Tiernan, E. P. (2009). A survey of registered nurses \200\231 knowledge and attitudes regar ding pediatric pain assessment and management: an Irish perspective. Arch Dis Child , 93 (1 002), n18 . McGrath, P. J., Watters, C., and Moon, E. (2010). Technology in pediatric pain management. In G. A. Finley, P. J. McGrath, and C. Chambers (eds.), Bringing pain relief to children: t reatment approaches , pp. 159 \200\223176 . Totowa, NJ : Humana . Turnquist, K. M. and Engel, J. M. (1994). Occupational therapists \200\231 experiences and knowledge of pain in children , Phys Occup Th er Pediatr , 14 (1), 35 \200\22352 . Twycross , A. (2002). Educating nurses about pain management: the way forward. J Clin Nurs , 11 , 705 \200\223714 . Murinson, B., Mezel, L., and Nenortes, E. (2011). Integrating cognitive and aff ective dime nsions of pain experience into health professions education. Pain Res Manag , 16 (6), 421 \200\223426 . Twycross, A. (2004). Children \200\231s nurses \200\231 pain management practices: theoreti cal knowledge, perceived importance and decision-making . Unpublished PhD Th esis, Universi ty of Central Lancashire. Oakes, L. (2011). Infant and child pain management . New York : Springer Twycross, A. (2007). What is the impact of theoretical knowledge on children \200\231s nurs es \200\231 postoperative pain management practices? An exploratory study. Nurse Educ Today , 27 (7), 697 \200\223707 . Publishing Company . O \200\231Brien, M. A., Rogers, S., Jamtvedt, G., Oxman, A. D., Odgaard-Jensen, J., Kristof f ersen, D. T., et al. (2008). Educational outreach visits: eff ects on professional practi ce and health care outcomes. Cochrane Database Syst Rev , 4 , CD000409 . Twycross, A. (2008). Does the perceived importance of a pain management task affect the qua lity of children \200\231s nurses \200\231 post-operative pain management practices? J Clin Nurs , 17 (23), 3205 \200\2233216 . O \200\231Conner-Von, S. (2000). Preparing children for surgery: an integrative Twycross, A. and Collis, S. (2012). How well is acute pain in children managed? A snapshot in one English hospital. Pain Manag Nurs . 29 March. [Epub ahead of print.] research review. AORN J , 71 (2), 334 \200\223343 . O \200\231Conner-Von, S. (2008). Preparation of adolescents for outpatient surgery: using an Internet program. AORN J , 87 (2), 374 \200\223398 . Twycross, A. and Finley, G. A. (in press). Parents \200\231 and children \200\231s views ab out O \200\231Conner-Von, S. (2009). Coping with cancer: a web-based educational program for ea rly and middle adolescents. J Pediatr Oncol Nurs , 26 (4), 230 \200\223241 . pain management. J Clin Nurs . Twycross, A., Finley, G. A. and Latimer, M. (2013). An in-depth study of pediatric post-ope rative pain management practices. J Specialist Pediatr Nurs . 24 March. [Epub ahead of prin t.] Palermo, T. and Valenzuela, D. (2003). Use of pain diaries to assess recurrent and chronic pain in children. Suff ering Child , 3 , 1 \200\22314 . Twycross, A. and Roderique, L. (2011). Review of pain content in three-year preregistration pediatric nursing courses in the United Kingdom. Pain Manag Nurs . 11 July. [Epub ahead of print.] Rieman, M. T., Gordon, M., and Marvin, J. M. (2007). Pediatric nurses \200\231 knowledge an d attitudes survey regrading pain: a competency tool modifi cation. Pediatr Nurs , 33 (4), 303 \200\223313 . Uman, L., Chambers, C., McGrath, P. J., and Kisely, S. (2010). Psychological interventions for needle-related procedural pain and distress in children and adolescents. Cochrane Datab ase Syst Rev , 11, CD005179. Available at <http://www.thecochranelibrary.com>. Rycroft -Malone, J. (2010). Promoting Action of Research Implementation in Health Services (PARIHS). In J. Rycroft -Malone and T. Bucknall (eds.) Models and frameworks for implementi ng evidence-based practice: linking evidence to action , pp. 109 \200\223136 . Oxford : Wil ey-Blackwell . US Department of Health and Human Services (1992). Acute pain management in infants, childr en, and adolescents: operative and medical procedure. Quick reference guide for clinicians . AHCPR Pub. No. 92 \200\2230020. Rockville, MD : Agency for Health Care Policy and Researc h . Salantera, S., Lauri, S., Salmi, T. T., and Helenius, H. (1999). Nurses \200\231 knowledge about pharmacological and non-pharmacological pain management in children. J Pain Symptom M anage , 18 (4), 289 \200\223299 . Sato, A., Cliff ord, L., Silverman, A., and Davies, W. H. (2009). Cognitive- behavioral int erventions via telehealth; application to pediatric functional abdominal pain , Child Healt h Care , 38 , 1 \200\22322 . Vincent, C. V. H. (2005). Nurses \200\231 knowledge, attitudes, and practices regarding children \200\231s pain. MCN , 30 (3), 177 \200\223183 . Vincent, C. V. H. and Denyes, M. J. (2004). Relieving