It doesn’t have to hurt

Samina Ali, MDCM, FRCPC(PEM)

As a paediatric emergency physician at the Stollery Children’s Hospital, I can tell you the exact moment that I realized we, as a community of pediatric care providers, were not doing enough to prevent and treat children’s pain in Canada. It was during a shift in the emergency department in 2008, and I was reviewing a case with a resident. I had to keep asking her to repeat herself, because her voice was drowned out by the piercing cries of a baby—many rooms away--receiving bloodwork and an IV. We all know that cry. It has a very specific pitch and quality, as well as the capacity to break my heart with its pain and innocence. In 2008, we knew about the benefits of topical anesthetic creams for IVs, comfort positioning, and sucrose drops. But their use was limited across Canada and my site was no exception. So began my journey to do what I could to improve pain care for Canadian children. Working with incredible people across Canada, many CPS members and leaders, we progressed from small clinical trials to quality improvement collaboratives, two CPS statements, and now, the world’s first national pain standard for children. 

Setting the standard for paediatric pain management

Canada is a leader in paediatric pain research, but this knowledge is not routinely implemented in practice. Over the last two years, Solutions for Kids in Pain (SKIP), a national knowledge mobilization network dedicated to better pain care for children, partnered with the Health Standards Organization (HSO) to co-develop the Pediatric Pain Management Standard (CAN/HSO 13200:2022). The standard draws on findings from literature reviews, clinical expertise, evidence-informed practices, and lived experience. It was developed with a working group from across Canada and beyond, whose 15 members have expertise in patient and family partnership, health policy and quality, hospital administration, medicine (paediatric anesthesiology and emergency), psychology, nursing, physical therapy, child life services, and equity.

Why should we care about pain care for children? First, it’s pervasive. One in five children have chronic pain. Hospitalized children experience an average of six painful procedures every 24 hours; this number goes up to up to 14 per day in the neonatal intensive care unit. Untreated pain has short- and long-term consequences: Poor pain management leads to increased pain sensitivity, neurodevelopmental and socioemotional problems, health care avoidance, vaccine hesitancy, mental illness, opioid use, and socioeconomic disparities.​ But above all, pain management is a fundamental human right.

The Pediatric Pain Management Standard is the first of its kind globally, establishing a set of guidelines for children from birth to 19 years. The standard acknowledges and considers systemic factors that contribute to health inequities and exacerbate the experience of pain in children, including racism and trauma. It recognizes that children and families are equal partners of the health team who should be actively involved in discussions and decision-making about their pain care. It focuses on how Canadian organizational leaders and health teams should provide care and address untreated and unmanaged pain as a patient safety incident. The standard focuses on how organizational leaders and dedicated health care teams should provide pain care based on the needs, goals, abilities, and preferences of children and their families. It emphasizes the importance of having a variety of pain assessment tools readily available to reflect the needs and abilities of children and families, that teams receive the evidence-informed training necessary to provide equitable and quality pain management​, and that tertiary care sites provide timely access to consultation services so smaller sites can provide better pain care closer to home. Finally, the standard asks that preventable, untreated or unmanaged pain is reported and managed as a patient safety incident, thereby empowering change.

What to expect

What can families expect when being cared for in a HSO Pain Standard-compliant facility? They can expect multi-modal, evidence-based, family-centred pain care strategies to be employed. These include physical, psychological, and pharmacological options to immediately optimize a child and family’s experience, and positively influence their future interactions with healthcare. Children and families can expect to be involved in all discussions and decisions about their pain care, and to work with the care team to create an individualized pain care plan that reflects their goals, needs, abilities and preferences. Above all, families should feel safe to talk to others about their pain experience and access help if they need it.

Historically, pain management practices for infants and children have been inadequate. As recently as the 1980s, the medical community believed that infants did not perceive pain due to the immaturity of their brain, and pain medication was not a standard of care for pediatric cardiac surgeries. Fortunately, our understanding of pain has since evolved, and we now recognize that all children, regardless of age, experience pain. Clinicians can seek up-to-date, evidence-based guidance regarding therapies for procedural, acute, transitional and chronic pain from the Canadian Paediatric Society’s recently released national statements. Coupled with administrative leadership commitment to upholding the new HSO pain standards at their institutions, we can all work towards equitable pain care for all children in Canada.

Acknowledgement: Thank you to Laura Gibson (Solutions for Kids in Pain) for her kind support in informing this blog.

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The information on this blog should not be used as a substitute for medical care and advice. The views of blog writers do not necessarily represent the views of the Canadian Paediatric Society.