Pain in Children: A Practical Guide for Primary Care

Pain in Children: A Practical Guide for Primary Care will prove a useful and practical addition to the armamentarium of any primary care or hospital-based clinician caring for children and their families. The book is a comprehensive and practical guide to the diagnosis and management of acute and chronic pain conditions in children.

The book, organized into 5 major sections, makes the topic of pediatric pain accessible and understandable. The authors begin by presenting a general overview of pediatric pain, followed by an excellent review of acute, recurrent, and chronic pediatric pain conditions. Of utmost value is the focus on family-centered care and the detailed approach to diagnosing and treating 5 of the most common chronic or recurring pain conditions affecting children. Each chapter is well organized and ends with useful summaries of take-home points. The authors of the initial chapters provide a comprehensive review of the literature supporting the premise that failure to adequately treat pain in children has both immediate and long-term adverse consequences. The authors emphasize the ethical obligation practitioners have to manage pediatric pain. According to Walco et al, “All health professionals should provide care that reflects the technological growth of the field. The assessment and treatment of pain in children are important parts of pediatric practice, and failure to provide adequate control of pain amounts to substandard and unethical medical practice.”¹

In addressing the ontogeny of the pediatric pain experience, the book addresses and puts to rest the misapprehension that infants and children do not experience pain. Citing numerous data, the authors successfully establish the presence of pain response as early as 23 weeks' gestation. Subsequently, they highlight the principal variables including genetics, temperament, age, and previous pain experiences that affect and color an individual's response to pain. In covering the topic of pain management, the authors provide the practitioner with developmentally appropriate tools for assessing pain in children. The reader is provided with an outstanding overview of how to identify and modify environmental factors that have the potential to affect a child's experience of pain. This is followed by a comprehensive and practical guide to the use of topical and local anesthetics and potential uses for these medications in routine procedures such as immunization, venipunture, and urinary catheterization. The authors do not cover the important topic of pain control during circumcision and lumbar puncture—two of the most frequently performed pediatric procedures for which pain control is paramount and has historically been inadequate.

The books' review of opiate and nonopiate oral pain medications is exceptional. With regard to the use of nonsteroidal anti-inflammatory drugs (NSAIDs), a brief description of the potential effect of NSAIDs on bone healing and the importance of discussing use of these medications with the orthopedic surgeon comanaging fractures would have been beneficial. With regard to adverse effects of opiate analgesics, the authors recommend avoidance of a drug that has previously caused nausea and vomiting. While this is sage advice, a more comprehensive and potentially useful statement would be for clinicians to understand that they must anticipate nausea and vomiting—which often undermine the best of pain regimens—in their patients, and provide parents with instructions and medications to deal with this problem.

A great strength of this book is the inclusive coverage of the management of recurrent and chronic pain, with emphasis on factors that contribute to recurrent and chronic pain. They highlight the importance of a biophysical or biopsychosocial approach that attends to the body, the mind, the environment, and the family. A highlight of the book is a figure titled “Somatically-Fixated Physician-Patient Interaction.” This figure is an excellent and insightful schematic of the counterproductive and frustrating cycle that often ensues in the diagnosis and management of chronic and recurrent pain. After reviewing approaches to recurrent and chronic pain, the authors apply principal and practical approaches to 5 common chronic pediatric conditions. Appropriate emphasis is placed on assessing the functional impact of the pain syndrome by addressing limitations in physical, social, and emotional functioning. Although the section on musculoskeletal pain is exceptional, a more detailed review and approach to fibromyalgia would have enhanced its value. The book includes a necessary and useful chapter dedicated to complementary and alternative approaches for chronic pain. Specific evidence-based examples of how a practitioner might apply the principles of such approaches in each of the 5 most common pain conditions in children would have been helpful.

Although barriers to providing high-quality pain management are addressed throughout, a chapter summarizing the complex interactions of patient, practitioner, and parent when combined with societal stigma would have been useful. The authors of the “How to Talk to Parents About Recurrent and Chronic Pain” chapter might have placed more emphasis on the importance of exploring and validating patient and parent biases, perceptions, fears, judgments, and expectations.

Pain in Children does an excellent job of highlighting the enormous effect pain can have on the child and the family. It emphasizes the pivotal role pediatricians and other primary care clinicians play in identifying, diagnosing, and managing pediatric pain. The authors deliver a clear message that pediatric clinicians have a unique opportunity and a profound responsibility to create a safe and accessible pain experience for children. When successful in this endeavor, clinicians have the potential to favorably affect a lifetime of pain experiences. The book empowers pediatric clinicians to skillfully address and manage pediatric pain.