Pediatric Chronic Pain

Children 0-17 years old are a vulnerable demographic that need specific care in pain management since they rely on adults for assessment, prevention, and therapy. It is not uncommon for newborns, children, and teenagers to feel pain, both acute and chronic. Statistics gathered from pediatric hospitals show that children’s pain is widespread, frequently misdiagnosed, and inadequately addressed. 

According to a recent comprehensive analysis, neonates in intensive care units endure between 7 and 17 painful operations each day, with venipuncture, heel lancing, and peripheral venous catheter placement being the most common. 

Most infants do not make use of any analgesic methods. Children with life-threatening illnesses can endure numerous painful diagnostic and painful treatments (e.g., bone marrow aspirations, lumbar punctures). 

More so, even perfectly healthy kids have to endure a number of unpleasant medical procedures. Vaccinations are the most prevalent type of needle operation for children, and vaccine reluctance due to pain is a common problem.

Morbidity (e.g., intraventricular hemorrhage) and mortality are both enhanced when severe pain is endured without proper pain management. Premature infants that experience pain have been shown to have impaired cognitive and motor abilities, as well as increased pain self-ratings after venipuncture as they get older. 

Studies have indicated that childhood trauma can raise a person’s likelihood of experiencing mental health issues later in life (chronic pain, anxiety and depressive disorders). An effective pain management plan is essential for infants and children.

Prevention and Treatment of Pediatric Needle-related Pain

In the long run, untreated needle discomfort from operations including vaccines, blood draws, injections, venous cannulation, etc. can lead to needle phobia, pre-procedural anxiety, hyperalgesia, and healthcare avoidance, all of which raise the risk of morbidity and mortality. 

Four bundled modalities to reduce or eliminate pain experienced by children during elective needle procedures are strongly suggested based on current evidence, supported by guidelines from the Canadian Pediatric Society and HELPinKids, and recently brought forward by science-to-social media campaigns.

Healthcare providers and parents should generally speak in neutral terms and avoid phrases that may be perceived as deceptively soothing but instead serve to heighten anxiety (such as “it will be over soon” or “you will be ok”). 

Cognitive behavioral therapy, breathing techniques, distraction, and hypnosis were all found to be useful in lowering children’s pain and/or fear of needles in a recent Cochrane review. Many clinics and hospitals for kids across the globe now use a standardized protocol of four easy steps for all needle procedures involving children.

Needlestick Pain: Prevention and Treatment 

Provide a package of four approaches that have been shown to be effective for kids:

First, “Numb the skin” with topical anesthetics (for children 36 weeks corrected gestational age and older). 4% lidocaine cream, EMLA-cream, and the J-tip® (a sterile, single-use, disposable injector that uses pressured gas to drive drug into the skin) are all examples of topical anesthetics.

Infants aged 0-12 months can benefit from either sucrose or breast milk.

Relaxed holding, “Do not put down youngsters.” For any surgery involving a child, restraint is never helpful, always has a bad outcome, and exacerbates discomfort and fear. Swaddling, heat, skin-to-skin contact, and assisted tucking are all good options for babies. 

Children aged 6 months and up should be encouraged to sit up straight, with their parents either holding them or sitting nearby.

Distractions suited to the age group such as toys, novels, bubbles, pinwheels, stress balls, applications, films, or games on electronic devices.

Treatment of Severe Pediatric Pain

Tissue injury from disease, trauma, surgery, treatments, and/or disease-directed therapy can all contribute to nociception, or nociceptive pain. If acute pain isn’t addressed, it can cause dread of doctors and even prevent people from seeking care.

The standard method for treating complex acute pain nowadays is multimodal analgesia. Acute pain in children may require more than just pharmacology (including basic analgesia, opioids, and adjuvant analgesia). For more effective (opioid-sparing) pediatric pain control with fewer side effects than single analgesic or modality, the addition, and integration of modalities such as regional anesthesia, rehabilitation, effective psychosocial interventions, psychology, and spirituality is recommended.

