What Every Physician Should Know About Non-pharmaceutical Pediatric Pain Care
The physiologic, biochemical, and psychologic toll that chronic pain takes on adults has been well documented. Yet, while an estimated 15% of children in the United States suffer from some type of chronic pain, only in the past 20 years have physicians begun to focus on effectively assessing and treating pain in this population.1
The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.”2 Pain management pioneer Margaret McCaffery, RN, calls pain “whatever the experiencing person says it is, existing whenever he says it does.”3 Both definitions fail to address the experience of pain in infants and young children who cannot articulate what painful damaged tissue feels like or even where it is. Does that mean that infants and young children don’t experience pain? Certainly not. Recognition of this has finally led researchers to observe the behavior of infants and young and nonverbal children and to attempt to quantify their pain.
This article will review the tools for evaluating and measuring chronic pain in infants and young children and examine the biopsychosocial model and complementary therapies used to treat pain in pediatric populations. The pharmacological aspect of pediatric pain care has been well described elsewhere.4-8
Assessing and Measuring Pediatric Pain
There are many types of pain, each with its own distinct characteristics and etiology. Evaluating pain entails much more than merely quantifying it. In infants, children, and adolescents, assessment of pain should include a thorough biopsychosocial history, review of systems, and physical examination (these are usually obtained from parents in the case of infants and nonverbal children). Whenever feasible, physicians should ask the patient about the quality, location, character, duration, frequency, and intensity of the pain. It often helps, especially with older children and teens, to encourage the patient to tell a story about their pain in narrative form rather than asking a series of specific questions.9,10
While behavior and physiologic signs are useful, they can sometimes be misleading in pain evaluation.11 For example, a toddler undergoing an ear examination may scream and grimace out of fear, rather than pain. Conversely, children experiencing persistent pain from trauma, surgery, cancer, or sickle cell disease may seem withdrawn and quiet, leading their doctors (nurses, caregivers, even parents) to incorrectly assume that they are comfortable or sedated. Often, children don’t express or reveal pain because of fear (often well founded) of talking to strangers, disappointing or bothering people around them, getting an injection, or having to go back into the hospital, among other negative reinforcements. A child who is experiencing significant chronic pain may appear to be playing “normally” as a way to distract attention from pain. But this may be a coping mechanism and lead to the misinterpretation at another time that the child is “faking” pain. Therefore, the challenge for primary care providers is to interpret a child’s distressed behaviors and evaluate whether they reflect pain or any one of a range of other emotions.
In the United States, regularly documented pain assessments are now required for hospitalized children and children seeking treatment at outpatient hospital clinics and emergency departments. Several pain scales have been developed to assist in this process. Behavioral distress scales used for newborns, infants, and nonverbal children or those with communication difficulties evaluate a patient’s body movements, crying, and facial expressions.12-17 Autonomic and vital signs can also indicate pain but are non-specific; many may be indicative of fever, hypoxemia, and cardiac or renal dysfunction.
Children between the ages of three and seven are capable of describing the intensity, location, and quality of their pain. Self-report measures, such as drawings, pictures of faces, or graded color intensities, are often effective with this age group. Pain in children 8 years and older can be accurately evaluated using verbal or visual analog pain scales and numerical ratings. Verbal numerical ratings are now regarded as the “gold standard” for reliable pain assessment. The numerical ratings scale consists of numbers from 0 to 10, with 0 representing no pain and 10 representing very severe pain (there is some debate over the label that should be applied for the highest pain rating, but current consensus is to not use “the worst pain possible” since children can always “imagine” a greater pain).18 Researchers are also studying ways to assess pain in cognitively impaired children, but that remains a challenge (Table 1).
Non-pharmacological Treatment of Pain
In developing a pain management plan, non-pharmacologic approaches should be considered in addition to pharmacologic approaches regardless of the type of pain. Many simple techniques such as relaxation and breathing exercises, for example, have been found to work synergistically with pain medications to achieve optimal relief.
Thoroughly addressing psychological and developmental comorbidities at the outset can reduce the risk of ongoing pain later on following surgery, trauma, or even invasive medical procedures; these impact a child’s experience of pain and how he or she copes with it. Pediatric patients should be assessed for situational, general, separation and social anxiety, and post-traumatic stress, panic, and obsessive-compulsive disorders. They should also be evaluated for depression, including suicidal ideation and intent, as well as past history of suicidal attempts. Developmental assessments should include an evaluation of learning, motor, and communication disorders, including autism spectrum disorders.
Over the last decade numerous psychological and physical treatment modalities for pain relief have been shown to be safe and effective. They are now regarded as an essential part of an integrative approach to pain management.19 In some cases they have been proven to be more successful in treating chronic pain than their pharmacologic counterparts. For example, cognitive-behavioral treatments are more effective in treating chronic daily headaches in children than are many medications.20,21