Product reviews for A Child in Pain

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.