children \200\231s pain: nurses \200 \231 abilities and analgesic administration practices. J Pediatr Nurs , 19 (1), 40 \200\223 50 . Watt-Watson, J, McGillon, M., Hunter, J., Choiniere, M., Clark, A. J., Dewar, A., et a l. (2009). A survey of prelicensure pain curriculums in health science faculties in Canadia n universities. Pain Res Manag , 14 (4), 439 \200\223444 . Wisconsin Cancer Pain Initiative . (1989). Children \200\231s cancer pain can be Finley, G. A. and Schechter, N. L. (2003). Sedation. In N. Schechter, C. Berde, and M. Yast er (eds) Pain in infants, children, and adolescents , pp. 563 \200\223577 . New York : Lipp incott Williams & Wilkins , Schechter, N. L., Bernstein, B. A., Zempsky, W., Bright, N. S., and Willard, A. K. (2010). Educational outreach to reduce immunization pain in offi ce settings , Pediatrics , 126 (6) , e1514 \200\223e1521 . relieved . Madison, WI : University of Wisconsin . Simons, J., Franck, L., and Roberson, E (2001). Parent involvement in children \200\231s Wood, D. (1993). How children think and learn . Cambridge, MA : Blackwell pain care: views of parents and nurses. J Adv Nurs , 36 (4), 591 \200\223599 . Publishers . Simons, J. and Roberson, E. (2002). Poor communication and knowledge defi cits: obstacles t o eff ective management of children \200\231s postoperative pain. J Adv Nurs , 40 (1), 78 \200\22386 . Zisk, R, Gray, M., Medoff -Cooper, B., and Kain, Z. N. (2007). Accuracy of parental-globe-i mpression of children \200\231s acute pain. Pain Manag Nurs , 8 (2), 72 \200\22376 . Stinson, J., McGrath, P. J., Hodnet, E., Feldman, B. M., Duff y, C. M., Huber, A. M., et al . (2012). An internet-based self-management program with telephone support for adolescents with arthritis: a pilot randomized controlled trial. J Rheumatol , 37 (9), 1944 \200\223195 2 . Zisk-Rony, R., Fortier, M., Chorney, J., Perret, D., and Kain, Z. N. (2010). Parental posto perative pain management: attitudes, assessment, and management. Pediatrics , 125 (8), 1372 \200\2231378 . Soumerai, S. B. and Avorn, J. (1990). Principles of education outreach ( \200\230academic d etailing \200\231) to improve clinical decision making. JAMA , 263 (4), 549 \200\223556 . Online supplementary materials Figure 63.1 Additional resources CHAPTER 64 Th e ethics of pain control in infants and children Gary A. Walco and Maureen C. Kelley Introduction A common theme throughout writings in pediatric medicine is that \200\230chil dren are not little adults \200\231, oft en referring to physiological and psychological di ff erences related to maturation and develop- ment that must be taken into account in provi ding care. Similarly, in considering ethical challenges related to pain, it is important no t to simply extrapolate from our ethical approach to pain man- agement for adults who typic ally can describe their experience of pain, are fully responsible for themselves, and can r epresent their own interests in making treatment decisions. Unlike adults, younger children and certainly infants cannot speak for themselves and require parents and clinicians to as sess their pain, determine what is in their best interest, and advocate for their well-bein g. However, in pediatrics, these assessments occur in the context of a child \200\231s evol ving developmental capacities: as older children and adolescents mature, they begin to unde rstand and participate more in decisions aff ecting their health, to report symptoms, and t o communicate their wishes. In addition, as with other areas of clinical ethics, determinat ion of the best ethical practice must be considered against the backdrop of evolving data a nd evidence. Recent advances in the science of pain assessment can help inform the balance of competing ethical values related to pain in infants and children. interventions in infants and children, as clearly many of the modal methodologies tradition ally used for clinical trials in adults (e.g. placebo control designs) pose unjustifi able risk to younger indi- viduals. We will also discuss the importance of considering local con text as it impacts standards of care to guide ethical pediatric pain research. Ethical foundations of clinical pain control in pediatrics Th e starting point in thinking about the ethics of pain control in pediatrics is relatively uncontroversial at fi rst glan ce. Few would disagree that alleviating suff ering is fundamentally a good thing, especiall y among the youngest and most vulnerable human beings, and should thus be pursued universal ly. Failure to address pain in any patient would constitute a straightforward violation of the Hippocratic harm principle: \200\230First, do no harm \200\231 (Adams, 1891). Further, failure to address pain, when we have the means to do so, violates an important and basic human right to dignity and pre- vention