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14 Articles in Volume 12, Issue #8
Board-certified Doctor Cleared of Criminal Charges for High-dose Opioid Prescribing
John F. Kennedy's Pain Story: From Autoimmune Disease To Centralized Pain
Key Clinical Pearls for Treating Headache Patients
Lest We Forget Pain Treatment Is a Stepladder Approach
Mathematical Model For Methadone Conversion Examined
Pain Management Coding Changes Can Sting, But Knowledge Can Help Ease the Pain
Pain Treatment—Then and Now
Platelet Rich Plasma Prolotherapy For Rotator Cuff Tears: Case Challenge
September 2012 Letters to the Editor
September 2012 Pain Research Updates
The Sports Injury-Pain Interface: Highlights from the American Orthopaedic Society for Sports Medicine Annual Meeting
Trigeminal Neuralgia: A Closer Look at This Enigmatic and Debilitating Disease
What Every Physician Should Know About Non-pharmaceutical Pediatric Pain Care
When Referring Patients, Not All Pain Specialists Are the Same

What Every Physician Should Know About Non-pharmaceutical Pediatric Pain Care

This article discusses how to assess and measure chronic pain in pediatric patients and examines the various complementary therapies used in treatment.

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

Additionally, non-pharmacologic pain treatments may be generalized and applied to other treatment needs. For example, a child with cancer who learns self-hypnosis to reduce distress from lumbar punctures may successfully apply this skill to other stressful medical and nonmedical situations. In an abbreviated Cochrane Review of studies that examined the efficacy of psychological interventions for needle-related pain in children, the authors found that a combination of distraction, cognitive-behavioral interventions, and hypnosis produced larger effects in the treatment group than in the control group.22 Similarly, psychological and behavioral methods for acute procedural pain in infants and young children were supported in another Cochrane Review.23 Review of psychological interventions for chronic and recurrent childhood pain found these strategies effective in treating headache-related pain.19-21 Reviews also suggest that psychological interventions are effective in treating children with recurrent abdominal pain, sickle cell pain, and other chronic pain problems.19,24-27

When deciding which technique to use, it is helpful to pay attention to the child’s environment, positioning, and physical comfort. Be aware that non-pharmacologic techniques alone may not work for some children and analgesics may also be needed. Provide patients (and family members) with developmentally appropriate information as to what to expect given the child’s medical condition, procedures, and treatments. Include patients and their families in the discussion when deciding on a treatment modality.28,29 Finally, whenever feasible develop a communication plan among the treating clinicians to ensure a consistent message to the patient and parent and an integrative team approach.

Review of Therapies
The therapies that are often used in treating pediatric pain include relaxation, distraction, hypnotherapy (for school-aged or older children), biofeedback, yoga, massage therapy, individual psychotherapy, family education, acupuncture, transcutaneous electrical nerve stimulation, and physical therapy.30 Music and art therapy can be especially helpful for young and nonverbal children who have trouble with traditional talk therapy.

Relaxation
Relaxation techniques promote muscle relaxation and reduce the anxiety that often accompanies pain. These are commonly used techniques for preschool-aged and older children. To help induce controlled breathing, ask the child to focus on his breath and pretend that he is blowing up a big balloon, while pursing his lips and exhaling slowly.

Distraction
Distraction techniques help children of any age shift their attention from pain onto other activities. Bubbles, music, video games, television, the telephone, conversation, school, and play are all ample distractors. Asking children to tell stories, or having parents read to the child, or even mutual story telling can also help. Attending school and social and physical activities are powerful distractors but they help children develop self-confidence in their own abilities to cope and to regain function.

Hypnotherapy
Hypnotherapy, which is most effective for children 3 to 4 years or older, helps a child in pain focus on an imaginative experience that is comforting, safe, fun, or intriguing. Capturing a child’s attention alters his/her sensory experiences, reduces distress, reframes pain experiences, and creates time distortions that help the child to dissociate from the pain and enhance feelings of mastery and self-control.

For example, the child might be asked to imagine (picture in his head) a helium balloon with a string tied to his wrist. I might suggest that the child notice the color of the balloon and begin to feel the string tugging at his wrist as the wind begins to lift the balloon higher and higher. (Often at this point the child notices with curiosity that his arm is beginning to rise.) I might then suggest that when the balloon brings his arm up “high enough” he can “cut the string” and notice his heavy arm now drop to his lap. When his arm rests in his lap, that can be a signal for him to “be” in his favorite place … maybe watching TV, playing soccer, being at his birthday party opening presents, or wherever his brain takes him; when he is there, he can let me know. (At this point often the child has closed his eyes and will either tell me verbally or let me know with a raised finger that he is “there” in his favorite place.)

At this point, I might suggest that he take a few moments to really “feel” himself there, feel the sun on his shoulders and cool breeze across his cheeks if he is outside, and notice the feel of the ground beneath him, the colors, sights, sounds, and smells around him. I might then tell him that while he is there really enjoying himself, I will talk to the part of his brain that is the central control station for feelings and sensations in his body. He can look around and let me know when he finds the knob, lever, or switch that controls the feelings to his head (or arm or leg or whatever body part has the pain). Then he can turn down the volume of feelings to (that body part) and as he does so he might begin to notice the feelings in (that body part) begin to change. He needs to be sure to not turn down the volume too much or (that body part) might become numb with no feeling. He can turn it down until (that body part) has just as much feeling as he wants it to have. (Other suggestions can be provided and the child can be told that his brain has just learned something new and that it will be interesting to see what other new and pleasant things begin to happen. Then he can be helped to count himself out of the hypnotic state.)

