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History of pain in children 

History of pain in children
Chapter:
History of pain in children
Author(s):

Anita M. Unruh

and Patrick J. McGrath

DOI:
10.1093/med/9780199642656.003.0001
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Summary

The problem of pain has likely concerned humankind from the beginning as pain is a compelling call for attention and a signal to escape from its source. Early efforts to understand pain, and its origins, features, and treatment reflected the duality between spiritual conceptualizations of pain and physiological explanations depending on the predominance of such views in a given culture in any given historical period (McGrath and Unruh, 1987). In the absence of physiological or behavioural explanations to explain persistent pain without obvious injury, when spiritual perspectives dominated, prayer, amulets, supplication, and religious rites dominated approaches to pain treatment. Herbal remedies were often part of such strategies and might themselves have had potent properties (Unruh, 1992, 2007). In ancient writings about pain and disease, treatments for children were often given alongside discussions about the health issues of women. In this chapter, we trace early approaches to pain in children to the modern era highlighting points of transition and improvements in paediatric pain management.

A brief early history from ancient times to the mid nineteenth century

The earliest medical writings about the pain and diseases of children do not provide much information about symptoms of pain and disease in children but they do illustrate an understanding that children could not be treated medically as if they were adults. For example, the Atharva Veda of India (1500–800 bce) provided paediatric incantations for headache, earache, and musculoskeletal pains (Garrison, 1923). The Susruta Samhita of India (second century bce) gave dosages of drugs and herbal remedies for children separately from adults and advised administering them with milk, clarified butter, or in a plaster spread on the breasts of the nurse (Garrison, 1923). Hippocrates (about 460–357 bce), Celsus (25 bce–50 ce), Soranus (second century CE), Galen (130–200 ce), Oribasius (325–403 ce), Aurelianus (fifth century ce), Aetius (sixth century ce), and Aegineta (seventh century ce) all contributed to treatment of disease in infancy and childhood in their time period and beyond, in Greece and Rome, and in the Arab world. The Hippocratic writings of the fifth and fourth centuries bce described constitutional differences between adults and children, and gave different doses of herbal remedies and means of administration (Garrison, 1923; Still, 1931). Crying, restlessness, and sleeplessness were regarded as the primary symptoms of a child’s pain and distress (Unruh, 1992).

One of the most reported pains of childhood prior to the eighteenth and nineteenth centuries was teething pain. The treatments for teething pain (Table 1.1) are fascinating to the modern reader and illustrate the underlying concern with which a child-specific pain was regarded throughout those centuries, and the ways in which remedies were passed down and modified over time. It was not uncommon for children to die in infancy and childhood when they were teething though illness and death were likely due to issues other than teething (McGrath and Unruh, 1987).

Table 1.1 Historical treatments of children’s teething pain

Source

Treatments

Soranus, 2nd century ce

‘Before teething, the gums should be gently rubbed with oil or fats, and the child may be permitted to suck fat bacon without swallowing, but this should cease when the teeth appear. The gums should not be irritated by butter or acid substances, and if there is much inflammation, poulticing, and sponging are recommended’ (quoted in Garrison, 1923, p. 46)

Oribasious, 325–403 ce

‘If they are in pain, smear [the gums] with dog’s milk or with hare’s brain; this works also if eaten. But if a tooth is coming through with difficulty, smear cyperus with butter and oil-of-lilies over the part where it is erupting’ (quoted in Still, 1931, p. 38)

Aetious, 6th century ce

‘He advises the root of colocynth, hung on the child in a gold or silver case, or brambleroot, or the tooth of a viper, especially of a male viper, set in gold, or a green jasper suspended on the neck so as to hang down over the stomach’ (quoted in Still, 1931, p. 40)

Rhazes, 859–932 ce

‘And the treatment of it, when the gum is swollen, is that the gum should be rubbed a little with the finger, and afterwards with oil and hen’s fat or hare’s brain or dog’s milk; and apply to the child’s head water in which there have been boiled camomile and dill, and put plasters which have a dispersing effect on his jaws; and if the pain in the part increases after this, take butter and oil of laurels, mix together and apply over the part; or take cow’s butter and marrow from the thigh, and apply; and if the points of the teeth have appeared, put over the whole head and neck clean wool, and let some tepid water be sprinkled on the wool each day’ (quoted in Still 1931, pp. 46–47)

Avicenna, 980–1036 ce

‘For burning pain in the gums apply oil and wax as an epitheme or use salted flesh which is a little “high”’ (quoted in Gruner, 1930, p. 372)

