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Pediatric Chronic Pain

A Position Statement from the American Pain Society
Significance of the problem
Chronic pain is a significant problem in the pediatric population, conservatively estimated to affect
15% to 20% of children (Goodman & McGrath, 1991). Children* and their families experience
significant emotional and social consequences as a result of pain and disability. The financial costs of
childhood pain also may be significant in terms of healthcare utilization as well as other indirect costs,
such as lost wages due to time off work to care for the child (Li & Balint, in press). In addition, the
physical and psychological sequelae associated with chronic pain may have an impact on overall health
and may predispose for the development of adult chronic pain (Campo et al., 1999; Walker, Garber,
Van Slyke, & Greene, 1995).
* This term refers to all individuals in the pediatric age range (i.e., neonates, infants, and adolescents).
Definition of chronic pain
Acute pain follows injury to the body and generally disappears when the bodily injury heals. It is often,
but not always, associated with objective physical signs of autonomic nervous system activity. Chronic
pain, in contrast to acute pain, rarely is accompanied by signs of sympathetic nervous system arousal.
The lack of objective signs may prompt the inexperienced clinician to say the patient does not "look"
like he or she is in pain. (American Pain Society, 1999, p. 4)
Chronic pain can be differentiated from acute pain in that acute pain signals a specific nociceptive
event and is self-limited. Chronic pain may begin as acute pain, but it continues beyond the normal
time expected for resolution of the problem or persists or recurs for other reasons.
Chronic pain in children is the result of a dynamic integration of biological processes, psychological
factors, and sociocultural context, considered within a developmental trajectory. This category of pain
includes persistent (ongoing) and recurrent (episodic) pain with possible fluctuations in severity,
quality, regularity, and predictability. Chronic pain can occur in single or multiple body regions and
can involve single or multiple organ systems. Ongoing nociception can result in a sensitization of the
peripheral and central nervous systems to produce neuroanatomical, neurochemical, and
neurophysiological changes. It is important that assessment and treatment strategies be based on this
definition and related dimensions.
To evaluate and treat chronic childhood pain efficiently and effectively, the mind-body dualism must
be abandoned. It is meaningless to dichotomize chronic pain as organic versus nonorganic, because all
pain is associated with, at minimum, neurosensory changes. Maintaining this dichotomy is harmful
because such faulty thinking leads to over-medicalization (inappropriate investigations, procedures,
and interventions) or insufficient acknowledgment of the child's multidimensional experience and
underlying neurophysiology.
The International Association for the Study of Pain (IASP) characterized chronic pain as less than 1
month, 1 to 6 months, and greater than 6 months (Task Force on Taxonomy, 1994). Formerly chronic
pain was defined as having pain for longer than 6 months. It is now recognized that key elements of
chronic pain can be evident much earlier. Definitions also are influenced by developmental factors. For
example, recurrent migraine headache that lasts 1 hour in a 4-year-old is typical, whereas headache of
this length in adolescents would not likely be classified as a migraine.
Chronic pain may include varying amounts of disability, from none to severe, and may be independent
of the amount of tissue damage and perceived severity (Melzack & Wall, 1965). Biological,
psychological, social, cultural, and developmental factors can impact pain-related functioning.
Assessment
An evaluation of a child with chronic pain should include consideration of the biological,
psychological, and sociocultural factors in a developmental context (Bursch, Walco, & Zeltzer, 1998).
