Pediatric team targets kids' pain
North Carolina pain management approach gains popularity
RALEIGH, N.C. — Two surgeries on Christina Shaban's legs, just 10 months apart, were worlds different in terms of the pain the Chapel Hill, N.C., teenager endured.
After a procedure last May at UNC Hospitals in which her femur was broken to begin lengthening the bone, Christina, now 14, writhed in agony. Narcotics made no dent.
For the procedure this past March, in which the femur was again broken and the knee reconstructed, Christina hurt, but nothing like before.
"It was soooo much better," she said.
The difference was the involvement of a pediatric pain team, established a year ago at UNC Hospitals — the first such team in North Carolina. Its mission is to manage aggressively the pain children feel from surgeries and traumas.
While all hospitals take care with children, the UNC Hospitals' pediatric pain team consists of nine specially trained anesthesiologists who work in an around-the-clock service dedicated exclusively to children. They use nerve blocks, epidurals along the spinal column, opiate medications and other techniques to ease pain throughout their young patients' hospital stays and beyond.
Although new to North Carolina, the pain unit approach is gaining in popularity, ending the last vestiges of the bizarre myths that children either don't feel pain as acutely as adults, or somehow can't communicate it. Anyone within earshot of a child with a skinned knee can attest to the fallacy of such notions.
"Pediatric pain for many years has been very poorly understood," said Dr. Peggy McNaull, one of the pain team specialists. "People are frightened and timid about pain control in children, primarily because of the lack of understanding."
A 2004 clinical report by the American Academy of Pediatrics noted that inadequate sedation and pain control can cause lasting problems for children.
"Post-traumatic stress disorder can occur after procedures or stressful medical experiences that are not accompanied by appropriate pain control or sedation," the authors wrote.
Yet aggressive pain management is not always pursued. Many fear children can be over-sedated, hampering efforts to discover the source of pain or trauma. In addition, heavy use of opiates such as morphine can cause respiratory distress, severe constipation and other problems.
Dr. Mark Piehl, medical director of WakeMed Children's Hospital, said such fears are easing, and hospitals are changing the way they approach pain care for children.
"There's a lot of literature and talk about it," Piehl said. He said his staff, while not part of a formal pain unit, strives to eliminate all pain, and is rated on how well they succeed. Even simple procedures such as drawing blood are done with a local numbing agent.
"We can't promise 100 percent pain-free, but that's my goal," Piehl said. He said his team is also aggressive using sedation during procedures that are not painful, but anxiety-provoking. Imaging technologies such as MRIs, for example, can cause great distress, so a mild sedative can be useful.
"It helps us take better care of children, frankly," Piehl said.
Dr. Karene Ricketts, a member of the pediatric pain unit at UNC Hospitals, said it's important to manage pain early and aggressively in children, just as it is in adults.
"If we can manage acute pain, then we can hold off the development of chronic pain," Ricketts said, noting that by staying ahead of pain, nerve pathways are less apt to become stuck in pain mode.
The UNC Hospitals group believes children recover more quickly with better pain management.
Christina Shaban's experience suggests such an outcome. Born with a condition in which her right leg was significantly shorter than the left, Christina underwent an initial surgery last May. Doctors cut the long bone in half, then attached a device that made tiny adjustments each day, pulling the bone apart to prompt constant growth until the desired length was achieved.
After that first surgery, Christina was in the hospital for a week, and pain was excruciating.
"I saw the terror in her eyes," her mother, Tina Shaban, recalled. "She was screaming for me to help her ... the IV pain medicine was not doing the trick."
Shaban said the pain slowed Christina from tackling the physical therapy she needed to gain strength.
For the second procedure, needed to straighten the leg and rebuild her knee, the pain team was in place. This time, Christina had an epidural anesthetic administered through a catheter in her back, and it was left in place long after surgery.
McNaull said the team can keep an epidural for up to five days to numb pain when regional anesthesia is warranted. Such efforts diminish the need for morphine.
"It offers better pain control by infusing the nerves that are activated by pain, and minimizing intravenous opioid's. Kids are more awake and more alert," McNaull said.
Christina left the hospital after five days, and felt as if her recovery was fast-tracked. She hopes to begin high school this fall without the braces and crutches she's worn for a year.
"I mean, it still hurt, but it was just a lot better than the first time," she said. "And I just don't have that fear."
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