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• Author's reply
  Catherine Crock
  Published on: 28 March 2003
• Pain control during painful procedures: not only pharmachological approaches
  Giovanna Russo
  Published on: 20 March 2003

• Published on: 28 March 2003

  Author's reply

  • Catherine Crock, Medical practitioner

  Dear Editor

  We appreciate the comments from Drs Russo et al.[1] Psychological and behavioral therapies are central to paediatrics and should be a part of any pain management program. Several professionals at our institution have a major focus in these areas.

  Our aim is for our families to be well informed and able to choose what is best for their child. An essential part of this is to accurately pre...

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  Dear Editor

  We appreciate the comments from Drs Russo et al.[1] Psychological and behavioral therapies are central to paediatrics and should be a part of any pain management program. Several professionals at our institution have a major focus in these areas.

  Our aim is for our families to be well informed and able to choose what is best for their child. An essential part of this is to accurately present the risks and benefits of alternative pain management strategies to the families. For example, the statement in the letter that "GA implies risks, costs and a great amount of stress at an emotional and physical level" is misleading. Inadequate pain control has long term sequelae that are well described in the literature but rarely discussed with parents. Sedation, with or without psychological or behavioral therapy, does not meet recognised safety guidelines in many centres and is less safe than brief inhalational GA. Many of our families say they are more stressed emotionally and physically if they are not offered a GA.

  Cost is often given as a concern with GA. In our centre, where many but not all children have GAs, there are cost savings using GA. Procedures under GA are four times more efficient, specimens are of better quality, procedures never need to be repeated, children are less resistant to other procedures done on future visits such as venesections, and the risk of litigation is less. Litigation may arise from staff or parents being injured while restraining sedated children or from families who were not warned in advance of the long term effects of pain and restraint.

  We are not aware of any study of psychological or behavioral therapy in children with cancer having painful procedures that showed benefits similar to those shown in our study. In addition to the benefits described in the paper, we have received comments from staff unconnected to the study who work in the oncology outpatient clinics. These staff have observed that clinic days are different now that we are routinely offering GA. One nurse commented that children are more relaxed and interact with each other more normally. They participate in play therapy much more. They have venesections with less distress. One clerk commented that it was now rare to see a child struggling as they went into the treatment room.

  Many of these children have 30 or more procedures. It is highly desirable that these children develop resilience and coping strategies to deal with these procedures and other sequelae of their cancer. However, some families do not wish to spend their days in hospital teaching a screaming child how to deal with their terror. Families need to be offered an informed choice. Ideally, this choice should include being able to have a rapid, safe, and painless GA for these procedures.

  Reference

  (1) Russo G, Favara-Scacco C, La Spina M. Pain control during painful procedures: not only pharmachological approaches [electronic response to C Crock et al.General anaesthesia or conscious sedation for painful procedures in childhood cancer: the family‘s perspective]. archdischild.com 2003http://adc.bmjjournals.com/cgi/eletters/archdischild;88/3/253#442

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  Conflict of Interest:
  None declared.

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• Published on: 20 March 2003

  Pain control during painful procedures: not only pharmachological approaches

  • Giovanna Russo, Associate Professor
  • Other Contributors:
    • Cinzia Favara-Scacco and Milena La Spina

  Dear Editor

  For our Paediatric Haematology Oncology Unit, the opportunity to offer the most appropriate support to children with cancer during painful procedures has always been a fundamental goal to achieve. Your article seems to stretch the value of general anaesthesia (GA) as the most adequate solution. But it is important to take into consideration that many paediatric Oncology Units do not include a surgery roo...

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  Dear Editor

  For our Paediatric Haematology Oncology Unit, the opportunity to offer the most appropriate support to children with cancer during painful procedures has always been a fundamental goal to achieve. Your article seems to stretch the value of general anaesthesia (GA) as the most adequate solution. But it is important to take into consideration that many paediatric Oncology Units do not include a surgery room; moreover, GA implies risks, costs and a great amount of stress at an emotional level as well as at a physical level to which we have to add those provoked by a long fast. Children with leukemia are particularly exposed, since painful procedures need to be repeated many times, as part of their treatment regimen.

  The support our Unit has been using since 1997 is a psychoemotional support through Art Therapy (AT) methods to which, in 1999, we added pharmacological sedation through oral midazolam. Different AT methods are applied in three different moments of the painful procedure. Before starting the procedure, the child is helped to increase his coping abilities; menwhile, the child is supported through distraction, relaxation or visual imagination, choosing the most appropriate technique for his/her personality traits; afterwards, the child is helped release uncomfortable emotions developed during the procedure.

  The combination of both approaches, pharmachological and behavioural, has a key role, since we have observed that medication without an adequate psychological support is insufficient to control child’s anxiety and to allow an adequate collaboration, especially in younger children (<8 years old). On the other hand, medication synergizes the effect of psychological support. We observed that combining both techniques achieves a significant increase in children’s compliance and, consequently, a decrease of parents’ anxiety.

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  Conflict of Interest:
  None declared.

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