The New England Journal of Medicine, Volume 331, Issue 8: Page 541-544, 25 August 1994.
Gary A. Walco, Robert C. Cassidy, Neil L. Schechter
It has long been recognized that patients receive less relief from pain than they should1,2 . A recent review concluded that pain can be relieved effectively in 90 percent of patients but is not relieved effectively in 80 percent of patients3 . The tendency toward undermedication for pain is even more pronounced in children than in adults.4 There are large discrepancies between the amounts of postoperative analgesia ordered for and administered to adults and those ordered for and administered to children who have the same diagnoses and have undergone the same procedures.5,6
Interest in pain control in children has blossomed over the past decade, but there remains an incongruity between what is available technologically and what is practiced clinically.7 Possible reasons for this disparity include incorrect assumptions about pain and its management, individual and social attitudes toward pain, the complexity of assessing pain in children, and inadequate research and training.5 In each of these areas, one must ask whether the apparent undertreatment of pain in children is ethically justifiable.
The fundamental principle of responsible medical care is not ``do not hurt'' but ``do no harm.'' Harm occurs when the amount of hurt or suffering is greater than necessary to achieve the intended benefit. Here lies the basic ethical challenge to care givers: Since pain seems harmful to patients, and care givers are categorically committed to preventing harm to their patients, not using all the available means of relieving pain must be justified. Possible justifications can be divided into three types: revisionist, comparative, and pragmatic.
Usually, medical decision making relies on objective data. Pain is a subjective experience, however, and a direct quantitative assessment of it is difficult. Therefore, physicians rely on behavioral observations and knowledge of the specific pathophysiologic processes involved, as well as patients' own reports, to make judgments about children's experience of pain.8 The fact that pain is undertreated in children suggests that the final assessment tends to minimize the level of pain.9
One possible reason for this tendency is the mistaken notion that there is a ``correct'' amount of pain.10 The error results from the assumption that there is (or should be) a uniform response to a given pathophysiologic condition or pain stimulus. Despite studies showing the individual nature of children's experience of pain,11,12 many care givers continue to ignore the individual child and provide treatment based on their idea of the ``appropriate'' child.13
Adults are often considered more reliable in reporting children's pain than are children. The concern that children may feign or exaggerate suffering to obtain some secondary gain may cause adults to discount children's reports of pain.10 Furthermore, because pain is sometimes difficult to treat, care givers may diminish the seriousness of children's suffering and alleviate their own frustration by blaming children for protesting too much.14
Many myths about pain in children have been discredited. One myth was the belief that very young infants do not have the neurologic capacity to experience pain. Neuroanatomical studies, however, have shown that by 29 weeks of gestation, pain pathways and the cortical and subcortical centers involved in the perception of pain are well developed, as are the neurologic systems for the transmission and modulation of painful sensations15 . Behavioral16,17 and physiologic18 studies have shown that even very young infants respond to painful stimuli. Premature infants undergoing surgery with minimal anesthesia, which was once standard practice, have significantly higher stress responses (by hormonal and metabolic measures) and significantly higher rates of complications and mortality than those given deeper anesthesia.19,20
A related misunderstanding is the belief that even if very young children experience pain, they have no memory of it, and therefore it has no lasting effect. However, recent studies have concluded that pain and distress, such as those associated with circumcision, can endure in memory, resulting, for example, in disturbances of feeding, sleeping, and the stability of the state of arousal.21 Preliminary data even suggest that early experiences of pain may produce permanent structural and functional reorganization of developing nociceptive neural pathways, which in turn may affect future experiences of pain.22
Another belief that has been dispelled is that children's pain cannot be measured accurately. Pain in children can be assessed through physiologic indicators, systematic observation of behavior, and reports by the children themselves.23 The key psychometric properties are reliability, validity, clinical sensitivity, and utility, and the consensus is that from the age of about five years, children are very reliable reporters of their own experience of pain. If there are discrepancies between a child's report of pain and the observation of a parent or physician, it is best to defer to the child's perspective.24
Even very young children feel pain and can communicate that response in a number of ways. The care giver's job is to use the available strategies to observe the child sensitively, assess his or her condition objectively, and treat it effectively. Denial of relief from pain that is proportionate to the expressed need for such relief must be judged an unjustified harm, unless such deprivation serves a substantially greater good.
Even if we accept children's self-reported pain as reality, we still have to weigh the benefits and risks of unrelieved pain against those of pain relief. A responsible conclusion may be that the harm of unrelieved pain is less severe than the harm of pain relief. In arriving at such a conclusion, one must consider the physiologic state of the child, the disease causing the discomfort, and the analgesics themselves, as well as how an analgesic will be administered and its potential side effects and long-term consequences. Once again, recent data indicate that many concernsabout analgesia may no longer be valid.
The traditional management of moderate-to-severe acute pain in children has involved the parenteral administration of opioids, often intramuscularly. Particularly among young children, fear of the needle often causes substantial anxiety and distress, sometimes resulting in the decision to withhold potent analgesics. Recent technological advances and a better understanding of the pharmacokinetics of opioids offer some help.25 Opioids should be administered orally. If this is not indicated, essentially painless intravenous access can be obtained through the use of local anesthetic cream. Potent opioids can then be administered by means of a bolus dose or continuous infusion. Patient-controlled analgesia has been used successfully in children as young as six years, with a high degree of satisfaction reported by the children and their parents.26 Transmucosal, transdermal, and epidural routes of administration can also be used.27 These innovations have eliminated the need for repeated injections, thus considerably reducing the child's distress.
