8/7/2019 Children Are Often Under Treated for Pain

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BMJ VOLUME 327 22 NOVEMBER2003 bmj.com 1185

Children in pain rarely seem toget the attention they need. There is a substantive gapbetween what we know and whatwe do, said Dr Richard Howard,from the anaesthesiologydepartment at Great OrmondStreet Childrens Hospital, Lon-don, speaking at the AmericanMedical Associations briefing inNew York to launch JAMAstheme issue on pain.

Infants used to get much lesstreatment than adults for thesame conditions, he said, because

doctors feared side effects in chil-dren. Although improvementshad been made in the past 20yearsas doctors learnt moreabout the immature nervous sys-temthere were few good evi-dence based studies, he said.

In his paper reviewing thecurrent status of pain manage-ment in children, he said thatchildren were not good atreporting pain, even when using visual scales ranging from nopain to worst pain (JAMA2003;290:2464-9). Doctors arenow better at using indirectmeasures to gauge pain and theeffectiveness of treatment, andself controlled analgesia and

epidural anaesthesia have beenadapted for use in children.

Neuropathic pain resultingfrom damage to the nervous sys-tem is more common than pre- viously thought, but little isknown about treating it, said DrHoward. He said that the ner- vous system is not fully devel-oped at birth and grows throughdifferent stages in infancy andthat infants and children mayperceive pain differently at thedifferent stages.

Little is known about the

long term effect of brief painasfrom needles used in immunisa-tioncompared with pain aftersurgery, he said. For minor pain,such as that from needles, hesuggested using local anaestheticcreams or behavioural methodsto reduce childrens anxiety.

A Dutch team, led by Dr Dick Tibboel of Erasmus MedicalCenter-Sophia Childrens Hos-pital in Rotterdam, reported inanother journal published by the American Medical Associationthat 151 premature babies in aneonatal intensive care unit had14 painful procedures every dayduring their first two weeks oflife, many without analgesia

( Archives of Pediatric and Adoles-cent Medicine2003;157:1058-64).

The clinicians estimated that 26of 31 procedures in a checklist ofall procedures would be painful.Each day less than 35% of thebabies received analgesia before apainful procedure, and nearly 40%did not receive any analgesia dur-ing their time in the unit. The teamsaid painful procedures should bereduced and analgesia improved.

However, another study byDr Tibboels team found noanalgesic effect from routinecontinuous intravenous mor-phine in premature babies onventilator support, nor did theyfind a beneficial neurological

effect (JAMA 2003;290:2419-27). There is confusion over the

use of morphine in such babies. The team studied 150 preterminfants in neonatal intensive careunits. The babies were ran-domised to placebo or mor-phine (100 micrograms per kgand 10 micrograms per hour, forup to seven days).

The pre-emptive morphineinfusion did reduce intra- ventricular bleeding, but theauthors suggest that morphineinfusions should not be used inpremature infants on ventilatorsupport until more is knownabout the long term conse-quences.

Children are often undertreatedfor painJanice Hopkins TanneNew York4, 339, 71

Painkillersbefore kneesurgery improveoutcomesJanice Hopkins TanneNew York

4,96Patients who had pre-emptivetreatment of pain with a cyclo-oxygenase-2 (COX 2) inhibitorbefore knee replacement surgeryhad less pain and vomiting afterthe surgery, needed fewer opi-oids, slept better, had better kneeflexion, and needed less physicaltherapy. The randomised con-trolled trial was reported by Dr Asokumar Buvanendran andcolleagues at Rush-Presbyterian-St Lukes Medical Center, Chica-go (JAMA 2003;290:2411-8).

Knee replacement is among

the most painful of operations,Dr Buvanendran said. The 70patients, aged 44 to 77 years,

were assigned to placebo treat-ment or to treatment with 50 mgof oral rofecoxib 24 hours beforesurgery, another 50 mg an houror two before surgery, 50 mgdaily for five days after surgery,and 25 mg daily for the nexteight days. All patients were givenepidural anaesthesia and self con-

trolled analgesia after surgery.Range of motion is an impor-tant outcome measure after kneereplacement. The degree of kneeflexion needed for climbingstairs is 83, for descending stairs90, and for tying shoelaces 106.At discharge, patients in the rofe-coxib group had 84.2 of activeflexion and patients in the place-bo group had 73.2. One monthafter surgery the figures were109.3 and 100.8 respectively.

Dr Buvanendran said that theimprovement meant an increasein satisfaction among patients, a

quicker return to work or usualactivities, and a reduction in thecosts of physical therapy.

News

Treatment fordepressionimproves pain inelderly patientsJanice Hopkins TanneNew York

4,83, 208 Treating elderly patients fortheir depression can reducetheir pain and disability fromarthritis, finds a randomisedcontrolled trial of 1801 elderlypatients with depression in five western US states (JAMA 2003;290:2428-34).

Of the patients, who wereaged over 60 years, 1001 (56%)had arthritis as well as depres-sion. They were randomlyassigned to usual care or totreatment for depression withantidepressants or six to eight

sessions of psychotherapy.At follow up at three, six, and

12 months all the patients who

were treated for depression saidthey had less functional impair-ment, better health, and betterquality of life.

Dr Elizabeth Lin, of the Cen-ter for Health Studies at theGroup Health Cooperative,Seattle, who coordinated thestudy, said that before entering

the study patients had signifi-cant pain, but few were takingpain medications or antidepres-sants.

Depression treatment wasdoubly effective, she said. Mostpatients had other chronic dis-eases, and depression leads toless compliance with medicationregimens. Better depression care reduced depression, reducedpain severity, and increased thequality of life.

Treatment for depressionprobably also reducedhealthcare costs, she said,

because depressed people usehealth care 50% more thanpeople without depression.

Doctors estimate that 26 out of 31 procedures used in neonatalintensive care are painful, but many babies do not receive analgesia

BSIP/ASTIER/SPL

Pain management was the subject of a special issue of JAMA last week