of suff ering (James, 1993). While the harm princip le is an eff ective argument against undertreatment of pain, the rights argument lends a mo re powerful universal appeal to the case for expanding access to pain treatment to all chil dren, regardless of background, socioeconomic status, or geographical location (Southall et al., 2000). Such a perspective shapes the position of the World Health Organization on pai n in children (World Health Organization, 1998), and the recent International Association f or the Study of Pain, the Declaration of Montreal (Cousins and Lynch, 2011), which states: In this chapter we will off er a way of framing the ethical balance of competing considerat ions in pain treatment in infants and chil- dren, distinguishing between analyzes of harms and benefi ts, from other more pragmatic, contextual, and cultural considerations. We begin with the ethical foundations behind good pain manage- ment for any patient, and especially children: the ethical duty to prevent harm by alleviating pain or suff ering, and the impo rtance of assuring equal access to pain treatment. Historically, the driving ethical concer n in pediatric pain has been the pervasive under- treatment of pain in children. In the sec ond and main section of the chapter, we off er a detailed analysis of the practical ethical chal- lenges involved in weighing the harms and benefi ts of pain relief against untreated or undertreated pain. In the third section, we will discuss the more specifi c concerns of socioeconomic and cul- tural determinants to pediatric pain treatment. Finally, in the las t section, we will address concerns in conducting research on pain Recognizing the intrinsic dignity of all persons and that withholding of pain treatment is profoundly wrong, leading to unnecessary suff er- ing which is harmful; we declare that the following human rights must be recognized throughout the world: Article 1. Th e right of a ll people to have access to pain management without discrimination. Article 2. Th e right o f people in pain to acknowledgment of their pain and to be informed about how it can be ass essed and managed. Article 3. Th e right of all people with pain to have access to appropri - ate assessment and treatment of the pain by adequately trained health care professionals. SECTION 9 special topics 662 Because pain is very common in hospitalized children, the International Association for the Study of Pain, Special Interest Group on Pain in Childhood supported the Bellagio Declarat ion (ChildKind International, 2010), calling for all health care facilities to commit to th e developmentally appropriate prevention, assess- ment, and management of pain in children and adolescents aged 0 to 18 years. Lack of knowledge and subjective biases oft en have inf l uenced decision-making about pain treatment in children, leav- ing the deleterious eff ec ts of untreated pain minimized or ignored. Such deleterious outcomes violate the principle of do no harm and a comprehensive and balanced analysis, relying on data rather than person al bias or speculation, is required. to cultural infl uences; it is a signifi cantly subjective experience. Because we do not ha ve undisputed data to guide us on many of the decisions we make, individuals \200\231 persp ectives come into play. Walco et al. (1994) argued that because pain and related suff ering seem harmful to patient s, and because caregivers are categorically committed to preventing harm in their patients, not using all avail- able means of relieving pain must be justifi ed. Both sides of this b alance, however, have shift ed a great deal over time. As outlined by Olmstead et al. (2010 ), our thinking on this topic has evolved. Until about four decades ago, the general lore w as that young children, in particular, did not experience pain and certainly had no last- i ng memory of it if they did. Th us, the harm of untreated pain was not recognized. In the l ate 1970s and onward, there was increasing recognition that pain was undertreated in childr en compared to adults and that even very young premature infants have nocicep- tive systems in place and thus have capacity for pain perception. Th e work of developmental physiologi sts provided even greater insights and by the turn of the century, there were ample data to show that untreated or undertreated pain in young children was associated with lasting del eterious eff ects (Fitzgerald, 2005) (see Grunau, Chapter 4, this volume). For addressing pain in older children and adolescents, develop- mental appropriateness in c linical assessment and interventions also tracks to the involvement of the more mature pedi atric patient in pain management decisions. Th e growing literature in child development ov er the past two decades has helped shape a much more nuanced approach to