Phaer, 1546 ce

‘There be divers things that are good to procure as easy breeding of teeth, among them the chiefest is to anoint the gummes with the braynes of an hare nyxte with as much capons grece and hony, or any of these thynges alone is exceadynge good to supple the gummes and the synewes … And whan the peyne is greatte and intolerable with apostema or inflammacion of the gummes, it is good to make an ointment of oile of roses with the juyce of morelle otherwise called nightshade, and in lack of it annoint the jawes within with a little fresshe butter and honye’ (quoted in Still, 1931, p. 121)

Sainte-Marthe, 1569 ce

‘Hare’s brain, honey and red coral ring as amulet’ (cited in Ruhrah, 1925)

Ferrarius, 1577 ce

‘A dead man’s tooth in the opinion of some, through some particular virtue when hung on the neck of an infant, soothes and disperses the pain of teething’ (quoted in Still, 1931, p. 156)

Primerose, 1659 ce

‘Tooth of a dog, wolf or male viper hung around the neck to ease teething pain’ (cited in Still, 1931)

Determining whether a child was in pain was a challenge and not surprisingly generally determined by appeals to observation of changes in the child’s behaviour. Aurelianus (fifth century ce) illustrates the emphasis on a child’s behaviour as an indicator of pain:

The child groans in its sleep, rolls about, gnashes its teeth, tends to lie prone, cries out suddenly, or falls silent, is seized with convulsions, sometimes becomes somnolent, the face becomes emaciated and loses its colour; the child gets cold and answers questions with difficulty; sometimes throws itself about with outstretched hands, working etitself into perspiration. (Quoted in Garrison, 1923, p. 47)

Though changes in general behaviour were important, crying was usually regarded as the chief indicator of a child’s pain. Some physicians, such as Omnibonus Ferrarius (1577) (an Italian physician), (Still 1931), and Starr (1895) and Holt (1897) (both American physicians), believed that children only cried if there was a reason associated with distress. Both Starr (1895) and Holt (1897, 1908) associated different features of cries with specific illnesses and severity of pain. For example, a sudden, very loud and paroxysmal shriek was described as hydrencephalic cry associated with headache (Starr, 1895, p. 6). Holt (1987) described acute pain as having a sharp and piercing cry that was usually accompanied by contracting facial features and drawing up the legs and sometimes falling into an exhausted sleep. He ascribed these pains to earache and colic. Starr (1895) may have been the first physician to describe facial expression of pain. He also used these features to identify the source of pain:

The picture (of a healthy child) is altered by the onset of any illness, the change being in proportion to the severity of the attack. An expression of anxiety or suffering appears, or the features become pinched and the lines are seen about the eyes and mouth. Pain most of all sets its mark upon the countenance, and by noting the features affected it is often possible to fix the seat of serious disease. Thus, contraction of the brow denotes pain in the head; sharpness of the nostrils, pain in the chest; and a drawing up of the upper lip, pain in the abdomen. (Starr 1895, pp. 3–4)

At least two surgical procedures, trepanation (a hole bored in the skull to treat headaches, mental illness, and convulsions) and circumcision, were performed on children in the ancient world throughout history (Liskowski, 1967). Other paediatric surgeries included repair of inguinal hernia, and harelip, tonsillectomy, and severance of the frenulum of the tongue (Mettler and Mettler, 1947). Opium, hyoscyamus, mandragora, and wine were used for pain relief during surgery (e.g. Celsus 25 bce–50 ce and Avicenna 980–1036 ce) (McGrath and Unruh, 1987; Mettler and Mettler, 1947) but physical restraint was the more common approach. For children, surgical procedures were exceedingly painful and difficult for the patient and physician. Celsus’ advice for the surgeon was:

A chirurgien must have a strong, stable and intrepid hand and a mind resolute and merciless; so that to heal him that he taketh in hand, he be not moved to make more haste than the thing requireth, or to cut less than is needful, but which doth all things as if he were nothing affected with their cries. (Quoted in Griffith, 1951, p. 127)

Children suffered when they had pain throughout this period (Newton, 2011). Although there is evidence that children were also cared about, and efforts made to manage their pain (McGrath and Unruh, 1987), it was anaesthesia that offered the first prospect of significant pain relief.