The evaluation should begin with a history of the current problem, including a careful description of
the pain, detailing the sensory characteristics, intensity, quality, location, duration, variability,
predictability, exacerbating and alleviating factors, and impact of pain on daily life (e.g., sleeping,
eating, school, social and physical activities, family and peer interactions). The history, evaluation, and
treatment of the current pain problem in terms of its onset and development should be detailed. Inquiry
should include the magnitude of distress for the child and family attributed to the pain, and the impact
of the pain on cognitive functioning, anxiety, depression, and feelings of hopelessness. Assessment
also should include what the child and family members perceive as the cause of the pain and how they
respond to it. History of past pain problems in the child and in other family members also should be

and shape appropriate public policy. physical interventions (e. For example. Education Pain management should be part of the educational curriculum of all health professionals who care for children. family interventions. TENS. referral to the appropriate subspecialist is indicated for more thorough evaluation. Most of the currently employed pharmacological strategies are extrapolated from adult trials without evidence of efficacy in children. the physical examination always should include observation of the child's general appearance. a typical pediatric history should include medical-surgical history. Controlled trials are needed to address safety and efficacy in this population. This approach includes specific treatment targeting possible underlying pain mechanisms. A complete neurological examination should be conducted. & Turner. marital disruption.. However.e. Muscle spasms. massage. opioid and non-opioid analgesics. friends. and ibuprofen seems to be more effective than acetaminophen (Hamalainen. Treatment also should address pain-related disability with the goal of maximizing functioning and improving quality of life. antidepressants. For example. oral routes for medication are preferable. and temperature. 1997b). McGrath. 1997a. support of children with chronic pain. reinforcement). weight. a treatment approach for a child with a recalcitrant myofascial shoulder pain might include amitriptyline for facilitating sleep. developmental milestones. and massage for pain. alpha-adrenergic blockers. For example. & Blanchard.g.). more detailed discussion can be found in the references organized by topic at the end of this document.. anticonvulsants. in adolescent migraine headache. Specific pain conditions and treatments Although the previously mentioned treatment strategies apply to all children with chronic pain. transcutaneous electrical nerve stimulation (TENS). Particular attention should be paid to recent stressful events.. gait. biofeedback. Vital signs should include height. Mass media coverage of chronic pain in children should be promoted (Kuttner. blood pressure. posture. and systemic and regional pharmacological interventions (e. physical therapy. A review with the family of current treatments for the pain should include inquiry about home remedies and alternative and complementary therapies (Zeltzer. Education of the public will increase community awareness. moves. Valkeila. Finley. such as deaths. assessment and management of chronic pain in children should be a mandatory part of pediatric residency. Kim. behavioral techniques (e. school. heart rate. Chen. Targeted . It is common for children with chronic pain to develop secondary myofascial pain because of abnormal body posturing and prolonged inactivity.g. hypnotics. and family medical and social history.. The physical examination will vary depending on previous assessments the child has undergone and the specific symptoms. cognitive- behavioral (e. School staff may benefit from education to facilitate reintegration and support of children with chronic pain in the classroom. partial or complete return to school should often be an early target of treatment for children with pain-related school absenteeism. Somatic pain may be elicited when the child tenses his or her muscles due to fear of the examination. For example. Whenever possible. acupuncture. It can be helpful to examine the painful area(s) multiple times during the examination. as well as symptom-focused management addressing pain. new school). anesthetics. It is helpful to remember that visceral pain. 1997). Bush. In addition to the pain history. 1995).elicited.g.g. & Santavuori. & Riveral. 1996. Referral to a pediatric pain program should be considered for children with complex or refractory problems. sleep disturbance. etc. If significant findings that have not been previously addressed are identified. self-regulatory behaviors such as hypnosis or biofeedback) strategies. Evidence-based treatments should be used whenever available.g. Treatment Treatment strategies should be based on the findings of the assessment and should address the inciting and contributing factors. may be referred to as somatic dermatomes.. occupational therapy). trigger points. Research More research is needed to provide evidence-based treatments in chronic pediatric pain. A multimodal approach often is more effective than a single sequential treatment approach. respiratory rate. or depressive feelings. social history (i. Treatment techniques include education about the pain experience and the pain problem.. and areas of somatic sensitivity to light touch should be assessed. and emotional and cognitive state. cognitive behavioral interventions have better evidence for efficacy than triptans (Hermann. birth and early childhood history. interests). anxiety. Multidisciplinary pediatric pain programs are a particularly valuable resource for this training. because of its afferent pathways. 1992). and other changes in life circumstances (e. anxiolytics. Hoppu.

