Publications
APS Bulletin • Volume 14, Number 4, Summer 2004
Resource Reviews
John D. Loeser, MD, Department Editor
Pain in Infants, Children and Adolescents
N.L. Schecter, C.B. Berde, and M.Yaster. Lippincott, Williams and Wilkins, Philadelphia, 2002. 892 pages, hardcover. ISBN 0-7817-2644-1. $149.
Once again, Drs. Schechter, Berde, and Yaster have treated us with a superb tome that belongs in the library of anyone who cares for a child in pain. What Dr. John Bonica’s book The Management of Pain did for the understanding and treatment of adult pain, this book does for the pediatric pain world. Like the first edition, the second edition is a comprehensive review of the state of the art of pediatric pain and symptom management. It is a multi-authored book with international representation but a decidedly North American flavor. The second edition contains almost 300 more pages than its 1993 predecessor. This book covers almost every important aspect of pediatric pain and symptom management. Missing is a detailed discussion of the economic impact of childhood pain, how to set up a pain service, and the logistics of making a pain service work in an adverse economic and political environment.
The book is divided into three major sections. Specific subsection headings, like Pharmacological Interventions and Psychological Interventions, have been removed throughout the book. Part one examines the theoretical aspects of pediatric pain and gives an overview of pain and symptom management in a variety of age groups. The developmental anatomy, physiology, and psychology of the pediatric patient are extensively reviewed. Although this part remains 10 chapters in length, the excellent Chapter 4, “Long-Term Consequences of Pain in Neonates,” is a welcome new addition. Chapters on pain assessment and the psychological development of pain responses in infants and toddlers are combined. A weak point in this part is Chapter 3, which appears to be more reflective of the promotion of a specific laboratory model as a surrogate for neonatal pain rather than an extensive review. It also does not maintain the high quality writing found throughout this part. I understand that it can be difficult to make clinical pharmacology exciting, and although the concept of contact sensitivity is raised in this chapter, it is covered very superficially. This is such an important concept it deserves expanded treatment since it has links to the development of tolerance and weaning.
Chapter 6, “Modifying Psychological Factors,” is very comprehensive, well referenced, and well written and should be mandatory reading for all trainees and staff involved with the care of children. Of note are the excellent, practical suggestions for helping children cope with pain. The next chapter presents a critical analysis of current pain measures in infants and toddlers. Although it is well organized and thorough, it leaves me wondering what is the best tool for measuring pain in infants? Since hormonal measurements are influenced by a number of non-pain factors, and “neonatal facial coding” requires expensive equipment and trained personnel, I am not sure how practical a tool it is. Chapter 9 discusses the effect of culture (both the patient’s and provider’s) on pain perception, tolerance, and treatment. This chapter begs the question as to what influence globalization will have on pain? Through the rapidly progressing advances in telecommunication and computer technology, we have seen many interesting changes in language, dress, and dance. Examples include Parisian teenagers break dancing and Michael Jordan T-shirts being worn in the far corners of the globe. Will the impact of these changes lead to homogenization of behavior and perception? Historians and anthropologists need to be implored to document and study how these technological and social pressures influence pain.
Part II, “Therapeutic Interventions,” deals with the pharmacologic, psychological, and physical interventions used in pediatric pain control. On the whole, this part is well engineered, and the writing is very even and enjoyable. Chapter 11 discusses nonsteroidal anti-inflammatory drugs (NSAIDs). The authors explore many of the important aspects of NSAID usage in children. It would have been interesting to know what the authors’ practice was for the use of regional anesthesiology in children receiving Ketorolac. They cite a study in which “extra measures were required to obtain homeostasis” after 1 mg/kg of Ketorolac was administered to children under going tonsillectomy. In light of this, should one avoid central regional anesthesia blockage if a child is receiving or will receive this Ketorolac? Table 11.1 lacks units for the terminal elimination half-lives. It is presumed that the units are in hours. Chapter 12 has an excellent discussion of opioid agonists and antagonists. Ketamine, an old agent gaining a new following, and Tramadol, a newer agent that is seeing increasing usage, are skillfully and fully discussed. In the discussion of naloxone, the authors fail to mention pulmonary edema as one of the associated “opioid reversal effects,” and also the administration of naloxone through the endotracheal tube.
