Treat pain in children differently than adults

Children can suffer chronic pain like adults, but they also are more apt to recover from it, said Dr. Keith Slifer, the founding director of the pediatric psychology program at the Kennedy Krieger Institute’s department of behavioral psychology.

Slifer, also a part of Kennedy Krieger’s comprehensive pain rehabilitation program, talks about the best way to treat pain in children.

What are some common causes of chronic pain in children?

There are many different causes ranging from sports, other orthopedic or traumatic injuries, hyper flexible joints, inflammation, autoimmune conditions, intestinal dysmotility, and emotional or psychological distress. Sometimes the cause cannot be identified. It is typical for the pain to begin with an illness or injury.

With chronic pain, it continues even when the original physical condition has resolved. The continuing severity of pain and disability experienced by the patient typically cannot be explained by results on medical tests or scans. The most common pediatric conditions with chronic pain include: complex regional pain syndrome, recurrent abdominal pain, generalized chronic pain, migraine headache, concussion, sickle cell disease and Ehlers Danlos Syndrome, a connective tissue disorder. Other diagnoses may include fibromyalgia, myofascial pain syndrome, neuropathic pain and psychogenic pain. Recently the term “Pain Amplification Syndrome” or “AMPS” has been used to describe some of these conditions in which, for unknown reasons, the central nervous system interprets normal sensations from movement and touch as pain.

Why are children more able to recover from debilitating pain than adults?

Generally speaking the sooner a person can begin to receive interdisciplinary intervention for their chronic pain the better. Children are in the processes of physical, emotional and behavioral development and can be expected to have more plasticity or flexibility in their functioning. This occurs at the level of neuronal development because the brain is still developing and pruning networks of connections that can change with experience.

Although there is evidence of some plasticity in the adult central nervous system, the potential for regrowth and reorganization is much more limited. This is also the case with patterns of thinking, emotional responding, behavior and coping. Said plainly, children are less “set in their ways.”

When children can receive early and appropriate interdisciplinary treatment including physical therapy, cognitive-behavioral therapy and behavioral parent training, they have the best chances for complete rehabilitation and recovery. They have the potential to gradually resume typical physical functioning and recalibration of their nervous system to return to normal thresholds of pain perception.

Is it okay to treat pain in children with opioids?

Except in the cases of acute, intense pain from active illness, recent injury or surgery, it is best to avoid the use of opioids. The determining factor should be if there is physical disease or trauma that would be expected to cause the level of pain being reported or non-verbally expressed by the child until healing can occur. In such cases opioids for acute pain can be appropriate and helpful.

For pain in the absence of detectable physiological abnormality, nonsteroidal anti-inflammatory drugs, antispasmodic medications and non pharmacological physical intervention, such as cold packs or a heating pad, are usually the treatment of first choice.

Continued use of opioid medications beyond the acute phase of pain is more problematic. These drugs are not without negative side effects such as somnolence, lethargy, constipation and drug tolerance, requiring increasing dosages. Increasing dosages over time can be an insidious problem if opioids are continually increased in response to patient-reported pain experience and can, with the best of intentions, reach levels that can be dangerous, despite patients saying they do no more than “take the edge off” or help with sleep. A good rule of thumb is that if the pain continues after tests and scans show that injury or illness has resolved and patients continue to report high and unchanged levels of pain despite the use of opioids, it is most likely that the opioids are no longer effective or appropriate. They should be weaned under the care of a qualified physician and replaced with other medications that are more appropriate for chronic pain.

How is treating children with pain different than adults?

Children have greater potential for neurological, cognitive, emotional and behavioral plasticity. They also may have greater capacity for resilience and motivation to recover. With early intervention they are less likely to get locked into a downward spiral of catastrophizing, avoidance behavior, demoralization and depression. With appropriate intervention they can be taught helpful cognitive and behavioral coping skills to avoid long-term functional disability.

Although they are certainly impacted by psychosocial challenges that cause anxiety and distress and can amplify pain perception, children may have fewer responsibilities and demands that complicate their ability to focus on rehabilitation activities.On the other hand, in our modern western society some children are overburdened and over scheduled with educational, social, recreational sports and family activities.High achieving, perfectionistic adolescents whose parents have high expectations for their behavior and academic performance can be at particular risk.

Parents also may be vulnerable to becoming over solicitous and allowing a child who reports chronic pain to escape or avoid normative physical, educational and social demands. While attempting to let their child rest, recover and avoid emotional distress, they may allow the child to fall into a pattern of increasing inactivity, physical deconditioning, emotional dependence and social withdrawal. With children experiencing chronic pain, parent training and family therapy are particularly important.

What are the best ways to treat chronic pain in children?

Chronic pain in children is best treated by interdisciplinary rehabilitation services based on a biopsychosocial model of chronic pain. Depending on the child’s current level of functional disability, these services can be provided through outpatient medical, cognitive-behavioral and physical therapies or they may require more intensive day hospital or inpatient rehabilitation. The interdisciplinary services may include anesthesiology, physical therapy, rehabilitation medicine, and cognitive-behavioral therapy.

At the more intensive day hospital or inpatient levels, cognitive-behavioral therapists, pediatric psychologists and social work therapists provide emotional support for the children and parents. Educational, neuropsychological, occupational and recreation therapies as well as psychiatry services may also be indicated.

The combined therapeutic focus is on helping the child and family learn new ways to think about pain, new skills for coping with pain, and on systematic exposure to gradually increasing physical and social activities. Children are weaned from ineffective opioid medications, and may be prescribed other medications to calm inflamed or overactive nerves, manage anxiety and treat depressive symptoms. The child and family may benefit from hopeful encouragement and coaching on the use of cognitive-behavioral pain and anxiety management skills.

Children must learn to confront and fight back against their pain and reclaim their lives by gradually returning to school, physical activities, and participation in social, family and community life. The process can be slow and variable. Setbacks may occur, so therapists and families need to provide support and help motivate the child’s continuing effort and adherence to a long-term plan. In time, the pain may dissipate and eventually fade from the child’s daily focus and priorities.

When should parents seek help when their children are experiencing pain that won’t go away?

Chronic pain is defined as that which persists or recurs for greater than three months. If the child has been evaluated by medical specialists, medical testing and scans show no modifiable physical trauma or abnormality, and yet pain complaints and emotional distress continue, specialized help is needed. After a few months and repeated visits to physicians, if the child continues to report debilitating pain and avoids typical school, athletic and social activities, it is time to seek assistance from a specialized pediatric chronic pain rehabilitation program.

amcdaniels@baltsun.com

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