Taryn Wheelock, MS, CCLS
Child Life Specialist - Inpatient / ER
Gundersen Health System

What is pain?

Pain is one way that our body protects us. Pain messages tell us if there is something wrong with every part of our body including our organs, muscles, bones, ligaments, and tissues, which are all interconnected with nerve fibers and pain mediators that carry pain messages to and from our brain (Kuttner, 2010). Without pain, children would not learn that touching a hot stove is dangerous, they wouldn’t learn that if they eat too much candy, they could get a stomachache, and they would continue to walk on broken bones or sprained ankles. By learning to pay attention to our bodies, even young children can be taught to share pain sensations so that we can determine what is going on and what will be most effective in helping the pain go away (Kuttner, 2010). 

Pain is defined by the International Association for the Study of Pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage (Collins et al., 2011). There are many things happening in your body when you feel the unpleasant sensory and emotional experience of “pain.” The interactions between your thoughts, beliefs, emotions, memories all contribute to the pain experience (Kuttner, 2010). This is what makes pain subjective.   

Everyone will experience pain at some point in their lives, either from an illness or bumps and bruises that happen in everyday life. Pain is also something that many children are worried about when they come to the hospital or doctor’s office. As child life specialists, we know that this worry can make medical experiences much more difficult for not only the patient, but for staff, too. This is why it’s so important for us to understand pain and have a tool kit of strategies to help children manage pain both in the medical setting and once they are discharged home.  

Types of pain

There are two types of pain: Acute or chronic.

Acute pain is what we think of when we think of the “protective pain” explained above – pain caused by a burn, cut or fracture. These sensations are referred to as “nociceptive pain” which means that they are caused by stimulation of intact nociceptors (pain receptors that are free nerve endings) as a result of tissue injury and inflammation (Haun, 2016). The pain begins suddenly (after injury) and follows a predictable path: First warning that the tissue has been damaged, and over time the pain lessens as the tissue heals and the pain subsides (Kuttner, 2010).  Adults often work with children to determine where they are feeling the pain, what the pain feels like, and what caused the pain to start in order to determine what can be done to help alleviate the pain. Kids then remember this pain, and it is these memories that can cause anxiety and fear, which, as we know, can lead to a whole host of other problems.

Chronic pain is pain that lasts much longer than it is useful for protective and informative purposes. It is often caused by stimulation or abnormal functioning of damaged sensory nerves (Haun, 2016). Pain is considered chronic when it lasts longer than 3-6 months (Kuttner, 2010).  When pain is persistent like this, the nerve fivers are altered and the nerve pathways don’t respond in that predictable manner like acute pain does, which can lead to more pain and may impede the healing process (Kuttner, 2010).  This is why it is so important for acute pain to be managed appropriately to prevent it from turning into chronic pain. 

What can we do about it?

Pain can be controlled in many different ways.  Medicine is often given to help control pain and should be given according to the doctor’s instructions and schedule. 

But what about in between doses of pain medications, or when pain medication is not an option?  There are many cognitive and behavioral strategies to help children feel more comfortable without medicine or in addition to the pain medicine prescribed. 

• Distraction:  Distraction is an intervention that tends to refocus thinking by directing attention away from the pain and onto something more pleasant (Cavender et al., 2004). This can be anything from a favorite toy, a movie on TV, bubbles, or even virtual reality.  
• Guided Imagery: Guided imagery is a form of relaxed and focused concentration where children are helped to reach an altered state of consciousness in which she visualizes familiar or interesting images (Ott, 1996).  One example of this would be imagining they are at their favorite place.  If this is their grandma’s house, it’s instructing them to focus on what her house smells like, what sorts of decorations are on the walls, what they like to play with at her house, and a favorite meal their grandma makes.
• Listening to music: Music in any form (lullaby, singing, listening to a favorite playlist) can promote relaxation and can be used as self-expression.
• Deep breathing: Our initial reaction to pain is to hold our breath.  When breathing is shut down, contraction in the muscle fiber increases and tension builds (Kuttner, 2010).  When you exhale, you release muscle tension, and the pain can more easily disperse (Kuttner, 2010).  Deep breaths can also help with anxiety, which often comes along with pain.
• Using cold and heat: Ask your doctor if you should use heat or cold on the place the hurts.  They might have specific recommendations based on type and place of injury. 
• Comforting touch: Touching or rubbing a non-hurting area (patting on the head, running fingers through hair, etc.) are another form of distraction. When you are rubbing a non-hurting area, the pleasant feeling of comforting touch will compete against the painful sensation. 

Whatever you chose to teach children to help manage their pain, to be effective, cognitive and behavioral strategies should invoke a child’s imagination, sense of play, and attention must be considered so as to be appropriate to child’s age, developmental abilities, and preferences (Sinha et al., 2006).

Pain is something that is inevitable in life.  Children will experience pain starting from infancy and will continue to experience pain at various points of their life through adulthood.  Learning to understand and describe their pain can help them keep their body safe, determine when to seek treatment, and understand how to alleviate some of that pain using various coping strategies.

References:

Cavender, K., Goff, M.D., Hollon, E.C., & Guzzetta, C.E. (2004). Parents positioning and distracting children during venipuncture. Journal of Holistic Nursing, 22, 32-56. DOI:10.1177/0898010104263306

Collins, P., Czarnecki, M., Doellman, D., Reynolds, J., Turner, H., & Wrona, S. (2011). Procedural Pain Management: A Position Statement with Clinical Practice Recommendations.  American Society for Pain Management Nursing. doi:10.1016/j.pmn.2011.02.003.

Gershon, J., Zimand, E., Pickering, M., Rothbaum, B. O., & Hodges, L. (2004). A pilot and feasibility study of virtual reality as a distraction for children with cancer. Journal of the American Academy of Child & Adolescent Psychiatry, 43(10), 1243-1249.

Huan, M (2016, August). Pain: What Really Happens in the Body. Association of Child Life Professionals. www.childlife.org.

Kuttner, L. (2010). A child in pain: what health professionals can do to help. Crown House Publishing.

Ott MJ. Imagine the possibilities! Guided imagery with toddlers and preschoolers. Pediatric Nurse. 1996;22(1):34–38.

Sinha, M., Christopher, N. C., Fenn, R., & Reeves, L. (2006). Evaluation of nonpharmacologic methods of pain and anxiety management for laceration repair in the pediatric emergency department. Pediatrics, 117(4), 1162-1168.