A Child in Pain

What Health Professionals Can Do to Help

By: Leora Kuttner, PhD


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Size: 152mm x 229mm
Pages : 416
ISBN : 9781845904364
Format: Paperback
Published: April 2010

This comprehensive book is designed to help health professionals of all disciplines who work with children gain understanding and skill in how to approach and treat children's pain, and help children understand and cope with their own pain. Pain is the most common reason for children to seek a medical consultation and sometimes the most common reason for avoiding it. This book examines children`s fears and anxieties that accompany their need for pain relief, and gives health professionals communication skills and words to calm these fears. Without doubt, this volume will become a standard on pediatric pain management for many years to come.

Picture for author Leora Kuttner, PhD

Leora Kuttner, PhD

Leora Kuttner, PhD is a pediatric clinical psychologist who specializes in children's pain management. She is a Clinical Professor in the Pediatric Department of the University of British Columbia and BC Children's Hospital, Vancouver, Canada. Dr. Kuttner has authored A Child in Pain: How to Help, What to Do, a book for parents, and has also co-produced and directed award winning film documentaries on pediatric pain management, No Fears, No Tears, No Fears, No Tears ' 13 Years Later, and When Every Moment Counts.


  1. This is an exceptional book. From the initial flick through to a more thorough reading I was really impressed by this text. It is heavily referenced and contains up to date material ranging from the straight-forward acute pain scenarios to the more complex and poorly understood persistent pains. It is extremely well written and so even complex concepts are communicated clearly and can be easily understood. It is comprehensive, covering behavioural, emotional and physical responses to pain and containing loads of great practical tips for helping children cope with pain. I have never encountered a book before that covers such a breadth of material in such a user-friendly and clinically useful way. I am going to make this book highly recommended for our child Field of Practice nurses and I will also be encouraging students from other branches to read it.
  2. I had to review this book while experiencing intense stomachaches and trying to figure out with what end I should address the toilet. Let me tell you something, this book really helped me understand what children go through! Buy it!
  3. The book immediately grasps your active involvement as you see the desperate expression of the child on the cover. You easily can feel the need and importance of doing whatever possible to offer relief. Knowing that pediatric pain relief is a `human right` (p360) and that as cited `pain is a more terrible lord of mankind than even death itself` (p 346) tends to mobilise whatever practice or methods to help. Not surprising one could pretend that studying methods for pain relief can be seen as rather an obligation and a duty for all partners involved in children`s care.

    Reading this book with its 389 pages is a way to becoming familiar with the methods to offer relief. It`s attractive outlook, the style with a good balance bridging theory, implementation in health care, examples and well-chosen illustrations makes it agreeable to read. The well-structured outline promotes usefulness for different users and objectives: as a manual for teaching and education, a compendium to check med`s, guidelines about how to implement the knowledge into institutions. An index helps you to find quickly what you need. Due to the clear language it`s also accessible for non-professionals: parents who are experts on their child and key resources in caring and managing their child`s health (94) can benefit from the reading alike. Nowadays not only health care professionals but also parents and others are actively involved in child care, and feel a need to get information.

    A main feature of the book is that one approach doesn`t eliminate or disqualify the other, but a combination of different approaches is recommended giving a better outcome as a result. As in professional settings common sense knowledge is often forgotten, it`s worthwhile to include it in this work as `natural methods`- warmth, cold - to ease pain, or holding, touching, stroking when a child is in pain.

    Lack of knowledge and research has caused a lot of harm and suffering in the past, like a misconception that babies couldn`t feel pain. Current knowledge about pain mechanism makes `proactive pain management imperative` (p. 26). Scientific evidence (p. 24) is sufficiently convincing to make a priority of pain control: newborn babies and even a fetus in utero by 26 weeks is capable of experiencing pain! (p. 24)

    Explaining pain mechanisms (chapter 2) gives insight in pain; talking about pain modulation opens a window to pain-relief mechanisms and a hint to be helpful. When pain is not effectively controlled long term changes in the spinal cord and brain occur, which creates a `memory of pain` (p. 62) with turning on of genes and molecular changes as a memory trace of the injury. Easier made than erased, this helps us understanding how phantom pain is possible and the limited success of some surgery for persistent pain. The clue for relief here lies in somatosensory (and motor cortex) reorganization and remapping.

