Pediatric Office Pain: Crying for Attention

October 2011 marked the close of the Global Year Against Acute Pain.1 This campaign, initiated by the International Association for the Study of Pain, was developed to promote uniformity in the treatment of pain associated with surgery, trauma, and childbirth. The effort likely escaped the notice of most pediatricians whose days and nights are typically spent providing care to children in less dramatic situations. The important implications of this initiative for office-based practitioners are nevertheless worth reviewing.A mere few decades ago, neonatal surgery was often performed without anesthesia,2 postoperative pain management was typically an afterthought,3–5 and many significant procedures were conducted without local anesthesia or sedation. The recognition that pain exists in children, as well as its measurement and treatment, are products of research undertaken toward the end of the 20th century. Numerous textbooks,6–8 the American Academy of Pediatrics,9 and a litany of other professional societies10–12 have summarized this new information and developed evidence-based guidelines to reduce pain, especially in the hospital setting.13Despite dramatic improvement in addressing pain in the hospital,14–17 pain in the pediatric office has received limited research attention; yet it is in the pediatric office where common painful conditions are first encountered, uncomfortable procedures often performed, and pain necessarily inflicted in the course of routine health care maintenance. However, the self-limited pain problems in the office lack the poignancy of more dramatic scenarios in the hospital. As a result, with only a few exceptions such as needle pain, researchers have not been drawn to such seemingly mundane concerns. Further blunting interest and attention to pediatric office pain are very legitimate considerations about decreased office productivity, diminished efficiency, and additional expense. Despite these constraints, it is important to address pain in the office because it has both short- and long-term effects on children and can alter the relationship with their health care provider.18–22The lack of research on office pain problems is all the more striking due to their frequency. Otitis media, the most common illness diagnosis made in pediatric practices and the source of countless sleepless nights, is a case in point.23 Given the many pain-sensitive structures in the ear, children with otitis media often experience significant distress. Studies have shown that antibiotics have limited effect on the associated otalgia,24 yet, remarkably, only a handful of studies have examined how to optimize local and systemic pain treatment in otitis.25–27 Similarly, there is limited research on pain reduction during other infections such as pharyngitis, urinary tract infections, and gingivostomatitis; on the pain that accompanies normal development such as teething and growing pain; and on pain reduction during common office procedures such as urinary catheterization. Typically, pain-alleviating strategies are often seen as "tricks"28 and relegated to "anecdotal experiences," if published at all, because large-scale trials may not be feasible or attractive to investigators.Even when considering needle pain,29,30 for which there is a solid research foundation and practice guidelines do exist, many clinicians continue to administer injections as they were given 50 years ago. This outdated practice persists despite an extensive array of available local anesthetics, research on the pain-relieving effects of oral sucrose in infants, and the voluminous body of research on behavioral techniques to reduce injection discomfort.31 Failure to adopt such techniques is all the more striking given the dramatic increase in the number of immunizations, the incidence of needle phobia (10% in some studies),32 and the effect that preoccupation with this process has on the physician–patient encounter.33Obviously, no office can be pain free. Many diseases and procedures are inherently unpleasant, and little can be done to dampen their discomfort. Yet we can certainly do better than we are presently by routinely incorporating available techniques into practice and encouraging the development of others.34 Increased good will and better vaccine adherence might well offset any small additional office costs.Although the Global Year Against Acute Pain may be over, office-based pain remains a problem and deserves our attention. A good beginning would be to compile existing literature into a user-friendly format for the busy practitioner. The American Academy of Pediatrics could promote guideline development and encourage workshops through its educational forums. Anticipatory guidance for parents about pain and its reduction should be integrated into formats such as Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Third Edition and healthychildren.org. An ongoing online forum could cull the collective wisdom of seasoned pediatricians, pediatric subspecialists, and pain physicians. Office-based cooperative research networks, such as the Pediatric Research in Office Settings Network, can conduct pain research and generate additional evidence. It is time to match the strides we have made in reducing illness with efforts to make children's routine medical office experiences as pleasant as possible.