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SPA Newsletter

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Reported by Rita Agarwal, MD
Denver Children's Hospital

The 5th International Symposium on Paediatric Pain was held in London, June 18-21, 2000. The Program was organized by the Special Interest Group-Pain in Childhood, of the International Association for the Study of Pain (IASP). Ann Goldman (Great Ormond Street Hospital for Sick Children, London) and Maria Fitzgerald (University College, London), the Local and International Scientific Committees put on an excellent, diverse and interesting program. More than 400 people attended (a significant increase compared to the last gathering). There were participants from almost all the continents (although no one from Antarctica was on the roster!). The theme of the conference was "From Basic Research to Clinical Care".

The meeting opened on an uncharacteristically hot summer day (local temperature records were set!) with an Education Day on Sunday 18 June. Session 1 focused on Pain Assessment with lectures by Patrick McGrath (Dalhousie University, Canada), Celeste Johnston (McGill University, Canada), Bonnie Stevens (University of Toronto, Canada) and Anne Hunt, (Institute of Child Health, UK). Dr McGrath spoke on Pain Assessment in Children, while Drs. Johnston and Stevens discussed Pain Assessment in Infants. Ms. Hunt ended the session by presenting the problem of Pain Assessment in Children with Chronic Conditions.

Session 2 focused on Acute Pain - Mechanisms and Management. Dr. Katharine Andrews (University College London, UK) started the session by discussing The Developmental Aspects of Acute Pain Processing. The discussion was continued by Dr. Richard Howard (Children Nationwide Pain Research Centre, UK) with a lecture on The Management of Post Operative and Ongoing Pain in the Intensive Care Unit. The session ended with Drs. Lonnie Zeltzer and Michael Joseph both from UCLA Pediatric Pain Program, USA, presenting options on the Management of Procedural Pain.

The day's final session concentrated on Chronic Pain. Professor Tony Dickinson (University College London, UK) presented the Biological Mechanisms of Persistent Pain. Drs. Chuck Berde (Boston Children's Hospital, USA) and Leora Kuttner (University of British Columbia, Canada) discussed the Management of Chronic Pain. Dr. John Goddard (Sheffield Children's Hospital, UK) finished the day by presenting suggestions on Setting up a Multidisciplinary Chronic Pain Service for Children.

On Monday 19 June the meeting continued at The Royal Lancaster Hotel. The initial morning sessions concentrated on Advances in Basic Science with a presentation by Professor Clifford Woolf (Harvard Medical School, USA) on Recent Advances in the Neurobiology of Pain. Dr. Martin Koltzenberg (University of Wurzburg, Germany) discussed Development of Sensory Receptors. The final talk prior to the break was more clinical, by Patrick McGrath on How Children Learn To Express Pain.

After the break, the session continued with two simultaneous workshops and a poster session. Workshop 1: New Developments In The Treatment Of Pain In The Newborn was presented by Drs. KJS Anand (Arkansas Children's Hospital, USA), Connie Houck (Boston Children's Hospital, USA) and Yuan-Chi Lin (Stanford Medical Center, USA). Workshop 2 was on Pain in Children with Profound Cognitive and Neurological Handicap, presented by Drs. Patrick McGrath, Tim Oberlander (University of British Columbia, Canada), Katinka van Dongen (Maastricht University, The Netherlands) and Anne Hunt. Poster Session 1 covered a variety of topics including procedural pain, pain assessment, acute pain and human physiologic responses.

After lunch, Dr. Henrik Kehlet (Hvidovre Hospital, Denmark) presented Optimizing Acute Pain Management with Current Resources. He emphasized the need for multi-modal approaches to providing analgesia and minimizing side effects. As part of any routine, dynamic pain relief is important, as is maximizing mobility. This was followed by a lecture on New Developments in Acute Pain Management by Dr. Navil Sethna (Boston Children's Hospital, USA). Dr. Sethna reviewed the pharmacokinetics, utility and safety of several newer medications including the use of epidural clonidine. Finally, Andrew Rice (Imperial College School of Medicine, UK) discussed New Analgesic Therapies, with the primary focus of his lecture on cannabinoid analgesics in inflammatory and neuropathic pain.

The day ended with another two simultaneous workshops and a poster session. Workshop 3, Psychoneuroimmunology, the complex relationship between pain, immune function and recovery and was given by Drs. Patricia McGrath (Children's Hospital of Ontario, Canada), Lonnie Zeltzer, and Al Aynsley-Green (Institute of Child Health, UK). Workshop 4 was on Children's Self-Report of Pain: Gold Standard of Fool's Gold. Drs. Ken Craig (University of British Columbia, Canada), Belinda Goodenough (Sydney Children's Hospital), Carl von Baeyer (University of Saskatchewan, Canada) and Christine Chambers (University of British Columbia, Canada). The Poster Session was a continuation of the morning's session.

Tuesday 20 June was a day with much more typical London weather (rain, drizzle and more rain). The morning started with a discussion of Novel Sodium Channels and Pain by Michael Gold (University of Maryland, USA). He presented evidence supporting the theory that pain associated with tissue injury reflects an increase in the excitability of primary afferent neurons and voltage-gated sodium channels. Tony Yaksh (University of California, San Diego, USA) followed with a review of The Biology of Neuropathic Pain in Man and Animal Models. This lecture focused on the changes that occurred after injury to the primary afferents including spontaneous activity, sprouting, hyper-innervation of ganglion cells by sympathetic terminals, cross-talk between A and C fibers. This presentation was followed by the announcement of the Young Investigator Award in Paediatric Pain, presented by AstraZeneca. This award went to Bonnie Stevens from the University of Toronto for her work on pain assessment in premature infants and neonates.

