OF PEDIATRIC PAIN
MANAGEMENT PROGRAMS IN POST-ACUTE
is a signal, developed through the evolutionary process, to protect
the body from further stress or injury. If prolonged, particularly
in the young, it can cause distress, anxiety, and suffering. It
is surprising, therefore, that prior to the 1960's, few studies
or articles addressed the nature of pain in children. In fact, recent
studies in the 1990's revealed that children in pain are still often
under treated. Reasons for this inadequacy may be due to current
myths on pediatric pain and pain management. For example, some believe
that young children do not experience pain because of neurologic
immaturity. However, studies have shown that pain pathways as well
as cortical and subcortical centers necessary for pain perception
are developed by 30 weeks of gestation. Children not only experience
pain, but also often have changes in behavior, eating and sleeping
patterns, following painful medical procedures.
in the use of narcotics affect the role of pediatric pain management.
Although there are concerns regarding the respiratory depressant
effects of narcotics due to slower metabolisms than adults, and
the possibility of addiction, studies have indicated that children
older than the age of 6 months demonstrate adult-like pharmocokinetics
and, when weaned over a period of time, have rare occurrences of
the past three years, St. Mary's Healthcare System for Children
has developed a pediatric pain management program to address the
need for pain management in post acute rehabilitation settings.
The facility has documented this ongoing process in the format of
this handbook that we hope will be useful for other institutions
interested in undertaking a similar endeavor.
pediatric pain management programs are located in academic medical
centers and often focus on acute pain, particularly in the inpatient
setting. Outpatient clinic settings are often arranged to help children
suffering from chronic pain. However, in post-acute rehabilitation
settings, pediatric inpatients experience both chronic and acute
pain. Pain management is particularly important in providing accurate
pain assessment and consistent care for both communicative and non-communicative
patients in post-acute settings.
children with pain involves a balance of pharmacological and adjuvant
therapies. When using drugs, it is important to clarify the difference
between addiction and physical dependence. Addiction is drug-seeking
behavior due to psychological dependence. Physical dependence, on
the other hand, is exhibited by the signs and symptoms of withdrawal
and can be treated by gradually weaning the patient from the drug.
addition to pharmacotherapy, adjuvant therapies are also recommended
in pain management. They include psychotherapy and complementary
(alternative) medicine treatments, such as acupuncture and acupressure.
Pain management is a common reason for patients to pursue complementary
Mary's Healthcare System for Children is a post-acute rehabilitation
facility that provides care to children often with illness that
are chronic in nature. The care if provided both on an inpatient
as well as home care basis. Our inpatient capacity consists of a
97-bed facility in Bayside, New York, and a 44-bed facility in Ossining,
New York. Our home care program includes over 1600 families in the
greater New York area.
St. Mary's, prior to the establishment of a pain management program,
pain was treated on an as needed basis. Although treatment was instituted
following a patient's complaint of pain, the treatment often varied
from practitioner to practitioner. We also realized that assessment
is often difficult in children, particularly in children who are
unable to communicate. Due to these observations, we embarked on
a pain management program to create an "ouchless" environment in
both of our facilities by proactively assessing the presence of
pain before patients complained of pain.
For Our Programs
In 1997, our goal to establish a pain free facility in our institution
was made possible through the generosity and support of The Mayday
Fund. We began the development and implementation of a pain management
program that would utilize the available resources of our post-acute
setting and deliver treatment that would adequately relieve pain
in children. In addition, we decided to record this process in the
form of a handbook to act as a blueprint for any other organization
that would be interested in implementing a pain management program
at its facility.
designing the pain management program at St. Mary's, we determined
that the program would involve the following team members:
and Family Members
with Training in Complementary Medicine
pain management program utilized not only the traditional tools
for pain management such as pharmacology, but also tools from complementary
medicine. These would include imagery, biofeedback, hypnosis, massage
therapy, music therapy, acupressure, and acupuncture. Specialists
(such as an anesthesiologist) would also be available for consultation
on an as needed basis.
of the pain management program involved two steps: the first was
to develop a model appropriate for the inpatient setting, and the
second was the adaptation of the model for the pediatric home care