Health & Well-Being - A real pain?

Pain is a universal sensation, but one that can be difficult for babies and children to articulate, leading to worry and panic on the part of the adults who care for them, or even the possibility of overlooking something more serious.

Pain that goes unaddressed not only prolongs a child’s physical suffering but can make them scared and even cause changes in the brain, which make future pain worse.

Kenneth Craig, professor emeritus of psychology at the University of British Columbia and director of the BC Pain Research Network, explains, ‘Maybe 30 years ago, we had almost total insensitivity to infants’ experience of pain. Even if we accepted that they felt it, we thought they wouldn’t remember it and it wouldn’t have a long-term effect.

‘Now, we recognise children may not be able to verbally express pain, but they can indicate high levels of distress, and that pain should be controlled if we want to avoid immediate and long-term psychological and physiological consequences.’

Dr Rahul Chodhari, member of the Royal College of Paediatrics and Child Health, describes pain as ‘an unpleasant sensation perceived by the brain’ and advises looking for ‘the cause of the pain rather than at the pain itself’. However, locating the pain can be challenging.

‘Children experience a broad range of states which are very natural and spontaneous, such as feeling tired, irritable or hungry,’ says Professor Craig. ‘The challenge is identifying the difference between these “aversive states”. We want to find a behavioural signature uniquely associated with pain. Pain can be physical, psychological and behavioural, and while I can’t say we have a full solution, if we focus on the behavioural expression, we can begin to take cues as to what is happening.’

PRE-VERBAL COMMUNICATION

In babies, behavioural expression is particularly important to monitor. Dr Chodhari explains, ‘Pre-verbal children are by far the most difficult. We, as medical professionals, get it wrong many times. Babies cry when they are hungry, thirsty, tired or have a wet nappy. It can be difficult to appreciate the difference between that and a cry of pain. We have to look for all the other ways they might express pain.’

There are certain markers which can indicate a pain response, including:

• insistent, high-pitched cry
• grimacing
• open mouth
• wrinkled or lowered brow
• eyes squeezed shut in a neonate
• tense or stiff posture, or arching of the back
• squirming and writhing when they are held
• not eating or sleeping at the usual time
• not being soothed by normal measures such as rocking or feeding.

VERBAL DEVELOPMENT

As children get older, it should theoretically become more apparent when they are experiencing pain, says Dr Chodhari. ‘With toddlers, it is much easier because they are becoming more vocal, and pain becomes much more prominent,’ he says. ‘They may lose interest in play, be still or quiet, or avoid using their body in areas where there is pain.’

However, as GP Dr Raj Thakkar points out, there is a higher likelihood of miscommunication when children start to verbalise their pain. ‘Young children might be able to localise the pain by pulling at the affected area, or limping, for example. But a sore throat might present as earache, or a tummyache as a headache. Sometimes, children may be unable to localise the pain themselves, or they might have a coexisting problem somewhere else they are unaware of.’

Similarly, children may identify a feeling of physical illness when, in fact, they are nervous or apprehensive about something, or feel emotionally uncomfortable in a situation.

ROOM FOR CONFUSION

Professor Craig says while children’s ability to articulate their feelings undoubtedly develops, we should take their words with a pinch of salt when it comes to assessing pain.

‘In newborns, the reaction to distress of any type is all or nothing. As babies mature and biological development takes place, the capacity to modulate the reaction and specify the cause to others develops. However, it takes many years for children to truly become articulate enough to describe internal sensations. We must continue to be sensitive to non-verbal expression until well beyond four years of age.’

In his research, Professor Craig found it takes children until about the age of seven to actually use the word ‘pain’, although ‘ow’, ‘ouch’, ‘booboo’ and similar language appears from around 18 months.

‘I wouldn’t rely on language in order to discern pain in infants,’ he warns. ‘Everything important really continues to lie in non-verbal expression.’

Dr Chodhari agrees there is room for confusion. ‘The language children use sometimes depends on what they have heard. They might point at their tummy and say they have a headache because that is what they know, if that is what their mummy says when she feels unwell, for example.’

IDENTIFYING AND RESPONDING

A good method of ascertaining whether or not a child is genuinely in pain is seeing whether they can be distracted, according to Dr Chodhari.

‘Distraction does work. Children love being part of their peer group and it is not uncommon for them to be hurt by a trip or fall but only show discomfort when their parents come to pick them up. Distraction is not a test, because pain itself is not a disease, but it can be used as a marker for whether or not to explore other causes.’

Distraction can also help alleviate symptoms when a child truly is in pain, Dr Chodhari adds, recommending soft music or blowing bubbles, singing together or finding a rhythmic pattern in a book to read aloud.

Professor Craig says research into alleviating pain during immunisations found distraction techniques were more effective than the use of reassuring phrases such as, ‘it will be over in a minute’, or, ‘it’s OK, settle down’, which were more likely to create a fear of needles or mistrust of healthcare professionals.

He explains, ‘Reassuring talk seems to create more distress in children, who pick up on the idea that the adult is in distress. Infants are born with a high degree of sensitivity to the emotional reactions of adults.

‘Distraction, humour and encouragement to become task-orientated or focus on play are much more advantageous to children. Even ignoring their expressions of distress can become helpful at some stages of the game. Of course, we should attempt to discern what is happening first, but the risk of excessive care can be problematic.’

CRYING WOLF

While children may misinterpret or mislabel feelings of discomfort or pain, Dr Chodhari rejects the idea that they might ‘cry wolf’ as they get older and they begin to associate illness with treats, extra attention, or a day off school.

‘Children don’t complain about pain for no reason,’ he says. ‘If they complain, it should be taken seriously. Children enjoy life, and are the most distractable things you will ever see. Especially when complaining comes on suddenly, we should always think of a medical cause first.’

RED FLAGS

Regardless of the difficulty of discerning pain in children, it is vital that carers are on the lookout for signs that a child might require more significant intervention.

Dr Thakkar says, ‘One of the first things we are taught to ask in medical school is, do they look well? A change of behaviour is very important. If they are still running around playing and look well, that’s a good sign. But if they are behaving differently, they might be stressed or worried, or there might be something medically wrong. The commonsense approach and gut instinct are key. If a child is displaying different behaviour, it is best to seek advice.’

According to Dr Chodhari, red flags that require medical attention without delay, if present either in isolation or along with signs of pain, include:

• appearing confused
• unable to walk or weight-bear
• green vomit
• tender tummy to the touch
• pointing to pain in genital area.

Above all, Dr Chodhari agrees that instinct is vital. ‘There is a wealth of experience in the nursery sector, and practitioners will have a good idea of what might be all right. The most important thing is to know what represents a red flag, and to respond to it quickly.’