ethical decision-m aking with adoles- cent patients. Th e now standard ethical model calls for the increas- in g respect for the developing autonomy of teens and young adults as they develop the capacit ies to understand medical information, appreciate the implications of various health decisi ons, and develop the ability to weigh the risks and benefi ts of immediate and long- term c onsequences (American Academy of Pediatrics Committee on Bioethics, 1995). Th ese decisions are ideally made with parental permission and support, not in isolation, but as pediatric patients are increasingly able to participate in important health decisions, they should be encouraged to do so, and their questions, concerns, and decisions should be increasingly r espected (Ross, 1998). In the context of pain, this requires listening carefully and princi pally to the voice of the patient, since even the most well-meaning parents may err in inte rpreting the symptoms of suff ering or pain in their own children. Beyond the very importan t principle of respecting the adolescent patient \200\231s emerging voice and autonomy, so much of good pain management depends on quality communication with the patient. Actively in volving more mature patients becomes par- ticularly important in addressing recurrent or ch ronic pain and in palliative settings, where ongoing relationships with patients are so imp ortant to providing the best care. Th ree potential justifi cations have been proposed for not ade- quately treating pain in c hildren, namely revisionist, comparative, and pragmatic justifi cations (Walco et al., 1994 ). First, because pain is fundamentally a private, subjective experi- ence, it is diffi cult t o assess with validity, especially in the young- est patients who do not express themselves verbally. A revisionist justifi cation focused principally on aspects of pain assessment i n the young and involves a tendency for care providers to \200\230overrule \200\231 or \200\230revise \200\231 evidence of pain based on a number of preconceived notions, such as believing there is a \200\230correct \200\231 amount of pain asso- ciated with a given de gree of tissue damage or pathophysiologi- cal condition, as well as attributions to other m ore benign factors (the infant is cold or hungry as opposed to in pain). In the last two de cades, the fi eld has come a long way in demonstrating reliable, valid, and clinically sens itive means of assessing pain in children of all ages (see Lee and Stevens, Chapter 35; von Baeyer, Chapter 36, this volume). Because many of the existing measures are based on physi ological indicators that may be non-specifi c to pain, as well as observed behavioral indic ators that are dependent on the exper- tise and knowledge of the observer, there is still r isk of care pro- viders revising or minimizing the signifi cance of pain responses. Develop ing more objective indicators with enhanced reliability and validity would be most helpful (see Lee and Stevens, Chapter 35, this volume). However, to minimize or discount available data because we lack ideal assessment methods does not justify under- treating pain in the interim. Balancing harm and bene \201 t of pediatric pain control in clinical practice Withholding pain treatment without further justifi cation consti- tutes a violation of the harm princip le in medicine, and may, as well, constitute unjust suff ering and violation of the basic h uman right to dignity and non-discrimination in health treatment. However, as is oft en the case in practical clinical ethics, the apparent \200\230no brainer \200\231 of alleviatin g pain and suff ering in an unqualifi ed manner becomes a bit less straightforward in clini cal practice (Lantos and Meadow, 2007). While the ethical foundation driving improved pain treat- ment and control in children provides strong impetus for address- ing undertreatment or unequal access to treatment, we need a more nuanced approach to guide actual clinical d ecisions at the bedside. Th e balance of harm and benefi t in alleviating pain in infants a nd children needs to be evidence based and requires appreciation of context. As the evidenc e evolves, preventing or minimizing present and long-term harm in children can become a mor e challenging balancing act. Th e expression and meaning of pain are subject In revising children \200\231s pain complaints, care providers make implicit judgements abo ut the validity of those responses. Such judgment and invalidation is most obvious in the u se of placebos to treat pain. Th e clinical use of placebos to treat pain may fulfi l patie nt and family expectations to receive some medication to treat the condition as well as a c linician \200\231s aim to promote a desired clini- cal outcome using \200\230inert \200 \231 substances (Miller and Colloca, 2009). Consider