Pediatric pain

Canada is a leader in pain research. So why are kids suffering?

by Elizabeth MacCallum

Michelle Del Guercio/Science Source

Pippa is a big girl now, almost 4, so she’s very good on the swing. “Higher! Higher!” she squealed and James McKee, her father, obliged with delight. Then it happened. The nightmare. Pippa sailed through the air like a bird and crash-landed with her right leg underneath her. To avoid hours in the notoriously slow waiting room at the Hospital for Sick Children’s emergency ward in Toronto, McGee and his wife, Amy Nugent, took Pippa to a general hospital nearby. Waiting there more than five hours for an ambulance—because children with serious broken bones in Toronto go to Sick Kids—Pippa would doze off briefly, only to wake screaming. No one was around at the ER desk who could respond to McKee’s pleas for more appropriate medication for his daughter. When the family arrived at Sick Kids, Pippa was immediately made comfortable with the completely necessary pharmacological brew, as she waited until orthopaedic surgeons pinned the fracture in her femur later that day in the operating room.

Pippa was actually extremely lucky. She ended up in one of the best pediatric pain centres in the world. Canada has only seven hospitals with children’s-pain departments to serve the entire country; Manitoba, P.E.I., Newfoundland and the North have none. Despite the fact that this country is one of the world leaders in pediatric pain research, many children in Canada do not live within access of proper pain care. The groundbreaking pediatric pain management program at the renowned IWK Health Centre in Halifax flourishes, its brilliant research included. But if you live in Cape Breton and have a child with chronic pain—regular pain that continues for months and often years—every appointment can mean a long drive to the hospital, overnight stays, time off work and missed school days. These hospital-based clinics provide complete interdisciplinary care at no cost to the family. If the child sees local physio- or massage therapists outside a hospital setting instead, each professional must be paid directly, unless the family has a plan through work. That usually covers only a few appointments, nothing like the costs of regular visits for the long haul. Most families are shocked to discover just how inadequate pain care for children can be.

For almost a century, as professional doctors took over from midwives and female family members in the birthing business, a myth was born that newborns and premature babies don’t feel or remember pain. In the early 1980s, the anaesthesiologist for a premature infant, Jeffrey Lawson, didn’t believe he would feel any pain during open-heart surgery. She provided no pain relief during surgery, just Pavulon, a drug that left him unable to move, but totally conscious. The only good news in this horror story that ended with Jeffrey’s death a few weeks later is that his mother, Jill Lawson, went on a public rampage when she learned the facts of the surgery, and went so far as to get her story published in the medical journal Birth in 1986. The anaesthesiologist “seemed sincerely puzzled as to why I was concerned,” Lawson wrote. A neonatologist explained to her that “babies, unlike adults, don’t go into shock no matter how much agony they suffer.” Lawson argued in her article that anaesthesiologists took advantage of this, coupled with the patient’s inability to complain. “I’m convinced that Jeffrey was paralyzed for the convenience of the surgeon. Once paralyzed, he couldn’t distress the operating team by demonstrating his pain, so they didn’t give it any further thought.” Her story shocked families and professionals alike and significantly vitalized the current wave of research on pain in babies and children.

The most delicate premature babies endure up to 10 painful procedures a day, often while lying constrained in their incubators. Ruth Grunau, a professor of neonatology at the University of British Columbia, has found that the more painful procedures a child endures, the more brain-development and behaviour problems it suffers. Babies soon behave like adults who have chronic pain, and develop an infant form of depression. The problem is that regular opioids can be damaging to infants, and topical anaesthetics don’t always work.

Fortunately, not all solutions involve medication. Celeste Johnston, a nurse specializing in neonatal pain at IWK and a professor emeritus at McGill University, studies “kangaroo care,” a tactic that had mothers keep their premature babies snuggled against them, skin to skin. The strategy was first developed in the ’70s in Colombia, which had a shortage of incubators. Even with children born at as little as 32 weeks’ gestation, mortality rates fell. Johnston’s research showed that premature and term infants held skin to skin, much like a baby kangaroo in its mother’s pouch, show significantly less pain throughout tests and injections. Johnston and her colleagues are currently assessing 16 studies from around the world for the Cochrane Review, the respected medical research journal, proving the benefits of kangaroo care.

Johnston doesn’t forget fathers’ contributions to pain relief, either. In an interview, she describes watching a film clip of a father never breaking eye contact with his little boy, who was in the process of being anaesthetized. He regaled his son with stories about their dog and what would happen if it were let loose in the hospital. The child went under happy and relaxed.

