Procedures, Pain, and Parents

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PEDIATRICS Vol. 87 No. 4 April 1 991 563

COMMENTARIES

Opinions expressed in these commentaiies are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.

Procedures,

Pain,

and Parents

During the past decade certain types of pain in children have been the subject of much research and discussion. The pain associated with cancer, sickle cell disease, and the preoperative and post-operative periods have all been extensively studied and reviewed.’ Less information is available about acute pain inflicted in emergency rooms. Children commonly undergo procedures such as venipunc-tune, intravenous cannulation, lumbar puncture, and manipulation of fractures in emergency rooms without the benefit of any analgesia.

What techniques are available to reduce the pain and anxiety that children feel when they undergo procedures? Traditionally, physicians have tried to reduce pain by using pharmacological agents. We are familiar with the use of lidocaine to repair lacerations. More recently, the combination of te-tracaine, adrenaline, and cocaine has been intro-duced.5 This combination has many benefits, pri-manly its application as a topical solution, sparing

a patient the pain and fear associated with an

injection. Unfortunately, it is effective only in areas

where the skin has been damaged and there have

been case reports of severe adverse reactions, in-cluding convulsions and death following inappro-priate application. Fewer techniques are available to reduce the pain associated with venipuncture, intravenous cannulation, or lumbar puncture. Al-though little information is available, it is my ex-perience that few children undergoing these proce-dures are given any analgesia to reduce the pain.

Even when children undergo lumbar puncture, a

procedure for which adults routinely receive a local anesthetic, children frequently do not have any pain medicine administered. In a recent review of the

Received for publication May 9, 1990; accepted Jul 9, 1990.

Reprint requests to (H.B.) Dept of Pediatrics, Boston City Hospital, Talbot Bldg, 818 Harrison Aye, Boston, MA 02118. PEDIATRICS (ISSN 0031 4005). Copyright © 1991 by the American Academy of Pediatrics.

charts of all patients undergoing lumbar puncture in the Boston City Hospital pediatric emergency room during a 1-year period, no information was found suggesting that a local anesthetic had been

used during any of 252 lumbar punctures

per-formed.6 Eighty-six percent of the children

undergoing lumbar puncture in the emergency room

were younger than 2 years of age. Although the

results from this study are limited because they were collected by chart review, the chief residents in pediatrics believe the results are accurate.

Why have we avoided confronting the issue of

pain associated with these routine procedures? First, the old notion that “children don’t feel pain” still lingers, although I believe that when the ma-jority of physicians use the expression “don’t feel

pain” they mean that children don’t remember

pain. Little conclusive evidence exists that very young infants do remember, although medical per-sonnel who work with them have little doubt that they experience pain.7 Many of us care for children who spend months in the neonatal intensive care unit where infants are repeatedly subjected to pain-ful procedures, and it does not appear that this experience has any long-term detrimental effects. There is no information, however, about how well premature infants might grow and develop if their experiences of pain were dramatically reduced.7 In addition, long-term follow-up studies of premature infants do not examine outcomes such as phobias or anxiety disorders, problems that are considered

to occur following painful experiences. There is

little doubt that older children remember painful experiences. Even children as young as 6 months have consistent changes in their behavior associ-ated with painful experiences.8 This is probably best represented by some children’s obvious fear at being placed on an examination table prior to rou-tine immunization.

A second reason why we have not confronted the issue of pain associated with procedures is that many health care providers believe that some pain is not harmful and is a part of life. There is little information available to support this statement, but

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564 PEDIATRICS Vol. 87 No. 4 April 1991 after observing and talking with residents and other physicians, I believe it is accurate. We are aware of the pain that children are feeling and often react to it, but we usually rationalize that there is no alternative. This behavior is in conflict with a basic tenet of medicine-the reduction of pain and suf-fening.

Finally, there are few drugs or techniques avail-able that are simple, rapid, and safe to reduce the pain associated with procedures. As providers, we continually balance the pros and cons of any ther-apy or intervention. It makes little sense to give a child an intramuscular injection of an analgesic to

mitigate the pain of venipuncture. Although an

orally administered analgesic, such as codeine, may be effective, the time involved does not make it a viable option in an emergency room. Other, newer forms of analgesia such as lidocaine and pniocaine

prepared as a cream (EMLA) have recently been

introduced.9 Popular in Europe, EMLA may be

available in the United States within the year. Unfortunately, the analgesic effect of the cream is not apparent for at least 30 minutes, posing the same logistical problem as oral analgesia.

