Pediatric Chronic Pain
from Caring For Our Future, Summer 2003
Chronic pain in pediatric and adolescent patients presents an increasing challenge for nurses and other healthcare professionals. Chronic pain and complex pain problems are becoming more recognized in children and are being treated in pediatric hospitals, specialty clinics and primary care offices around the country. Goodman and McGrath (1991) estimate that 15 percent to 20 percent of all children are affected by chronic pain sometime during their childhood. In spite of this prevalence, the National Institutes of Health, the American Pain Society, The American Academy of Pediatrics and other organizations continue to report the under-treatment of acute and chronic pain in children. This under-treatment of pain can be partially blamed on gaps in knowledge about chronic pain and its mechanisms, but should also be partially blamed on inadequate or incomplete application of therapies and knowledge that nurses and healthcare providers DO have. Improving nursing knowledge about chronic pain and its mechanisms, and increasing communication about effective strategies for handling chronic pain in children can help to improve treatment and outcomes for pediatric patients with complex or chronic pain.
Chronic pain is best defined as “any pain that persists beyond the usual course of an acute injury or illness, or beyond the usual time expected for recovery.” Many practitioners are more familiar with the definition of chronic pain commonly used for adult populations. This definition arbitrarily defines chronic pain as “pain that lasts longer than 6 months.” The International Association for the Study of Pain (1994), however, includes “pain that lasts 1 to 6 months,” and “pain that lasts less than 1 month” in their definition of chronic pain. These definitions are much more appropriate for the pediatric population. Chronic pain is pain that has no useful biological function, and imposes severe emotional, physical, economic and social stress on the child and family. Pediatric chronic pain can also cause financial difficulties in terms of healthcare utilization and time off work for parents.
No matter how a child with chronic pain appears on physical exam, it is important to remember that the amount of tissue damage experienced does not bear a one-to-one relationship with the amount of pain experienced, i.e. nociception and pain are not the same thing. Pediatric chronic pain can be experienced in isolation of a noxious event, and even an extensive physical workup may reveal no evidence of trauma. It is important to listen carefully to the child and family and to treat pain in a timely fashion in order to prevent changes in the child’s nervous system. “Ongoing nociception can result in a sensitization of the peripheral and central nervous systems to produce neuroanatomical, neurochemical and neurophysiological changes” (American Pain Society, 2001). Thus, children who endure pain for an extended period of time during childhood may be prone to experience more complex pain in the future.
Early assessment and intervention are very important if it is suspected that a child may be developing chronic pain. The approach to treatment is very different from that of acute pain. When there is a defined acute disease process or injury, the conservative approach is usually to rest the painful area and to couple this rest with specific medical treatment. In the case of chronic pain, however, there is often not a defined cause for the pain and the treatment is not always straightforward. Instead of resting the painful area, normalizing the child’s activity level and providing encouragement for slowly increasing function may mean the difference between recovery and long-term disability.
Nurses and healthcare providers are familiar with pain behaviors that are displayed during acute pain. A child in acute pain is likely to display intense sensation, alertness to the affected area, concern about harm, fear, anxiety and anger. On the contrary, a child with more chronic pain is likely to demonstrate despair, hopelessness, frustration and low expectations. Healthcare providers are often uncomfortable caring for patients who do not “appear to be in pain” and are more likely to suspect depression as the cause of the child’s behavior.
There are several different types of chronic pain that children may experience. Chronic pain in children may be associated with somatic or visceral processes, central or peripheral nervous system dysfunction, minor injuries (i.e., fractures, sprains, nerve injuries and tissue trauma), and disease states such as sickle cell and cancer. It also can develop in isolation of other physiologic problems. A child who reports pain that “just appeared one day” may have the same pain syndrome as a child who can identify a recent injury or illness. All children who report unusual pain should be evaluated and appropriately referred as soon as possible. Pediatric chronic pain can be continuous or recurrent, involve single or multiple body regions, and involve single or multiple organ systems.
Critical to the identification of a chronic pain syndrome is a careful history and exam. The history should include how and when the onset occurred, how it developed, a description of the pain, its sensory characteristics, the intensity, location, duration, variability, predictability, and its exacerbating and alleviating factors. Other areas to assess include family history of pain problems, the pain’s effect on the child’s life (i.e. sleeping, eating, school, activities, family interactions and friendships), previous treatments tried (including complementary therapies), and what specialists have been seen so far. The physical exam needs to be complete and comprehensive. Children should be re-examined fully once a complaint of pain has continued beyond its expected course. X-rays, MRIs and CT scans can be helpful in finding and/or ruling out pathologies, but should not be used as proof that nothing is wrong when the findings are negative. It is important to rule out other related illnesses by checking symptoms such as fever, cough, nausea/vomiting, dizziness and fatigue. Lab tests such as CBC with differentials, liver function, electrolyte panel, etc. are helpful in ruling out possible illnesses. While completing a complete head-to-toe exam, be sure to assess for muscle spasms, trigger points, and areas of somatic sensitivity to light touch (American Pain Society, 2001).
