For decades, it has been recognized that children frequently are not medicated enough for pain that results from disease or surgery. The under-medication has resulted, in part, from fear of the effects of strong analgesics on children but also has occurred as a result of the failure to recognize the presence or degree of pain in pediatric patients. “There is a big difference in managing pain in children, because there are issues related to problems associated with age,” said Dr. Juan Gutierrez, an anesthesiologist at the Children’s Hospital of Alabama. “Adults can tell you where it hurts, but younger children can’t always communicate that hurt. They might act out or be scared because of the pain.” Identifying pain in infants can be even more difficult, Gutierrez pointed out. Prior to the 1970s and 1980s, it was widely believed that neonates didn’t feel pain. Circumcisions, for example, were done without medication of any kind. “It wasn’t that the doctor didn’t care. There just wasn’t any way to measure the pain,” said Gutierrez. A study published in the New England Journal of Medicine in 1987 by Drs. K.J.S. Anand and P.R. Hickey outlined evidence of and ways to assess pain experienced by human neonates and fetuses. The study’s conclusion stated, “Numerous lines of evidence suggest that even in the human fetus, pain pathways as well as cortical and subcortical centers necessary for pain perception are well developed late in gestation, and the neurochemical systems now known to be associated with pain transmission and modulation are intact and functional. Physiologic responses to painful stimuli have been well documented in neonates of various gestational ages and are reflected in hormonal, metabolic and cardio-respiratory changes similar to but greater than those observed in adult subjects. Other responses in newborn infants are suggestive of integrated emotional and behavioral responses to pain and are retained in memory long enough to modify subsequent behavior patterns.” Gutierrez said that recognizing that all children experience pain was the beginning of much advancement in treating pediatric pain over the past 30 years. “We now have ways to measure the physiological changes in children who are suffering from pain. A child’s heart rate and blood pressure usually increase, and a newborn’s oxygen saturation may drop,” he said. Other measures of pain in children include numerical or spatial scales, behavioral and/or face scales. Gutierrez said that increased understanding of analgesic and anesthetic pharmacology are also helping physicians do a better job of treating post-operative and procedural pain in children. “Pain medications have been developed for adult dosage. In many cases, doctors have to extrapolate the use of these drugs because they are not approved for use in pregnant mothers or children under age 18,” he said. “The Society of Pediatric Anesthesiology is working with the FDA to investigate pain medications for infants and children and to provide some incentives for those investigations.” Researchers want to create drugs so specifically targeted that they provide pain relief with few side effects, and Gutierrez said Dr. Charles Berde, director of the Pain Treatment Service at Boston Children’s Hospital, is testing new local anesthetics that could provide relief for up to four days. Gutierrez added that a drawback in efforts to fight pediatric pain is that there are still too few hospitals that offer comprehensive pain programs for children. Children’s hospitals offer more expertise in pain management, but not all patients have access to those facilities. In addition, even the children’s hospitals could use more resources. “We would love to have a chronic pain clinic here at Children’s Hospital, but we can’t afford it because we get no remuneration,” Gutierrez said. He added that pain clinics are expensive, and insurance companies tend to reimburse only for surgeries and medication for children but not other therapies to manage pain. “We must educate healthcare providers and third-party payers and insurance companies that these are things they need to consider,” he said. August 2007