Over the past 3 years, we have been investigating

another type of analgesia in the emergency

room.’#{176}” An effective analgesic must be simple, safe, inexpensive, and readily available. Few drugs would ever meet these criteria, but there is a differ-ent type of analgesia that has not been used on any formal or consistent basis-that is, the comfort of a parent. Although most parents want to be with

their children during procedures, many are

ex-eluded.’0.’1 Pediatricians have reported varying opinions about parents being present during pro-cedures. In general, more experienced pediatricians tend to have less restrictive policies than their younger colleagues, although all physicians

main-tam

a hierarchy of preference.’2 In other words, for certain procedures that are deemed “very invasive”

pediatricians report that parents should not be

present.’2 Unfortunately, the difference between pediatricians in practice and those in training may be critical, inasmuch as many children who undergo

procedures in emergency rooms are cared for by

residents and not by experienced pediatricians. Many physicians do allow parents to be present when their children undergo a procedure but do not tell those parents how they can help their children; they either assume that parents instinctively know how to help their children, or they are too busy or unsure of what guidance to offer. In preliminary studies in our emergency room, we have found that many parents want to be with their children but

need information about effective way to reduce

their child’s pain.’0” Although some parents will sit comfortably at the head of the bed, few talk with

their children on touch them. Information available from other settings suggest that talking to and touching a child is both soothing and potentially anxiety-relieving.’3’14 For physicians caring for acutely ill children who are about to undergo pro-cedures, it is important not only to ask parents whether they want to be present, but also to offer them guidance, making the parents active partici-pants in the process.

Can it be harmful if parents are present? Many of us believe that we are more effective at intrave-nous cannulation or venipuncture ifparents are not

present. Parental presence makes us nervous.

There are no data suggesting that this is true, but physicians must decide for themselves whether they are less effective when a parent is present. If we consistently exclude parents, though, physicians will never develop the ability to perform procedures without anxiety when parents are present. If par-ents were present most of the time, most physicians would probably become as effective at performing procedures in their presence as in their absence.

What benefits are there to having parents present during procedures, other than the potential reduc-tion of children’s reaction to pain and anxiety? First, part of our responsibility as physicians is to help parents raise their children in a responsible

and supportive manner. It seems inconsistent to

ask parents to leave the room during an invasive procedure, when a child needs parental support and

when most parents want to be supportive. More

than 99% of children between the ages of 9 and 12

report that the “thing that helped most” was to

have their parents present during a painful proce-dure.’5 At some point, most of us have hinted to

parents that they should leave the room when a

procedure is to be performed, suggesting that they

can be the “good” person after the procedure is

completed, by returning to “rescue” their child. I believe that this scenario actually reflects our own anxiety. Second, parents who want to be with their children during procedures, and who are encour-aged to be, may be more satisfied with the health care delivery system and its responsiveness.

There are probably some procedures that parents should not observe, just as there are some parents who will indeed have a very difficult time if they are present. However, I believe that the scales are tipped in the wrong direction. Too many parents are excluded from too many procedures. By realiz-ing that parents may be effective allies, perhaps we can enlist them more regularly in our struggle to reduce the anxiety and fear-enhanced pain associ-ated with procedures. Equally important, when par-ents are present, we should help them keep them-selves and their children calm; just being with their children may not be sufficient. We need to explain

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COMMENTARIES 565 the procedure to the parents, telling them where to

sit and to talk with and touch their child. The parents should not be involved in restraining their child.

We are currently involved in a series of investi-gations delineating the most effective type of pa-rental support. Outcomes of interest include the degree of anxiety and pain of the child, the extent of anxiety of the physician and parent, the success of the procedure, and parental satisfaction with health care. Even if we find that parents cannot

help reduce the anxiety and/or pain that their

children experience, there may be other benefits in having them involved in the care of their children.