Biofeedback
Biofeedback involves controlled breathing, relaxation, or hypnotic techniques used with a mechanical device that provides visual or auditory “feedback” to the child when the desired action is approximated. Common targets of action include muscle tension, peripheral skin temperature through peripheral vasodilation, and anal control through rectal muscle contraction and relaxation. Biofeedback also enhances the child’s sense of mastery and control, especially in children who need more “proof” of change than that from hypnotherapy alone.

Yoga
Iyengar yoga is the type of yoga used in our pain program and is especially effective for treating chronic pain, reducing anxiety, and improving mood, energy, and sleep. Over time, it enhances a sense of mastery and control while also promoting strength, balance, and flexibility. Through a series of “asanas” (body poses) Iyengar yoga is oriented to the specific medical condition or symptoms and the use of props, such as blankets, bolsters, blocks, and belts, helps children to assume healing poses (Figure 1). The child may also learn certain types of breathing (pranayama) for added benefit.

Figure 1. A child patient doing a back bend yoga pose.

Massage Therapy
Massage therapy, which is especially effective in children with myofascial pain, involves the therapist touching and applying varied degrees of pressure to the patient’s muscles and skin. For young children, it can be helpful to have parents learn and perform brief massage on their children before bedtime.

Psychotherapy
Individual psychotherapy can be used to address the cognitive, behavioral, and psychological contributors to pain. Assessing and treating these contributors—maladaptive coping, anxiety, depression, learning disorders, social problem-solving deficits, communication problems, relationship issues, unresolved grief or trauma, school avoidance, or other identified problems—can reduce acute distress and chronic stress load on the central nervous system, thereby reducing excessive arousal and pain.

Family education and/or psychotherapy, particularly cognitive-behavioral family approaches, have been shown to be effective by helping family members cope better with their child’s distress, as well as with their own. Through education, parents learn the mechanisms of pain and how to identify and alter family patterns that may inadvertently exacerbate the child’s pain experience. A major goal in pain treatment is to develop a plan that enables the child to manage his own symptoms and function independently. Towards that end, parents, caregivers, and teachers may need guidance to develop a behavioral incentive plan that will help the child return to school—perhaps with tutoring and other academic support—after a prolonged pain-related absence.

Physical Therapy
Physical therapy is effective in children with chronic musculoskeletal pain and those deconditioned from inactivity. Exercise appears to specifically benefit muscle functioning, circulation, and posture, also improving body image, body mechanics, sleep, and mood. The physical therapist and the child can develop a graded exercise plan for enhancing the child’s overall function.

Acupuncture
Acupuncture involves the placement of needles, pressure, laser, or electrical acupuncture points along a meridian, or energy field. Studies have show that acupuncture alleviates chronic nausea, fatigue, and several chronic pain states, including migraine and chronic daily headaches, abdominal pain, and myofascial pain. It is important for the acupuncturist to relate well to the child so that the experience isn’t traumatic, since added stress will undo the benefits gained.

TENS
Transcutaneous electrical nerve stimulation (TENS) is the use of a battery-operated tool worn by the child to send electrical impulses into the body at certain frequencies set by the machine. TENS is believed to be quite safe and can be tried for many forms of localized pain. Children often find TENS helpful and effective, especially for focal myofascial pain. There are no studies to determine for which types of pain TENS is most helpful.

Music and Art Therapy
Music and art therapy help young and nonverbal children, who would otherwise have difficulty with traditional talk psychotherapies, communicate feelings through creative non-verbal pathways. Some children more easily express fears and negative emotions through creative expression and, with the therapist, learn about themselves in the process.

Conclusion
Pain is a complex phenomenon encompassing physiological nociception, conscious perception, and emotional experiences within a psychosocial milieu. The diagnosis of pain and pain syndromes in children should be thorough and extensive. It is important to understand how pain affects the child’s social and school functioning, attendance in school, and parental behaviors towards the child. Ideally, laboratory testing and diagnostic procedures are guided by clinical indication. Overall, the management of chronic pain should emphasize the use of both pharmacologic and non-pharmacologic approaches and strategies, with a focus on enhancing coping and functioning. When conservative management strategies fail—and depending on clinical circumstances—physicians may find pain relief for their patients through medical management, such as opioids, or interventional procedures, such as nerve blocks. Even sucrose can be helpful.31,32

However, these more powerful medications used alone are not enough. Good psychological assessment and the inclusion of mind-body intervention should also be part of the treatment plan. A range of non-pharmacologic therapies has been proven to be highly effective in relieving chronic pain in children. Sometimes they are the modality of choice in lieu of pharmacologic approaches. In either case, they should always be considered and are an essential part of an integrative approach to pediatric pain management. Pharmacologic strategies, without adjunct approaches, are likely to fail if used in isolation.

Last updated on: March 25, 2015
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