Procedure-Related Cancer Pain in Children
Authors: E J Chambers, T L Chambers
Journal: Journal of the Royal Society of Medicine (2002)

Once upon a time, life was simple. Children undergoing unpleasant procedures were either managed by brute force (‘hold her down more firmly, Sister’) or treated beforehand with agents such as rectal Pentothal or oral chloral hydrate. Though the ‘pharmacological mallet’ and the ‘sedative’ made doctors feel they had done something to spare unnecessary distress, their use often itself required physical restraint. For some doctors, the issue was not important because of a forgivable but mistaken notion that children felt less pain than adults. Also, suitable drugs were either unavailable or untested on children for efficacy and safety (has much changed here?); paediatric anaesthesia/symptom relief services scarcely existed except at the largest children's hospitals, and pain-relief clinicians for adults were either too busy or too timid to apply their skills to children (we acknowledge the few honourable exceptions). Thankfully the position now is quite different and Christina Lossi's book tells you how.

Six lively and comprehensive chapters cover the nature of procedure-related pain, its assessment and its psychological management—the last occupying half the book. Ms Lossi, a lecturer in health psychology, tackles five and a medical colleague (Richard Hairn, like her from Cardiff) deals with the pharmacological approach. Both insist on the importance of a comprehensive and multidisciplinary approach: pain avoidance and relief should be seen not as a means to the end of performing a particular procedure but as a technique in itself—sometimes more complex and requiring more preparation than, say, the lumbar puncture which the child is to undergo. The emphasis is practical (particularly the psychological and behavioural management) but the authors manage to avoid a recipe-book approach. We agree with them that the use of Entonox has been insufficiently researched in children. The full reference lists include publications from 2001. We have few quibbles. In the 1970s ketamine made a huge difference to the quality of children's lives and it is a shame that the pioneering work of the late great Dr Leonard Arthur is not acknowledged; the pharmacological chapter might benefit from greater prescriptiveness; two prolix forewords seem generous for a shortish paperback.

The publishers say that this book should be read by all professionals who offer palliative care or oncology services for children and adolescents. We agree—adolescents in particular, who fit neither the child nor the adult mould. Professionals can have unrealistic expectations of adolescents at a time when they are most vulnerable; apparent hostility and animals grunts are easily misconstrued. How odd then that adolescents do not have an entry in the otherwise excellent index. The publishers also recommend the book to those caring for children with diabetes and those undergoing dialysis. This seems a bit strong: in both these groups there are special considerations, and we would argue for a more comprehensive book on symptom avoidance/relief in children—including the newborn and those with life-affecting symptoms which are unexplained. And what about adults? If and when either of us has to undergo a bone marrow trephine, we would prefer to be well prepared and unaware at the time; how likely is that in the hurley-burley of internal medicine? Perhaps adult medicine has a few things to learn about civilized care from paediatrics.

Procedure-related Cancer Pain in Children ought to be available on every ward that admits children and young people. Its culture should influence all who are responsible for relieving these patients' pain and distress—and the distress of their parents. If your manager thinks such services a luxury, press her to read it and then do as she would like her children or grandchildren done by.