A child’s perception Imagery helps control pain

Press, 7 September 1989, Page 9

A child’s perception Imagery helps control pain

The special problem at Patricia McGrath’s hospital was cancer, with treatments which produce pain sometimes administered for several days. “Children seemed to become allergic to drugs and sedatives used prior to treatment. They complained of a lot of pain, and showed lots of signs of apprehension, such as throwing up, and needing to be restrained,” she says. In these situations she has found hypnosis and relaxation techniques helpful. A child needing -a spinal tap, for example, has to curl up to make the backbone accessible. Three-year-olds, especially when they are fighting sedation, have to be held very tightly because it’s important not to move.

“They hated being held, hated sedation. So the practical thing we came up with was to teach them to relax in the foetal hold.” During a practice session, some children couldn’t do it without some help. “Pretend you’re a vegetable,” they were told. “Curl up like a big, fat watermelon.” “Children’s imaginative life provides an incredibly rich ground. With adults, we would have had to spend hours getting them to accept suggestions that sound hokey,” Dr McGrath says. “Children’s pain is very plastic. It can be modified by suggestion.” Guided imagery helps children to imagine something which is incompatible with pain, such as a pleasant scene, or to imagine an area of known-ness, such as pins and needles. “They breathe deeply and slowly and imagine they have control of a numb spot and guide that feeling to the spot where they are going to be injected,” she says.

Some children take a trip during a painful procedure, coming to the clinic having done some research about the place they will visit, so they can tell the therapist about it. If they start being distracted by the pain, the therapist can guide them, asking questions that focus on detail, such as “What colour was that?”

These techniques are considered complementary to sedation and analgesics.

“What interested me so much was how many children preferred to have nothing,” Dr McGrath says. “Children live in the present. They really hate to be out of control, to lose a day of their life. Whereas an adult will say, ‘Just put me out’.

She says studies show that between the ages of three and 17, nine out of 10 children do not want sedation. Parents may find this hard to accept, often

wanting the child to be sedated, while the child does not. In this case, she advises parents not to watch the procedure, but to allow the child to do as he or she wants. If it is not a success, this could lead the child to accept sedation another time. She also finds it important to teach children with cancer what to expect as normal. Scrapbooks have been made with pictures showing the different procedures, and pain ratings taken of different techniques. The procedures with the lowest paint ratings are chosen.

“Shut the pain gates” is a phrase the children like to use, she says. Again, parents often need help in finding the best way to deal with the situation.

“We tell parents to treat treatment days the same as normal days. If on treatment days, dad takes time off work, everyone comes to the hospital, and they won’t let the child play, the message they are giving the child is, this is bad,” she says. “I think childhood cancer is one of the worst things that can happen to a family. Parents have to try and channel their protectiveness and consider what behaviour will increase pain and what will reduce it.”

Giving children some control over the procedures also helps, she finds. They allow children on their pain programme to do their own finger pricks to get blood samples. “Choice might not be so important for adults, because we have choice about so much, but a child doesn’t. It may be the worst pain the child has ever had in it’s life,” she says. Predictability is also important. The clinic makes sure information about every part of the procedure is available in age-appropriate language. Many children want to see what is happening, so treatment rooms have plenty of mirrors.

The clinic’s work in cancer has now been extended to children with different diseases, such as arthritis and diabetes, or recurrent headaches or recurrent abdominal pain, or pain after surgery.

The inevitable pain after surgery has caused the clinic to pay attention to drug delivery systems. In place of four-to-six-hourly shots of intra-muscular agents, they prefer continuous infusion techniques. "Often ward staff are less happy because this requires more monitoring and surveillance, but it may be less painful for the child,” she says.