Dr. Christine Chambers, who holds the Canada Research Chair in pain and child health and is a professor of pediatrics and psychology at Dalhousie University in Halifax, was part of a group that generated clinical guidelines for parental behaviour when children experience mild discomfort or severe pain. Despite the instinctive tendency to empathize in rising vocal tones, her research shows that this actually makes the child feel worse. Chambers and her colleagues teach parents to distract a child, even during regular vaccinations. What affects the child’s attitude to future medical procedures isn’t so much the degree of pain a child reports feeling at the time, as it is his memory of the event. If the parents are positive and confident—without actually lying—the child will be less fearful and have less pain.

Nurse Cathy Lewis in Calgary has learned all about the power of distraction on the job. For one or two days a week, she gives vaccinations. Distressed by the unhappiness generated by this straightforward public health work, she thought back to a film about distraction techniques and clowning. Now, with her invisible magic gloves and her captivating routine, kids often don’t realize they have just had a shot—or even two. She’s proud when four-month-old babies laugh after inoculations.

At a surprisingly young age, children can help themselves, too. Celeste Johnson tells the horrifying story of a four-year-old girl who reported everything that had gone on in a procedure when she was so deeply sedated, staff thought she was unconscious. Because of this experience, the little girl hated everything about hospitals. Eventually, she came up with her own way of calming herself down. She worked out that her very own purple boots gave her magic protection. If she wore them to the hospital and kept them on always, she could be invincible. That was the end of hysterical, tearful arrivals. All it took was her imagination and understanding medical staff.

More concrete solutions will take some political will, and financial resources. In an interview, Dr. Mary Lynch, president of the Canadian Pain Society, lamented the fact that only two per cent of children with chronic pain in Canada get the care they need, and argued that will never improve without a national strategy. “There is a perfect parallel in the Canadian strategy for cancer control, based on a 2006 paper that summarized a five-year plan, substantially financed by the government.”

Chronic pain costs Canada $60 billion every year, she says. Those resources can be better deployed. Last spring, Lynch, along with other experts from the Canadian Pain Coalition, blitzed Parliament Hill during the first national pain summit. Rather than emerging with a national plan, they failed to have even one conversation with a Conservative politician. “This federal government has no interest at all in national strategies,” said Lynch. “They could call a task force to put [one in]. That’s what we asked for at the summit. We have a blueprint and would be happy to help them.”

As Lynch sees it, pain is about much more than dollars. “If children don’t receive appropriate care, they miss out on formative years, and pain can wreck their entire lives. That has a major cost to the child, their family and our whole of society.” Any child can tell you: pain really hurts.




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Pediatric pain

  1. wow, that story about the surgery on the premature baby was horrible! as if they thought he couldn’t feel pain just because he was young!

    However, I cannot help but notice that if he had still been in the womb, where he was supposed to be, his limbs could be torn off while he was still alive and nobody would have expected him to feel pain. Abortion is painful for the victim, the unborn child. He has no protection under law. Doctors fight to help premature babies and advocates speak up for their pain, yet the unborn child is only valued if his mother feels like having a child, and the idea of fetal pain is scorned. Pain really hurts, and for these youngest members of society, it can literally “wreck their entire lives”. Abortion is a “major cost to the child, their family and our whole of society”. Canada, we need a law!

    • Please, lets not use this story for you to try and spread your anti-abortion right ideology. Partial birth abortion (what you are referring to) is mostly illegal, unless absolutely needed, in the United States and Canada. Almost all abortions are preformed way before the fetus has even developed a nervous system and therefore cannot feel anything and have no conscious. Partial birth abortion is only performed when there is an absolute danger to the mothers life, and when this happens the mother is put under anaesthesia which also puts the fetus under anaesthesia. So the child feels no pain as well as the mother. As a Pediatrician it is insulting that people would think that a doctor would mutilate a child while they were conscious.

      • And yet it’s okay for you to spread your pro-abortion view, right? And what defines the time that a “fetus” is no longer a fetus but a human being? 2 weeks? 4 weeks? 12 weeks? So on and so forth. You claim to know the distinction and yet we are still unable to scientifically prove when abortion is not the killing of an unborn child. The truth is, life begins at conception, that is the one thing we scientifically know as fact – disproving that so a woman can live a more comfortable life is unethical, immoral and built upon a false ideology in today’s society. It’s scary to know you’re a pediatrician; anyone that’s pro-abortion has blood on their hands, both literally and figuratively.

        • You believe that the primary reason women get abortions is so that they can “live more comfortable lives”. Is there even ONE woman who has told you about the real reasons she terminated a pregnancy? You don’t sound like the kind of man with whom women would feel comfortable enough to share that part of your lives. Your misogyny is palpable.

