What is Pain?

We all know "pain" is a hurt that we feel, however, only recently have we begun to understand how pain works.

Most parts of our body, both inside and out, have "pain receptors".When these are activated by pressure or damage to body tissue, a pain message is started. The message passes along our nerves to the spinal cord (in the backbone), and then to the brain. Our brain "reads" the pain message, and we feel pain.

The pain system is very complex, with "switches" or "pain regulating centres" found where the pain starts, in the spinal cord, and at several places in the brain. These switches can affect how much of the pain message the brain actually reads.

Pain is also a very personal thing. Each person is different. For example, the same physical damage can cause very different amounts of pain in different people. As well, the same procedure can cause a different amount of pain each time it is done.

WHAT MAKES PAIN WORSE?

We know that some things make pain worse. Controlling any or all of these can help a child have better pain control.

Anxiety, depression, and fear: No matter how they are caused, negative emotions can make pain worse. If a child has had a bad experience with poorly managed pain, he or she will fear a procedure more and have more pain. Similarly, if a child believes pain is a "bad sign", or that a procedure or treatment is not going to work, pain will be more severe. Fear and anxiety spread easily, and children whose parents, brothers, or sisters show these emotions are likely to have worse pain.

Lack of control: Children who think they have no control are likely to feel more pain. For example, kids who say "I feel like a pin cushion that everyone just sticks" suffer more than children who have been given some choices and control.

Exhaustion: A child who is exhausted by other symptoms, such as nausea, fatigue, or shortness of breath, will have worse pain.

Unfair expectations: If parents or medical staff encourage extreme levels of bravery (such as never crying), or encourage a lot of complaining, children are likely to have a more difficult time.

Surroundings: Dull or inappropriate surroundings, such as a room with no toys, or baby toys for a 10 year old, will make pain stronger. In the same way, pain is often worse at night when little is going on.

HOW CAN PAIN BE MEASURED?

It is important to have a consistent way of measuring pain. That way, we can tell when pain is getting b etter or worse.

The best way to measure pain is to ask children how much pain they feel. Three ways to help children describe their pain are listed below. With children less than 4 years old, it is harder for them to tell us how much pain they are having. In these cases, we need to watch for changes in their behaviour.

Pieces of hurt: A child is givenfive poker chips or small stones and asked how many "pieces of hurt" they feel. It is explained to the child that one piece m eans a little hurt, two pieces mean more hurt and allfive pieces mean the most hurt. This method is useful with children over 4 or 5 years of age.

FACES scales: The FACES scale shown below can be used with children over 5 years old. The child is asked to point to the face that best matches how much pain or hurt he or she is having. If you use this scale, it is helpful to enlarge the faces to about 6 cm (2 1/2 inches) high.

[Pain 1990; 41:139 -50 - reproduced with permission from the authors and Elsevier]

0 - 10 scale: A simple way to measure pain is to ask an older child (8 years and above) to rate their pain from 0 to 10. Zero is "no pain" and 10 is pain "as bad as it can possibly be".

Behavioural measures: Changes in how children act may be a clue that they are in pain. Behaviours that suggest pain include crying, fussing or being irritable, avoiding people, sleeping poorly, having a "pain" face, holding or protecting a body area, not being easily comforted, not eating well, not playing, and not being able to pay attention.

Behavioural changes do not always mean a child is in pain. Sometimes, the behaviour means something else, such as hunger, cold, or fever. On the other hand, a child in serious pain may show little response and just be very withdrawn and quiet.

Children differ in the way pain affects their behaviour. Because of this, parents are often able to see changes that mean pain mo re readily than a doctor or nurse. Although behavioural change is not a perfect way to tell if there is pain, for young children it may be the only way we have.

CULTURAL ISSUES

Culture is made up of the traditions and values of a society. Different families have different cultures because of their own heritage and this is important in pain for many reasons. For example, some cultures promo te "being strong" while other cultures promote "expressing oneself". These may result in different responses from children.