    As a model of understanding chronic pain, the Body-Self Neuromatrix of Melzack is introduced to understand mechanisms and different approaches in pain management. It is a highly integrated neural network, genetically determined and modified by sensory experiences. Also mood, fearful or anxious thoughts modify the neuromatrix. As inputs to body-self neuromatrix are mentioned: cognitive-related brain areas, sensory signaling systems and emotion-related brain areas. Outputs from body-self neuromatrix produce pain perception, action programs and stress-regulation responses. Even a 7 year old can understand this mechanism, when the author explains is with the diligence, fine-tuning to pacing with a child`s world of experience and vocabulary.

    Even if you only can read one chapter, I would recommend chapter 3. You`ll find essential skills and knowledge that all people working with children should know- exercise - practice to develop a helping attitude.
    You find effective responses, considerations in choosing language, and unhelpful responses, summed up in a table (useful to consult everywhere, or copied on flash-cards) and further worked out in a text with examples. As children in pain often are in a negative trance like state, words may be interpreted literally instead of grasping the real meaning. For that reason special attention in the choice and use of words that clarify and don`t confuse, talking the language of the child, is a prerequisite in care. Having the role of crying (p 89) explained as a natural and automatic response to pain, where tears release the physiological tension produced by trauma and pain, you get some guidelines in dealing with crying, dependent on age, meaning and context. There are many reasons why encouraging crying isn`t a good idea" although discouraging it isn`t a good idea either. `(p. 92)
    In contrast to earlier years where parents were sent away, they nowadays in the 21st century, have a central role in health care ` parents as partners-in-care" (p. 95), another central idea in this book. This issue deserves special attention in the chapter on communication! Parents teach children the meaning of pain, share coping strategies, model responses on pain and have influence on the impact of treatment. In real life `a kiss takes the pain away` (p.97), and once learned a child can start turning on the downward inhibitory modulation of pain, one aspect of the formation of the early circuitry of the child`s neuromatrix. Indirectly the reader learns there is no way to effectively helping the child without knowledge of parent`s belief system and coping responses.

    Pain mechanisms put together in a bio-psycho-social model of pain is a key process in understanding pain, reaction to painful medical experiences and the 3 P`s approach to offer relief. Psychological, Physical and Pharmacological pain treatments are the 3 pillars of intervention. I like the idea of `working as a team with the child` and discovering how progressively the child will be empowered and `move into the driver`s seat, as the pain hopefully moves to the backseat` (p. 143). I fully agree with the idea that various combinations of the 3Ps give the best result, without competition between them, but rather synergism. Approach according to the 3Ps is also `maintaining as many strings on our treatment bow as possible.` (p.143)
    In chapter 5 on Psychological Methods to Relieve Pain all kind of readers can discover how children can be helped, find relief in a creative way with input from art, music, imagery and storytelling. Work with hypnosis is gently introduced asa more absorbing, focused way of imagery`. Some recent research data on the working mechanisms of hypnosis encourage learning to work with it, but is restricted to those health care workers who took a specific training in hypnosis. I would highly recommend to learn and practice the 12 steps in language and have them `at hand` in your communication. A very useful principle is to avoid negative words: saying `dont be afraid, it won`t hurt much` the child hears `afraid and hurt much` (p.150) Practice is useful to become familiar with a positive, helpful communication style and this book is really a helpful tool for that purpose. When a child is startled and frightened by the sight of his/her own blood you can say `What a beautiful blood you have! It`s a bright strong red. Look! I can tell it is healthy by its color. Your blood is doing a good job of cleaning the wound out. That`s excellent.`(p.150) As a reader you get plenty of ideas about how medical settings can be enriched by imagery of a favorite place or activity, by storytelling, by all kind of music experiences, practices and listening, by playing, by somehow bringing the child`s world into the hospital, instead of metaphorically `sterilizing` the environment in a cool, cold, frightening place. You find nice examples of how mobilizing creativity as in using imagery and storytelling is helpful in dissociating from the pain or coping with pain. You might feel invited to integrate more creativity into daily work and ease your own and your patients` suffering.

