Melanie Noel is a pediatric pain researcher and psychologist at University of Calgary, a self-designated "Newfi" whose speech still contains slight traces of that particular accent, a slightly hard "R" in words like "hARd" and "embARk." She is interested in preventing children from becoming adults with chronic pain, and has uncovered evidence-based ways to intervene.
Melanie Noel #SDPAIN2020
She began with a horror story: in 1981, the year she was born, she could easily have been one of the infants who underwent surgery for a congenital heart problem with only paralytics but no pain management, because infants were (and in some cases still are - perish the thought) regarded as having no capacity to form pain memory. She is adamantly opposed to this idea;
"Early painful experiences from the time of birth set the stage for the adult that lies in front of you if you're a massage therapist or the adult that you work with."
She discussed papers that back up her point of view. One study (Taddio et al 2002) compared babies who received lots of post-birth heel pricks compared to babies who did not, and their fear memory reactions a few months later in a vaccination clinic. Thay would cry and demonstrate "fear, distress and pain expressions," as soon as a totally non-nociceptive cleansing swipe was applied to their thigh, prior to the actual needle.
In another study (Weisman et al 1998), children with cancer who received painful medical procedures were divided into two groups, one of which received fentanyl prior to the procedure and one which did not. It turned out that children in the group which did not receive the fentanyl, but in a second round of painful procedures did, received less benefit from the analgesia than the "kids who had had their pain properly managed from the getgo, raising the suggestion that not only is pain remembered from the first days of life, but, if it's not well-managed, those memories can actually influence whether or not whether a child can benefit from pain management."
In other words, as adults, these children have a greater chance of developing chronic pain issues.
"These memories are powerful drivers of future pain experience."
Even aiming for "less unpleasantness" is a good idea. In a randomized trial (Redelmeier et al 2019), 682 subjects underwent colonoscopies. One group was treated as usual, while subjects in the other group were treated more gently, as in, the scope was removed more slowly, "less unpleasantly." It turned out their memories of the event measured as having been less unpleasant, leading the researchers to hope they would be more likely to be compliant with future medical visits and tests.
Girls develop more negatively biased memories than boys. Seventy percent of our chronic pain patients are female. "Anxiety is the biggest culprit in everything." An anxious person is more likely to remember what they expected to happen than what actually happened. Negatively biased memory is increased in children with anxious negatively biased parents. Pain seems to come out of nowhere right around puberty. Scanning the brain of a kid with chronic pain vs. without, there are differences in size of hippocampus, and connectivity between hippocampus and frontal areas and hippocampus to amygda are different.
Her own research is about finding ways to block pain memories from gaining any traction in children. Speaking as a mother of three, and a pain researcher, she says, children age 4 to 6 are very suggestible. She says, "catastrophization is a thinking style." How children frame pain will be learned from parents. So she wants parents to:
1. Not enhance or engage in any exaggerated pain talk with their children or within their earshot
2. Focus on related but positive distraction topics instead. E.g., Remember the nice nurse who gave you that popsicle after you had your tonsils out? She was nice, wasn't she? They will remember the event clearly but the pain of it will be remembered a lot less clearly.
...........
I had not really seen the connection between pediatric pain and adult chronic pain as clearly before listening to Noel's talk as I do now. She will be back next year to keynote the summit again, which I look forward to.
SDPAIN2020 Part 1SDPAIN2020 Part 2
SDPAIN2020 Part 4
REFERENCES
1. Taddio A, Shah V, Gilbert-MacLeod C, Katz J., 2002, Conditioning and hyperalgesia in newborns exposed to repeated heel lances. JAMA. 2002 Aug 21;288(7):857-61
2. Weisman SJ, Bernstein B, Schechter NL, 1998, Consequences of inadequate analgesia during painful procedures in children. Arch Pediatr Adolesc Med. 1998 Feb;152(2):147-9.
3. Help Eliminate Pain in Kids: The Hidden Cost of Immunization Nov 19, 2013 YouTube video
4. Nancy White, 2012, Needle phobia in childhood linked to future health-care fears. The Star Feb 21, 2012. "One in ten" adults have needle phobia.
6. Redelmeier, Donald & Katz, Joel & Kahneman, Daniel. (2003). Memories of Colonoscopy: A Randomized Trial. Pain. 104. 187-94. 10.1016/S0304-3959(03)00003-4.
7. Melanie Noel, Jennifer A Rabbitts, Gabrielle G Tal, Tonya M Palemo, 2015, Remembering pain after surgery: a longitudinal examination of the role of pain catastrophizing in children's and parents' recall. Pain. 2015 May; 156(5): 800–808.
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