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Delivering Transformative Action in Paediatric Pain: a Lancet Child & Adolescent Health Commission

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Delivering Transformative Action in Paediatric Pain: a Lancet Child & Adolescent Health Commission The Lancet Child & Adolescent Health Commission Delivering transformative action in paediatric pain: a Lancet Child & Adolescent Health Commission Christopher Eccleston, Emma Fisher, Richard F Howard, Rebeccah Slater, Paula Forgeron, Tonya M Palermo, Kathryn A Birnie, Brian J Anderson, Christine T Chambers, Geert Crombez, Gustaf Ljungman, Isabel Jordan, Zachary Jordan, Caitriona Roberts, Neil Schechter, Christine B Sieberg, Dick Tibboel, Suellen M Walker, Dominic Wilkinson, Chantal Wood Executive summary discovery in these areas. Greater investment is also needed Lancet Child Adolesc Health 2020 Every infant, child, and adolescent will experience pain at in larger international birth cohort studies that incorporate Published Online times throughout their life. Childhood pain ranges from comprehensive pain-related measurements. October 13, 2020 acute to chronic, and includes procedural, disease- Third, make pain visible. Pain can and should be https://doi.org/10.1016/ S2352-4642(20)30277-7 related, breakthrough, and other types of pain. Despite assessed in every child. Methods for pain assessment See Online/Comment its ubiquity, pain is a major challenge for individuals, throughout childhood and in all clinical scenarios need https://doi.org/10.1016/ families, health-care professionals, and societies. As a to be optimised. Although subjective pain report is the S2352-4642(20)30318-7, private mental experience, pain is often hidden and can primary and desirable method when this is possible, https://doi.org/10.1016/ go undiscussed or ignored. Undertreated, unrecognised, many of the methods and measures that are in common S2352-4642(20)30317-5, and https://doi.org/10.1016/ or poorly managed pain in childhood leads to important use can and should be improved. There have been S2352-4642(20)30336-9 and long-lasting negative con sequences that continue developments in our understanding of the biological Centre for Pain Research, into adulthood, including continued chronic pain, correlates of pain, and in broader patient-reported University of Bath, Bath, UK disability, and distress. This undertreatment of pain outcome variables that can provide a more holistic (Prof C Eccleston PhD, should not continue, as there are available tools, understanding of patients’ pain status. Finally, a greater E Fisher PhD); Cochrane Pain, Palliative, and Supportive Care expertise, and evidence to provide better treatment for focus should be placed on assessing outcomes that are Review Groups, Churchill childhood pain. important to patients, rather than those that are central Hospital, Oxford, UK In this Commission, we present four transformative to researchers and clinicians. (Prof C Eccleston, E Fisher); goals that will improve the lives of children and Fourth, make pain better. This goal can be achieved by Department of Paediatrics (Prof R Slater PhD), Wellcome adolescents with pain and their families. These goals, advancing our knowledge of multiple treatment options Centre for Integrative taken at face value, might seem simple and obvious. in all areas (eg, psychological, pharmacological, and Neuroimaging, Oxford Centre However, if the goals were easy to achieve, there would physical interventions). Few randomised controlled trials for Functional MRI of the Brain, be few, if any, young people reporting poorly managed of pain interventions in children have been done, and the Nuffield Department of Clinical Neurosciences (Prof R Slater), acute pain, pain after surgery or procedures, or ongoing pipeline for innovation and new treatments is running and Oxford Uehiro Centre for chronic pain. Pain is multifactorial, and influenced by dry. Novel drug discovery studies and trial design Practical Ethics, Faculty of biological, psychological, and social factors, making it (eg, using single-case designs when the randomised Philosophy complex and difficult to treat effectively. We take a controlled trial is not ethical or practical) could advance (Prof D Wilkinson DPhil), University of Oxford, Oxford, developmental perspective that encompasses children treatment options. There is innovation in new ways to UK; Department of Clinical- from birth to 24 years, and focus on how the provision of personalise individual treatments, but greater investment Experimental and Health paediatric pain treatment and services can be improved. in research and coordinated approaches at all levels are Psychology, Ghent University, First, make pain matter. Pain has not mattered enough, needed. Ghent, Belgium (Prof C Eccleston, as evidenced by common failings to provide adequate or These four goals are not sequential and must be G Crombez