Another concern is the possibility of side effects of analgesic medications, particularly respiratory depression or arrest associated with opioids28 . Although the potential for these difficulties is not disputed, in deciding whether the risk outweighs the potential benefit to the patient, one must consider several relevant facts. The risk of narcotic-induced respiratory depression in adults is about 0.09 percent,29 whereas in children it ranges between 0 percent30 and 1.3 percent.31 In the study by Dilworth and MacKellar,31 a dose reduction corrected the problem in all but one case. There are no data to support the notion that children are more susceptible to respiratory depression than are adults32 . A better understanding of opioid pharmacokinetics allows more accurate predictions of the peak time of respiratory depression in children receiving opioids by various routes (although there may be substantial individual variation).33 Especially with a continuous infusion, respiratory slowing occurs long before notable respiratory depression or arrest.34 Thus, with adequate monitoring and adherence to appropriate guidelines for dosages, respiratory depression should be a rare event in children. In addition, because agents are available to reverse the effects of opioids, the condition can be treated if it occurs.35
Respiratory depression and arrest nevertheless remain of concern. Inevitably, some deaths are associated with the administration of opioids, despite optimal monitoring. In medicine and in our daily lives, we make decisions knowing that despite every precaution, there remains some level of risk. In this instance, parents (and patients) should be informed of the potential risk, however small, associated with opioid administration, as well as the possible advantages of adequately controlled pain over uncontrolled pain (earlier mobilization, deeper breathing, less potential for atelectasis, and less suffering).
Finally, concern about addiction causes substantial apprehension about the administration of analgesics. Survey data indicate that 39 percent of physicians are concerned about the risk of addiction resulting from the use of narcotic analgesics in young patients,36 and this concern may be reinforced by parents' objections to giving narcotics to their children.9 It is essential to distinguish between physical dependence (a physiologically determined state in which symptoms of withdrawal would occur if the medication were not administered) and addiction (a psychological obsession with the drug). Addiction to narcotics is rare among adults treated for disease-related pain and appears to depend more on psychosocial factors than on the disease or medically prescribed administration of narcotics.37 Studies of children treated for pain associated with sickle cell disease38,39 or postoperative recovery32 have found virtually no risk of addiction associated with the administration of narcotics. There are no known physiologic or psychological characteristics of children that make them more vulnerable to addiction than adults.
An overestimation of the risk of analgesic-induced addiction leads to an underestimation of the harm of untreated pain. When analgesics are administered properly, the risk of addiction is minimal. As Angell declared, ``I can't think of any other area in medicine in which such an extravagant concern for side effects so drastically limits treatment. We are used to a closer balance between risks and benefits''.40 In summary, any comparative justification for withholding pain relief must be rigorously judged on the basis of the comparative risks and benefits and empirical data, not speculation or undocumented lore.
The comparative justification recognizes that pain is bad but concludes that it is not as bad as the risks associated with the relief of pain. The pragmatic justification acknowledges that unrelieved pain is bad but asserts that such pain may be necessary to achieve a greater goal. Pain may be seen as useful to monitor an illness. For example, the patient's response to palpation of the abdomen may be an important aid in diagnosis. Pain may also indicate the ineffectiveness or limits of treatment, such as discomfort during rehabilitation after orthopedic surgery. Masking such pain could obscure physical signs and actually harm the patient. One must therefore weigh the benefit of immediate relief against that of long-term recovery.
Another goal, character development, is based on a moral view that champions traits such as courage, self-discipline, independence, and self-sacrifice. Although in principle encouraging such virtues may be ethically defensible, imposing the burden of character development on a child already encumbered by sickness and suffering reflects a lack of compassion and is ethically questionable, at best. When the total eradication of pain is not possible (as in the case of chronic pain associated with chronic illness), strengthening the child's capacity to cope with the pain is beneficial and may be justifiable. However, to withhold analgesics from a suffering child in the hope of influencing character development ignores the child's real, present need for relieffrom pain.
The ethical responsibility of clinicians is to provide full treatment of pain in children unless otherwise justified by defined therapeutic benefits. Three specific tests should be applied. First, is the pain useful? Is it the means to achieving an important goal? Second, is the pain necessary? Are there other, less hurtful means of achieving that goal? Third, is the pain at the lowest possible level? If there is a therapeutic benefit from a child's pain, one must be exquisitely economical with it.
There are now published guidelines for the management of pain in children, which are based on recent data.41-44 However, guidelines and continuing medical education do not necessarily alter physicians' behavior.45,46 Specific administrative interventions are required. For example, hospitals may include standards for the assessment and management of pain as part of their quality-assurance programs.47 The Joint Commission on Accreditation of Healthcare Organizations has established standards for pain management.48 To meet such standards, multidisciplinary teams must develop specific treatment protocols with the goal of reducing children's pain and distress. In addition, pressure from parents and the legal community is likely to affect clinical practice.
All health professionals should provide care that reflects the technological growth of the field. The assessment and treatment of pain in children are important parts of pediatric practice, and failure to provide adequate control of pain amounts to substandardand unethical medical practice.
Gary A. Walco, Ph.D.
University of Medicine and Dentistry of New Jersey
Newark, NJ 07103
Robert C. Cassidy, Ph.D.
Schneider Children's Hospital, Long Island Jewish Medical Center
New Hyde Park, NY 11042
Neil L. Schechter, M.D.
University of Connecticut Health Center
Farmington, CT 06032
We are indebted to Dr. Barbara Shapiro for her helpful comments on the manuscript.
Address reprint requests to Dr. Walco at the Tomorrows Children's Institute, Hackensack Medical Center, 30 Prospect Ave., Hackensack, NJ 07601.
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