Chapter 13 contains a very nice discussion of drug metabolism, and the cytochrome P450 system and its isomers, that may have may have fit better in the pharmacology chapter of Part I. Also, given at least one published report of clonidine associated respiratory depression, some might take issue with the Chapter 13 authors’ statement that clonidine lacks respiratory depressant effects.
An excellent presentation of posttraumatic stress syndrome in pediatrics can be found in Chapter 15. The chapter on somatoform disorders is very useful. These patients represent a small but labor-intensive subset of pediatric pain patients. Chapter 19, “Neurosurgical Procedures for the Treatment of Pediatric Pain,” leads off with a very enthusiastic discussion, but seems to contradict itself when the authors overtly state or allude to a lack of permanent pain relief or long-lived functional disabilities for almost all of the neurosurgical procedures they discuss. Chapter 20, page 354, has a somewhat confusing section on neuraxial opioid side effects. The authors state, “Conversely, the hydrophilic agents are more potent analgesics than the hydrophobic opioids because of better binding of these opioids to the receptors in the spinal cord adjacent to the area in which the drug is administered.” This is incorrect. The hydrophobic (lipophilic) agents bind better to the area adjacent to administration and produce a more segmental analgesia.
A good discussion of the controversies of the use of central regional anesthesia blocks as compared to peripheral anesthesia blocks is presented in Chapter 21. He lays out a discussion of the overarching principles that should guide regional anesthesiology practice. He makes a cogent case for limiting the use of central blocks. The remaining chapters in Part II are all very good. The addition of the chapter on complementary and alternative medicine is timely. With the increased utilization of these types of therapies by patients and their families, it behooves practitioners to be familiar with the techniques. The deletion of separate chapters on TENS and PCA and inclusion of these techniques into broader chapters reflect the experience and familiarity gained with these techniques since the publication of the last edition of this book. The techniques discussed in the procedural pain chapter in the first edition were covered in specific chapters such as the cancer pain management and burn pain management chapters.
Part III of the book follows the form of the previous edition including important information for the management of pain in specific settings such as sickle cell pain, neuropathic pain, and pain in critically ill children. The chapter on pain in children with developmental disabilities is new and excellent. This growing population of patients has only recently begun to be recognized as a very undertreated population. They are very much like the neonatal population prior to the 1990s with regards to inadequate pain assessment tools. The content of the last chapter deserves to be in Part I. It sheds new light on behaviors associated with pain and helps to form a framework from which to view, evaluate, and treat chronic pain. The authors take a more holistic approach and help the treating physician to be less procedurally oriented.
The book does suffer occasionally from some of the vagaries inherent to a multi-authored text. There is some redundancy, like the repeat descriptions of the concept of central sensitization. Several dosing discrepancies surface throughout the book, such as the dosing recommendations for codeine found in Table 35.6 and in the Appendix/Formulary. The Appendix recommends a q 3–4 hour schedule, whereas Table 35.6 recommends a q 6-hour administration. Fentanyl dosing in Chapter 35 is twice that recommended in the Appendix/Formulary. Occasionally problems like the lack acronym definitions arise. An example can be found on page 20, where the author uses the term “GDNF.” I presume that this means glial-derived neurotrophic factor, a term that is not in most readers vocabulary. Another example can be fund on page 36, where the expression “EM” appears. This usually means electron microscopy but may not in this case given the context of the sentence. Use of older terminology such as “Sudeck’s Atrophy” in Chapter 19 instead of the newer term “complex regional pain syndrome” used throughout the rest of the book sometimes occurs. Several misspelled words and photographs that are too dark are occasionally present. The edition of more forms and protocols used by those authoring the book would save the uninitiated from reinventing the wheel.
This excellent, extremely comprehensive textbook should be required reading for all who care for children. It is currently the seminal work on pediatric pain management.
Dr. Anderson is Professor of Anesthesiology at the University of Washington and Director of Pain Management at Childrens Hospital and Regional Medical Center, Seattle.Reviewer content represents the opinion of the reviewer, not APS.
Reviewer content represents the opinion of the reviewer, not APS.
Please direct your suggestions for future Resource Reviews to John D. Loeser, MD, Department Editor, at jdloeser@u.washington.edu