    Physical methods presented in the book involve practices that children can apply themselves like blowing away the pain, or a red cloud technique, or blowing bubbles for the younger ones, relaxation and breathing exercises for older. Here again all methods are used with plenty of creativity, like relaxing by `becoming a wet noodle` (p.189) or using a floppy rag doll and invite the preschooler `to flop in a chair like a Raggedy Ann or Andy` (p. 193). Other methods remind old remedies, still useful and natural, like cold-ice packing and heat. Methods requiring some professional skills, like acupuncture and acupressure are reviewed with objective data of working mechanisms, research, evidence of activity. Informal methods involving touch for parents (p. 214) deserve special attention as when being held, touched and supported when in pain cuts through the isolation of experiencing pain. It`s worthwhile to encourage parents - even in hospital settings - to do what they naturally tend to doing when their child is in pain.
    The book wouldn`t be complete without an overview of the best analgesics currently in use for acute and chronic pain. WHO `By the Clock analgesic medication schedule` is explained and motivated. Pain prevention deserves particular attention, as less medication is required when pain medication is given to prevent pain! Ways of administration are compared, and maybe the most important, how to motivate your choice to make it acceptable for the child.

    Part III on pain and anxiety management in pediatric practice teaches clinicians how to manage fear and anxiety particularly when pain is involved. Often topics of pain and anxiety management are not well covered during medical school or residency (p. 274) Knowing that the `limbic system is hardwired to perceive threat`(p. 268) and that `children require only one aversive painful experience to alter their perception and experience of pain for subsequent procedures`(p. 269) should make clinicians aware of how easily anxiety can be conditioned, and how important it is to prevent this harm! As stated correctly visiting a doctor`s office should be a learning opportunity where a child receives information and learns how to behave and gets help to cope with distressing procedures. Health care workers, dentists, MD`s should take responsibility and train themselves to become familiar with appropriate skills to prevent children`s anxiety and pain. You find clear guidelines and examples of how to do it that are easy to apply in practice. After reading what a difference it makes you become more alert on explaining while doing a painful exam. You will see parents as allies and utilize their presence as fit. Asking the parent`s containing hug for an injection. You may find your own language, like in the example of talking to a 2.5 year with possible middle ear infection `Hold very, very still so that I can take a close look and find the bunny rabbit that jumped into your ear,.That`s great! I can see him; hes jumping over the fence. Hold Still! Oh! He`s gone across to the other ear. Quickly, let me look in the other ear.` (p. 277)

    In a special chapter on managing pain and anxiety in dental practice, you read that 75 % of adults with dental anxieties acquired these fears early in life, a reason to address fears and general anxieties proactively. The dental terms made child-friendly (p. 308) help to reframe the whole setting. The TSD - TellShowDo- introduces the child into each instrument, and when you can tell that `the suction makes a noise like a vacuum cleaner, but feels like little kisses on your hand` (p. 307) most of children become curious to feel that experience, instead of being scared.

    One example of making a hospital stay less painful is given in Dr. Neil Schechter and colleagues `The Ouchless Place` where different protocols for pain management were used. 10 years later they moved to creating `Comfort Central`, a stable and enduring program to create a culture of comfort. This initiative has been followed by many other children`s hospitals. This is another evidence that children`s pain and fear does matter because it has significant psychological and physiological impact with short, and long-term consequences.

    One core theme of the whole book to remind is that children`s pain and anxiety is a real issue, deserving full attention, a human right to be supported and helped. All involved in care have responsibility. All need to inform themselves, get training, become familiar with the issue and prevent harm. Reading this book, using it as a workbook to practice skills, making flash-cards to remind oneself of main guidelines can be a first step in improvement. This book is really a must-read for all involved in care of children. I can fully recommend it as a manual for training in communication and pain management educational programs. It`s useful for professionals trained in imagery or hypnosis techniques to find more ideas on practical applications.

    The book is well scientifically underpinned, offering references and an extensive bibliography. An index facilitates access to some issues one needs to review.
  4. It was a pleasure to review this book. Not only is it generally informative about children, the recognition and assessment of their pain, how to communicate and manage it, but it was affirming of the value of working in paediatric pain medicine. I was continually reminded of memories of the warm and entrancing qualities of the author, these memories going back to my first real exposure to psychological management of pain in children more than twenty years ago. Dr Kuttner is a paediatric clinical psychologist specialising in children`s pain management. She is a clinical professor in the Pediatric Department of the University of British Columbia and BC Children`s Hospital, Vancouver. She has been an outstanding leader and exemplar in the field of children`s pain management now for many years and thus her knowledge and experience extends well beyond clinical psychology and qualifies her to write a book on this broad multidisciplinary topic. Her book A Child In Pain, How to Help, What to Do, last reprinted in 2006, has been an immensely useful guide to parents of children in pain contexts. This new publication, directed at health professionals, is also potentially very useful for educated parents and probably some older adolescents, and would enable critical evaluation of the communication and management skills of the health professionals in situations involving pain.

