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Gustaf Ljungman, MD, PhD Unit for Pediatric Hematology/ Oncology

Gustaf Ljungman, MD, PhD Unit for Pediatric Hematology/ Oncology Dept of Women ’ s and Children ’ s Health Children ’ s University Hospital Uppsala Sweden gustaf.ljungman@kbh.uu.se. Procedural Pain - The history and the future. Past Present Future Partly from a ped/onc perspective

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Gustaf Ljungman, MD, PhD Unit for Pediatric Hematology/ Oncology

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  1. Gustaf Ljungman, MD, PhD Unit for Pediatric Hematology/ Oncology Dept of Women’s and Children’s Health Children’s University Hospital Uppsala Sweden gustaf.ljungman@kbh.uu.se

  2. Procedural Pain - The history and the future • Past • Present • Future • Partly from a ped/onc perspective • ISPP June 2013 Stockholm

  3. Pain - adaptive warning system • Helps prevent further harm; tissue injury • Not applicable to medical procedures • Aim restore good health or treatment of disease • Obligation to minimize pain

  4. Pain, fear and axiety • The affective experiences of pain and fear are associated, respectively, with representations of injury and (life) threat. • Asmundson GJG, et al. Understanding and Treating Fear of Pain. Oxford: Oxford University Press, 2004. • Vlaeyen JWS, Linton SJ. Pain 2000; 85:317-332.

  5. Pain, fear and axiety • Although it is not always easy to recognize the difference in clinical practice, the distinction between fear and anxiety is theoretically based on the focus of threat • The term “fear” connotes an identifiable threat • Rhudy JL, Meagher MW. Pain 2000; 84:65-75.

  6. Pain is a symptom much feared by children and parents in ped/onc • The most feared for younger children. • Lansky SB et al. Pizzo et Poplack eds. Pediatric Oncology 1989:1127-39 • Enskär K et al. J Pediatr Oncol Nurs 1997;14:18-26

  7. Pain – the history • Hippocrates 2300 years ago concluded that children tolerate pain less than adults • Chadwick J, Mann W. The medical works of Hippocrates. Oxford: Blackwell scientific publications; 1950. • Since then several myths about children’s pain and its treatment have obstructed a sound development

  8. Pain history – the myths • Children tolerate pain and discomfort better than adults. • Flechsig in 1872 during experimental embryological research found that myelination in the newborn was not complete, and that associative cortical areas were undeveloped • Rey R. The history of pain. 1 ed. Cambridge, Massachusetts: Harvard University Press; 1993.

  9. Pain history – the myths • Darwin in his work, The Expression of Emotions in Man and Animals, stated that expressions of pain or other emotions in “animals, children, savages, and the insane” could under no circumstances imply the awareness of pain • Darwin C. The expression of emotions in man and animals. 1 ed. London; 1872.

  10. Pain history – the myths • These ideas resulted in the practice of performing surgical operations on newborn children and infants without anesthesia, still quite common in the 1950s • Rey R. The history of pain. 1 ed. Cambridge, Massachusetts: Harvard University Press; 1993.

  11. Pain history – the myths • In earlier days management methods for pain and fear scarce; common to restrain or even strap children to perform procedures • An argument supporting this practice was the incomplete myelination at birth. • Tilnet F, Rosett J. The value of brain lipoids as an index of brain development. Bull Neurol Inst NY 1930;1:28-71. • McGraw M. The neuromuscular maturation of the human infant. New York: Columbia University Press; 1943.

  12. Pain history – the myths • …. and it was often stated that children were unable to perceive and experience pain the way adults do, because their nervous system is immature. • Levy D. The infant's earliest memory of inoculation: a contribution to public health procedures. Journal of General Psychology 1960;96:3-46.

  13. Pain – the attitudes • In addition to myths about pain and opioids • Several individual and societal attitudes obstacles to improve pain management. • Even more problematic; cannot be proved or disproved. • To increase professionals’ knowledge often straightforward; to influence and change attitudes takes considerable time.

  14. Pain – the attitudes • Pain character building • Overcoming it hardening effect; improves personality and ability to compete. • Concerning physicians’ attitudes toward pain management in children: • Tend to attribute pain to medical procedures that were out of their direct control; think procedures performed by physicians in other specialties more painful, less well handled. • Schechter N, Allen D. Physicians' attitudes towards pain in children. J Dev Behav Pediatr 1986;7:350-354.

  15. Procedures • Vary widely in: • How intensive • How much pain and fear they cause • Experience affected by • Cultural factors • Anxiety level in child and parent • Fears and expectations of child • Coping style • Vulnerability in child • Invasiveness and duration of procedure • Previous pain experiences • Prognosis, etc.