an instance in which a child or adoles cent continues to complain of pain despite being administered what is deemed by the practit ioner to be suffi cient quantities of analgesic medication. Especially when observed pain b ehavior is inconsistent or does not match up with verbal reports, there is a tendency to at tribute CHAPTER 64 the ethics of pain control in infants and children 663 the pain to other than nociception, which may be \200\230proven \200\231 by the patient ex periencing pain relief with a placebo. very young age as well as neurodevelopmental, respiratory, or car- diac comorbidities. Using placebos in this setting is problematic for a number of rea- sons. First, there is a great deal of literature to show that placebo eff ects operate across circumstances, includ ing when there is lit- tle or no doubt of the pathophysiological basis of the pain (Foddy, 2009). Th us, the presumed purpose of using placebo, to determine if the pain is \200\230r eal \200\231 cannot be achieved. Second, once the patient becomes aware of the clinician \200\231s intentional deception, trust is lost not only in that provider, but in providers throughout the medi- cal system in general (Cahana and Romagnioli, 2007; Foddy, 2009). Th i rd, and related, if the clinician uses placebo to acquiesce to the desires of parents or fa mily members, the threat of trust being vio- lated extends beyond the immediate clinician-p atient relationship as generalization to healthcare providers in general is possible. As a result, there is consensus, including a strong statement from the American Medical Associat ion (Bostick et al., 2008), that the clinical use of placebos without informed consent is c ategorically unethical (Cahana and Romagnioli, 2007; Foddy, 2009). In children over the age of 2 years, there is consensus that the data on the safety and eff i cacy of opioid medications parallel fi ndings in adults (Berde et al., 2012). However, ba sed on developmental fac- tors, the pharmacokinetics and pharmacodynamics of opioids are mo re variable in younger children. Clinically, this means that, espe- cially in preterm and y ounger infants, the risk of deleterious eff ects, such as respiratory depression, may be gr eater (Simons and Anand, 2006). Th us, increased scrutiny in prescribing and administering opioid medications is needed, with special attention to aspects of the patient \200\231s st atus that may place them at increased risk for such complications. However, once again, the se concerns should not automatically deter the use of methods to alleviate pain, recog- niz ing that such adverse outcomes may be mitigated by proper monitoring. A review of the literature conducted under the auspices of the American Society for Pain Ma nagement Nursing showed that there are no universally accepted guidelines to direct eff ect ive and safe assessment and monitoring practices for patients receiving opioid analgesia (J arzyna et al., 2011). Furthermore, there have been very limited carefully controlled studie s to show the actual benefi ts of specifi c monitoring methods, including pulse oximetry an d cap- nography, in hospitalized patients receiving opioids for pain. With this as backgrou nd, a position paper was generated highlighting the need to evaluate the individual patient for risk factors, includ- ing age, anatomic anomalies, physical characteristics, primary a nd comorbid medical conditions, psychological states, and functional status; of note risk a ssociated with age was focused only at the upper end of the spectrum (>65 years). Based on these risk factors and the nature of the intervention, monitoring to detect diffi culties e arly on, before serious adverse events, is deemed essential. With these safeguards, patient s are not denied access to pain relieving strategies but risks of respiratory depression ma y be minimized. In addition, in the unfortunate circumstance when respiratory depres- sion is of clinical signifi cance, eff ective reversal agents may be used (American Academy of P ediatrics Committee on Drugs 1990). It should be noted that the guidelines espoused by Jarz yna et al. do not focus at all on pediatric populations and our review yielded no similar d ocuments addressing the needs of children. Certainly patient safety may be enhanced with ev idence-based monitoring practices for children, thereby better addressing concerns about un toward side eff ects of opioids used to reduce pain. A comparative justifi cation focuses on weighing the benefi ts and risks of unrelieved pain against those of pain relief. In some circumstances, a responsible conclusion may be that the harm of unrelieved pain is less severe than the harm of pain relief. Many of the tradit ional concerns have focused on fears of addiction and dangerous side eff ects of analgesic medications, neither