    The book is in three parts. The first concerns understanding, assessing and communicating with a child in pain. The second reviews treatments, psychological, physical and pharmacological. The third addresses pain and anxiety management in paediatric practice (doctor`s office, dental practice and hospital). It is not a medical textbook in the sense of covering disease-related pathology, medical aspects of pain syndromes and their specific procedural and other interventions. There is some cover of particular categories of pain disorder, including migraine, headaches and recurrent abdominal pain, but generally the book covers principles and practical details of assessing, communicating with and managing children with acute, procedural, recurrent and chronic pain disorders.

    A comprehensive assessment of pain requires consideration of pathology with nociceptive inputs from inflammatory or traumatic disease processes, injured or disordered nerve fibres, appraisal of the neurobiology of the nociceptive transmission in the central nervous system, and consideration of the psychosocial influences. Appropriately she has not attempted to address to any degree aspects of somatic pathology or develop any detail on peripheral neuropathic pain disorders. The general health professional reader is less well informed about the neurobiology of pain in the central nervous system and about the pain matrix. The latter is a large distributed brain network accessed during nociceptive processing interrelating with cognitive and emotional circuitry, the descending pain modulation system and motivation and motor connection. Dr Kuttner has provided the general reader with an evidence-based overview of these neurobiological processes. Those more specialised paediatric practitioners might feel the benefit for more up-to-date referencing derived from the numerous current neuroimaging and other neurobiological studies, however there are already twenty pages of references.

    The great strength of this book is the wise guidance on assessing and communicating with children and on the psychosocial management. Even when discussing pharmacotherapy there is practical advice regarding the administration of medications from the perspective of the child, such as how to take tablets. Other strengths of the book include illustrative anecdotes about children, how to explain pain to a child, and useful conceptual illustrations and diagrams. The book leaves this reader at least with a strong sense of `I can do better`.

    There are some minor negative points that overall do not detract much from the overwhelming merit of the book. From the Australian perspective there is a certain amount of North American language, such as `owie` and `boo-boo` for young children`s pain language, and North American terminology for a number of the medications. There has been an important emerging paradigm shift in the understanding of functional pain disorders which are very prevalent and important in childhood, a concept of their common genetic, neurobiological and psychological influences and their co-morbid interrelationships. That might have been mentioned in the section on migraine headache and functional abdominal pain. The myofascial paradigm is more critically appraised in Australia than in North America, and the hypothetical nature of some of the concepts might reasonably have been acknowledged. The features of allodynia and hyperalgesia, which are very common in somatic pain syndromes and puzzling to patients and to health care professionals, were discussed only briefly and mainly related to neuropathic pain. There was some inconsistency regarding empathy, which was stated to be desirable for health care professionals and elsewhere for dentists, but stated to increase the child`s pain reports, under the sub-heading `Don`t use Reassurance and Sympathy`. The puzzle of the counter-intuitive adverse influences of reassurance could have been further developed, although much of the new research has been published subsequent to completion of the manuscript.

    Ideally this book should be read by all health care professionals working with children and adolescents who are in pain or at risk of procedural pain. This book has a unique place because of the wealth of information, wisdom and guidance on psychosocial aspects of acute and chronic pain. It is hoped that the book will be widely available and promoted in Public Health.
  5. This splendid book provides practical, clear advice to guide the health professional in working with youth in pain. Dr. Kuttner artfully blends science and evidence with the voices of children to help professionals comprehend state-of-the-art pain care, understand children`s experiences, and acquire language to better communicate with children in pain. This is a must-read!
  6. `Like a breath of fresh air, Dr. Kuttner brings clarity, authority, and evidence to this crucially important area of paediatric practice. She allows the patient`s voice to be heard, grounds her advice in what is known about best practice, but remains sensitive to the needs of the health professionals, who are trying to help now. Bravo!`
  7. Pain can be evaluated in many forms but for children it can be something completely different, from not sleeping, being tired, acute, stress, chronic, etc. The work and research carried out by the author is astonishing. Every aspect of a child from birth to teens has been covered. This in depth research into children and pain is what every health professional needs to read. Each age group has been covered and how to deal with the pain and what techniques can be used through play, cd`s, hypnosis, breathing, imagery, art etc. It goes on to explain what physical methods can also be used. I can go on and on, but this is something which needs to be read, to be appreciated. This book is ideal for parents who want to understand or who are with children that are in pain of any sort. This book is highly recommended to professionals that work with children.