Acute Pain: Prevention and Management Using a variety of Pain Relief Techniques

When compared to the use of a single analgesic or modality, the synergistic benefits of multimodal analgesia result in more effective pediatric pain control with fewer adverse effects There are a variety of medications that may be prescribed (based on the specifics of each case):

• Analgesics at the most fundamental level (paracetamol/acetaminophen, NSAIDs, COX-2 inhibitors, etc.)  
• Opioids (e.g. tramadol, morphine, methadone)
• Additional pain relievers (e.g. gabapentin, clonidine, amitriptyline)
• Intrathecal port/pump, neurolytic block, peripheral/plexus nerve block, and other forms of regional anesthesia
• Recuperation, Third (e.g. physical therapy, graded motor imagery [32], occupational therapy) (4) Psychology (e.g. cognitive behavioral treatment) (e.g. cognitive behavioral therapy)
• Integrative (“non-pharmacological”) methods (including mind-body techniques like diaphragmatic breathing, bubble blowing, self-hypnosis, progressive muscle relaxation, biofeedback, plus massage, aromatherapy, acupressure, and acupuncture) (5) Spirituality (e.g. chaplain)

Methods for Treating Chronic Pediatric Pain

There is a considerable problem with pediatric chronic pain, with conservative estimates indicating that 20% to 35% of children and adolescents are affected by it worldwide. More than 10% of hospitalized children display signs of chronic pain, and yet this pain is often misdiagnosed and untreated. 

About 3% of pediatric chronic pain patients require rigorous rehabilitation, while the majority of children who report chronic pain are not significantly impaired by it.

According to the American Pain Society’s 2012 Position Statement on the Assessment and Management of Children with Chronic Pain, chronic pain in children is the result of a dynamic integration of biological processes, psychological factors, and sociocultural variables within a developmental trajectory. 

However, a more functional definition is used to characterize chronic pain in children, such as “pain that extends beyond the expected period of healing” and “hence lacks the acute warning function of physiological nociception”. This is in contrast to the way chronic pain is typically defined in adult medicine, where arbitrary temporal parameters (such as 3 months) are used.

There appears to be success with an interdisciplinary strategy that includes 

1. rehabilitation; 
2. integrative medicine/active mind-body approaches; 
3. psychology; and 
4. regularizing daily school attendance, sports participation, social activities, and sleep. 

Pain relief and even complete disappearance are normal outcomes of functional rehabilitation. Main pain syndromes, such as centrally mediated abdominal pain syndrome, primary headaches (tension headaches/migraines), or extensive musculoskeletal pain, are not appropriate for opioids, and other drugs are rarely used as initial treatment.

A recent Cochrane review found that in-person psychosocial interventions for children and adolescents with headache and other chronic pain may be useful in improving pain outcomes. 

Both immediately following therapy and at follow-up, psychological interventions have been shown to be beneficial in lowering pain-related impairment in children and adolescents with a variety of chronic pain problems. 

Cognitive-Behavioral Therapy and Acceptance and Commitment Therapy are the two main types of psychological treatments studied extensively.

Incorporating parents into the multidisciplinary treatment is recommended because of growing evidence that it is crucial to address parents’ catastrophizing thoughts, parents’ anguish, and parents’ behaviors in relation to their children’s pain (e.g., protective behaviors).

Chronic Pain and Main Pain Disorders: Boxed Treatment

(1) Modalities of rehabilitation (such as physical therapy, graded motor imagery, and occupational therapy) 

(2) Modalities of integration (or “non-pharmacological” approaches) (e.g., mind-body techniques such as diaphragmatic breathing, bubble blowing, self-hypnosis, progressive muscle relaxation, biofeedback plus modalities such as massage, aromatherapy, acupressure, acupuncture)

(3) Science of Mind (e.g., cognitive behavioral therapy, acceptance, and commitment therapy)

(4) Getting Back to Normal (usually, life gets back to normal first, then the pain goes down – not the other way around). It may include activities like;

• Exercise and sports
• Sleep-hygiene
• Life in Society
• Going to Class

(5) Medications (may or may not be required) (may or may not be required)

First-line pain relievers (such as acetaminophen/paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs), and COX-2 inhibitors)

Additional pain relievers (e.g., gabapentin, clonidine, amitriptyline)

Importantly, opiates are typically NOT needed in the absence of new tissue injuries, such as in epidermolysis bullosa or osteogenesis imperfecta.

Finally

For more information on chronic pain management, pain disorders, chronic pain resources, psychogenic pain, effective chronic pain treatment options or other physical therapy, you should book a consultation session with a specialist at Chronic Therapy today, to give you professional advice that will suit your personal experience.

Also, for people with chronic pain who are constantly worried on how to treat chronic pain or get their chronic pain treated, our specialist at Chronic Therapy have made huge success over the year in recommending reliable resources to manage chronic pain from nerve pain or any other developing chronic pain conditions.