Book Review

A child in pain: what health professionals can do to help

Kuttner L (2010). Bethel, CT: Crown House, 420 pp. ISBN 978-184590436-4 (Paperback: $49.95 USD).

Reviewed by Marie-Claude Grégoire

printable version (PDF)

Over the past few weeks, I had the pleasure to read and review Dr. Leora Kuttner’s latest book, A Child in Pain - What Health Professionals Can Do to Help. In general, this book is very accessible and easy to read with a nice balance of research and clinical references. Kuttner’s book is definitely a great tool for health professionals of all disciplines, in training or who want to learn more on pediatric pain, and to a certain extent, to families of patients living with chronic pain who want to push their knowledge further.

The book is divided into 3 main sections. The first one discusses the current scientific understanding of pain (chapters 1-4), the second reviews treatments for pediatric pain (chapters 5-7) and the third section explains how to translate the knowledge of the first two sections to clinical practice (chapters 8-10).

Chapter 1: Pain in children’s lives

This initial chapter explains the value and role of pain, and reviews many important historical references on this topic. Pain as an entity is subdivided into three types, according to the duration and timing pattern of the pain, as opposed to physiological subdivisions, in order to facilitate understanding. Multiple excellent clinical examples and patients’ stories are shared to illustrate the theoretical concepts presented by the author. The most useful section of this chapter is the one stating and illustrating the seven most important myths on pediatric pain, myths that any healthcare trainees should be aware of.

Chapter 2: How pain works

This chapter describes the processing of pain, starting with the peripheral mechanisms, then leading to the central nervous system. The accompanying figures are clear, simple and easy to understand. The Gate Control Theory is also presented to explain how pain is controlled by the nervous system, and a list of references is provided for further reading. This chapter includes a good description of the challenges in our understanding of pain, using clear examples, that makes what is usually a dry topic easy to read. It concludes by presenting the Neuromatrix Theory and how this theory can help us understand the current puzzle of pain.

Chapter 3: Communicating with a child in pain

This chapter includes examples (in useful table format) of how to respond appropriately and effectively when communicating with a child in pain (p.72) and what words (in English) to use with children to avoid confusion (p. 78-79). Suggestions of concrete versus unfamiliar explanations (p. 82) and great tips on how to avoid being unhelpful when responding to pain (p. 85) are provided.

In addition, the role and response to crying and anger are presented in simple terms, while reinforcing the importance of parental education and preparation to their child’s pain. The book’s longest chapter ends with an explanation of the process of coping, both from the child’s and parent’s point of view.

Chapter 4: Assessing and measuring pain

Measurement of specific pain parameters and the broader topic of global pain assessment are discussed in this chapter. Practical examples of how children understand pain and what to look for when assessing them are given, from infants to adolescents. Useful questions to ask when performing a pain assessment are listed. Three categories of pain measurement tools are described, with examples in each of the categories: self-report, observation of behaviors, and physiological. The value of using measurement tools is well explained.

Chapter 5: Psychological methods to relieve pain

This chapter delivers valuable advice to healthcare professionals and parents about helpful psychological interventions to relieve pain. Appropriate language is described, including a list of 12 ways to make the pain go away. Detailed information is provided on pain-relieving mind skills such as distraction and thought-stopping. Hypnosis and imagery are explained, including how to construct imagery by dissociating from the pain or associating the pain to an external object or modifying the pain. The best techniques by age group and by type of pain are clearly listed. Additional information is given on art, play and music therapy, on biofeedback and the more recent acceptance and commitment therapy.

Chapter 6: Physical methods to relieve pain

This chapter is divided into five sections. Self-directed methods are presented first, with breathing as the main and most utilized technique, followed by relaxation. Methods involving the use of cold, heat or water are next, with examples of ice, vapocoolant, water and heat usage. Multiple techniques requiring the participation of a trained professional are also discussed, including some research data on acupuncture, acupressure, physiotherapy and TENS, massage and yoga. The chapter ends with a discussion on informal but important techniques used by parents, and on methods used specifically with newborns and infants. All methods are explained in clear terms with practical examples and are divided by age, type of pain, and duration/time of treatment.

Chapter 7: Pharmacological methods to relieve pain

This is a substantial chapter exploring the current pharmacological methods to treat pain in children. The main principles recommended are use of “around the clock” medication (vs. as needed) and the WHO ladder. Common medications are reviewed in two categories: non-opioids and opioids. Each non-opioid medication presentation is divided into benefits, drawbacks and cautions. General information and advice is provided on opioid usage, including tolerance and rotation of opioids. A useful starting dosage and equianalgesic dosage table on weak and strong opioids is presented (pp. 234-235). Practical advice and tips are given on different routes of medication administration in children. Two special sections, one on medication for procedural pain and one on medication for complex/chronic pain (adjuvant medications) are included at the end of the chapter.

Chapter 8: Managing pain and anxiety at the doctor’s office

The role of the physician as an educator is explained. A list of useful and easy to apply recommendations to examine a child with the least pain possible is offered to readers. Similarly, multiple practical tricks and tips on how to handle common acute pain situations at the doctor’s office are provided. The final section of this chapter discusses the most common recurrent and persistent pain encountered at the pediatrician/family physician’s office, especially headache and abdominal pain. The basic physiology of these conditions is explained, followed by concrete examples of treatment following a biopsychosocial approach.

Chapter 9: Managing pain and anxiety in dental practice

As the fear of dental care is often higher than the pain itself, and since that fear often starts early in life, the importance of prevention and control of pain is presented in this chapter. The environment and context of care and the involvement of parents is also discussed. Developmentally appropriate advice and tricks are given for use during dental examination. A useful list of friendly dental vocabulary is provided (p. 308). Practical options (pharmacological and non-pharmacological) for dental pain management are suggested, including general anesthetic and sedation. Finally, common problems in the dentist’s office such as fear and gagging are reviewed.

Chapter 10: Managing pain and anxiety in the hospital

The last chapter includes powerful quotes from cancer survivors, reflecting on the pain related to the treatments they went through. The history of the “Ouchless Place” and 10 years later “Comfort Central” (by Dr. Neil L. Schechter and his team) are presented, with emphasis on the lessons learned in these stories. Following these real life experiences, advice on how to provide information to children about painful procedures, and on how to obtain informed consent/assent from children is provided. The author also discusses the benefits, for patients, to receiving adequate and timely information about procedures, and some specific concern about managing pain in hospital, such as keeping the bed a safe place. The book closes with Helen’s story, a teenage girl who has lived with pain all her life, and her own personal message to healthcare professionals.

Appraisal

Dr. Kuttner’s latest book is a great addition to the library of any in-training or practicing clinicians involved in managing pain in children. It represents a nice introduction to pediatric pain management by providing explanations and examples accessible to all, without the complexity and heaviness of more traditional textbooks. It will also help hospital and healthcare administrators understand the importance of good pain prevention and management.

I was concerned with the number of personal opinions quoted in the book. In reality, this only reflects how much more research is needed in the field of pediatric pain, to establish evidence-based treatment guidelines and go beyond experts’ opinion. In a future edition, it would be helpful to include generic names of medications and devices used instead of brand names (e.g. MP3 player instead of iPod®, celecoxib instead of Celebrex®, etc.). It would not only be less biased toward specific brands, but also less confusing for readers outside of North America, since medications often have different brand names on different continents.

With its helpful figures and powerful real life examples, this book will teach new knowledge even to the most experienced clinicians. Easy to read without being superficial, it is a must-have book!

Cite as: Grégoire M-C. Book review: A child in pain: what health professionals can do to help. Pediatric Pain Letter 2010;12:23-25. ppl.childpain.org