Headaches, abdominal pain and limb pain are the most common chief complaints among pediatric chronic pain patients. Migraines are reported in 3 percent of 7-year-old children and 11 percent of 14-year-olds. Migraines are more common in females during adolescence, but gender differences are less prevalent in younger children. The prevalence of tension headaches also increases through adolescence (DiMaggio, 2002) and these headaches are often accompanied by muscle spasms or trigger points. True cluster headaches and trigeminal neuralgia are uncommon in children, however, some children do suffer from these disorders. Treatment options for headaches can range from simple NSAID use to complex nerve blocks and IV infusions. Many headaches in children and adolescents can be managed by combining medications with a relaxation/biofeedback program and manual therapy to retrain poor posture habits and release muscle trigger points.
Abdominal pain is common in school-age children and adolescents. A careful history, including past medical history and social/behavioral history, is crucial when evaluating a patient with chronic abdominal pain. Treatment options may include medications to control specific GI abnormalities, medications to relieve muscle spasms in the abdomen, stress reduction programs, and physical therapy to balance the abdominal muscles and work on core stabilization. Many patients who are not treated for their abdominal pain promptly, develop secondary shoulder, back and neck pain as they adopt a hunching, protective posture.
Limb injuries are virtually unavoidable during childhood. Most children will incur minor injuries and will require no special treatment. Some children will have more complex fractures or other injuries that require intervention from a medical specialist. Almost all children fully recover from limb injuries with no sequelae. Rarely, children will develop pain in their limbs that is known as Complex Regional Pain Syndrome (CRPS). CRPS is a syndrome of pain that is not well understood. It sometimes presents with burning pain, autonomic dysfunction and trophic changes (these children can arrive with limbs that are shriveled, mottled, cold and hypersensitive), but CRPS can also be seen in children who have no obvious physiologic signs. Some children will simply present with a chief complaint of pain and hypersensitivity that is out of proportion to the limb appearance. CRPS was formerly called Reflex Sympathetic Dystrophy (RSD), but the new name describes it more accurately. CRPS is rarely reported before 9 years of age, however the incidence is increased in adolescent girls (DiMaggio, 2002). CRPS is more common in lower extremities in children, but can also be found to have upper extremity involvement as well. Fifty percent of children with CRPS report no previous trauma.
A team of physicians, nurses, occupational and physical therapists, psychologists and other specialty providers are needed to address the complex needs of children with CRPS and other types of chronic pain. Regardless of the pain source, treatment options for children with chronic pain include non-narcotic medications, complementary therapies (biofeedback, massage, acupuncture), regional anesthesia and nerve blocks, physical and occupational therapy and psychological support and counseling. Commonly prescribed medications for chronic pain include non-steroidal anti-inflammatories (NSAIDs), tricyclic antidepressants, NMDA blockers, alpha-2 agonists, local anesthetics and anti-convulsants. Historically, interventional therapies for children were secondary treatment options because children usually dislike needles. Today, interventions such as epidural diagnostic blocks, trigger point injections, continuous epidurals (caudal, lumbar or thoracic), and sympathetic and peripheral nerve blocks are used as primary treatment options because it is preferable to stop the chronic pain cycle as early as possible. These interventions are performed with deep sedation or general anesthesia in children in order to minimize pain and fear.
Medical treatments for chronic pain are intended to minimize the pain in order to allow the child to participate in active physical therapy. Treatment during therapy is focused on preserving the use of the painful area (DiMaggio, 2002). Physical and occupational therapy options can include TENS (Transcutaneous Electrical Nerve Stimulation) or other modalities, manual therapy, posture management, core stabilization, normalization of limb activity, aerobic training and desensitization. Exercises to increase flexibility, range of motion and strength can all be done under the guidance of the therapist in order to safely increase activity levels.
Nurses have powerful tools to assist children with complex and chronic pain. Paying attention to the child’s story while expressing concern and interest will build trust and hope in both the child and family. Providing choices to the child and family and taking an educational approach can help to refocus families on the things the child can do and may get them moving in a positive direction. Patient and family education and assistance with coordination of the various appointments are important factors in aiding a successful outcome. Nurses can also help by redefining goals toward increasing function, decreasing disability and improving self care and finding out how to motivate the child to engage in normal childhood activities. Combining knowledge with empathy, caring and nurturing will allow nurses to care for children with chronic pain more effectively.
References
American Pain Society. (2001). Pediatric chronic pain. APS Bulletin, Jan/Feb, 10-12.
DiMaggio, T. (2002). Pediatric pain management. In American Society of Pain Management Nurses (Ed.) Core curriculum for pain management nursing (pp. 398-408). Philadelphia : W.B. Saunders Company.
Goodman, J.E., & McGrath, P.J. (1991). The epidemiology of pain in children and adolescents: A review. Pain, 46, 247-264.
Task Force on Taxonomy. (1994). Classification of chronic pain: Descriptions of chronic pain syndromes and definitions of pain terms. Seattle : IASP Press.