PhD); Department of appropriate pain relief in clinical practice, insufficient addressed simultaneously. It is time for change. Anaesthesia and Pain Medicine, training among health-care professionals, a lack of Paediatric pain should matter to everyone, and cross- Great Ormond Street Hospital sector collaboration is needed to make quick and effective for Children NHS Foundation investment in research and services, and inequity in Trust, London, UK access to pain management. Despite some good progress. By bringing the issues of paediatric pain into (R F Howard FFPMRCA, examples of knowledge translation, investment in a the open, we call for policy makers, funders, and health- Prof S M Walker PhD); Clinical strong social science research base for paediatric pain is care executives, researchers, and clinicians to engage Neurosciences, UCL Great Ormond Street Institute of needed to catapult us into a new era in which the social enthusiastically and to deliver both the easy and the Child Health, London, UK and cultural context of pain can be understood and difficult changes needed to improve the lives of children (R F Howard, Prof S M Walker); addressed. and adolescents with pain. School of Nursing, Faculty of Second, make pain understood. There has been excellent Health Sciences, University of Ottawa, ON, Canada progress in our mechanistic understanding of nociception Introduction (Prof P Forgeron PhD); and pain perception for both acute and chronic pain Pain is a feature of life that is present across all cultures Department of Anesthesiology states, but gaps in knowledge remain. Pain research needs and ages.1–3 It is often associated with acute injury or is a and Pain Medicine, University to include the whole biopsychosocial model, including its symptom of disease, but it can also be evoked by physical of Washington, Seattle, WA, USA (Prof T M Palermo PhD); subjective nature and the multiple inputs at different activities or social interactions: from play and sport Center for Child Health, stages of development that affect the pain experience. to body adornment and religious ritual. Regardless of Behavior and Development, Advances in developmental biology, genetics, psychology, its origin, pain is typically experienced as unpleasant, Seattle Children’s Research nosology, and classification will all help to speed up negative, and threatening. Although a primary function Institute, Seattle, WA, USA www.thelancet.com/child-adolescent Published online October 13, 2020 https://doi.org/10.1016/S2352-4642(20)30277-7 1 The Lancet Child & Adolescent Health Commission (Prof T M Palermo); Department (4) make pain better. These four goals are not sequential of Anesthesiology, Panel 1: Jill Lawson’s advocacy for pain management in and must be addressed simultaneously. Although our Perioperative and Pain infants goals look simple, delivering them is complex and needs Medicine, University of Calgary, AB, Canada It was a mother, Jill Lawson, who contributed to one of the multidisciplinary attention from policy makers, funders, (K A Birnie PhD); Department of most radical changes in pain research and pain treatment researchers, clinicians, and the public. Anaesthesiology, University of since Ronald Melzack and Patrick D Wall presented their In this Commission, we take a developmental Auckland, Auckland, New Zealand theory of CNS plasticity in 1965. In 1986, her son, perspective and consider children of all ages, from (Prof B J Anderson PhD); Jeffrey Lawson, was born prematurely and placed in the care of infants to late adolescents (up to age 24 years). We focus Department of Psychology and the Children’s Hospital National Medical Centre in on how middle-income and high-income countries can Neuroscience, and Department Washington, DC, USA. Jeffrey underwent extensive surgery improve their provision of pain treatment and services, of Pediatrics, Dalhousie University, Halifax, NS, Canada without adequate anaesthesia or analgesia because, as while recognising that the different challenges for (Prof C T Chambers); Centre for recently as 1985, the belief that infants did not have the low-income settings are beyond the scope here. The best Pediatric Pain Research, IWK capability to experience pain was common and prevalent pain management practices need to be adopted when Health Centre, Halifax, NS, 5,6 treating children who experience all types of pain—from Canada (Prof C T Chambers); among medical professionals. Although parents like Department of Women’s and Jill Lawson often assumed that their infants would be given routine immunisation to cancer pain management, to Children’s Health, Uppsala pain relief during surgeries, the medical community were the provision of complex residential multidisciplinary University, Uppsala, Sweden reluctant to provide analgesic and anaesthetic agents because rehabilitation for idiopathic disabling pain. Beyond the (Prof G Ljungman
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