of which may be taken lightly. With regard to the former, certainly th ere is concern for misuse and addiction of opioids among children and adolescents, especial ly those prescribed to others and subsequently scavenged by adolescents (Bailey et al., 200 9). Th ere is little to show, however, that there is risk of addiction when these medicatio ns are appropriately prescribed and administered in pediatrics set- tings (Yaster et al., 2 003). Th us, if one is careful about prescribing appropriate dosages and, in particular, th e amount of medication prescribed in ambulatory settings, withholding opioids for pain mana gement due to fear of addiction is not justifi ed \200\224this is true for all ages. Th e second concern, deleterious eff ects of analgesic medica- tions, requires careful cost \200\223benefi t analysis when weighing effi cacy against adverse events. A common concern of opioids focuses on signifi cant sedation and respiratory depression and, more recently, questions about long-term deleterious eff ects of opioid administra- tion on cognitive dev elopment in the young have arisen. A recent prospective study reported on the incidence, nature, and severity of serious clini cal incidents (SCIs) associated with continuous opioid infusion, patient-controlled analges ia, and nurse-controlled analgesia in neonates, infants, and children under the care of ped iatric acute pain teams in the UK and Eire (Morton and Errera, 2010). Predefi ned SCIs fell into three grades: (1) death/ permanent harm; (2) harm but full recovery, technique stoppe d or changed, intervention required; and (3) potential harm but no actual harm. With a deno minator of 10 726 opioid infusions, there were one Grade 1 SCI (cardiac arrest associated w ith aspiration pneumonitis and an underlying neurological condition), 28 Grade 2 SCIs, half of which were respiratory depression, and 17 Grade 3 SCIs (all of these last category occu rred in a single center related to programming or prescribing errors). It is noteworthy tha t of the 14 cases of respiratory depression, half of the children were less than 1 year of age. Th e authors emphasized the need for heightened monitoring for children posing increas ed risk factors, including Th ere is some question as to whether prolonged use of opioids, especially in very young in fants, may have deleterious long-term eff ects. Specifi cally, opioids have oft en been use d on an ongoing basis in an attempt to maintain the comfort of neonates who were receiving mechanical ventilation. A 5-year follow-up study indi- cated, however, that there may be so me signifi cant eff ects on intel- lectual functioning associated with this practice (de Gr aaf et al., 2011). While these data certainly serve as an alert, it is diffi cult to attrib ute deleterious outcomes specifi cally to opioids as there is an array of developmental, me dical, and environmental factors that may impact the relatively unstable physiological syst ems of prema- ture neonates (Grunau et al., 2006; see also Grunau, Chapter 4, this volume). Th us, a simple concept of \200\230the more the better \200\231 in utiliz- ing agents to reduce pain and distress may need to be tempered as more data emerge (Lantos and Meadow, 20 07; Mancuso and Burns, 2009). SECTION 9 special topics 664 Th e pragmatic justifi cation focuses on the potential benefi ts of pain persisting. In oth er words, while it is acknowledged that unre- lieved pain is bad, such pain may be deemed n ecessary to achieve a greater goal. Two general areas may be cited here, the value of pain to provide diagnostic information and the utility of pain to help build character. In the f ormer, pain may be seen as useful to monitor an illness (cf. Bromberg and Goldman, 2007) or to indicate the ineff ectiveness or limits of treatment, such as discomfort dur- ing rehab ilitation aft er orthopedic surgery. Eliminating or mask- ing such pain could actually harm the patient and therefore one must weigh the benefi t of immediate relief against that of long-term recovery. In such circumstances, the clinician is deemed to be oper- ating in the patient \200\231s best interest by maintaining a degree of pain or discomfort. To assure t hat is the case, three specifi c tests should be applied. First, is the pain useful \200 \224is it the means to achieving an important goal? Second, is the pain necessary or are th ere other, less hurtful means of achieving that goal? Th ird, is the pain at the lowest pos sible level? Because it is not acceptable to allow children to suff er if there is any othe r means of achieving outcome data, if there is a therapeutic benefi t from a child \200\231 s pain, one must be exqui- sitely economical with it. In many ways, as the knowledge base for the assessment and management of pain grows and med ical education fails to