chronic pain in children

What Is Chronic Pain In Children?

Chronic pain is often defined as recurrent or continuous pain lasting more than three months. Chronic pain is not a uniquely adult issue. It is estimated that at least 15% of children live with chronic pain. Girls suffer more frequently from chronic pain than boys. Furthermore, rates of chronic pain increase with age. The most common cause of chronic pain in children is headache (23%), followed by abdominal pain and musculoskeletal pain.

Pain, whether acute or chronic, tends to be neglected in children. First, children react differently than adults when it comes to pain. Second, doctors may focus on the source rather than the symptom. Third, some doctors just don’t understand pain management in children.

Signs of discomfort or pain in children may be:

  • A decrease in activity, also known as lethargy
  • Favoring one arm or leg over another
  • Decreased appetite
  • Difficulty sleeping
  • Irritability
  • Neediness
  • Non-verbal cues such as gasping, frowning, or wincing
  • Physical cues such as dull eyes, rapid breathing, sweating, or flushed skin

Chronic pain in children is indeed an important public health problem. A Canadian study concluded children and adolescents with chronic pain have a difficult time with peer relationships. A Dutch study recorded chronic pain in 25% of children taking part in the clinical trial. A German study found more than two-thirds of responding children with chronic pain reported restrictions in daily living activities due to pain.

In the same study, 30 to 40% of children with chronic pain responded that pain had moderate effects on the following areas:

  • School attendance
  • Participation in hobbies
  • Maintenance of social contacts
  • Appetite
  • Sleep
  • Increased utilization of health care services

Causes Of Chronic Pain In Children

Chronic Pain in ChildrenPain is a very personal and subjective topic. A pain history is a key tool in diagnosing and finding the cause of chronic pain in children. Characteristics routinely taken into account are the patient’s own description of the type, timing, and location of pain. Descriptors of pain such as dull or sharp, intermittent or constant, or aching or burning may provide great clues. Chronic pain occurs in a variety of locations in the body and for many different reasons.

Chronic pain in children may be caused a number of diseases and conditions and include:

  • Arthritis
  • Chiari malformation (structural defects in the area of the brain called the cerebellum)
  • Chronic regional pain syndrome (CRPS)
  • Inflammatory bowel disease—Crohn’s disease and ulcerative colitis
  • Dysautonomia
  • Ehlers-Danlos syndrome
  • Marfan syndrome
  • Fibromyalgia
  • Multiple sclerosis (MS)
  • Postural orthostatic tachycardia syndrome (POTS)
  • Reflex sympathetic dystrophy (RSD)
  • Syringomelia
  • Tethered spinal cord
  • Sickle cell disease

Treatments For Chronic Pain In Children

The treatment of chronic pain in children requires a multidisciplinary approach and a combination of drug and non-drug therapies. The pain team in children with chronic pain often includes a physician (pediatrician or anesthesiologist), nurse, clinical psychologist, physical therapist, and other professionals such as occupational therapists and social workers.

As a general rule, chronic pain in children is under-recognized and undertreated. Many clinicians base their treatment of chronic pain on discussions among themselves at meetings, or base their treatment of children on adult models, which is not always appropriate. It should be made clear that most of the drugs used to treat chronic pain in children have not been approved for pediatric use or for the specific pain conditions for which they are used. This fact is oft cited as a major disadvantage for clinicians treating chronic pain in children.

Analgesics, or pain relievers, such as acetaminophen (Tylenol) and non-steroidal anti-inflammatory drugs (NSAIDs) are commonly part of the treatment of chronic pain in children. Despite acetaminophen being used as a first-line agent, there are no clinical trials, ongoing or in the past, looking at its use for chronic pain in children. Examples of over-the-counter NSAIDs include ibuprofen (Advil, Motrin) and naproxen sodium (Aleve). Currently there are no recommendations for the long-term use of ibuprofen in children with chronic pain. Children with chronic pain have often tried various doses of acetaminophen and NSAIDs with little benefit.

Anti-seizure medications such as gabapentin (Neurontin) and pregabalin (Lyrica) have become popular in the treatment of chronic pain attributed to nerve pain (neuralgia) or disease (neuropathy) in adults. But in children with chronic nerve pain there is no conclusive evidence for their use. Tricyclic antidepressants also are used in children with chronic nerve pain, although there is no published evidence supporting the practice in children. The antidepressant duloxetine (Cymbalta), which is helpful in adults with fibromyalgia, is not labeled for use in children. Opioid, or narcotic, medications are used infrequently in children with pain not due to cancer. Again there is no evidence to support their use in children with chronic pain.

Psychological therapies such as relaxation, hypnosis, coping skills training, biofeedback, and cognitive behavioral therapy (CBT) may be helpful in the treatment of children with chronic pain.  Evidence exists that supports the effectiveness of psychological therapies in reducing chronic pain in children as a result of headache and non-headache pain conditions, but these effects were only maintained for children with headache pain conditions. Psychological therapies were also effective at reducing post-treatment anxiety in children with chronic pain secondary to headache.

Conclusion

Chronic pain in children is widespread, under-treated, and poorly understood. The adequate treatment of chronic pain in children requires a multidisciplinary and multi-treatment method approach. Drug therapy is based on adult models for chronic pain. Non-drug therapies, specifically psychological treatments, have been found helpful in reducing chronic pain in children with both headache and non-headache conditions.

Overall, there is consistent agreement for the need of rigorous randomized clinical trials with respect to the treatment and management of chronic pain in children.

References

  1. Goodman JE, McGrath PJ. The epidemiology of pain in children and adolescents: a review. Pain. 1991 Sep; 46 (3): 247-264.
  2. Eccleston C, Malleson P. Managing chronic pain in children and adolescents. BMJ. 2003 June; 326: 1408.
  3. King S et al. The epidemiology of chronic pain in children and adolescents revisited: a systematic review. Pain. 2011 Dec; 152 (12): 2729-2238.
  4. Roth-Isigkeit A et al. Pain among children and adolescents: restrictions in daily living and triggering factors. Pediatrics. 2005 Feb; 115 (2): e152-162.
  5. Perquin CW et al. Pain in children and adolescents: a common experience. Pain. 2000 Jul; 87 (1): 51-58.
  6. Forgeron PA et al. Social functioning and peer relationships in children and adolescents with chronic pain: a systematic review. Pain Res Manag. 2010 Jan-Feb; 15 (1): 27-41.
  7. Eccleston C et al. Psychological therapies for the management of chronic and recurrent pain in children and adolescents. Cochrane Database Syst Rev. 2012 Dec 12; 12: CD003968.
  8. Gregoire M, Finley GA. Drugs for chronic pain in children: a commentary on clinical practice and the absence of evidence. Pain Res Manag. 2013 Jan-Feb; 18 (1): 47-50.

 

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