Early modern history starts with anaesthesia 1840–1950

The experience of pain was transformed by the development of anaesthesia in the nineteenth century. In 1842, Crawford Long used diethyl ether to excise a cyst from a patient’s neck (Long, 1849), and then in 1846 William Morton gave a public demonstration of the use of ether for a dental procedure (Costarino and Downes, 2005). Children were involved in the earliest clinical applications of anaesthesia; the third patient who received ether from Long was an 8-year-old boy whose diseased toe was amputated on 8 July 1842 (Stewart, 1989). John Snow (1885), Queen Victoria’s anaesthetist, started using diethyl ether for children in 1847 and 10 years later reported on his use of chloroform with several hundred children, 186 of whom were infants (Costarino and Downes, 2005). While children commonly received anaesthesia for surgery from the beginning, they were also perceived to have more problems associated with anaesthesia such as nausea and vomiting, hypotension, respiratory depression, and cardiac arrest, especially with chloroform (Costarino and Downes, 2005). The first recorded deaths due to anaesthesia occurred in children (Stewart, 1989). Some invasive procedures were considered so short or so minor that anaesthesia was thought not to be required. For example, Wharton (1895) did not consider a tracheotomy painful if there was marked dyspnoea, and thought that it was only the first incision that was painful. Similarly, Casselberry (1895) did not feel an anaesthetic was needed for a tonsillectomy because of the brevity of the procedure unless the adenoids were also to be removed. Pernick (1985) noted that procedures other than amputations of limbs were often considered minor.

In 1898, August Bier used cocaine to induce spinal anaesthesia in six patients, two of whom were children but he did not perceive spinal anaesthesia to be beneficial (Brown, 2012). By 1910, three papers had been published in The Lancet each referring to 100 or more paediatric cases in which spinal anaesthetics, rather than general anaesthesia, were used (Gray, 1909a, 1909b, 1910). Regional anaesthesia may have evolved due to the associated risks of general anesthesia in children but as paediatric general anaesthesia improved in the 1930s to 1950s, regional anaesthetics were less frequently used and are still not widespread (Brown, 2012).

The advancement of paediatric pain management during surgery was dependent on the development of anaesthetic agents, management of negative side effects of these agents, adequate training of physicians in the use of anaesthetics, and development of anaesthetic equipment that was appropriate for use with infants and children. Rendell-Baker (1992) described the historical evolution of paediatric anaesthesia equipment as having different developmental phases including: use of open drop mask for chloroform; introduction of tracheal intubation (beginning in 1909); development of various breathing systems (Magill’s breathing system, Mapleson E T-piece breathing system, paediatric laryngoscopes, paediatric tracheal tubes, the Crowe–Davis mouth gag, the laryngeal mask airway); design of cyclopropane and carbon dioxide absorption systems (non-rebreathing valves); the T-piece system; specialization of paediatric anaesthesia as a medical subspecialty; use of halothane and low-dead space paediatric face masks and related equipment; introduction of standard breathing systems; and use of constant positive airway pressure and intermittent mandatory ventilation. The first paediatric anaesthetic textbook, Anaesthesia in Children by Langton Hewer, appeared in 1923, with a second textbook, Leigh and Belton’s Pediatric Anesthesia, available in 1948.

The primary advantage of anaesthesia was the relief of pain with the secondary effect of permitting increasingly more complex (and invasive) surgical procedures. At the outset, in its earliest period, the beneficiaries were most likely to be women, white people, young children, and people from upper and middle classes (Jackson Rees, 1991). Children were viewed as more sensitive to pain, and more difficult to control if they were anxious and fearful about the procedure (Pernick, 1985). But with respect to the pain experience of infants, there was disagreement about the best approach. On the one hand, there were those physicians, like Eliza Thomas (1849), who regarded infants as hypersensitive to pain (cited in Pernick, 1985). There were other physicians whose views resonated with Henry Bigelow (1848) who wrote: ‘The fact that it [infant] has neither the anticipation nor the remembrance of suffering, however severe, seems to render this stage of narcoticism [full anesthesia] unnecessary’ (quoted in Pernick 1985, p. 172). Stewart (1989) wrote that infants were considered ideal patients for surgery by some because they were considered relatively insensitive to pain, unable to appreciate it, and even capable of sleeping through the surgery. In 1938, Thorek wrote: ‘Often no anesthesia is required. A sucker consisting of a sponge dipped in some sugar will often suffice to calm a baby’ (p. 2021).

This view of relative insensitivity to pain in infants seemed to be supported by studies that endeavoured to elicit pain. In 1917, Blanton reported on studies of the response of infants to procedures such as blood draws, lancing of infections, and exposure to pin pricks during sleep. She observed crying and defensive escape behaviour but reported them as complex and advanced, reflexive and instinctive behaviours. In 1941, McGraw used pin pricks to examine the maturation of nerves in 75 children from infancy to 4 years. She maintained that the diffuse body movements of neonates with crying reflected a limited sensitivity to pain in the first 2 weeks of life and that it was unlikely for there to be any neural mediation above the thalamus.

