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11 Articles in Volume 15, Issue #4
Biofeedback: Information for Pain Management
False-Positive Screen for Marijuana
Hypnosis: Tool for Pain Management
Managing Headaches in Children and Adolescents
National Pain Strategy—A Positive Step Forward
Neuropathy in HIV Patients: Pain Management Concerns
Novel Treatment Device for Phantom-Limb Pain
Pain in Children
Pain Studies Program Emphasizes Pain Education as a Public Health Imperative
Targeting a Saboteur of Surgical Outcomes: Pain Catastrophizing
The History of Prolotherapy

Pain in Children

Children can experience a wide variety of painful conditions—from migraine headaches to growing pains.

How does age influence the perception of the pain experience? We start at the beginning of the age continuum—from infants to children—and examine the role of age as it relates to social and physiologic development, cognitive processing, and coping skills.

The American Pain Society Task Force on Pediatric Chronic Pain has defined chronic pain as recurrent or persistent pain lasting longer than normal tissue healing time, approximately 3 to 6 months.1 Not long before this, it was believed that very young children did not feel pain. This belief was based on research from the 20th century that argued that for pain to be perceived, the myelination of the nerve pathways must be complete.2 In 1941, research by McGraw stated that because of the incomplete development of the cerebral cortex, children were incapable of any memory before the age of 6 months.3 Based on these findings, it was believed that infants and young children, who cannot articulate what pain feels like, rarely needed analgesic medicine after surgery.

Today, we know that nociceptors are in place from the 20th week of intrauterine life and that the peripheral pathways, although not yet myelinated, are in place before the end of the embryonic period.4,5 Therefore, we now know that all of the neurophysiologic structures involved in processing the pain signal are in place several weeks before birth. In addition, based on recent research, it now is believed that newborns are more vulnerable to pain compared to adults.6-8 Recognition of this has led researchers to observe the behavior of infants and young and nonverbal children to attempt to quantify their pain.

Children can experience a wide variety of painful conditions, such as cancer, arthritis, diabetic neuropathies, complex regional pain syndromes, fibromyalgia, irritable bowel syndrome, and headache, to name a few. For those interested in a more complete discussion on the types of pain in childhood, Schechter et al wrote an excellent chapter.9

Components of Pain

Because of the inconsistent criteria used in assessing pain in children, prevalence numbers vary widely. According to Perquim et al, during childhood the most frequent pain conditions are abdominal, musculoskeletal, and headache pain.10 The best estimate of the incidence of moderate to severe pain in childhood is 5%.11

The central question that needs to be explored is how children experience pain. Recent thinking has identified 3 components involved in childhood pain: the directive, discriminative, and cognitive components.5 According to Marchand, the directive component is transmitted by the C fibers, which represent slow and diffuse pain.12 The discriminative component is transmitted by the A-delta fibers, which are the faster, smaller myelinated fibers. The cognitive component refers to the brain and its capacity to understand the pain experience. The cognitive component is influenced by family, culture, education, and previous painful experiences.12

To better understand how these components interface, Table 1 provides a brief review of the major stages of child development. According to Piaget, the major stages of development are completed by age 14 years.

Chronic Pain in Children

As noted, one of the most frequent type of pain in children is headache, both tension and migraine (Figure 1). It is estimated that 20% of all pain in children is head pain, with migraine frequency increasing with age. Children with recurrent headache tend to be anxious, hypersensitive, and excessive worriers.13 Recurrent headache also appears to run in families, with at least one parent experiencing similar pain during their childhood.7 (See Headaches in Children).

Abdominal pain is the second most frequent type of chronic pain in children. Its incidence varies from 10% to 18%, with it most frequently occurring between the ages of 8 and 10 years. There are several reasons that have been forwarded to explain why this occurs. Children during this age tend to imitate their parents, and if they see significant others reacting to stress in maladaptive ways, they will model similar coping styles. The research suggests that abdominal pain also tends to run in families in which pain is a way of life.13

The third most frequent recurrent pain found in children generally is called limb or growing pain. This type of pain usually occurs between the ages of 8 and 12 years, and it affects about 4% to 15% of the children in this age range. It is difficult to treat because there rarely is any organic cause that can be determined and usually is not associated with any redness or swelling.13

Focus on Family Key

The above research strongly suggests that most of the different types of recurrent pain that children experience are directly related to family influences, both genetic and environmental. When I evaluate a child who has recurrent pain, the inclusion of at least one parent or caregiver is required. If the child is an appropriate candidate for behavioral treatment, the parent is required to sit in and participate. If I teach the child relaxation techniques, the parent also must learn the same techniques. I have found this format useful, because it allows the parent and child to practice together as a family in their own home. This approach also is beneficial because it reduces the pressure on the child as the identified patient and shifts the focus to the family.

Shifting the focus of treatment to the family has gained research support over the past decade. It now is recognized that parents who experience depression and anxiety are more likely to have children with chronic pain.14 The same research group also found that mothers of children with functional abdominal pain were 4.9 times more likely to have a history of depressive disorders and 4.8 times more likely to have a history of anxiety disorders.

