Conference moira::parenting

1041.0. "Painkillers for Children" by SAPPHO::DUBOIS (Bear takes over WDW in Pooh D'Etat!) Tue Oct 31 1995 13:13

    Pediatric painkillers, an area long neglected


    (c) 1995 Copyright Nando.net

    Children's aspirin has been on the market for decades, joined more
    recently by children's acetaminophen. Both are mild pain relievers,
    although mainly used to reduce fevers. But when it comes to quelling
    severe pain -- the kind, for example, associated with sampling bone
    marrow, setting a broken arm or sewing up a bad cut -- children have
    long been therapeutic orphans.

    Drug companies feel that the pediatric market does not offer enough
    economic incentive to warrant the costly testing and approval process
    required to license pain medication in a form suitable for small
    children.

    Most potent painkillers are administered by injections that are
    themselves painful and frightening for children. And when doctors want
    to reduce anxiety in children undergoing painful medical procedures,
    they are often forced to reformulate into an oral preparation a drug
    called Versed that is marketed only in an intravenous form.

    The drug companies' reluctance to develop pediatric analgesics has been
    tacitly supported by doctors who have long harbored many myths about
    pain in children, including the notions that they do not feel pain as
    much as adults, that they do not remember their pain and that they
    might become drug addicts if given narcotics.

    Such beliefs account for the longstanding failure of doctors to use
    painkillers when circumcising newborn boys.

    Too often, instead of being given pharmacological or other forms of
    relief, frightened children about to undergo painful procedures are
    simply restrained physically, a practice pain specialists call
    barbaric.

    Infants may be unable to verbalize pain and small children may be
    afraid to, but there is no longer any doubt that children suffer as
    much as adults, and it is clear from their response to repeated
    procedures that they remember the pains of the past all too well.

    In fact, as noted by Dr. Lynda J. Means, an anesthesiologist at James
    Whitcomb Riley Hospital for Children in Indianapolis, "infants may
    actually have a heightened response to pain because inhibitory
    mechanisms, while present, have not fully matured."

    Dr. Kathleen M. Foley, chief of the pain service at Memorial
    Sloan-Kettering Cancer Center in New York, said pain in children might
    be worse than pain in adults because children are often unable to
    understand that "the pain may be short-lived, that relief is possible
    or that the pain associated with treatment or diagnostic procedures can
    have long-term benefits." Dr. Foley added, "Some children, especially
    those with chronic disease, become desperately afraid of needles and
    those who wield them."

    Furthermore, anxiety and unrelieved pain can complicate recovery,
    prolong hospitalization and even increase the risk of dying from a
    medical procedure, said Dr. Myron Yaster, a pediatric anesthesiologist
    at Johns Hopkins Hospital in Baltimore.

    The nervous system circuitry for feeling pain is present in fetuses
    from 30 weeks of gestation onward. There are several ways to measure
    the pain of children too young to describe accurately how they feel.

    Pain profiles have been developed for infants based on such physical
    symptoms as breathing and heart rate, skin color and facial expression.
    Babies as young as 18 months can express pain and tell where they hurt.

    For preschoolers there are facial scales, like the "Oucher" Scale, that
    allow them to point to a picture that best describes how much they
    hurt. Other scales use poker chips or colors that help young children
    indicate the intensity of pain.

    Last year a small company, Anesta Corp. in Salt Lake City, won approval
    for the first potent analgesic specifically designed for and tested in
    children.

    The drug, fentanyl, an opiate, acts fast but is short-lived, making it
    an ideal medication for providing relief during painful medical
    procedures. It has the added virtue of being absorbable through the
    mucous membranes in the mouth and so could be formulated in a
    "lollipop" that makes it easy and painless and not frightening to
    administer.

    This form also enables doctors to remove the remaining drug from the
    child's mouth when a sufficient dose has been absorbed.

    But Fentanyl Oralet, as the analgesic lollipop is called, has yet to be
    used for most of the procedures for which it is intended. That is not
    because it is unsafe or ineffective, but because some outspoken doctors
    have raised concerns about possible subsequent drug abuse by patients
    who receive it, as well as objections to the link it establishes
    between candy and opiates and its potential for abuse as a street drug.

    Yaster maintains that these are empty arguments that simply deprive
    children of the kind of comfort readily provided to adults undergoing
    painful medical procedures.

    In an editorial in the journal Pediatrics earlier this year, he pointed
    out, for example, that "most orally administered medications are made
    palatable for children so that they can be better tolerated -- 'a
    spoonful of sugar helps the medicine go down.' "

    He also noted that addiction and drug abuse do not result from "the
    judicious use of analgesics" and that the frightening situations under
    which children would be given the opiate lollipop "are not the type of
    life experiences that children will want to voluntarily repeat."

    There is another new medication to reduce the pain and resulting fear
    of needle injections and other external procedures for adults as well
    as for children.

    It is topical anesthetic called EMLA Cream, manufactured by Astra
    Pharmaceutical Products Inc. of Westborough, Mass. It combines two
    local anesthetics, lidocaine and prilocaine, and rather than being
    injected, it is first smeared on the skin; the area is then covered for
    one to two hours until the drug is absorbed.

    It temporarily deadens nerve endings, providing pain relief for several
    hours after the cream is removed. It has been shown to reduce pain
    significantly in children undergoing insertion of an intravenous line,
    a spinal tap or aspiration of bone marrow.

    It may also help to diminish the distress associated with immunizations
    and circumcision.

    For children 6 and older who are experiencing chronic or prolonged
    pain, there is now also the option of using patient-controlled
    analgesia. Patients give themselves medication by triggering a
    microprocessor-controlled infusion pump that is designed to prevent
    overdosages.

    This technique allows drug doses to be individualized, prevents
    anxiety-inducing delays in relieving pain and gives children a sense of
    involvement in and control over their own care.

    Experts in pediatric pain urge parents to be aggressive in assuring
    that their children do not suffer unnecessary pain during medical
    treatment. They say that children's complaints of pain should always be
    taken seriously and treated with the same respect and care that an
    adult would receive.