But there continued to be opposing points of view. Charles Robson, anaesthetist at the Hospital for Sick Children in Toronto, perhaps the first paediatric anaesthesiologist (Mai and Yaster, 2011), vehemently rejected outright assumptions about infant insensitivity to pain:

First, it has been stated that infants under seven days of age do not require anesthetics for operations—that their association tracts for pain are not fully established and that minor operations may be carried out without any damaging effects on the infant. Personally I do not believe this and it is simply vivisection to operate on a conscious screaming wriggling infant without using a general or local anesthetic. (Robson, 1925, p. 235)

Robson used open-drop ether and cyclopropane along with tracheal intubation for infant anaesthesia (Mai and Yaster, 2011).

Views such as Robson’s were probably in the minority. There is little discussion about pain in early textbooks about paediatric anaesthesia, not even with respect to neonates. Smith’s The Physiology of the Newborn Infant (1945) did not mention pain at all. Leight and Belton (1948) made only one substantive comment about pain:

Newborn infants are not as sensitive to pain and some degree of analgesia is present without anesthetic. Most infants, however, do have some pain sensation even at birth and one cannot rely on the old adage that there is no pain sensation for the first three weeks of life. It is nearer the truth to say that sensitivity to pain is decreased. Since there is some basic analgesia, very low concentrations of anesthetic agent will produce complete analgesia. (p. 30)

By the mid twentieth century, the prevailing view, that infants had reduced sensitivity to pain, provided an accepted position for the use of minimal anaesthesia for surgery on infants. In the 1950s, Gordon Jackson Rees in Liverpool, England, introduced an approach that came to be known as the Liverpool technique. He modified a part of the paediatric anaesthetic equipment to permit better monitoring of respiratory movements of anaesthetized children and provide intermittent ventilation if needed (Costarino and Downes, 2005). He also introduced curare and other relaxants into practice and nitrous oxide and oxygen anaesthesia without ether (Jackson Rees, 1960). In his 1950 discussion about anaesthesia in the newborn, Jackson Rees argued that the newborn was substantially different from an adult in neuromuscular structure and physiology (mechanical differences, sensitivity of the respiratory system, muscle tone). While he supported using muscle relaxants to reduce the amount of anaesthetic agents, he believed that control of respiration was possible with light anaesthesia without muscle relaxants for infants because of these structural and physiological differences. He believed the ‘operative risk’ to full-term infants was slight because fetal cord blood levels of corticosteroids at birth paralleled those of the mother, hence surgical trauma was less at birth but then increased rapidly during the first week of life. The optimum operative period was regarded by Jackson Rees (1950) to be the first 24 hours of life. Jackson Rees (1950) noted that Leigh and Belton (1948) had suggested premedication with morphine for very young infants with morphine but believed it was generally not necessary:

This treatment appears to facilitate the smooth maintenance of anesthesia, and would seem to be desirable if respiration is not to be aided or controlled. It does, however, make the induction of anesthesia by inhalation agents—a tedious process at best—a very prolonged procedure. (p. 1421)

In his 1960 paper, Jackson Rees discussed in some detail the anaesthetic complications of paediatric anaesthesia such as the tendency for infants under 6 months to become hypothermic in response to anaesthesia whereas older infants became hyperthermic. Hypothermia was more readily managed but hyperthermia sometimes led to convulsions and death. Ether anaesthesia and atropine premedication contributed to this risk. In summarizing his views, Jackson Rees (1960) wrote:

The respiratory deficiencies of the infant during early life and the hazards of hyperthermia in older children suggest that controlled ventilation during the maintenance of anaesthesia has special advantages. It should be regarded as an essential part of the technique for prolonged operations, and is highly desirable for shorter procedures. Anesthesia can be maintained at very light levels with nitrous oxide-oxygen and a relaxant drug, with the result that recovery is rapid.… There are, therefore, cogent practical and theoretical reasons for maintaining anaesthesia with controlled ventilation, a relaxant drug, nitrous oxide and oxygen. (p. 138–139)

Although Jackson Rees is said to have introduced nitrous oxide and oxygen anaesthesia without ether, it had already been in use for some years in the US by some physicians. Mary Botsford in San Francisco (1935) reported using this preparation over a 2-year period for children from 1 month to 4 years of age for procedures of 4 minutes to 1 hour and 40 minutes. However, for the youngest infants, Botsford regarded ether as the anaesthetic of choice. Botsford also noted that by the 1930s, chloroform had been almost completely discontinued for infants and children because of deleterious effects on the liver, cardiac depression, and postoperative acidosis. In the discussion section of Botsford’s paper, where responses were provided from colleagues, two writers, Weeks and Delprat, commented, ‘We are glad to see that she still allows us to use ether in babies, even though she so strongly favours nitrous oxid[e] and oxygen’. Weeks and Delprat maintained that for abdominal surgery nitrous oxide and oxygen provided too little relaxation of the tissues, and they were prepared to risk a less safe anaesthetic (ether).