This pattern of familial influences on the incidence of pain appears to carry over into the adolescent years. Mothers of adolescents with pain exhibited more symptoms of stress, anxiety, and depression compared to mothers with adolescents who were pain free.15 In addition, in a large population-based study in the Netherlands, maternal symptoms of anxiety during pregnancy predicted increased somatic complaints in the baby at 18 months of age.16 We need to be careful not to over interpret the research, but it suggests that maternal mental health may predict or predispose a child to develop recurrent pain. Early identification of mothers at risk for mental health issues is improving and early intervention is becoming more proactive.

Parental cognitive dysfunction and catastrophizing (ie, rumination, magnification, and helplessness) also appears to have influence on children who develop chronic pain.17,18 (See Catastrophizing). Research by Hechler et al suggests that a high level of catastrophic thinking in parents was related to the child’s level of pain intensity.18 Protective responses by parents also have been examined, and the research suggests that frequently attending to pain symptoms, such as by allowing the child to avoid regular activities, is related to increased levels of disability in children with chronic pain.19

Assessing and Evaluating Pain in Children

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 usually are 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.20,21

While behavior and physiologic signs are useful, they sometimes can be misleading in pain evaluation.22 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 assume incorrectly 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 that can 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 now are required for hospitalized children and children seeking treatment at out-patient 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.23-28 Autonomic and vital signs also can indicate pain, but they are non-specific; many may be indicative of fever, hypoxemia, and cardiac or renal dysfunction.

Between the ages of 3 and 7 years, children generally begin to be capable of describing the intensity, location, and quality of their pain. Self-report measures, such as drawings, pictures of faces, or graded color intensities, often are effective with this age group. Children 8 years and older can use verbal or visual analog pain scales and numerical ratings to help clinicians assess their pain. Verbal numerical ratings now are 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” because children can always “imagine” a greater pain).29 Researchers also are studying ways to assess pain in cognitively impaired children, but that remains a challenge (Table 2).30

Pain Treatment In Children

The treatment of pain in children has changed dramatically in recent years in the wake of an accumulating body of research that indicates a more proactive approach is warranted. In the past, children who experienced recurrent pain were treated minimally or not at all. There were a number of factors that contributed to this approach, including the fear of addiction, a lack of knowledge about how children communicate, and limited information about pediatric anesthesia.9,31

Any treatment plan involving children should be based on a multidisciplinary approach. Keep in mind that the main difference between the child and the adult is that the child usually is fearful, which requires pain providers to be patient, supportive, and understanding. Adult patients have a greater knowledge base that mitigates fear and misunderstanding for the most part. Providers also should be familiar with childrens’ physical, emotional, and mental development. Family-related influences must be taken into account because they may contribute to making the pain worse. Often children are overlooked when the pain provider is explaining the treatment. Pain practitioners should include the child by presenting the treatment in terms he or she can understand and providing reassurance that the treatment will be helpful.

Finally, it is important to include the parents or caregiver in this process because the child will look to them for emotional support.7

Physical Approaches to Treatment

A pain management plan should consider nonpharmacologic approaches 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.

The use of massage and therapeutic touch has been found to be useful to providers who have experience working with children. It also is helpful to teach parents these techniques so that they can provide additional emotional and physical support when providers are not available. Parents and providers should realize that children are more sensitive to physical contact compared to adults.

The use of acupuncture rarely is used because of the fear of needles in children, although there is one study on the use of acupuncture in a pediatric population that reported a high level of success.32 In addition, there is another study supporting the use of transcutaneous electrical nerve stimulation in a pediatric sample that demonstrated positive effects.7 Physical and occupational therapies may be especially beneficial because they are consistent with a child’s need for movement and activity. This approach could include the use of stretching, especially if the parent can model the activity and make it fun.

Behavioral Approaches

In my own practice, I have used relaxation therapy augmented by biofeedback for both children and adolescents. The youngest child I have treated was a girl, age 8, who presented with recurrent headaches. I remember that she was exceptionally curious, which helped her understand the nature of her pain. I should also mention that her mother sat in and also learned the same techniques so that they could practice together in their own home. She and her mom both did well, and the frequency and intensity of the child’s headache pain subsided to a point where all pain medicines were discontinued.

Parent participation is helpful, particularly for younger children, because it assists with generalization in the child’s environment, especially in identifying triggers that may be a result of a painful episode. Adolescents, on the other hand, present a unique challenge because sometimes they do not want their parents present. If that is the case, I will meet with the parents separately to go over treatment goals and approaches.

The research support for cognitive-based behavioral therapy for children has expanded in recent years. Initially, this support focused on children who presented with recurrent headache.33 Research has expanded to include abdominal, musculoskeletal, and disease-related pain.34 According to Palermo, research support for the inclusion of parent-strategies, including operant learning techniques, is growing.34 The focus of this approach is modifying parents’ response to pain complaints and encouraging adaptive methods to promote well-being.

In a related recent systematic review of parent interventions for chronic health conditions, problem-solving therapy was helpful in improving mental health of participating parents.35


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 and attendance in school, as well as parental behaviors towards the child. Ideally, laboratory testing and diagnostic procedures are guided by a clinical indication. Overall, the management of chronic pain should emphasize the use of both pharmacologic and nonpharmacologic approaches and strategies, with a focus on enhancing coping and functioning.

Last updated on: July 31, 2019

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