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  1. Rivard, Patrick


Abstract: Children have historically been undertreated for pain. Children with chronic disabilities may face multiple, complex surgeries that cause severe postoperative pain. In addition, underlying problems with increased muscle tone can cause painful postoperative spasms. Gillette Children's Specialty Healthcare treats children with chronic disabilities. Our orthopaedic surgeons have developed a single surgical approach referred to as "multiple lower extremity procedures" (MLEPs) to correct the patient's primary, underlying orthopaedic deformities all under one anesthesia. Because of the intensity of postoperative pain caused by this approach, Gillette Children's uses epidural analgesia or patient-controlled/nurse-controlled analgesia to manage postoperative pain.


Gillette Children's pain control practices involve preoperative planning, postoperative pain assessment and documentation every 2 hours, interventions to control pain guided by the patient's response (including pharmacologic and nonpharmacologic approaches), and patient/family education about how to manage pain at home.


Historically, children across the country have been undertreated for pain (Macfadyen et al., 1999). Myths, such as the long-held belief that children experience less pain than adults, have contributed to this undertreatment. There is also a persistent fear of cardiorespiratory complications that may be associated with pain relief medications (Deshpaude & Tobias, 1996). However, our experience has shown that well-managed analgesia dramatically reduces this concern.


The nature of a child's illness, injury, or condition is a key factor to consider when developing a pain management plan. Typically, there is a differentiation between pain management for children with acute conditions and those who are being treated for conditions related to chronic disability. Children in an acute-care hospital are usually treated for urgent or serious illnesses and injuries on a short-term basis. Either intramuscular or intravenous administration of pain medication is historically the method of choice in such cases and can be highly effective. IM injections, however, while still widely used, are extremely painful and frightening to children (Maikla, 1998).


Pain management for patients who have a chronic disability often requires a more aggressive and closely monitored approach. While it is true that patients with disabilities may have relatively short hospital stays following surgery, the chronic nature of their conditions must be considered when developing a pain management plan.


For example, more than 40 percent of all children who have surgery at Gillette Children's Specialty Healthcare in St. Paul, Minnesota, have a primary diagnosis of cerebral palsy. Many of them face a series of major surgeries to correct secondary conditions (such as muscle contractures and bony deformities) throughout the period of their growth and development. In addition to the sheer number of surgeries that such children face, the procedures themselves are typically complex, increasing the patient's need for closely managed pain control.


Many children with cerebral palsy undergo multiple lower extremity procedures (MLEPs)-sometimes as many as a dozen - under the same anesthesia. Spinal surgery to correct severe scoliosis may involve the removal of vertebral elements, repositioning of the spine, and/or placement of bone and instrumentation for stability and fusion.


Often, these multistage procedures require the surgeon to enter the child's body from more than one side. Other surgical interventions, such as selective dorsal rhizotomy (SDR) to reduce spasticity, involve complex neurologic procedures that leave nerve endings acutely sensitive to pain.


Underlying difficulties with muscle tone that complicate postsurgical recovery are found in many children with disabilities. In patients with muscle spasticity, the correction of muscle contractures, disturbance of muscle during a procedure, or neurologic intervention can temporarily increase the level of muscle spasms. Our experience has shown that postsurgical spasms can cause excruciating pain for the patient.


A child's cognitive and functional abilities are further factors that must be taken into consideration when managing pain for children with disabilities. Many children with physical disabilities are cognitively impaired and may not understand what is happening to them or why. Separation from their everyday environment and routine may cause them anxiety or fear. It is well recognized that emotions play into a person's perception of pain, which can be exacerbated by fear and anxiety (Price, 1999). In addition, past experience with painful procedures, especially with acute pain that was not well managed, can directly impact the effectiveness of pain control (MacGrath, 1989).