  16. Procedural pain in pediatric oncology – the Past • 40-50 years ago almost all children with cancer died; today 75-80% survive • No central lines/ports (came during eighties) – more pain and fear • BMA, biopsies and LPs very seldom performed in anesthesia; often only sedation with diazepam • ”Suffering for the child, parents and personnel” • Gradual increase of anesthesia from the beginning of eighties. • Increased use of NO during the eighties; revival the last ten years. • Conscious to deep sedation with benzodiazepines, mainly midazolam, or in combination with opioid. Later propofol, but only in hands of anesthesiologists. • Increased use of clonidine in minor procedures.

  17. The Measurement of Symptoms in Children with Cancer; MSAS 10-18 Collins J J Pain Symptom Manage 2000;19:363-377 • Pain compared to other symptoms • Determines symptom prevalence, characteristics, and distress in children with cancer during the previous week • Most prevalent symptoms (%) • lack of energy 49.7 • pain 49.1 (most common S in inpatients 84.4, outp 35.1) • drowsiness 48.4 • nausea 44.7 • cough 40.7 etc. • Of symptoms prevalent in >35%; highest distress (% quite a bit to very much) • feeling sad 39.5 • pain 39.1 • nausea 36.6 • lack of appetite 35.8 • feeling irritable 34.7

  18. Pain in children with cancer - Etiology Ljungman G et al. Acta Paediatr1999;88:623-630 Ljungman G et al. Pain 1996;68(2,3):385-394 Also shown by: McGrath PJ et al. J Psychosoc Oncol 1990;8(2/3):109-124 Elliott S et al. Clin J Pain 1991;7:263-268 Zernikow B et al. Eur J Pain 2005;9:395-406

  19. Procedural pain – children with cancer • Port needle, iv sampling & cannulation, finger pricks • LP • bone marrow aspiration/biopsy • fine needle/true cut biopsy • pleurocenthesis • brachytherapy, etc. Ljungman G et al. Pain 1996;68(2,3):385-394 Ljungman G et al. Acta Paediatr 1999;88:623-630

  20. McGrath P J Psychosoc Oncol 1990;8(2/3):109-124 McGrath P, Hsu E, Cappelli M, Luke B, Goodman J, Dunn-Geier J. Pain from pediatric cancer: A survey of an outpatient oncology clinic. • cross-sectional, n = 77, age range = 2-19y • ped onc outpatient clinic • % > VAS 30 mean VAS BMA 78 24 LP 61 45 venipuncture 18 20 finger prick 23 18 chemotherapy 41 25 disease 37 24

  21. Other procedures in children • Burn dressings • Laser treatments for port-wine stains • Suturing of lacerations • Repositioning of fractures • Botox injections • Etc.

  22. Procedural pain in children – the evidence • Amethocaine superior to EMLA (AstraZeneca Canada Inc) for reducing needle pain • Distraction and hypnosis nonpharmacological interventions effective for management of acute procedure-related pain in hospitalized children • J Stinson, J Yamada, A Dickson, J Lamba, B Stevens. Review of systematic reviews on acute procedural pain in children in the hospital setting. Pain Res Manage 2008;13(1):51-57.

  23. Procedural pain – the present • Over the past 10 to 15 years, several epidemiological surveys emphasize: • significant proportion (49% to 64%) of hospitalized children receive inadequate pain management despite the increase in knowledge and available treatments. • Helgadóttir HL. Pain management practices in children after surgery. J Pediatr Nurs 2000;15:334-40. • Johnston CC, Abbott FV, Gray-Donald K, Jeans ME. A survey of pain in hospitalized patients aged 4-14 years. Clin J Pain 1992;8:154-63.

  24. Procedural pain • Insufficient pain management in procedures at the beginning of a disease trajectory may reduce the effect of treatment in later procedures. • Weisman S. Arch Pediatr Adolesc Med 1998;152:147-149

  25. Procedural pain – the Future • The ideal situation • The ideal cicumstances • Assessment of pain and fear to adjust treatment • The ideal method/drug • Combined analgesia and sedation • Short time to action • Short effect duration • No respiratory or circulatory depression • No side-effects • Often a combination of pharmacological and psychological methods

  26. Conclusions procedural pain • Still a lot of pain, fear and suffering in pediatric procedures due to insufficient management • Barriers • Ignorance, myths, attitudes, insufficient logistics, etc. • Obligation to reduce this pain, fear and suffering as much as possible

  27. Thank you for your attention! Collaborators: Lena Hedén, Jenny Thorsell, Tove Kamsvåg-Magnusson, Annika Englund, Louise von Essen, Anders Kreuger, Torsten Gordh, etc. gustaf.ljungman@kbh.uu.se

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