Nitrous oxide and oxygen anaesthesia with a muscle relaxant was considered for many years a light anaesthetic that was sufficient for many paediatric procedures. It appeared to reduce a number of surgical risks, especially for infants, based on the knowledge in this period of the physiology of infants and children. Although there were some efforts to understand the responses of the paediatric patient to surgical procedures, evidence of informed decision-making was typically on the basis of published clinical series. Such papers provided clinical information but very limited data about an infant’s physiological stress response to invasive procedures. Paediatric pain research during this period was limited and focused on the first epidemiological studies and not clinical care.

Scientific approaches to pain in children

The second half of the twentieth century can rightly be considered the modern era of paediatric pain research and management. Major developments occurred that brought scientific thinking to the area and widespread realization in the health system that paediatric pain was an important issue. Development of the field of paediatric pain was, and continues to be, uneven. Even in developed countries, the provision of services is not at all uniform. In the developing world, paediatric pain research is just beginning (e.g. Forgeron et al., 2009). Advances in science have not always resulted in advances in implementation of care. There were significant landmark events that led to the modern era of paediatric pain.

Recurrent pain in children certainly was known and written about earlier (e.g. Matthews, 1938), but programmes of research about pain in children developed primarily in post-war Europe. The seminal work in headache was by Bo Vahlquist (Vahlquist, 1955; Vahlquist and Hackzell, 1949) and later by his protégé Bo Bille (1962) in Sweden. Vahlquist defined criteria for diagnosis of headache in children and presented clinical series and described common features. Bille’s doctoral dissertation, published as a monograph in Acta Pediatrica, was a large-scale epidemiological study of the children of Uppsala. He described the prevalence and correlates of migraine and provided a more detailed set of lab studies and interviews with a subgroup of children who had pronounced migraine. Bille personally followed the group of 73 children with pronounced migraine for 40 years (Bille 1997). This work was foundational for all subsequent studies of migraine and other headaches in children and adolescents.

John Apley and colleague (Naish and Apley, 1951) in Bristol, England, published epidemiological research on recurrent limb pains demonstrating that about 4% of children had such pain. This paper was followed by his groundbreaking epidemiological and aetiological studies on recurrent abdominal pain (Apley, 1959). Apley found that recurrent abdominal pain was common, affecting10.8% of children. Girls were more likely to have recurrent abdominal pain than boys. He linked recurrent abdominal pain to psychosocial problems and argued that overmedicalization of recurrent pain led to long-term consequences. Apley’s studies still inform our understanding of recurrent limb and abdominal pain. While these studies on recurrent pains in children were well known in the paediatric literature, and stimulated clinical practice, they did not trigger much systematic research interest until the 1980s.

In 1965, Melzack and Wall introduced an imaginative and comprehensive theory, known as the gate control theory of pain, to account for horrific injuries that sometimes were not felt as pain, and minor injuries that were sometimes felt as severe pain. They used recently discovered physiological data and clinical data to suggest that a mechanism in the substantia gelatinosa of the dorsal horn of the spinal cord gated sensations of pain from pain receptors before they were interpreted or reacted to as pain. This theory changed how pain was conceptualized and united clinical observations with physiology. Although not specifically describing mechanisms of action for the role of attention, thoughts, and emotions in pain, Melzack and Wall included these phenomena by hypothesizing a central control trigger that could mediate specific central activities. The development of modern models of pain increased interest in pain research and in the integration of clinical observation with the biology of pain.

