Paying attention to pediatric pain
Managing pain in children: a clinical guide for nurses and healthcare professionals (2nd edition)
Twycross A, Dowden S, Stinson J, editors (2014). West Sussex, UK: Wiley Blackwell, 312 pp. ISBN 978-0-470-67054-5 (Paperback: $55.00 USD). Link
Reviewed by Linda B. Hurd and Elizabeth Ely
For years, experts in the field of pediatric pain have taken up the gauntlet to convey the importance of recognizing and addressing pain in children. They have successfully moved us from the era when babies were thought not to experience pain, to today, where managing children’s pain has become a priority.
Today health care institutions have organizations and processes asking us how well we are taking care of our children’s pain. In the United States, the Joint Commission, a hospital accreditation body, examines the assessment, documentation and reassessment of pain, patient rights, pain management treatment plans, patient education, staff training and competence and discharge communication regarding pain management. Patient and family satisfaction regarding pain management is commonly sought, measured and reported in many hospitals along with other data about satisfaction with care. Thus, attention to how children and families perceive pain is being managed may drive policy or actions. Pediatric pain has moved into the forefront of hospital discussions and policies. This raises the question, “How prepared are we as clinicians to take on this daunting task, to optimally address and manage pain in children along with addressing the satisfaction of our patients and their families”? To this end, there is a greater urgency to prepare and educate all health care providers and to give pediatric pain the attention it needs. Additionally, to attain satisfaction with pain management, patients and families need to be involved in discussing pain management goals and expected outcomes.
The second edition of an excellent clinical resource for nurses and health care professionals has just been released: Managing pain in children, a clinical guide for nurses and healthcare professionals. Twycross, Dowden and Stinson, the editors of this comprehensive reference, are international expert clinicians and scientists in the field of pediatric pain. They have combined their vast collective experience and expertise to cover a broad range of topics related to pain, as well as providing recommendations for improving clinical practice. The eleven chapters easily move us through a summary of pediatric pain literature including diagrams, bulleted practice points, definitions, evidence based examples and references. The first edition of this text was published in 2009 and was reviewed in this publication (Hewson, 2010). In that review, detailed information about material in the text is provided by chapter. In this new edition, practice evidence has been updated with reviews of literature published between 2009-2013, bringing the information included up to date and adding easily accessible resources, such as links to websites and videos, along with relevant case studies.
One of the strengths of this textbook is its accessible format with boxes, tables, and graphic content highlighting clinically important practice points. Rather than merely citing research references, a brief overview of the research evidence is presented in a separate box. While providing easier access to pertinent research for the reader, a review of the strength of evidence presented and summarized would be useful. A comprehensive discussion of the strength of the evidence presented in tables and text varies by topic, but sometimes limitations and critique of the evidence is not mentioned. For example, pediatric studies often include smaller sample sizes with quasi-experimental methods used and thus confidence in results needs to be tempered. When systematic reviews of evidence are available, they have been included.
In this second edition of the textbook, certain aspects of pain management were given a greater focus and expanded. The addition of Dr. Stinson as an editor and author brings her extensive knowledge and expertise to the text, especially on the topics of pain assessment, managing pain in chronically ill children and areas for future research (Chapters 6, 8 and 11).
The book begins by giving voice to children’s views about the effectiveness of pain management, informing us that despite our advances, there are areas of pain management which need to be improved. For example, in Pölkki’s et al. (2003) study of 52 children who were asked about their postoperative pain experience, children indicated that they wished the nurse had given them more or stronger analgesic medicine, as soon as they asked for it and also wanted nurses to provide them with meaningful things to do to distract them from their pain. Also, the reader is reminded that children of all ages are able to express pain, participate in their own care, and help evaluate its effectiveness. The authors urge clinicians to be mindful of the need to modify our communication strategies and incorporate developmentally appropriate approaches to meet the pain management needs of children.
