What makes an ordinary day “special”? Amaze yourself
Yes, wonder in realizing that every time we see a child, we have the opportunity to look and see a miracle that we are given to caress and embrace
A miracle that grows day by day, becoming more and more autonomous, but not without the need to be contained, encouraged and protected to face daily challenges and pains. It is important to feel that you have your back covered to venture into a challenge, but it is even more so to allow yourself to experience pain without it devastating.
When a child manifests pain, and crying is the most immediate expression available to him, often the adult’s reaction is to deny or belittle that experience, but this reaction only adds the pain of not being heard to the pain he already feels.
I deliberately use only the word “pain” even when it is not physical but psychic pain because both lacerate, cut like a blade, take one’s breath away, but for both, listening, containing, sharing can ease it.
Why do I dwell so much on the subject of pain?
I believe that for each of us this topic triggers memories, feelings and experiences that, depending on the processing we have been able to put in place, we can deal with it more or less openly, but when we are faced with our children we have an obligation to listen to them, all the more so if our profession also leads us to inflict some pain on them.
Pain is a very common symptom during an illness and, in the pediatric setting, it is the one that most frightens both the child and the parents, but often also us professionals.
Until the mid-1980s, it was thought that infants and toddlers did not experience pain because of the immaturity of neurophysiological pathways, and it was more likely to interpret a young patient’s crying as “fear of the white coat.” The literature on this subject was still scarce, and as a result, clinical practice almost did not include pediatric analgesia and pain treatment.
In 1987, thanks to a paper by K.J.S. Anand, attention began to be paid to infant pain, and today, thanks to anatomo-physiological and behavioral studies, we know that toward the end of the second trimester of gestation the central nervous system is anatomically and functionally competent for nociception.
We also know that for the same painful stimulus, the child perceives more intense pain than the adult because the antalgic action of the descending inhibitory pathways is reduced: this results in greater excitability of the nociceptive system as a whole. The younger the person and therefore the lower the central and peripheral inhibition, the greater the perception of pain.
Just from the studies performed, today we can say that the pain experience, experienced during the neonatal period and in infancy, can determine the ultimate architecture of the adult’s algic system. Not only that, even the preterm infant remembers pain because the memory is formed and enriched in very early stages conditioning the perceived throughout life. It is true that many of these memories are unconscious, but they can result in behavioral and cognitive disorders.
If, as is desirable, we want to treat a child’s pain, it is absolutely necessary to measure it through the use of validated scales chosen according to the age of our little one. Measurement makes it possible to:
- establish the intensity of the pain at the time it is measured;
- assess the trend of pain over time;
- choose the most appropriate type of analgesia;
- verify the effects of the chosen treatment;
- use a common language among health care providers.
Without going into the details of drug therapy, which is a medical matter, I would like to briefly touch on nonpharmacological techniques (TNF) because many of them are simple to implement and can help reduce the distress and drama of the painful sensation, and not only of the child. The choice of type of technique depends on the age of the child/infant, the clinical situation, the type of pain, and the child’s ability and/or willingness to cooperate, but often the approach is multimodal.
Support/Relation Techniques
These are aimed at promoting support and advocacy for both the child and the family by providing relational skills, accommodation, and appropriate logistics.
Cognitive/Behavioral Methods
The main objective of this method is to divert attention from pain by selectively focusing it on stimuli that are different from or incompatible with it.
Included in these methods are:
- distraction;
- soap bubbles;
- breathing;
- relaxation;
- visualization;
Physical Methods
They aim to modify and alter mainly the sensory dimension of pain by blocking the transmission of nociceptive inputs along peripheral and central nerve pathways, modifying the reception of nerve impulses or activating endogenous pain suppression mechanisms.
Included in these methods are:
- body contact;
- hot or cold compresses;
- physiotherapeutic exercises;
- acupressure at acupuncture points.
Now that, broadly speaking, we have gotten an idea of what is the technique for dealing with the problem of pain in children, we need to “strip down” that technique and get seriously involved, even taking the risk of not pleasing our children, but without losing the opportunity to really “see” them.
In this regard, I want to tell you about one of my “special” days.
I have the good fortune to coordinate the Multidisciplinary Day Surgery service of the State Hospital of the Republic of San Marino.
This Day Surgery was established in 2007, has 6 beds used by different surgical specialties, and about 700 surgeries a year are performed.
The organization is on 5 days per week: 3 dedicated to surgical activity and 2 to pre-operations.
The organization chart consists of 1 medical manager, 2 nurses, and the writing nursing coordinator.
We now come to the interesting part.
Lorenzo is an almost three-year-old Patatino, or rather, ‘two and a bit,’ as he says, very black hair, two big, deep and disarming eyes, a huge and ever-present pacifier and two thumbs nailed in flexion. Obviously, having been born with this abnormality, his prehensile ability has adapted, but to ensure normal hand development, surgery becomes necessary. The surgeon decides to operate on one hand first and, a couple of months later, the other hand as well.
The first contact with the parents is made by phone and, sensing a veil of concern in the mother’s voice about the path the little one will face, I ask if they would prefer to stop by the ward to get the information. It is decided to meet and I ask that they also bring Lorenzo.
