- Anjana Kundu, MD
What Doesn’t Kill you Doesn’t Always Make you Stronger: 3 Common Myths in Pediatric Pain
Updated: Sep 26, 2020
Have you ever believed in something to be the truth until you found out it wasn’t?
Well, you’re not alone!
Myths and misconceptions have been part of the human history for as long as we can recall. Every culture has mythological stories, stories typically involving supernatural beings or forces, which embodies and provides an explanation, etiology, or justification for something, that isn’t true. As humans we have a tendency to believe in stories of courage, miracles and hopes, and these stories get called into question from time to time when a new aspect comes to light, to challenge everything we had believed. Take the example of the “healthy diet”, the new miracle cure for a great body, endurance, spirit or promise of longevity. The same is also true of pain and its treatments!
Anyone who has lived has experienced pain. Regardless of age, gender, education or geographic location, it is part of our lives, as minor cuts, bruises, bumps or major pain related to injuries, surgery or illnesses. As adults we can express how we feel, and how the pain affects us,but when it comes to children’s pain, the issue is as clear as mud. Whether we are the parents or healthcare providers, we’re still dealing with many myths and misconceptions surrounding children’s pain.
Pain management, and for that matter all of medicine itself, is a great example of how are beliefs shape the direction of our efforts.
In the ancient times, pain was believed to be an external force, an act of God, a punishment or a test of your strength, while during the renaissance times of Descartes, he described it as a mechanical phenomenon within the body, connecting the experience from periphery to the mind and creating a pain experience. Then the evolutionary theory proposes pain to simply be a defense mechanism or reflex to protect our bodies from that what is causing us the harm or pain.
The diverse explanations for the purpose, mechanism and treatment of pain have shaped the interpretation and treatment of the pain. This has determined what we do or do not do. This is especially poignant to the phenomenon of children’s pain.
Throughout history, the awareness about pain amongst children has gotten little attention. And even as recently as the 1980s, babies would routinely get a major surgery like open-heart surgery, without appropriate anesthesia and pain treatment, because of the misconceptions amongst the physicians about the babies’ brains development regarding pain. Thus, it was normal to assign the higher number of deaths and suffering among these babies to their delicate, immature constitution or the nature of their medical or surgical conditions. It was also normal to think that even if babies did feel pain, it wouldn’t ultimately matter because they wouldn’t remember it later.
Although these beliefs have been refuted by research since then and advances have been made to understand, describe and treat pain better, children still remain most vulnerable to the risk of under treatment of pain and its negative impact.
Here are 3 of common myths that continue to hinder the treatment of children’s pain.
Myth #1: Newborns, Infant and Children don’t feel pain like adults do.
Fact: I admit that there is some truth to this myth, but not in the way that we think.
We now know that our skin (and internal organs) has sensors for pain, called the “nociceptors”. These nociceptors only pick up the signals and need this information decoded to understand that this sensation is unpleasant or painful, which happens in the brain centers. The nociceptors and the brain are connected through a complex network of nerves that travel from body parts, through our spinal cord and finally to the centers in our brain. The brain centers also activate another set of network that tries to “modulate” or modify the pain signals, so as to limit the amount and duration of pain.
The pain sensing pathways, carrying the pain signals from our body to our brain, are present even in a fetus (as early as 20 weeks), but what are not developed until later childhood, are the pathways that can modify the pain intensity.
So newborns and infants not only feel pain, but they feel it even more intensely and for longer. We know this to be a fact through research work I also listed in my previous blog
Myth #2. We cannot assess pain accurately in babies and children
Fact: It is well established that pain is a personal experience and its intensity is subjective. Till date, the gold standard of pain assessment remains the verbal report of the person who is experiencing it. That means, that pain is what and how much, a person experiencing it says it is. As of now, here is no standard tool or test that can quantify pain across different people, but, in the majority of cases an accurate assessment of pain is possible, even in children who do not have the language to tell you. There are reliable, validated, age appropriate measurement tools based on the situation, health condition, age and development level of the child. There are also cues such as facial expressions, body movements, or behavioral changes that also play an important role to indicate the amount of pain a child or baby is experiencing.
Myth #3: Children will tell you if they are in pain
Fact: So many times, even when children can speak, they may not report pain.
I remember my daughter being 6 years old, who rarely complained about anything, although that has changed now that she is a teenager! She was wincing when eating her food, when she had a cold and fever, but it took my prompting for her to tell me that she had a “bad” earache even during the night, but didn’t want to tell me because she didn’t want to disturb my sleep or keep me going to work to help other children!
Sometimes, these sensitive little souls may believe that it will displease their parents, siblings and friends, or they may feel bad about “bothering” their parents or loved ones so they may not report their pain. Sometimes it’s due to fear of treatment or consequences or a desire to please those around them that keeps them from reporting their pain. It is also plausible that the child may not say he/she is in pain in order to avoid a further painful experience such as a taking medication or fear of an injection or because they may think that reporting pain might keep them in the hospital and separated from their parents. Some older children may not wish to appear “weak” by showing their pain, especially in front of their peers.
So what’s the big hoopla about children’s pain and how we respond to it? Haven’t we heard the old adage “what doesn’t kill you makes you stronger” ?
Are we going to raise a generation of wimps if we run and protect them from ever little cut, bruise, or scrape? Isn’t pain protective? A defense mechanism? Something that makes us more resilient?
Well, the short answer is - Not always!
Although acute pain can be a protective signal to avoid further physical harm like in case of touching a hot surface, twisting an ankle or breaking a bone, but when pain is unrelieved/untreated, it can have very harmful effects on the body, their function, psyche and their social structure.
Pain makes it hard for kids to be kids.
It affects their quality of life by unpleasant physical experience limiting their function, school, or sleep.
Untreated pain interferes with their healing.
It increases anxiety, fear and makes them sad and hopeless, which in turn can make their perception of pain even worse.
This can be very distressing for both children and their families. A child’s pain impacts the entire family.
Moreover, research also shows us that children with untreated pain have a much higher chance of developing depression, anxiety and growing up to become adults with chronic pain,
All this is quite contrary to the belief that they become stronger and resilient.
Up to 40% of children and adolescents experience pain at least once a week, and that 1 in 3 school aged children in USA report chronic pain (pain lasting longer than 3 months) which translates to 19 million kids between the ages of 6-18 years.
Unfortunately, research shows that children with pain don’t always get appropriate pain management either due to misconceptions about understanding their pain experience or lack of knowledge, fear and misconceptions about the treatment options.
Would it surprise you to read that Veterinary schools require at least five times more education on how to handle pain than medical schools do?
Well, It’s true as per the testimony of Nora D. Volkow, the director of the National Institute on Drug Abuse, before the Senate Committee.
We ought to do a better job of training our healthcare providers, and a better job of partnering with patients and families for safe and effective pain treatments for our kids.
I’ll leave you with this thought – do we think our children need or deserve any less than our pets?
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