After an excellent review of anatomy and physiology of pain, the biopsychosocial model of pain is well-presented, including a discussion of family and culture. Pediatric centers are continually challenged by the increasing number of international, multicultural families with complex conditions seeking out specialized medical attention for their child. In addition to meeting these patients and their families at their time of crisis, providers need to quickly adjust to their language and cultural differences in an attempt to determine how these may influence the child’s perception, experience and report of pain.
The pharmacology of analgesic drugs chapter provides a broad overview and updated references, including a useful reference table (Table 4.6) of opioid doses for children, summarizing dose onset time/peak effect and half-life of these medications. The section on physical and psychological approaches to managing pain includes an abundance of current literature and information, reflecting the increasing use and recognition of how these methods can positively impact the management of pain. The section on managing pain in neonates is especially useful including a comprehensive summary of research on physical and supportive pain management interventions such as facilitated tucking, kangaroo care and non-nutritive sucking.
Chapter 6, Pain assessment, provides current, comprehensive information directed to the hospital based clinician. Especially helpful are the tables and figures outlining pain history questions meant to address acute and chronic pain (Tables 6.1 and 6.2) and Figure 6.9 an algorithm for pediatric pain assessment. Focus on comprehensive pain assessment is critical to adequate pain management. Measuring pain intensity is common clinical practice used to document a number to represent the quantity of the patient’s pain intensity, but that assessment is built on the knowledge gained from the initial more complete assessment which supports the decision regarding which pain assessment tool to use. Case studies reinforce content while providing practical advice for complex situations.
Chapter 7, Managing acute pain in children, provides a comprehensive overview of pain management modalities, side effects and safety issues. The detailed section on regional analgesia underscores the importance of this modality in the treatment of pain as well as its ability to reduce the need for opioids and other analgesics. The complexity of chronic pain is discussed in Chapter 8. Case studies help to illustrate the multifactorial assessment and multimodal approach to managing chronic pain.
While the first 10 chapters provide the evidence and clinical guidelines for understanding and managing pediatric pain, the final chapter of this text focuses on where we need to move going forward. Challenges remain when it comes to consistently using the considerable knowledge available to improve pain management for infants, children and adolescents. This final chapter explores current thinking and strategies being used to address the conundrum of how to translate the considerable knowledge we have into meaningful practice change. The authors thoughtfully review evidence about barriers to practice change that are individual (e.g. knowledge and beliefs) and organizational (e.g. cultural and contextual). Innovative models of information dissemination (e.g. web based), organizational change strategies such as the promoting action on research implementation in health services (PARIHS) model which provides a structure to support behavior change, and increasing attention to the voices of children and families in our care are all potential solutions.
Managing children’s pain thoughtfully and effectively can be a daunting task given its complexity. A multidisciplinary approach that draws upon expertise of a variety of health care team members is optimal due to the biopsychosocial foci of pediatric pain management. Pain remains one of the greatest concerns expressed by pediatric patients (and their family members) who are sick or undergoing surgery. To that end, Managing pain in children, a clinical guide for nurses and healthcare professionals is a valuable clinical resource. This textbook can easily be used as a reference for all professionals working on inpatient, outpatient and procedural units and certainly can be recommended in nursing, psychology and other health care professional undergraduate and graduate courses. It is an excellent, well-written and welcomed resource for all those interested in helping children in pain.
Cite as: Hurd LB, Ely E. Paying attention to pediatric pain. Book review: Managing pain in children: a clinical guide for nurses and healthcare professionals (2nd edition). Pediatric Pain Letter 2014;16(1-2):32-34. www.childpain.org/ppl
Hewson KL. Book review: Managing pain in children: a clinical guide. Pediatr Pain Lett 2010;12:11-13. Link
Pölkki T, Pietilä AM, Vehviläinen-Julkunen K. Hospitalized children's descriptions of their experiences with postsurgical pain relieving methods. Int J Nurs Stud 2003;40:33-44. PubMed Abstract