Spaces in health care are important, but they are not always born child-friendly, so sometimes you have to rely on creativity and invent. That’s why, when the opportunity arose to have a Ferrari with a car seat, I didn’t think twice and brought it to the ward, thinking precisely of the little patients who would be able to ride in it.
The day of the first meeting arrived and, having agreed to it on a pre-reception day, all the patients had already left, which gave us the opportunity to walk around the ward without too many rules or noise, just listening to some music coming from the speakers of the sound system donated to us (at my insistence) by an electronics store.
While I was explaining to the parents what we were going to do on the morning reserved for preparation, the prerelease precisely, Lorenzo, in his mother’s arms, could browse through some children’s books found in the ward bookcase for the use of the patients and family members present on the ward.
Since he and I were to “fall in love,” I asked him if he would like to see my “garage.”
Needless to say, as he saw the Ferrari, love broke out!!!
He not only climbed on it, but also delivered into my hands his treasure: the pacifier.
We agree on the preparation appointment asking parents to bring, for that morning, some of Lorenzo’s toys to make him feel almost at home.
In children up to 12-13 years of age, it is our custom to apply anesthetic cream, covered with transparent adhesive film, to the site where venipuncture for blood sampling will be performed, so Lorenzo was given the same treatment, too, but asking for mom’s help. His mother’s restraining and reassuring skills allowed both the electrocardiogram and blood sampling to be performed with ease.
During the interview for anamnestic data collection, Lorenzo was able to give vent to all his pictorial skills. I must say that the interruptions were numerous: after all, “mama ti pace (like)?” or “dada ti pace?” could hardly be silenced.
At the end of the morning, Lorenzo’s paintings had to be attached to some wall, so hand in hand as only lovers know how to do, we chose “his” room and arranged the artworks. Artworks found on the day of admission for surgery.
When, among the day’s surgeries, we have children, they take priority over adults, so as soon as Lorenzo arrived at the ward he was prepared and again we had mom apply anesthetic cream on his arm, who by then had become an expert and also deserved the pin of the official spreader of the year, then in mom’s arms and accompanied by dad as well, we went to the operating room.
Returning from the operating room is always a delicate moment: much attention must be paid to the amount of light, noise, and jerking. Words have to be whispered in the ear; children, even if they don’t speak well yet, hear us very well, and very importantly, one has to treat and prevent the onset of postoperative pain. Pain that is easy to manage as long as you want to.
Now the time is stretching a little; my Little Warrior sleeps and will continue to do so until some primary need takes over. The parents have been very good, they have trusted and the trust is like translating into Lorenzo as well.
The only recommendation we give to the parents is to call us if they see signs of impatience that may hint at the onset of pain: there is no need, it is useless to feel it, and, most importantly, we have the means to avoid it–at least that.
By late afternoon Lorenzo is ready to go home with his huge pacifier, one arm bandaged, and, in his other hand, a blue foam sword carved just for him from the remnants of operating room instrument packaging. Every self-respecting warrior must have his own sword.
We say goodbye and he still leaves me a treasure: his paintings.
After a fortnight the surprise and the most welcome gift: with the blue sword held in his operated hand and in his mother’s arms, he knocks on the glass of the guardhouse my Little Warrior, enters the ward and for the first time runs up to me and hugs me.
All proud he shows the new movements of his thumb then, all of a sudden, he pulls a pouch out of his pocket: inside is a bracelet. It is for me.
Lorenzo a few weeks ago came back to perform surgery on his other hand. Now he has a new little sister “tiny, tiny like this,” a little train he’s proud of, but still his huge pacifier and those two big black eyes, deep and disarming.
This, however, is another story, but always “special.”
Children we all have been, childhood is a unique, unrepeatable time, but we have forgotten this and often we adults do everything to make our children grow up fast, pretending to make them the center of attention.
Every aspect of a child’s life has its own manual, and so we think we know everything about them, but it is just an exercise in acquiring a technique that deludes us into feeling powerful.
If only we stop to listen to what a child wants to tell us, even without words, we might discover that, unlike adults, children speak a simple, more immediate language made up of instinct and emotion. By learning to listen we can give them space so that they can tell us their joys, fantasies, desires and sorrows.
Bibliography
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Anand KJS, Stevens BJ, McGrath Pj. Pain in neonates. 2nd ed. Amsterdam: Elsevier, 2000.
Anand KJS. Pain assessment in preterm neonates. Pediatrics 2007; 119: 605-7.
Chen E, Joseph MH, Zeltzer LK. Behavioral and cognitive interventions in the treatment of pain in children. Pediatr Clin North Am 2000; 47: 513-25.
Fitzgerald M. The development of nociceptive circuits. Nat Rev Neurosci 2005; 6: 507-20.
Golianu B, Krane E, Seybold J, et al. Non-pharmacological techniques for pain management in neonates. Semin Perinatol 2007; 31: 318-22.
Grunau R. Early pain in preterm infants. A model of long-term effects. Clin perinatol 2002; 29: 373-94.
Harrison A. Preparing children for venous blood sampling. Pain 1991; 45: 299-306.
Walker SM, Franck LS, Fitzgerald M, et al. Long-termimpact of neonatal intensive care and surgery on somatosensory perception in children born extremely preterm. Pain 2009; 141: 79-87.
Elizabeth Ercolani
Nursing Coordinator
ASSD (San Marino Association for the Study of Pain) member
IASP (International Association for the Study of Pain) member