Pediatric Pain Disorders

Pediatric Pain Disorders

By Jennifer Stinson, RN, PhD

Most people think chronic pain is something that only affects adults, but children can develop chronic pain too.

What is chronic pain in children?

Chronic pain in children has been defined as any recurring or persistent pain lasting longer than three months. Examples of recurring pain include headaches, abdominal and limb pain. Examples of persistent pain include back pain, cancer pain, pain due to arthritis or neuropathic pain such as complex regional pain syndrome.

Children suffering from chronic pain may have varying amounts of disability, from none to severe. Most children with chronic pain function quite well; they can continue to go to school, interact with friends, and participate in social and recreational activities. However, some develop more complex chronic pain conditions with associated distress and disability. Biological, psychological, social, cultural, and developmental factors can strongly influence the severity of chronic pain and the amount of disability it may cause.

Many children with complex chronic pain problems have components of nociceptive and neuropathic pain. Nociceptive pain is normal pain and neuropathic pain is nerve pain. These types of pain can make their conditions more difficult to treat. While many chronic pain conditions in children can be treated by health care professionals such as family doctors in the community, interdisciplinary chronic pain teams are often necessary to treat more complex chronic pain conditions.

What are interdisciplinary chronic pain teams?

Chronic pain teams for children generally include specialized physicians (such as anesthesiologists, neurologists, psychiatrists), nurses, psychologists and physical therapists. The specific team members involved for any one child depends on the individual needs of the child and family.

A child's initial consultation includes either a joint team interview and physical examination or separate interviews with each health care professional. Comprehensive physical and psychosocial assessments may last a few hours to a full day, depending on the child's previous diagnostic tests and the team's core assessment battery (i.e. questionnaires). The team then meets to determine the child's pain diagnosis and treatment plan. The treatment plan will typically include:

  • the diagnosis: underlying causes and contributing factors
  • rationale for a rehabilitative approach with a clear description of the specific treatment options and an opportunity for the family to help fine-tune the plan

Some children's clinics also offer inpatient, day, or residential treatment programs.

What are the goals of interdisciplinary chronic pain treatment?

Interdisciplinary chronic pain programs use a rehabilitative approach to treating pain in children. The pain is treated with the most appropriate therapies, such as medications, psychological and physical therapies. The team assists children and their parents to improve children's function despite their pain. In some instances, teams work with families to help them understand that their child's pain might not be eradicated fully. Efforts are directed towards improving function and quality of life.

Interdisciplinary treatment goals include:

  • Comprehensive physical and psychosocial assessment of the child with pain and his or her family to evaluate what factors could be causing and contributing to the pain
  • Design and implementation of a flexible child-centred treatment approach that addresses all factors that help cause the pain
  • A treatment plan, typically including pharmacological, psychological, and physical therapies and in some cases medical interventions such as nerve blocks
  • The specific goals of the treatment plan including:
    • increasing independent function in terms of activities of daily living, school, social, and physical activity
    • facilitating adaptive problem solving, communication, and coping skills
    • treating specific problems identified from the comprehensive assessment such as depression or anxiety
    • helping children and their families to understand the nature of pain, the pain condition and its treatment from a holistic perspective
  • Ongoing assessment and re-evaluation of the treatment plan

Pharmacological therapies

Pharmacologic methods are an important component of an integrated, flexible approach that also includes psychological and physical strategies.

The choice of medication depends on the source of pain (nociceptive, neuropathic, or mixed). Pain medications are tailored to the individual needs of each child based on the results of his or her assessment. Drug therapies are divided broadly into analgesics (medications for pain) and adjuvant (additional) medications.

Medications for nociceptive pain

Analgesics are given in a stepwise approach and are recommended for pain conditions with characteristics of nociceptive or mixed pain. Simple analgesics, such as acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs such as ibuprofen), in adequate doses, are effective for some children. Opioid medications may be added to the analgesics when these mild analgesics do not alleviate the pain.

Medications for neuropathic pain

In contrast, pain conditions with characteristics of neuropathic pain are often resistant to drug therapies that typically relieve nociceptive pain. Therefore, other medicines called adjuvant pain medications are used. Examples of adjuvant pain medications include anticonvulsants and tricyclic antidepressants.

Gabapentin is the most commonly used anticonvulsant, as it is safe and well tolerated.
Amitriptyline is the most commonly used tricyclic antidepressant and is often recommended for children whose sleep is disturbed. Antidepressants are also helpful for children who have chronic pain and who are depressed.

Psychological therapies

Many psychological therapies are available to treat chronic pain in children. These
treatments include:

  • Counseling
  • Relaxation therapy
  • Biofeedback
  • Behavioural modification
  • Cognitive strategies including hypnosis and psychotherapy

Often these therapies are integrated into a comprehensive cognitive-behavioural therapy (CBT) program. CBT is directed at identifying and improving the factors that affect a child's pain and disability. A recent study has shown the effectiveness of CBT for chronic headache and abdominal pain in children.

CBT is often organized into a program of therapy that is delivered by various members of the chronic pain team (psychologists, nurses, physical therapists). The content of the programs varies across clinics but usually includes the following:

  • Teaching children specific pain and life coping skills
  • Encouraging positive family responses for resuming typical activities
  • Exercise therapy
  • Education and self-management strategies

The goal of these psychological therapies is to help children regain their lives and take back control from the pain.

Physical therapies

Chronic pain often leads a child to avoid physical activity due to fear of re-injury or because it makes the pain worse. Lack of muscle use leads to loss of muscle strength, flexibility and endurance, and overall muscle deconditioning. Therefore, physical therapies are an important part, and in certain instances the cornerstone, of treatment for children with complex chronic pain problems.

The most commonly used physical therapies include:

  • Exercise therapy
  • Physiotherapy
  • Thermal: heat and cold therapy
  • Sensory therapy: desensitization, transcutaneous electrical nerve stimulation (TENS)
  • Massage

Physical therapies are frequently used in combination.

Regular exercise (e.g. 20 min 3 × per week) should help improve sleep, mood, self-esteem, and energy levels. However, maintaining normal daily activities such as school, sports and play are often as effective as a formal exercise program.

Some children will benefit from intensive physiotherapy. Physiotherapy is usually given on an outpatient basis with the ultimate goal of teaching the child to do the program at home. A program the child enjoys and one where the amount of time spent in the activity is gradually increased is one the child is more likely to continue with.

In summary, children with complex chronic pain conditions experience prolonged suffering and disability. The pain negatively impacts all aspects of children's lives in terms of physical, psychological, social, and role functioning. Many sensory, cognitive, behavioural, and emotional factors may intensify the pain and prolong pain-related disability. Moreover, these complex pain conditions tend to have components of both nociceptive and neuropathic pain, which makes them more difficult to treat.

Given this complexity, unidisciplinary (one discipline such as medicine) and unimodal (just pain medicines) treatments are rarely successful. Therefore, children with complex chronic pain conditions must be treated from an interdisciplinary, multimodal, rehabilitation perspective. Pharmacological, physical, and psychological therapies should be incorporated into a flexible, child-centred program.

More information about chronic pain in children can be found at The AboutKidsHealth Pain Resource Centre at the Hospital for Sick Children: www.aboutkidshealth.ca.