But drawing attention specifically to pain in children did not come easily. Interest was sporadic and research still almost non-existent. Jo Eland was the first North American clinician scientist to bring pain in children to the forefront. In 1971, she was a faculty member supervising students on a paediatric oncology unit in Omaha, Nebraska. Children were typically diagnosed late, received ineffective treatment, and died in pain with little pain relief. In her President’s Message at the American Society of Pain Management Nurses in 2012, Eland said of this experience:

Watching so many children die in unrelieved pain caused me to begin reading everything I could about pain and soon found there was virtually nothing written about pediatric pain. The memories of so many children dying in unrelieved pain left a lasting impression that has never left me. (Reproduced with kind permission of Jo Eland)

Eland and Anderson (1977) noted that only 33 scientific articles had been published on pain in children by the mid 1970s and most of these papers were on paediatric recurrent pain. Their own important contribution to paediatric pain was a comparative chart review of the pain relief given to adults and children following similar surgical procedures. In the review of 25 children, aged 4–8 years, 21 children had been ordered analgesics but only 12 received any medication. Eighteen of the children were then matched with adults receiving similar surgery. The adult group were given 372 opioid analgesic doses and 299 non-opioid pain doses. There were methodological limitations to this review as a study: it was not experimentally well controlled, it used questionable matching, and did not measure pain. It is unknown whether the data from the adult sample came from a similar time period to that of the children or from the same institution. Nevertheless, the difference in the provision of pain relief between child and adult patients was startling and overwhelming in illustrating that children and adults were not treated similarly for pain. This study triggered two methodologically superior studies with similar though less extreme results. Beyer and colleagues (1983) compared 50 children with 50 adults on the postoperative analgesia they received following similar cardiac surgeries. The only patients who were not prescribed any analgesics at all were six children. Overall children received less than 50% of the analgesic doses given to adults. Schechter et al. (1986) reviewed charts for the postoperative analgesics received by 90 children and 90 adults who were randomly selected and matched for sex and diagnosis. Adults received an average of 2.2 doses of opioids narcotics per day, whereas children received half this amount. It is unknown whether the children in these studies were in more pain than adults, as pain was not measured. Nevertheless, these three studies critically established that children’s pain was significantly undertreated in hospitals.

Along with these early studies which identified the problem of recurrent pains, abdominal pain, and headache in childhood, and undertreatment of postoperative pain in children, work was beginning to untangle the cry of infants, crying long being regarded as symptomatic of pain and distress in infants. In the 1960s, auditory and spectographic cry analysis of infants was systematized by Ole Wasz-Höckert and colleagues in Finland (Wasz-Höckert et al., 1968). This work was sophisticated and well respected, and dealt with pain and other types of cries, but did not influence the investigation of pain outside of cry analysis.

The most seminal developments to draw attention to pain in infants and children were two events in the 1980s. The first was a series of studies by Kanwaljeet Singh Anand as a PhD student at Oxford University. With support from a Rhodes Scholarship and the John Radcliffe Hospital, Anand began one of the first research programmes on pain in neonates. Anand developed sophisticated methods of measuring hormonal stress responses using very small samples of blood (Anand et al., 1985). He then demonstrated in clinical series and well-controlled, randomized trials, that term and preterm neonates mounted a major stress response following surgery for patent ductus repair (Anand and Hickey, 1987; Anand et al., 1987, 1988, 1990). These studies showed that neonates receiving minimal anaesthetic, the ‘Liverpool’ technique that had been standard care since the 1950s, compared to neonates receiving halothane anaesthesia, had significantly elevated levels of plasma epinephrine, norepinephrine, cortisol, glucagon, beta endorphins, and insulin, and as well as increased mortality in the postoperative period.

Anand’s research was well received in the academic community. Anand won the 1986 Dr Michael Blacow prize for the best paper by a trainee at the annual meeting of the British Paediatric Society (Royal College of Paediatrics and Child Health, n. d.). For the public, the realization that infants were exposed to surgery with minimal anaesthesia came as a profound shock and was met with initial disbelief. In the media, Anand was viciously attacked in the Daily Mail (UK newspaper) in a story titled ‘Pain killer shock in babies operation’ (Daily Mail, 1987). Anand and colleagues were accused of experimenting on babies by withholding anaesthesia. The All Party Parliamentary Pro Life Group demanded that the General Medical Council investigate these experiments. Many distinguished medical scientists insisted that these studies were ethical, and methodologically rigorous challenges of then current standard of anaesthetic procedure for infants undergoing surgery, and would lead to better care. In 1988, Sir Bernard Braine, head of the All Party Group publicly apologized for his accusations (Anonymous, 1988).