keep pace, problematic outcomes appear even more amplifi ed. A rece nt report from the Institute of Medicine (2011) focuses specifi cally on how lack of educat ion and the overgeneralization of management principles related to acute pain have contribu ted to epidemic con- cerns about chronic pain. Certainly children are not immune from these same issues (McGrath and Ruskin 2007) and the problem is compounded by data indicating tha t untreated chronic pain in chil- dren and adolescents predisposes individuals to ongoing c hronic pain problems well into adulthood (Dengler-Crish et al., 2011; Walker et al., 2010). Armed with data on the poor treatment of pain in infants and children, there have been a nu mber of initiatives advocat- ing for improvement. Included here is a policy statement joint ly issued by the American Academy of Pediatrics and the American Pain Society (American Aca demy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health, American P ain Society Task Force on Pain in Infants, Children, and Adolescents 2001), a position stat ement of the International Association for the Study of Pain (IASP SIG on Pain in Childhood 2005), and a monograph by the World Health Organization (1998), all of which highlight the undertreatment of pain in infants and children and the need for improvements in the assess ment and treatment of pain and suff ering. A second potential pragmatic justifi cation derives from moral views held by some that cham pion traits such as courage, self-dis- cipline, independence, and self-sacrifi ce. Such cul tural or family views about pain may also track beliefs about gender diff erences: for exam ple, that a young girl should learn to tolerate severe men- strual pain, or that a boy ough t to \200\230tough it out \200\231 through a sports injury. Although in principle encourag ing such virtues as bravery and stoicism may be ethically defensible, imposing the burden o f character development on a child already encumbered by distress, sickness, or suff ering refl ects a lack of compassion and is ethically questionable, at best. When the total eradi cation of pain is not pos- sible (as in the case of chronic pain associated with chronic il lness), strengthening the child \200\231s capacity to cope with the pain is benefi cial and may be justifi able. However, to intentionally allow a child to suff er in the hope of inf l uencing character development disregards the child and the real and present need for pain relief. Th e scope of parental discretion, including refusals of pain treatment for reason s of character building, should be constrained by appeals to the harm principle (Diekema, 2 004). Recognizing socioeconomic and cultural determinants to pain control As pediatric pain medic ine has improved drastically in developed countries and for families with good access to he alth care, the next frontier in improving access to better pediatric pain treatment is to a ddress the inequalities of pediatric pain management for unders- erved patients and familie s. If untreated pain is an unjust suff ering, on either the rights argument or the basic re quirement of the harm principle, we have reason to address disparities in access to pain co ntrol in children between high-resource and low-resource com- munities. Included among such communities are not only low-in- come countries, but also low-income neighborhoods and reg ions in middle-to-high-income countries. Just as with adults, children the world over exper ience acute and chronic pain, and yet we still lack robust epidemiological data on childhoo d and adolescent pain prevalence (Berde et al., 2012; King et al., 2011). Accurately map- p ing the global burden of any disease is the fi rst step in recognizing suff ering, and a ne cessary step toward addressing a need in some- times marginalized populations. A fairly pervasive example of this phenomenon may be seen in the failure of broad-scale eff orts to treat needle pain. Oft en state- ments refl ecting the view that pain is a part of life and children need to cope with it serve as justifi cation for failing to treat pain a ssoci- ated with needles (Taddio et al., 2009). Th e unfortunate outcome is that immunizati on rates are lowered by individuals who avoid needles and an estimated 10% of adults avoid contact with medical institutions, even when indicated, due to fear of needles (Hamilton, 1 995). As our understanding of the global burden of pediatric chronic and acute pain prevalence an d causes improves, we can more eff ec- tively target the scale-up of pain treatment regimen s in underserved areas. Th e most pressing immediate need is for pain medicines and supplie s, and improved clinical training for pain diagnosis and treatment among medical care provi ders. Implementation of pain programs require evidence-based advocacy from