Providing Safe Pain Relief to Your Child

A study published online in January in the journal Pediatrics revealed that children prescribed morphine for at-home pain relief after having their tonsils and/or adenoids removed -- a procedure often performed to treat sleep apnea -- were at risk for respiratory complications that could prove fatal.

During the course of the study, 91 children ages 1 to 10 were either given standard doses of morphine and acetaminophen for pain treatment or ibuprofen and acetaminophen after undergoing a tonsillectomy. Parents were asked to monitor their children's oxygen saturation levels and pauses in breathing using a device called a home pulse oximeter.

Pain relief was evident in both groups, but on the first night of surgery, only 14 percent of the children in the morphine group showed improvement in oxygen desaturation incidents -- a drop in the blood's oxygen levels, which can deprive the body's tissues of the oxygen it needs to function -- while 68 percent of those in the ibuprofen group showed improvement. In the short term, the condition of the children in the morphine group continued to decline as more desaturation incidents were observed -- up to 11 to 15 events per hour -- than in the children in the ibuprofen group. One child even experienced a life-threatening drug reaction in addition to oxygen desaturation. Alarmed at their findings, researchers ended the study early and declared that the use of morphine as a post-operative pain treatment for children who underwent outpatient tonsillectomy should be discontinued.

Past studies from 2009 and 2012 have also documented respiratory problems and even death for children given codeine -- once the prevailing treatment for post-operative pain -- prompting the U.S. Food Drug and Administration in 2012 to issue warnings about its use in children, which has led to increased reliance on morphine for pain management.

But alternative and complementary methods for pain control have proven effective in children, as seen in a study published last month in Pediatric Surgery International. "We found that listening to patient-preferred audiobooks and music of their own choice to be an exciting new adjunct to standard postoperative pain management," says study author Sunitha Suresh, now a medical student at Johns Hopkins Medical School in Baltimore, but who was pursuing a biomedical engineering degree at Northwestern University at the time of the study.

About 60 children ages 9 to 14, all of whom underwent major surgery, were separated into three groups. One listened to 30 minutes of self-chosen music; another listened to 30 minutes of a self-chosen audiobook; and the last group listened to silence through noise-canceling headphones. Those who listened to music or an audiobook experienced a significant reduction in pain, while those in silence experienced no change in their pain levels.

Suresh and her colleagues hypothesize that audio therapy may have an effect on the brain's prefrontal cortex, an influential force in how we remember pain. Says Suresh: "We speculate that [audio therapy] may be a distraction from pain."

Another method for pain management in children is regional anesthesia, where "anesthesiologists use an ultrasound to guide a needle to the specific nerve that [supplies] the surgical site and deliver local anesthetic to numb only the nerves in that region," says Tarun Bhalla, director of acute pain and regional anesthesia at Nationwide Children's Hospital in Columbus.

Also called femoral nerve block, this process can lessen pain for up to 24 hours. Some patients are able to continue this treatment for approximately three days after surgery while recuperating at home, by way of a catheter connected to an external pump that delivers local anesthetic to the nerve.

Along with less pain and a faster recovery, "regional anesthesia through ultrasound allows the majority of patients to go home within hours of surgery and leads to less opioid use," Bhalla says. "Our recent study [also] showed [that] patients who did require hospitalization post-surgery spent fewer days inpatient."

Some hospitals have begun incorporating nontraditional approaches like acupuncture into their pain management programs. "Acupuncture may be used to help reduce postoperative pain, at times allowing for a reduction in the dosage required for adequate pain control or even the need for these medications," says Jaime Ralston-Wilson, a licensed acupuncturist at Seattle Children's. "It has been demonstrated that acupuncture has an effect on the central and peripheral nervous systems through the stimulation of sensory nerves and the release of neurochemicals which block pain messages."

Acupuncture can be used to treat a variety of pain conditions that commonly affect children, Ralston-Wilson says, including colic, headache, dental pain, sprain, sciatica and rheumatoid arthritis. "[It] has been used to aid in controlling pain, improving quality of life and reducing pharmacological-related side effects."

Patients typically will undergo six to eight treatments, and while improvement may be noticeable after one, this is often temporary. It usually takes several sessions to enjoy longer lasting effects.

A benefit of the process is that children can continue their treatment at home. "Patients and families receiving acupuncture or acupressure [the practice of applying pressure to acupuncture points] at Seattle Children's are instructed in acupressure at locations specific to their complaints either during their admission or prior to discharge to allow them to provide self-care and treatment," Ralston-Wilson says. "Additionally parents or family members are also taught some of these tools allowing them the ability to play a role in the care of their child."

In addition to offering acupuncture, the pediatric specialists at Children's Hospital of Wisconsin teach children biofeedback -- a form of mind-body control allowing a person to reduce the feeling of pain -- along with relaxation and meditation techniques. "Alternative therapies for pain management are essential for the management of all types of pain in children," says Steven Weisman, medical director of the Jane B. Pettit Pain Management and Headache Center at Children's Hospital of Wisconsin.

During a biofeedback session, a child outfitted with electrodes hooked up to electronic equipment may have his or her heartbeat, rate of breathing, blood pressure, brain waves, skin temperature, muscle tensions and/or perspiration measured. Once the body's functions have been recorded, a biofeedback technician will suggest mental and physical exercises to help the child gain control over a certain function, like relaxing certain muscles or slowing one's heart rate. A patient may learn biofeedback in only one or two sessions, while others may need as many as four to six.

Says Weisman: "Biofeedback works at many different levels to alleviate pain in children. It serves as a powerful distraction technique, so that the patient is not as focused on their pain. [And] it often enhances the actual stress reduction response."

Relaxation and meditation techniques work similarly to biofeedback, Weisman says. "One can learn acceptance, which often can allow a pain patient to start a program of rehabilitation for their pain problem. One might at first interpret this as learning to live with one's pain, but often that acceptance leads to a much better functional state, mood improvement and then reduction in pain itself."

In other words, the mind leads, and the body follows.

Headache, recurrent abdominal pain and post-amputation pain are examples of problems treated by biofeedback, relaxation and meditation techniques, but most pain problems respond to these processes, Weisman explains. Though, he adds, because "these methods are quite labor-intensive to teach, they are rarely directly used for post-surgical pain, which is usually short-lived." Weisman notes that patients can and should use these methods at home; they are routinely taught in outpatient clinics.

Given the distressing discoveries from recent research about pain treatments used in children, particularly those involving opioids, exploring the various alternatives or approaches that can lessen reliance on these powerful medicines could be beneficial and possibly safer in many ways. Says Suresh: "An adjunct to pain management with no side effects, such as audio therapy, has the potential to decrease the amount of opioid pain medication necessary and make patients more comfortable in their recovery period."