Parents will continue to seek care for their chil-dren in emergency rooms. It should be our goal to serve both their medical and emotional needs. Our diagnostic and therapeutic skills have improved over the past 20 years, but many of the new tech-nologies have only enlarged the gulf between the

parent and physician. Decades ago parents were

frequently asked not to visit their children when they were admitted to the hospital, but we realized that was a mistake, and now “rooming-in” is the norm in many hospitals. I believe that by making the parent an active participant during painful and stressful procedures we help bridge the gap between technology and good care by making allies of par-ents in an effort to minimize their children’s suf-fering.

ACKNOWLEDGMENTS

This work was supported in part by grant MCJ-250602 from the Maternal and Child Health Program.

I wish to thank RObert Vinci, Barry Zuckerman, and Chris Daly for their helpful comments.

REFERENCES

HOWARD BAUCHNER, MD

Divisions of Developmental and Behavioral Pediatrics and General Pediatrics Department of Pediatrics

Boston City Hospital and

Boston University School of Medicine

Boston, MA

1. McGrath PJ, Unruh AM. Pain in Children and Adolescents. Amsterdam, Elsevier, 1987

2. McGrath PA. Pain in Children, the Perception, Assessment,

and Control of Children’s Pain. New York, NY: Guilford

Press; 1990.

3. Ross DM, Ross SA. Childhood Pain: Current Issues,

Re-search, and Management. Baltimore, MD: Urban and

Schwarzenberg; 1988

4. Zeltzer L. Pediatric pain: diagnosis, assessment and man-agement. Pediatrician. 1989;16:1-123

5. Kemp CR. Pain management in the pediatric emergency department. Int Pediatr. 1989;4:14-18

6. Barnett ED, Bauchner H, Teele DW, Klein JO. Lumbar punctures as a marker for serious bacterial infection. Am-bulatory Pediatric Association. 66:1990.

7. Anand KJS, Phil D, Hickey PR. Pain and its effects in the human neonate and fetus. N Engl J Med. 1987;317:1321-1348

8. Craig KD, McMahan RJ, Morison JD, Zaskow C. Develop-mental changes in infant pain expression during immuni-zation injections. Soc Sci Med. 1984;19:1331-1337

9. Soliman IE, Broadman LM, Hannallah RS, McGill WA. Comparison of the analgesic effects of EMLA (eutectic mixture of local anesthetics) to intradermal lidocaine infil-tration prior to venous cannulation in unpremedicated

chil-then. Anesthesiology 1988;68:804-806

10. Bauchner H, Vinci R, Waring C. Pediatric procedures: do parents want to watch? Pediatrics. 1989;84:907-909

11. Bauchner H, Waring C, Vinci R. Parental presence during procedures in an emergency room: results from 50 observa-tions. Pediatrics. 1991;87:544-548

12. Merritt KA, Sargent JR, Osborn LM. Attitudes regarding parental presence during medical procedures. AJDC. 1990;144:270-271

13. Kuttner L. Management of young children’s acute pain and anxiety during invasive medical procedures. Pediatrician. 1989;16:39-44

14. Elliott MR, Fisher K, Ames E. The effects of rocking on the state and respiration of normal and excessive cryers. Can J Psychol. 1988;42:163-172

15. Ross DM, Ross SA. The importance of type of question, psychological climate and subject set in interviewing chil-dren about pain. Pain. 1984;19:71-79

Reflections

on the HIFI Trial

Mechanical ventilators have only two functions: to provide a flux to eliminate carbon dioxide from those who will not or cannot breathe and to estab-lish an adequate gas-exchanging volume to reduce

shunting. The concept of volume recruitment to

reduce shunting goes back at least to Mead and

Collier in 1959,’ who showed that without periodic inflations there was a progressive fall in compliance during prolonged mechanical ventilation. Much of the subsequent history of mechanical ventilation in acute lung disease has really been the search for

better methods of volume recruitment. The lung

has to be inflated past the pressure at which atelec-tatic lung begins to open and be maintained above its closing pressure (that pressure below which al-veoli and airways start to close again). Both of these pressures tend to be quite high in acutely

Received for publication Feb 20, 1990; accepted Jul 2, 1990. Reprint requests to (A.C.B.) The Hospital for Sick Children, 555 University Aye, Toronto, Ontario, Canada M5G 1X8. PEDIATRICS (ISSN 0031 4005). Copyright © 1991 by the American Academy of Pediatrics.

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1991;87;563

Pediatrics

HOWARD BAUCHNER