K. Finley. and healthcare utilization. Outcome variables should be broad and include measures of pain and distress.A. . (1996). & Blanchard. physiology.V. Kuttner. nosology.. and assessment strategies. A. E. Hoppu. Examples of key scientific areas that need to be developed include epidemiology. 239–255. & Brent. Pain mechanisms: A new theory. Kim. and children with complex or refractory chronic pain should be referred directly to pediatric pain programs when possible... Principles of analgesic use in the treatment of acute pain and cancer pain (4th ed. 233–245. Glenview.. S.. The treatment of chronic pediatric pain would benefit from the development and support of cooperative pediatric chronic pain research consortia. J. Zeltzer. 971–979. Garber. 107–117). & Zeltzer. (1999). Life-span developmental approaches to pain.. crossover study.government and private funding for research in pediatric chronic pain should be augmented.S.. Gatchel & D.. Long-term health outcomes in patients with recurrent abdominal pain. L. J. G. Point Roberts. placebo-controlled.C... measurement of pain and distress. Making cancer less painful: A handbook for parents.. C. Gartner. L. & Wall. E.J.A. family factors. S. & Riveral.R. Li. Hermann. (1997a). (1997b). (1999). Classification of chronic pain: Descriptions of chronic pain syndromes and definitions of pain terms. 60. Zeltzer. & McGrath. 247–264. 223–253. Hamalainen. Van Slyke.C. Adult outcomes of recurrent abdominal pain: Preliminary results. P. 45–53. function.B.. M. D. J. Neurology.. Bursch. Reimbursement policies should reflect the multidisciplinary complexity and efforts required to assess and treat children with chronic pain. D. M.. but also would be relevant. G. Walco. C. (1997). R. and the relationship between pediatric and adult chronic pain.E. & Greene. References American Pain Society. Di Lorenzo. 19. Seattle: IASP Press. Prevention and treatment.. J. IL: Author. Psychobiologic approach to pediatric pain: Part II. Valkeila. & Balint. sociocultural studies..). Pain. in the long term. (1994).. E. 263–284. P.K. P.). Turk (Eds. quality of life. Journal of Pediatric Psychology.. Current Problems in Pediatrics. NS. 1999). integrated treatment of medical. Behavioral and prophylactic pharmacological intervention studies of pediatric migraine: An exploratory meta-analysis. (in press). L.. & Riveral. Task Force on Taxonomy. (1995). Campo. Chen. WA: Hartly & Marks Publishers. Bridge.. A child in pain: How to help. randomized. developmental neurobiology. Clinical studies should include detailed attention to definition of populations. and social factors may be the most cost-effective approach in the treatment of complex and refractory pediatric pain problems. and developmental variables such as pubertal status and cognitive function. E. Orlando. Advances in Pediatrics. A psychobiologic approach to pediatric pain: Part I. 48. for reducing the enormous costs of adult chronic pain (Walco & Harkins. Such funding would not only benefit children with pain and their families. Science. D. health services research. (1992). & Turner. gender. Ibuprofen or acetaminophen for the acute treatment of migraine in children: A double-blind. culture.A. J. the developmental psychology of pediatric pain.W.. Halifax. L. 150. B. & Santavuori. P. Kocoshis. (1995).. G.. C. Bush. (1998). (1965). developmental pharmacology. J.P. In R. 20.A. Bush. 103–107. L. Clinical assessment and management of chronic pain and pain-associated disability syndrome.K. Melzack.. Many pain approaches validated on adults that lack a developmental and family focus may be inappropriate or even potentially harmful for children with chronic pain. clinical science (including clinical trials). Journal of Developmental and Behavioral Pediatrics.. P. what to do.. (1999).J. Walco. L.. psychological. Pain. Colborn.. Psychosocial factors in pain: Critical perspectives (pp. 46. & Harkins.L. History. 27. Chiappetta. J. documentation of interventions.D. 27.J.P.. New York: Guilford Publications. Walker. Goodman. McGrath. Chen. Policy Children with chronic pain should have access to appropriate services. Cyclic vomiting syndrome: The evolution of understanding of a brain-gut disorder.J.. Canada: IWK Hospital for Children.K. J. A. Comprehensive. FL: American Gastroenterological Association. Gaffney. B.P. (1991). Current Problems in Pediatrics. The epidemiology of pain in children and adolescents: A review. J.