Why We Should Care More About Children's Pain

Pediatrician offices need to do better.

Hi everyone! Today’s newsletter is Part One of a two-part series on managing children’s pain and fear at doctor’s visits. Today’s essay is free, but Part Two — which will be published next week and provide evidence-based strategies for supporting kids who are afraid of the doctor or who fear specific procedures — will sit behind a paywall. Subscribe to the paid newsletter today so you don’t miss it!

Last month, when my 7-year-old had the Fever That Would Not End, I took her to the pediatrician. They gave her a strep test, a flu test, a Covid test, and the doctor suggested that perhaps we should do a blood draw, too. Until recently, my daughter was terrified of the pediatrician’s office — especially when needles were involved — but in December we spent time a lot of time working through her phobia so she could get the Covid vaccine. I was proud of her, and when the doctor suggested the blood draw last month, she seemed nonplussed. She was ready. I was so proud of her.

The blood draw was a nightmare. When the needle went in, she flinched, and blood splattered everywhere, horrifying her. The nurses had to start over with her other arm, and before doing so, they instructed me to hold her in a tight bear hug and “not let her arm move,” which meant that she couldn’t relax (would you be able to relax if you were being tightly restrained?). Her arm was clenched so hard that the draw went very slowly, and I could tell she was in excruciating pain. For several days her arms were badly bruised and she was, once again, terrified of the doctor.

My daughter’s arms a few days after her blood draw.

This is not an isolated anecdote. Children regularly endure painful medical procedures without being offered options or strategies for pain management, and this isn’t just an inconvenience. It’s a travesty. We know, from published research, that most adults who are afraid of needles developed that fear because of painful experiences they had with needles as children — often, experiences that happened before the age of 5. We also know that some adults who avoid medical care do so because of needle fears. Put two and two together, and you can conclude that children’s bad experiences at the pediatrician’s office can shape their relationship with the medical system, and their overall health, for the rest of their lives.

You might think I’m making a big deal out of nothing. For some people — myself included — blood draws and other needle procedures don’t hurt that much. That’s in part because I’ve had a lot of them, I know what to expect, and I know how to relax and distract myself. But a terrified child who doesn’t have much experience with needles, who is clenching her arm as tightly as possible, is undoubtedly having a different experience. This is a big deal to them. Making matters worse, doctors and nurses rarely communicate with kids in ways that help to prepare them for procedures, even though doing so is an important aspect of patient-centered care.

Doctors have been sounding this alarm for a while. Here is the American Academy of Pediatrics’ guideline on managing acute pediatric pain, which was written in 2001:

An important responsibility of physicians who care for children is eliminating or assuaging pain and suffering when possible. It has been well documented, however, that in this regard a substantial percentage of children have been undertreated. The most common type of pain experienced by children is acute pain resulting from injury, illness, or, in many cases, necessary medical procedures. There is extensive literature that describes how to evaluate and treat acute pain in children using low-cost, widely available, convenient, and safe methods; this information, however, has not been readily applied.

Yet despite the frustration evident in the paragraph above, little appears to have been done in the U.S. since 2001 to address the problem. (Canada is a different story. There’s been tons of research, as well as multiple guidelines and evidence-based strategies, put forth by Canadian physicians and researchers in recent years on how to better manage pediatric pain.)

Why is so little being done? Meghan McMurtry, a clinical child and adolescent psychologist who runs the Pediatric Pain, Health, and Communication Lab at the University of Guelph in Canada, told me there are a handful of possible reasons. One is that doctors — and adults in general — underestimate pain and its importance. “A lot of people think of these procedures as ‘just a little poke.’ It's no big deal. But that really misrepresents the nature of pain,” McMurtry said. Pain is “influenced by biological, psychological and social factors. It does not one-to-one correspond with the amount of tissue damage.”

Sometimes, too, doctors and nurses may downplay the pain their patients experience to maintain their own peace of mind. If you were sticking needles in kids all day, wouldn’t you tell yourself it isn’t a big deal, and that the kids are totally fine? “It can be adaptive for them to not really focus on the pain,” McMurtry said.

Another problem is that physicians aren’t taught much about pain management in medical school or residency. In 2009, researchers reported that medical students receive far less training on pain management than — get this — veterinary students do. Whereas veterinary students in their analysis received, on average, 87 hours of instruction relating to pain and pain management during their training, medical students received an average of 16 hours. (And this was in Canada, where things are better — so how much larger is the discrepancy in the U.S.?)

Here’s an excerpt about the lack of education on pain management from a paper in the American Medical Association’s Journal of Ethics:

Until recently only 3 percent of medical schools in the United States had any part of their curricula specifically dedicated to pain education. In a 2009-2010 survey of 117 medical schools in the U.S. and Canada, the situation appeared much better: 80 percent of U.S. medical schools and 92 percent of Canadian medical schools required at least one pain session in their curricula. The actual content, style, and format of the education, however, were found to be “limited, variable, and often fragmentary.”

Another reason pediatricians may not focus much on pain mitigation: Time constraints. One established pain-relieving method involves putting lidocaine cream on the skin before a needle stick, but the cream can take 30 minutes to work, and doctors can’t have patients taking up waiting rooms for that long. Communicating with kids about what to expect, and how best to relax, can take time, too.

Also, pediatricians may not have strong incentives to make these changes. After all, pediatrician’s visits are generally not optional — you have to get a yearly check-up every year to attend school and camp, and provider choice can be constrained by location or insurance coverage. In other words, pediatrician’s offices probably aren’t losing tons of clients because they don’t manage pain well. Pediatric dentistry is, however, a different story. Whether or not they should be, dentist visits are often considered more optional — especially for kids — so to attract families, pediatric dentists have made a lot of changes in recent decades to better manage children’s pain and fear. While our pediatrician’s office has nothing to offer kids except the overwhelming smell of disinfectant, our pediatric dentist has arcade games for kids to play in the waiting area; individual TV screens above each dentistry chair; laughing gas offered before Novacain; and toys given as rewards after each cleaning or procedure.

Put another way, if dentists do a terrible job, parents will stop taking their kids to the dentist — or find a new one. “Parents will likely pick dental practices that pay attention to making the experience a positive one,” Playforth said. Since the choice of pediatrician “is more often dictated by other factors (such as insurance coverage), there may be less of an emphasis placed on how the experience is remembered.”

I don’t mean to paint all pediatricians negatively here (and neither does Playforth!). There are many exceptions — some pediatricians and pediatric nurses do a wonderful job of managing kids’ pain and fear. But researchers agree that, collectively, we have a long way to go before it becomes commonplace.

In the meantime, what can we do to help our kids? In Part Two, for paid subscribers, I will share evidence-based strategies for advocating for your kid, preparing them for procedures, and minimizing fear and pain. These responsibilities shouldn’t fall on parents, but they do — so I’m going to give you the information you need.

I am a guest on two podcasts that aired last week! On the Pandemic Parenting podcast, I talked about how parents can use research to inform their parenting. I was also on A Little Less of A Hot Mess, talking about my book and about my Atlantic article on the challenges of parenting during the pandemic.