          • The reason a woman gets an abortion is irrelevant to the fact it is the killing of another human being, therefore your argument is mute. Babies, as soon as they are born, are protected under the law just like every other person. As such, you would be tried in court if you take the life of your own baby. What I find interesting is how these laws magically disappear when that same baby is inside the womb. And if you’re going to tell me there is a significant difference between a baby just born, and a baby 1 week, 2 weeks, or even a month before birth, then you are severely confused. Misogyny? Please. A typical label you assign to people who are pro-life without even understanding the ethics behind their view. If you claim that I have hatred towards women for being pro-life, then I guess it follows that you hate all human life for supporting abortion. That should be a fair assumption based on your logic, yes?

            Now that we’re clear, I’ll humour you and look at the actual facts. There have been more than 50 million abortions since 1973. Women have cited ‘social reasons’, not their health or horrible cases such as rape/incest as their motivation for approximately 93% of all abortions. So, even if health, incest, or rape was a good enough excuse to kill the life of another human being, on average you’re accounting for 7% of all abortions that take place. Lastly, abortion isn’t exactly the perfect, comfortable, easy solution that society makes it out to be. Have you even witnessed an abortion? To date, 137 studies have associated a strong correlation between having just 1 abortion and future pre-term birth. What’s worse? Having more than 1 abortion increases the risk of future pre-term birth by 93%! Would you like me to reference these for you, because I’d be happy to do so? Abortion effects women’s reproductive health and is associated with at least one severe negative health outcome: future preterm birth. There are more studies being developed to show other negative health effects that have their root cause from abortion. Abortion is both damaging to mother, and obviously, the child. Misogyny? I laugh at your attempt for misdirection; “The most violent element in society is ignorance”.

            Good day.

      • First of all, I did not come here thinking “hmm what can I post about abortion today”, I read the news like anyone else, and I read this story like anyone else. I’m not wandering around dropping propaganda leaflets on your city, I just see a major connection between the story of the premature baby and the story of so many unborn children. The reason I am concerned is that there is NO law in Canada. So partial birth abortion is not “illegal” in Canada, it may be “unrecommended”, but that’s not solid enough. Also, I was not referring to partial birth abortion. In the partial birth abortion procedure, the foot is grasped and the entire body, except for the head, it brought out. Then, the doctor stabs the skull with scissors, and uses a suction machine to remove the brain. So, as far as I know, dismemberment is not a part of partial birth abortion. Dismemberment occurs in D&E abortions, in the second trimester. In earlier abortions, the fetus is sucked out of the womb in pieces, so although they are not big enough to be grasped with forceps, they are torn apart. If, at any stage, in any abortion procedure, they can feel, then they would be feeling pain. We need to know when.
        You say that the idea of a doctor mutilating a conscious unborn child is appalling. I strongly agree with you. However, is it alright to mutilate an unconscious unborn child? What if the doctor doesn’t think the child can feel pain when conscious? Physicians are divided on the time at which the fetus can feel pain, some deny it altogether. There is no law. Also, saline abortions kill over a period of several hours, and some fetuses have been born alive after a saline abortion. I would think, especially if they have the capability to live, if only for a few hours after birth, that they can feel pain. Anesthesia is given directly to the fetus in fetal surgery, so I would be interested to find out why this is necessary, if the anesthesia could be fully effective on the fetus by administering it to the mother only.

        Also, what sort of medical conditions would necessitate a partial birth abortion? Considering the mother’s health, would it not be safer to just induce labor, deliver the child and euthanize them? Is that worse than abortion? Is it wrong?

    • Ha ha ha ha ha! Man, nice segue into your abortion polemic. Really shocked me. I thought you were being facetious at first.

    • Ah, anti-choicers, never wasting the opportunity to derail an important issue to peddle their anti-woman, anti-life, anti-child agenda.

  2. Just two things: New Brunswick should have been included in the list of provinces with no children’s hospital or pain centre. It is also serviced through the IWK.
    And kangaroo care, as I remember learning about it in pre-natal classes, is something that fathers are also encouraged to do. It doesn’t have to be done by the mother to be effective.

  3. This article is poorly written.

    the anaesthesiologist for a premature infant, Jeffrey Lawson, didn’t believe he

    Only after reading more I figured out Lawson was the baby.

    • And so is your comment. You probably should have put quotes around the phrase you were quoting.

  4. That actually sounds like a pretty solid plan to me dude.

    ur-anon.tk

  5. You spelled ‘their’ wrong under the headline ass ‘there’.

    • You spelled “as” wrong you ass.

  6. Why are “there” children suffering??!??!? Are you kidding me. Did a 1st grader write this terrible article?

  7. Doctors do circumcisions without anesthesia or any pain medications every day for no reason

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