professional org anizations, and an appeal to the arguments from ethics and social justice presented above. Nearly 20 years ago, Walco et al. (1994, p. 543) concluded, \200\230All health professiona ls should provide care that refl ects the techno- logical growth of the fi eld. Th e assess ment and treatment of pain in children are important parts of pediatric practice, and failu re to provide adequate control of pain amounts to substandard and unethical medical practic e \200\231. Unfortunately recent data on required and optional coursework indicate that med ical school education in North America falls well short of the mark in preparing prac- titi oners to make these informed decisions (Mezei and Murinson, 2011). Th ose advocating for better access to pain control in resource- poor communities also face a perception that there are more dire needs to be met fi rst \200\224for example, malaria, childhood vaccination, clean water, or nutrition. Because a child \200\231s pain left untr eated is an CHAPTER 64 the ethics of pain control in infants and children 665 unjust suff ering, except in the cases where the pain treatment would cause more harm than the pain itself, pain treatment cannot be viewed as a luxury. It should be viewed as equall y critical, alongside the provision of preventive care, such as vaccinations, and the treat - ment of acute infections and other endemic diseases that dispropor- tionately aff ect chi ldren living in poverty. For health professionals serving children and families in poor com munities, greater eff ort may be required to advocate for coverage of good pain management and of palliative care when resources are not readily available. strong; my son does not need morphine \200\231 \200\224a provider \200\231s fundamental eth ical duty is to minimize harm and suff ering for the patient, but this can be managed with cultural sensitivity. As argued earlier in considering pragmatic appeals to non-treatment o f pain, the duty to prevent harm and the rights argument ought to outweigh any cul- tural a ppeal to allowing pain in children. Where adults may be free to martyr themselves or choose to undergo suff ering and pain for a greater good or for deeply held spiritual or cultural beliefs, they are not free to martyr their children ( Prince v Massachusetts , 1944). In p ractice, there are more sensitive and eff ective ways to navigate cul- tural beliefs in a f amily. Understanding cultural perceptions of pain can help shape care providers \200\231 co nversations with families about pain management; introducing current models of pain mechani sms and processing may counter cultural beliefs that mitigate adequate pain treatment. In t he end, awareness of cultural underpinnings for undertreatment of pain can help shape clini cal strategies but does not alter the basic moral obligation to treat a child or infant \200\231s pain. (Please see Clemente, Chapter 11, this volume.) As we expand eff orts to improve access to eff ective pain manage- ment for all families ac ross socioeconomic and political borders, we will also encounter a wider array of cultural beliefs about pain. Pain is a subjective experience imbued with social and cultural meaning , and this known variation in the experiences of pain has three sig- nifi cant ethical impl ications for practice in diverse patient popula- tions (Craig and Pillai Riddell, 2003). First, social and cultural factors may impact whether and to what degree parents pursue or have adequate access to information and resources for addressing their child \200\231s pain . Given that there is vari- ation in parents \200\231 acceptance of exposures to pain, inju ry, or risk in children (Goodman and McGrath, 1991), children from some com- munities may b e at greater risk for injury and pain, and less likely to have access to treatment. In this case, undertreatment of pediatric pain may be consonant with other socioeconomic determina nts of health care access for children from marginalized groups or com- munities and could be embraced as part of a more general eff ort to address health disparities in child health . Ethical considerations in pediatric pain research As already discussed, optimal clinical de cision-making is based on evidence. Th e more data we have on the safety and eff ectiveness of available treatments for the population to which they will be administered, the better. If, for example, we wish to understand the safety and effi cacy parameters of using a spec ifi c analgesic medica- tion for pain relief in premature neonates, ideally we would have d ata from pharmacokinetic and pharmacodynamic studies, as well as from effi cacy trials cond ucted in that population at our disposal (Anand et al., 2006). However, there are some sign ifi cant ethical and pragmatic challenges to be addressed in order to do so.