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"This won’t hurt a bit," you tell your young patient as you are about to administer an injection that delivers a stinging, burning medication. Think of it from the viewpoint of a 4-year-old: The needle looks like it is 3 feet long, and the medication you inject feels like fire in her vein. The patient could develop a little mistrust. After all, you promised it wouldn’t hurt — didn’t you?
Children feel pain, perhaps even more keenly than adults, says Brenda McClain, MD, DADPM, associate professor of anesthesiology at Yale School of Medicine in New Haven, CT. McClain is the director of Yale’s Pediatric Pain Management Services.
"There is no reason for any child to suffer through a medical procedure, however minor it may be," says McClain.
From minor methods, such as using distraction techniques for a vaccination, to major ones, such as acupuncture and guided imagery to relieve pain of advanced cancers, McClain’s mission is to keep her small patients as comfortable as possible.
In the past, she says, some physicians and parents were hesitant to use common pain medications in children for fear they were too strong. Others contended that the infant nervous system was too immature to feel pain. But current research shows that even premature infants feel pain, and young infants may even be more vulnerable to pain than adults.
Of the millions of children who undergo surgery every year, many receive inadequate pain relief, which prolongs the recovery period and can delay wound healing, McClain adds.
This can result in heightened sensitivity to pain, a change in temperament, and distrust of adults, physicians, and other caregivers. "When proper pain management is used, physicians have observed a faster return to normal activities, a lower risk of complications, and shorter hospital stays," she says.
McClain has used complementary pain therapies for children with cancer, sickle cell anemia, migraines, reflex sympathetic dystrophy, and postoperative pain from a variety of types of surgery.
The first step to providing complementary forms of pain relief in conjunction with mainstream pharmacology is to simply explain alternatives and adjuncts to routine pain medications to the child’s family, she says. "Some families will request complementary therapies like acupuncture, but most don’t even know they exist," she explains.
And another important tenet to remember, says McClain, is never lie to the patient. "Don’t tell them it won’t hurt if it will. You don’t have to tell them, This is going to hurt,’ instead you can say it will feel like a bee sting or it may burn a little," she advises.
From there, the jump to complementary therapies such as acupuncture, controlled breathing, distraction, and a variety of meditation techniques is a relatively short one.
Acupuncture is by far the most effective and fastest form of pain relief say McClain and her colleague Shu-Ming Wang, MD, an anesthesiologist who practices acupuncture, among other techniques, in Yale’s Pediatric Pain Management Service.
"Sometimes, the effect is immediate when the needles are inserted at the proper meridians," says Wang. "The first treatment is usually the most dramatic, and I like to see [patients] three times or more if it is necessary."
Textbooks say such patients should have three treatments a day, but that simply is not practicable, says Wang, so she devised a way of giving them almost continuous treatment until they get relief.
For some patients who may need multiple treatments, such as teen-agers with migraines, Wang developed a self-stimulation technique that involves placing a needle in the ear lobes, anchoring it with tape, and sending patients home to move the needles three times a day.
The patients can sleep, shower, and conduct their normal activities without any problems, although Wang notes that sometimes needles are dislodged or can become painful when patients use the telephone. Wang recommends placing needles in the ear the patients least often use when on the phone.
"I had a 16-year-old boy with chronic migraines whose pain disappeared after the first treatment. I saw him two more times and then he did not return because he had no more pain," says Wang.
There are many theories about how acupuncture works, and some of them are a stretch for the Western mind because they are based on Eastern medical precepts that seem at odds with Western mainstream medicine. However, Wang notes there is scientific evidence that acupuncture stimulates the nerve endings and sends signals to the central nervous system to modify neurotransmitters, which then modify the perception of pain.
"Some colleagues accuse me of practicing voodoo — or the kinder ones say acupuncture simply provides a psychological placebo effect," she says. "I say if it’s a placebo, so be it."
Eastern and Western medicine do not have to be at odds, says Wang, who grew up in a Chinese culture and received her medical education in the United States. "If we can combine the best of Eastern and Western medicine and relieve our patients’ pain while using fewer drugs, why not?"
She says she has recently been encouraged by the depth of interest in acupuncture and other complementary therapies among interns and residents. "It seems to me the new generation of physicians in training are more open-minded to different medical approaches and, as they begin to practice, they will facilitate this combination of approaches to medicine."
Physicians treating young patients with sickle cell anemia at Grady Health System in Atlanta have discovered they can add complementary therapies to their arsenal against the pain of this debilitating disease.
Deep breathing and visualization seem to have a beneficial physiological effect as well as psychological benefits, says Beatrice Gee, MD, assistant professor of pediatrics at Morehouse School of Medicine, also in Atlanta, and co-director of Grady’s Pediatric Sickle Cell Clinic.
Ideally, patients are taught deep abdominal breathing and visualization techniques before getting in a sickle cell crisis, because the technique works best with practice, says Gee.
"We teach the parents to work with their children and to practice the techniques at home," says Gee. Some families do their homework better than others, so the results during a crisis are mixed and usually temporary, says Gee, who thinks the techniques should be used in conjunction with pharmacological remedies.
Working with the child at home also gives the family members a feeling of comfort in knowing they can do something should a crisis occur.
Teaching a child to visualize lying on a beach with a warm breeze blowing or sitting in a field of daisies on a mountaintop helps divert the patient’s attention from the pain at hand and causes some physiological responses such as muscle and blood vessel relaxation and increased oxygenation of the blood — all key issues for sickle cell patients, notes Gee.
A very young child might be diverted with a favorite toy or older ones by listening to some favorite music, says Gee. The techniques vary depending on the child’s age.
Controlled breathing is fairly simple to teach and can have fast and powerful effects. Respiratory therapists work with patients to teach them controlled breathing techniques, often incorporating spirometers in the teaching process. "Controlled breathing improves the flow of oxygen, and it’s particularly helpful for sickle cell patients because it helps relieve the abnormal shape of the indented sickle cell, which has become that way because of a lack of oxygen," says Gee.
Deep breathing also helps muscles relax and blood vessels to loosen, offering even more relief, she adds. "Kids will almost always say they feel better — even a little bit better — when they are doing deep breathing," Gee says.
Pediatric pain can be difficult to treat because many physicians are slow in recognizing children’s pain. "They may say, She doesn’t look like she’s in pain.’ That isn’t helpful. We need to believe our patients when they say they are in pain," says Gee.
Health care professionals then can take the next logical step toward complementary therapies that may reduce the quantity of medications needed to control pain. "Many people think the only thing that can touch the pain of sickle cell is morphine," says Gee. "We can let our patients know we want to approach their pain from all different angles."