The second seminal event was related to Anand’s work but occurred in the US and was not research but one family’s experience. Like Anand’s research, the story of Jeffrey Lawson focused on neonatal anaesthesia and it too was debated in the public arena through the media. Jeffrey Lawson was born in February 1985, at 25–26 weeks gestational age, weighing 760 grams, and was admitted to the Washington National Children’s Hospital for treatment of patent ductus arteriosus—a not uncommon problem in a premature infant. The ductus arteriosus is a blood vessel that permits blood to circulate through the baby’s lungs before birth, closing a few days after birth. A patent ductus arteriosus leads to abnormal blood flow between the aorta and pulmonary artery, two major blood vessels that carry blood from the heart. After some medical attempts to correct this condition, Jeffrey Lawson underwent open heart surgery to correct this abnormality. His mother described Jeffrey’s anaesthesia during the surgery in this way:

Jeffrey was awake through it all. The anesthesiologist paralyzed him with pavulon, a drug that left him unable to move, but totally conscious. When I questioned the anesthesiologist later she said Jeffrey was too sick to tolerate powerful anesthetics. Anyway, she said, it had never been demonstrated to her that premature babies feel pain. (Lawson, 1986, pp. 124–125)

Following surgery, Jeffrey went into shock, catabolized, and suffered heart, kidney, and liver failure. He died on 31 March 1985, 5 weeks following surgery. Ms Lawson contacted many professional and social service agencies and other individuals to support her belief that babies should receive pain control for surgical procedures before her story was picked up by the media.

In writing the story of Jeffrey Lawson for The Washington Post, Sandy Rovner quoted Willis McGill, Chair of Anesthesia at the Children’s Hospital National Medical Centre. Dr McGill asserted that there were risks with anaesthesia and that ‘it doesn’t do any good to have a dead patient who doesn’t feel pain’ (Rovner, 1986, p. 7). The article in The Washington Post triggered other coverage emphasizing that babies were undergoing surgery without anaesthesia. The American Society of Anaesthesiologists (1987) and the American Academy of Pediatrics (1987) asserted that anaesthesia should not be routinely withheld from neonates. In 1996, the American Pain Society established the Jeffrey Lawson Award for Advocacy in Children’s Pain Relief to honour Jeffrey Lawson and the contribution of his mother to the advancement of pain in infants and children.

The Anand story in England and the Lawson case in the US were compelling. They were followed by a dramatic increase in professional and scientific interest in pain in children. Between 1981 and 1990, there were 2966 articles on paediatric pain with a striking increase occurring in the 1980s (Guardiola and Baños, 1993) and an upsurge in articles on pain in neonates (Baños et al., 2001). Books on some specific pains in childhood, such as Apley’s book on abdominal pain (1959), had already appeared, but now, the first books covering the broad area of childhood pain were published (Table 1.2). Most of these books have been directed to health professionals but some focused on helping parents to manage their children’s pain (Table 1.3).

Table 1.2 Books for health professionals on pain in infants, children, or adolescents

Author(s)

Title

Year

Ross and Ross

Childhood pain: Current issues, research and treatment

1988

McGrath

Pain in children: Nature, assessment, and treatment

1989

Schechter and Berde

Pain in infants, children and adolescents

1993

Kuttner

A child in pain: How to help, what to do

1997

Yaster et al.

Pediatric pain management and sedation handbook

1997

Finley and McGrath (eds)

Measurement of pain in infants and children

1998

Dahlquist

Pediatric pain management

1999

Finley and McGrath

Acute and procedure pain in infants and children

2001

Anand et al. (eds)

Pain in neonates and infants (three editions)

2002, 2004, 2007

McGrath and Finley

Pediatric pain: Biological and social contexts

2003

Tobias and Deshpande

Pediatric pain management for primary care (2nd edn)

2004

Finley et al. (eds)

Bringing pain relief to children: Treatment approaches

2006

Oberlander

Pain in children and adults with developmental disabilities

2006

Rogers

Managing persistent pain in adolescents

2008

Walco and Goldschneider (eds)

Pain in children: A guide for primary care

2008

Twycross et al. (eds)

Managing pain in children

2009

Kuttner

A child in pain: What health professionals can do to help

2010

McClain and Suresh (eds)

Handbook of pediatric chronic pain: Current science and integrative practice

2011

Oakes

Compact clinical guide to infant and child pain management: An evidence-based approach for nurses

2011

Chambers et al.

Pediatric pain: A clinical casebook

2012

Palermo

CBT for chronic pain in children and adolescents

2012

Table 1.3 Books for parents on managing children’s pain

Author(s)

Title

Year

Finley and Turner

Making cancer less painful: A handbook for parents

1992

McGrath et al.

