A CHILD'S PAIN

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Morning rounds on the surgical wards with Berde's team are a pleasant surprise to visitors. No one is crying or moaning. Children who had major operations only a day or two earlier seem comfortable. Some are provided with pumps they can activate as needed to inject pain killers through intravenous lines. Others have epidural catheters inserted in their backs, delivering medication into the space around the spinal cord to numb the lower part of the body. Such treatment provides steady control of pain, Berde says, and eliminates the need for the repeated shots most children dread.

The pain-treatment service came about because Berde and colleague Navil Sethna, faced with patients who had seemingly intractable problems, devised novel solutions, and because other doctors began to seek them out. One of their first cases was an 18-year-old boy with cancer. Suddenly, the boy's pain had spun out of control. "In three days he went from no morphine to 400 milligrams an hour, which is a pretty industrial dose," says Berde. "A normal amount might be 3 milligrams an hour."

Berde and his colleagues inserted a spinal catheter and gave the boy a local anesthetic and an opiate. The patient had been screaming; now he became comfortable and alert and was able to go home. Although that treatment had been used to control pain in adults, Berde says, "I don't know if it had been used much in kids. We had no protocol for it. But he clearly was terminal and not relieved by massive amounts of morphine."

Other difficult cases followed, among them children with chronic pain. Some of the toughest cases, like that of the boy with cancer, involved neuropathic pain caused by damage to major nerves. Such pain can result from amputations, injuries, cancer and other diseases that affect the nerves, and it often does not respond to standard therapy. "I was making it up by extrapolating what had been done for adults and knowing the pharmacological differences between children and adults," Berde says. "I began thinking there was a need for better ways of managing pain, and a need to have it be multidisciplinary." In some cases, he knew, particularly the chronic ones, psychologists and physical therapists would be essential.

Berde and Sethna told the head of pediatric anesthesiology that they wanted to work on pain management. "He wasn't opposed, but he didn't see a need for it," Berde says. But when 90 patients were treated in the first eight months, the boss changed his mind. Together with psychologist Bruce Masek, Berde and Sethna formally opened the service in 1986.

When it comes to treating pain in children, the medical profession has a checkered history. Until the 1970s, the mistaken idea that babies do not feel pain was widely accepted, and infants undergoing major surgery were often given little or no anesthesia, just drugs to paralyze them temporarily. "The reluctance to use anesthesia was not due to doctors' being mean and nasty," Berde says. "There were real risks. It was an era when some babies did die from anesthesia, especially the ones who were very sick. So if you didn't know how to anesthetize them safely, it was easier to believe they didn't feel pain."