After the break, the workshops continued. Workshop 5, Self-Regulation Skills for Children in Pain was presented by Drs. Timothy Culbert (Alexander Center for Child Development and Behavior, USA), Leora Kuttner and Laurence Sugarman (Rochester, USA). Workshop 6 was on Palliative Care in Children. Drs. Thomas Dangel (National Research Institute for Mother and Child, Poland), H Hujer Abu-Saad, (University of Maastricht, The Netherlands) and Susan Fowler-Kerry (University of Saskatchewan, Canada) were the presenters. Poster Session 1 continued during this time as well.

After lunch, Dr. John Collins, New Children Hospital, Australia discussed New Developments in Treatment of Cancer Pain. He reviewed the epidemiology of cancer pain in children and presented insights into the integration of psychological and pharmacological intervention, evolving models of care that incorporates the care of the dying child into the constituency of the pediatric pain service. Dr. Kevin Murray (Great Ormand Street Hospital, UK) changed topics by discussing The Pathophysiology of Joint Pain in Rheumatic Diseases of Childhood. He summarized the characteristics of joint pain in children with rheumatic diseases and the biologic basis for the pain and treatment modalities. The last presentation prior to the coffee break was on Long-Term Consequences of Early Intensive Care by Ruth Grunau (Research Institute for Children's and Women's Health, Canada). Her and others' research has shown that sensitization occurs to repeated tactile stimulation in premature infants below 35 weeks PCA on the neonate. Ongoing hyperarousal seen in former very low gestational age infants (VLGA) may lead to problems with self-regulatory functions throughout childhood.

After the break, the meeting continued with Workshop 7, Neurophysiological Approaches to Paediatric Pain and Workshop 8, Complex Chronic Pain and Pain Associated Disability Syndrome. Dr. Katherine Andrews, Professors Rolf-Detlef Treede (Johanes-Gutenberg University, Germany) and Max-Josef Hilz (Klinik f�r Neurologie, Germany) led the discussion. In Workshop 7, while Poster Session 2 commenced, topics as diverse as neonatal pain, chronic pain, psychological aspects and the developmental biology of pain were presented. The evening ended with a Gala Dinner at the Lincoln's Inn.

Wednesday 21 June was the final day of the meeting. The morning started with a discussion of Sprouting Responses of Sensory Neurones to Injury-Induced Cytokines. Drs. Stephen Thompson (King's College, UK) and William Cafferty (King's College, UK) presented compelling evidence that the developing neonatal nervous system is much more vulnerable to damage than the adults. Damage to the peripheral tissue results in extensive sprouting of the sensory nerve terminals and hyperinnervation. Professor Kevin Fox (Cardiff University, UK) discussed Plasticity in the Developing Cortex. Dr. Bruce Compas (University of Vermont, USA) discussed Children's Coping Strategies: Implications for Managing Pain. He presented a model of coping and self-regulation in response to pain, which can have a significant impact on pain frequency, intensity and duration.

Workshop 9, Ethics of Pain Research with Children and Workshop 10,: Pain in Paediatric Burns and Poster Session 2 continued after the break. Workshop 9 was presented by Drs. Richard Nicholson (editor, Bulletin of Medical Ethics, UK), Nick Pace (Western Infirmary, UK) and Neil Morton (Royal Hospital for Sick Children, UK) and Workshop 10 by Drs. Walter Meyer (University of Texas Medical Branch, USA), Susanne Martin-Herz (University of Washington Burn Center, USA) and Fredrick Stoddard (Harvard Medical School, USA). The topic of Neonatal Pain Measurement: Is the Cup Half Full or Half Empty? was presented after the lunch break by Linda Franck (King's College, UK). The important limitations and strengths of available neonatal pain measurement tools were reviewed and critiqued. A discussion of the barriers to providing consistent neonatal care was presented as well as suggestions to improve pain treatment. Dr. Ann Lynn (Children's Hospital and Regional Medical Center, Seattle, USA) was the last invited speaker of the meeting, and she presented the Pharmacodynamics of Opioids in Infants. She discussed the variability of opioid metabolism in infants of the same age as well as reporting techniques for using continuous infusions of opioids at steady states to provide safe and effective analgesia. The final two workshops of the meeting were Workshop 11, Adolescents with Chronic Pain with Drs. Chris Eccleston, Hannah Connell, Mrs. Zoe Sully (Royal National Hospital for Rheumatic Diseases, UK) and Professor Peter Malleson (University of British Columbia, Canada) and Workshop 12, Epidural and Intrathecal Analgesia with Drs. Tom Mancuso (Children's Hospital, Boston, USA), Jeffrey Koh (Arkansas Children's Hospital, USA), Tony Yaksh and Yuan-Chi Lin (Packard Children's Hospital, USA).

The final presentation of the meeting was a film/open discussion on the Long Term Impact of Pain Experience in Childhood. Drs. Leora Kuttner, Canada; Neil Schechter, USA; Gary Walco, USA; and Belinda Goodenough, Australia engaged in a lively discussion to end the day. See you all in Sydney, Australia 2003!

Rita Agarwal, MD