    Easy to read, with clear sub headings, it consists of 361 pages which cover everything.
  8. This book includes an impressively wide range of psychological, physical and pharmacological methods of managing acute and chronic pain in infants, children and young people in all healthcare settings. It is illustrated throughout with poignant and humorous examples from actual practice. Reference to previous and current research and developments in paediatric pain management tempt the reader to explore the subject in even more depth.
  9. What an excellent - and much-needed - book. Dr. Kuttner provides clear guidance on the understanding and explanation of children in pain and gives innovative and detailed methods of helping such children deal with the pain itself and the anxieties which naturally accompany it. This is a truly wonderful book which is certain to be THE textbook of the future for health professionals of all disciplines.
  10. This is an excellent introduction to the subject of paediatric pain and pain management and the author considers both psychological perspectives and practical treatment strategies.

    Leora Kuttner proposes a holistic approach to assessment and management and the substantive issues highlighted are well illustrated with pictures, diagrams and problem based-learning.

    I particularly like the fact that the author identifies `helpful` AND `unhelpful` treatment interventions and explodes some of the myths that have grown up around the subject.

    Chapter 3 will be particularly illuminating for student practitioners as it focuses upon child centred communication and the development of specialist interpersonal skills.

    It is refreshing that the author does not shy away from contentious subjects such as child protection and Chapter 10 contains useful advice for practitioners who have statutory responsibilities in relation to minors.
  11. When I initially picked up the book, I must confess to feeling slightly daunted by the subject matter and the fact that it was written by a medical doctor. Any reservations that I had were very quickly allayed by Dr Kuttner`s clarity, authority and thoroughly holistic approach to the subject.

    The book is extremely well organised and well written. Very importantly, it is interspersed with many patient stories and case studies that bring the research and theory `to life` and also supports the reader in both understanding and putting into practice the principles discussed. It is filled with suggested approaches, practical advice and an extensive range of tools.

    Divided into three parts, the book covers the mechanics/biology of pain, assessment, treatment (both pharmacological and psychological), fear and anxiety, and throughout stresses the importance of communication and the use of relevant language with children.

    Following a very extensive exploration of the types of pain, I found the section on `How Pain Works` (chapter 2) extremely useful in providing me with a thorough understanding of the complexity of pain, including the mechanisms by which it may manifest. I have already found this information extremely useful and applicable to clients (of adult age) presenting with symptoms of pain that they wish to address.

    The section `Psychological Methods to Relieve Pain` (chapter 5) provides a raft of extremely useful information and guidance in approaching the subject of children and pain. There are some excellent approaches suggested, including: the importance of words used, communication methods, effective listening, helping the child acknowledge the pain and supporting the child in reframing distress. Many tools and techniques are discussed, including hypnosis, distraction, dissociation and imagery. These include suggested approaches based on the child`s age and type of pain being experienced. Again, these are suggestions and techniques that can be adapted and/or used with people of any age experiencing pain.

    This is a work that is truly designed to help and support professionals of all disciplines.

    Overall, I feel Dr Kuttner`s work is a useful addition to the bookcase of any professional working in the field of children in pain. It will provide both a source of information and a stimulus for creative ideas.
  12. `Dr. Kuttner has provided simple, clear guidance for health professionals of every discipline, with just the right balance of research evidence made real by countless patient stories that bring the science to life. This book will be required reading for students and residents rotating through our clinic. There is no other book that fills this niche - easy to read, yet packed with practical advice and strategies that every pediatric clinician can use every day.`
  13. This is an extremely comprehensive look into pain management for children. Written in easy to understand language it includes explanations and illustrations on how the body reacts to pain. There are also little case studies throughout the book that help the reader to understand how to use Dr Kuttners insightful advice and strategies in their own practice. This book is essential reading for any professionals who work with children.

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