There are few sounds as piercing as a child in pain. But while most of us would like to think we'd do anything to alleviate a child's suffering, a new study has found that hospital emergency departments could be doing a lot more.
In a survey of nurse managers and medical directors from 72 Alberta hospitals (two of them children's hospitals) in 2009, Dr. Samina Ali of the University of Alberta has found major deficiencies in assessing and treating the pain of children who are injured or ill, and inconsistent standards in routine procedures such as prepping a child for an IV insertion or a spinal tap for testing purposes.
Ali, the university's assistant dean of professionalism at its medical and dentistry school and an associate professor of pediatrics and emergency medicine, writes in the study that children are at high risk for the undertreatment of pain – and that better policies should be created and implemented across Canada.
Researchers believe they are the first to study pain management for children in general emergency departments – where the vast majority of kids are treated – as opposed to only pediatric hospitals. Ali does mention a study of one Canadian pediatric emergency department where pain was documented 60 per cent of the time and analgesia was provided for only 27 per cent of children. She recommends efforts such as staff education and access to current pediatric policies and guidelines – all options the hospitals reported being interested in exploring – and refers to one group's initiative as a start: Translating Emergency Knowledge for Kids (TREKK).
But Ali asserts that her study is "not a critique of the care that is being provided by the emergency departments in Alberta, but a call to action that more can be done," in an e-mail interview.
In the meantime, she says, parents should trust their gut instincts.
"If you think your child is in pain due to illness or injury, advocate for them by asking for pain medications and using distraction (in the form of music, TV, iPad games, bubble blowing etc.)," she writes in an e-mail. "If they are having a painful procedure (e.g. intravenous insertion, blood draw, vaccination), ask your health care provider 'is there anything else that can be done to make my child more comfortable?'
"Parents have tremendous potential to influence the care that their child receives. Health care providers and researchers need to continue to empower parents with knowledge and openly permit them to advocate for their child."
Among the study's key findings:
The use of analgesia for children was particularly "suboptimal" when it came to preparing children for medical procedures even adults would find painful. While using topical anesthetics on the skin before procedures such as the insertion of an IV or a "lumbar puncture" (spinal tap) is widely recommended for children, the study has found they were used in only 70 per cent of IV insertions and 30 per cent of lumbar punctures.
The use of sugar water for children under six months of age – a method considered safe and effective during painful procedures and recommended by the American Academy of Pediatrics – was consistently used less than 5 per cent of the time for procedures such as lumbar puncture and urinary catheterization.
Pain management was better in cases such as broken legs and ear infections, but emergency departments appear reluctant to use opioids in all cases. "Patients with a mid-shaft femur fracture were reported to be treated with IV opioids only 65 per cent of the time," Ali writes. "Given the severe pain associated with this injury, one would expect almost universal use of opioids."
Less that one-third of respondents had a policy for mandatory pain documentation in triage.
Less than half of respondents said they had a policy when it comes to sedating kids, a procedure that carries with it risks such as airway obstruction.
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