early 1980s, the pain of children and infants was thought to be different from that of adults and was sometimes treated differently, or sometimes not treated at all.

Change doesn’t always come easily in medicine, so there’s a certain onus on parents to make sure that their children get state-of-the-art pain management around procedures, large and small. That means preparation before any planned surgery, ideally with a child life specialist, and it means careful attention to the child’s pain afterward, with parents well backed up by medical specialists.

Let me start in the bad old days: About 30 years ago, when I was doing my residency, my 4-year-old son fractured his femur. After surgery, he found himself on the orthopedic ward of my very own hospital, and in a fair amount of pain (the femur is the biggest bone in the body, and there was a lot of tissue damage).

As his busybody on-call pediatric resident mother, I discovered that the pain control ordered by the surgeons was “IM MSO4 PRN.” That meant he could have an intramuscular dose of morphine whenever the pain from the fracture was so bad that it overcame a 4-year-old’s fear of shots. To get pain relief, he would have to request the needle.

I paged the orthopedic resident and demanded that the order be changed to IV pain control, since he already had an IV. When the resident tried to scare me by telling me that IV morphine might suppress his breathing, I just plain pulled rank, insisting that I was a doctor myself and had managed lots of kids on IV morphine. My son got the IV pain control, but it was very much a case of special pleading.

You shouldn’t have to do any special pleading (or be a doctor yourself) to get pain relief for your child nowadays.

We’ve come a very long way in the management of pediatric pain over the last few decades. In fact, children used to get much less pain medicine than adults with the same problems, said Dr. Neil Schechter, the director of the chronic pain clinic at Boston Children’s Hospital, who showed in the 1980s that adults got two to four times as many doses of pain medicine as children with the same problems, and much of the pain control was indeed done by intramuscular injection, “and for children, that’s obviously particularly noxious and feared.”

“On top of that, one of the issues with kids historically is there was no easy way to measure pain in kids,” Dr. Schechter said. If your 4-year-old was crying it might be “because he missed mommy and daddy, or he was anxious.” The real problem, he said, was that nobody knew how to dose pain control medications safely in children, because the research hadn’t been done.

Today, “nobody’s getting intramuscular injections,” said Dr. Charles Berde, the founder of the division of pain medicine at Boston Children’s Hospital. As pain management improved. a first, the focus was indeed on giving opioids — like morphine — but on giving them intravenously, and with older children at least, on having the patient actually control the dose, with devices called PCAs, for patient-controlled analgesia.

But over the last 15 years, Dr. Berde said, the focus has shifted to optimizing all the nonopioid methods of pain control. That means using regional anesthesia, like nerve blocks, using nonsteroidal anti-inflammatory drugs, like ibuprofen and its relatives, and using acetaminophen (Tylenol). Dr. Berde, who wrote a 2016 review of the different modalities for pain control, said that opioids are still important for the most painful surgeries, such as large spine operations and open chest operations, although even in these situations, most children get them for less than a week. For smaller surgical procedures, he said, they should be used as “rescue” drugs when others fail, not as the predominant agents.

“Pain medicines act on different sites in the periphery and in the central nervous system,” Dr. Berde said. “Combinations are often more effective than a single medicine.” Thus, in the first couple of days after a minor surgical procedure, a child might get round-the-clock acetaminophen and nonsteroidal anti-inflammatory medication, using opioids only as backup, very short-term for a midrange procedure.

Surgical procedures nowadays often use minimally invasive methods like laparoscopy and arthroscopy, with easier recoveries and less pain, and patients are generally encouraged to return to activity much more quickly than in the past. Procedures are often done on an ambulatory outpatient basis, which puts responsibility for pain management on the parents when they take their child home. “Ideally, you want to have your kid in a hospital where they make it a priority to have systems in place,” Dr. Berde said. Parents need clear guidance, and they should know whom they can call with questions and problems.

“Kids benefit from a very individualized tailored approach,” Dr. Berde said, “from being honest with them about when there is discomfort and giving them ways to get through it, ways to feel like there is some mastery.” A child’s pain control should be tailored not only to the particular surgery, he said, but also to past experiences with pain, and even to the individual biology of the child. “There are clear biological differences between people in how much medicine they need and how well it works for them,” he said, and in the near future, it may be possible to predict these differences and tailor individual pain regimens.

Parents should be vigilant that their children are in fact receiving adequate pain management. “Parents assume everything possible is already being done for their child when we know in fact many of the evidence-based solutions for acute or procedural pain many times are not used in practice,” said Christine Chambers, a professor and children’s pain researcher at Dalhousie University in Halifax, Nova Scotia. “Pain skill isn’t given the priority that it deserves.”

Busy clinicians are not always aware, Dr. Chambers said, that “the experience of poorly managed pain early in life makes you more vulnerable physiologically and psychologically to pain later on.” In a study of infant circumcision, she said, the babies who did not receive proper analgesia showed more distress later on with vaccination.

Perhaps the biggest impact of parent advocacy involves surgery on premature infants, which was sometimes done without any pain medication only a few decades ago. The landmark story often cited here is the case of Jeffrey Lawson, a premature infant whose mother, Jill Lawson, requested his medical records after his death in 1986, and discovered that he had been paralyzed for heart surgery but given no pain medicine, on the belief that the immature nervous systems of the premature baby did not really feel pain.

The American Pain Society gives an annual Jeffrey Lawson Award for advocacy in children’s pain relief to commemorate his mother’s efforts to bring about better pain control in children, a reminder that it can take more than science to change clinical practice.

This is the first in a series of columns on pain in children.