EDITORIAL

Pain control in children:
Joining hands around the elephant

Control of pain was an underappreciated component of the care of children until the late 1980s. It wasn't that pediatricians generally thought children do not feel pain; rather, we worried that, given the pharmaceutical options, treatment would be more detrimental than the pain itself. We're even told that some pediatricians believed newborns could not feel pain associated with surgery, although it's more likely those clinicians feared the consequences of prolonged administration of anesthetics and hoped for patients' amnesia over traumatic events.

During the past 15 years, researchers have determined that pain— even brief pain in newborns—can have a prolonged physiologic impact. During those same years, the pharmacology of pain control has extended to infants and children. The results of these two avenues of investigation are that we understand the importance of controlling pain and we understand better how to control it safely.

Three articles in this issue of Contemporary Pediatrics demonstrate, however, that a great deal of work remains to develop "best practices" regarding pain control. The articles come from physicians in three pediatric disciplines:

• A child and adolescent psychiatrist ("Managing pain: An exploration of psychotropic medications") provides current information on the wide array of psychopharmacotherapeutic approaches to pain control. She also reminds us, however, of the paucity of research on many of those medications in children and adolescents.

• A general pediatrician and a child psychiatrist, both experienced at treating pain in children using an integrative approach ("For chronic pain, complementary and alternative medical approaches"), outline a multidisciplinary approach to chronic pain management that includes herbs, acupuncture, dietary restrictions, massage, and mind-body therapy. Their review is thorough and up-to-date but, again, they point out that the available information is inadequate to permit consistent recommendations.

• A pediatric neurologist ("Breaking the cycle of medication overuse headache"), describes the important role that overly enthusiastic use of pain control for headache plays in causing even more frequent headaches.

In pursuing effective therapies for infants, children, and adolescents who suffer chronic and acute pain, we appear to be at the stage that the proverbial blind men found themselves when trying to understand an elephant by feeling about the animal. Each medical discipline, lacking irrefutable evidence of efficacy and safety, analyzes and addresses the problem using methods with which it is most familiar. As the authors of these articles demonstrate, however, each discipline recognizes many opportunities to improve pediatric pain management through further investigation. In addition to the key role that federal law has in requiring pharmaceutical manufacturers to study their products in children (the Pediatric Rule), it will also be important for the pediatric specialists who are standing around this elephant to open their eyes and recognize the contributions that can be made by their colleagues.

Julia A. McMillan, MD, editor-in-chief of Contemporary Pediatrics, is professor of pediatrics, vice chair for pediatric education, and director of the residency training program, Johns Hopkins University School of Medicine, Baltimore.

Julia McMillan. Editorial: Pain control in children: Joining hands around the elephant.

Contemporary Pediatrics

October 2003;20:10.