Children’s pain in hospital undertreated: study

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A look at Canadian children’s hospitals finds that doctors aren’t documenting pain relief for the majority of painful or uncomfortable procedures kids experience in the hospital.

For seven out of every 10 procedures - things like blood sampling and inserting or removing intravenous lines and catheters - children received no pain treatment specific to that procedure, although eight out of ten procedures were done within 24 hours of some pain relief.

“Our worry is that (children) are getting painful procedures without any pain management,” said Dr. Bonnie Stevens, the lead researcher on the study and a professor at the University of Toronto.

Stevens and her colleagues collected data from eight children’s hospitals over a 6-month period.

The procedures ranged from uncomfortable - such as suctioning fluids from the nose - to severely painful - such as inserting a breathing tube.

Though most procedures occurred within a day of a treatment for pain, it wasn’t clear if that treatment alleviated the pain of the procedure.

The study, funded by the Canadian Institutes of Health Research, did not include major surgeries, cancer treatments, and trauma care.

On average, children underwent six painful procedures each day.

The researchers looked for documentation that children received either a pain medication, a physical or psychological treatment—such as swaddling or distracting with a video game—or were on an intravenous drip of pain medicine.

The most painful procedures were more likely to be treated.

For instance, nurses or doctors provided pain medication for putting in a breathing tube roughly 80 percent of the time. Another 20 percent of the time, children were receiving continuous pain relief through an I.V.

Rarely did the less painful procedures get a specific treatment.

Taking a blood sample from a finger prick, for example, was accompanied by pain relief five percent of the time (another seven percent happened while children had an I.V. drip of pain medication).

For many procedures, medication isn’t necessarily the best approach, Stevens said, but there are many other psychological or physical ways to reduce pain.

Nurses and doctors “can give babies a pacifier to suck on, distract them with a toy, or give them some drops of sucrose” to reduce pain, Stevens told Reuters Health.

“Any time we do a painful procedure on a child, even if it’s short-lived and of mild pain intensity, we should use these,” she added.

The study found that there was hardly any evidence of them being used; less than 1 percent of children received a psychological form of pain relief.

Similarly, less than 5 percent of children received physical interventions, such as swaddling or stroking.

Dr. Wick Kraemer, an assistant professor of anesthesiology at the Children’s Hospital of Philadelphia, told Reuters Health that health care providers regularly use non-drug strategies to help kids cope with pain, but they often don’t write them down.

Stevens agreed that some lapses in documenting pain relief could partially explain the numbers.

“My guess is it’s some combination between people not using (non-drug) strategies and not documenting them,” Stevens said.

Kraemer, who was not involved in the study, said that Stevens’s results might underestimate pain treatment, but he agreed that pain during routine care can be overlooked.

“Children might not cry, but we have to (treat) their pain. They have all the tools to feel it,” Kraemer said.

Dr. Lonnie Zeltzer, a fellow with the American Academy of Pediatrics and the director of the pediatric pain program at UCLA’s children’s hospital, said staff might undertreat children because of concerns about the side effects of medication.

“I think a lot of it is a lack of knowledge about what the options are” for treating pain, including non-drug approaches, Zeltzer, who was not involved in the study, told Reuters Health.

Though the study, published in the latest issue of the Canadian Medical Association Journal, looked only at Canadian hospitals, Zeltzer said it’s likely that the results reflect pain treatment at hospitals in the United States as well.

She added that staff should also be trained and rewarded for documenting the non-drug ways of helping a child cope with a painful procedure.

“This is to show the next person who comes along what has worked for this child,” Stevens said.

SOURCE: Canadian Medical Association Journal, April 4, 2011.

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