• Open Access

A Child in Pain: What Health Professionals Can Do to Help

By Leora Kuttner, PhD , Published by Crown House Publishing , UK 2010 , paperback , 420 pages , ISBN: 9781845904364 ; RRP $103.95

Reviewed by David Champion

Department of Anaesthesia and Pain Medicine, Sydney Children's Hospital, New South Wales

It was a pleasure to review this book. Not only is it generally informative about children, the recognition and assessment of their pain, how to communicate and manage it, but it was also affirming of the value of working in paediatric pain medicine. I was continually reminded of memories of the warm and entrancing qualities of the author, these memories going back to my first real exposure to psychological management of pain in children more than 20 years ago.

Dr Kuttner is a paediatric clinical psychologist specialising in children's pain management. She is a clinical professor in the Pediatric Department of the University of British Columbia and BC Children's Hospital, Vancouver. She has been an outstanding leader and exemplar in the field of children's pain management now for many years and thus her knowledge and experience extends well beyond clinical psychology and qualifies her to write a book on this broad multidisciplinary topic. Her book A Child in Pain, How to Help, What to Do, last reprinted in 2006, has been an immensely useful guide to parents of children in pain contexts. This new publication, directed at health professionals, is also potentially very useful for educated parents and probably some older adolescents, and would enable critical evaluation of the communication and management skills of the health professionals in situations involving pain.

The book is in three parts. The first concerns understanding, assessing and communicating with a child in pain. The second reviews treatments, psychological, physical and pharmacological. The third addresses pain and anxiety management in paediatric practice (doctor's office, dental practice and hospital). It is not a medical textbook in the sense of covering disease-related pathology, medical aspects of pain syndromes and their specific procedural and other interventions. There is some cover of particular categories of pain disorder, including migraine, headaches and recurrent abdominal pain, but generally the book covers principles and practical details of assessing, communicating with and managing children with acute, procedural, recurrent and chronic pain disorders.

A comprehensive assessment of pain requires consideration of pathology with nociceptive inputs from inflammatory or traumatic disease processes, injured or disordered nerve fibres, appraisal of the neurobiology of the nociceptive transmission in the central nervous system, and consideration of the psychosocial influences. Appropriately, she has not attempted to address to any degree aspects of somatic pathology or develop any detail on peripheral neuropathic pain disorders. The general health professional reader is less well informed about the neurobiology of pain in the central nervous system and about the pain matrix. The latter is a large distributed brain network accessed during nociceptive processing interrelating with cognitive and emotional circuitry, the descending pain modulation system and motivation and motor connection. Dr Kuttner has provided the general reader with an evidence-based overview of these neurobiological processes. Those more specialised paediatric practitioners might feel the benefit for more up-to-date referencing derived from the numerous current neuroimaging and other neurobiological studies; however there are already 20 pages of references.

The great strength of this book is the wise guidance on assessing and communicating with children and on the psychosocial management. Even when discussing pharmacotherapy there is practical advice regarding the administration of medications from the perspective of the child, such as how to take tablets. Other strengths of the book include illustrative anecdotes about children, how to explain pain to a child, and useful conceptual illustrations and diagrams. The book leaves this reader at least with a strong sense of “I can do better”.

There are some minor negative points that overall do not detract much from the overwhelming merit of the book. From the Australian perspective there is a certain amount of North American language, such as ‘owie’ and ‘boo-boo’ for young children's pain language, and North American terminology for a number of the medications. There has been an important emerging paradigm shift in the understanding of functional pain disorders which are very prevalent and important in childhood, a concept of their common genetic, neurobiological and psychological influences and their co-morbid interrelationships. That might have been mentioned in the section on migraine headache and functional abdominal pain. The myofascial paradigm is more critically appraised in Australia than in North America, and the hypothetical nature of some of the concepts might reasonably have been acknowledged. The features of allodynia and hyperalgesia, which are very common in somatic pain syndromes and puzzling to patients and to health care professionals, were discussed only briefly and mainly related to neuropathic pain. There was some inconsistency regarding empathy, which was stated to be desirable for health care professionals and elsewhere for dentists, but stated to increase the child's pain reports, under the sub-heading, ‘Don't use Reassurance and Sympathy’. The puzzle of the counter-intuitive adverse influences of reassurance could have been further developed, although much of the new research has been published subsequent to completion of the manuscript.

Ideally, this book should be read by all health care professionals working with children and adolescents who are in pain or at risk of procedural pain. This book has a unique place because of the wealth of information, wisdom and guidance on psychosocial aspects of acute and chronic pain. It is hoped that the book will be widely available and promoted in public health.