Pain, pain go away: Helping children with pain

1994

Kuttner

A child in pain: How to help, What to do

1997

Krane and Sinberg

Relieve your child’s chronic pain: A doctor’s program for easing headaches, abdominal pain, fibromyalgia, juvenile rheumatoid arthritis, and more

2005

Zeltzer and Schlank

Conquering your child’s chronic pain: A pediatrician’s guide to reclaiming a normal childhood

2005

The International Association for the Study of Pain established a Special Interest Group on Pain in Childhood (〈http://www.childpain.org〉) in the 1980s. One of its activities is the International Symposium on Pediatric Pain (〈http://childpain.org/ispp.shtml〉), the first was held in Seattle in 1988. The PEDIATRIC-PAIN electronic discussion list began in the 1990s (PEDIATRIC-PAIN@lists.dal.ca〉). At present it has over 800 members and remains an active discussion forum. The Pediatric Pain Letter (〈http://www.childpain.org.ppl〉) began in 1996. The International Pediatric Pain Forum is another paediatric pain meeting. It is held every 2–3 years on a focused theme (〈http://pediatric-pain.ca/content/IFPP〉).

It is difficult to know how much of this increased attention on children’s pain was due to the public attention and debate that surrounded the research of Anand, or the tragic story of Jeffrey Lawson. The research in this area was gaining sufficient momentum for the first paediatric pain books to appear and the first paediatric pain conference to be held. Nevertheless, there is no doubt that these events highlighted in undeniable ways the assumptions and misconceptions that prevailed and persisted in children’s pain, their serious potential for harm, and lent urgency to the need for change.

The contributions of modern science to paediatric pain and the future

Science relies on assessment and measurement. Until the last three decades of the twentieth century, measurement of children’s pain relied on unstandardized, largely descriptive approaches to determine whether a child was in pain. Empirical research confirmed that an infant’s cry due to distress had specific spectrographic properties (Wasz-Höckert et al., 1968), and that cries due to pain, hunger, and fear could be distinguished from each other by trained observers and by spectrographic analysis (Anand and Hickey, 1987). Moreover, there are behavioural and spectrographic differences in the pain cries of healthy full-term neonates, preterm neonates, and neonates with neurological impairments (Anand and Hickey, 1987). Facial characteristics of a child in pain, the features noted by Starr in 1895 with respect to the brow, the nostrils, and the upper lip, are characteristics of the pain face now captured in paediatric pain measures such as the Neonatal Facial Action Coding System (Grunau and Craig, 1987). In the 1970s and 1980s, the first self-report measures of pain were developed and later, self-report measures based on facial characteristics—e.g. the Faces Pain Scale (Bieri et al., 1990) and the Faces Pain Scale—Revised (Hicks et al., 2001). In addition, observational measures of children’s pain behaviour, particularly in the postoperative context, were constructed and validated. Measures were also developed for children with developmental disabilities and for pain in infants. Such tools provided the capacity to measure the effectiveness of pain intervention for infants, children, and adolescents. Much of this work is reviewed in the books mentioned in Table 1.2 and in Section 5 of this book.

In addition to pain measurement, attention was drawn to special areas of pain in infants, children, and adolescents and its treatment such as in burns, procedural pain, cancer pain, arthritis, and so on. There was greater appreciation of the immediate and long-term consequences of pain in childhood due to physical and sexual abuse. In the last 10 years there has been a more solid focus on the social and cultural context of children’s pain and the role of parents in children’s learning about pain. A great deal of work has focused on children’s pain in the Western world. Recently, researchers have come to recognize that the pain of children in underdeveloped countries is even more greatly challenged by the lack of education about child pain and limited or no access to appropriate pain management.

Only fools try to predict the future but some emerging trends are evident. There will certainly be greater advances in our understanding of the biomedical, social, cultural, clinical, and health systems science of pain in children. The yet to be resolved problem of insufficient access to scientifically demonstrated treatments for pain for infants, children, and adolescents is slowly being recognized, and is leading to new ways of developing interventions such as Web-based alternatives (see Stinson and Jibb, Chapter 55, this volume). The need for personalized approaches to care is being understood. But will all of our progress in science make a difference in practice? Will the financial crisis that is gripping many parts of the world lead to less care for the most vulnerable who have the least ability to demand better care? Will there be better solutions to the inadequate management of pain in children in all parts of the world? We need to consider and take responsibility for narrowing the gap between the generation of evidence and its application in the real world where pain occurs.

Acknowledgements

McGrath’s research is supported by grants from the Canadian Institutes of Health Research and his Canada Research Chair. This chapter is based on previous publications including McGrath (2011), McGrath and Unruh (1987), and (Unruh, 1992).

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