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Managing Chronic Pain in the Pediatric Patient

Most people think that chronic pain afflicts the elderly and those who have a number of different chronic medical conditions. Unfortunately, chronic pain is also a problem in pediatric patients. The American Pain Society recently released an article indicating that about a quarter of children worldwide suffer from chronic pain.

In children, there are many different types of chronic pain. Common examples include musculoskeletal pain, abdominal pain, and sickle cell disease. 

Functional Abdominal Pain
Functional pain is one of the most common reasons why children complain of abdominal pain. Unfortunately, functional pain is often a diagnosis of exclusion and is typically only diagnosed after a number of other tests have ruled out organic causes. Some important points to keep in mind include:

  • Functional abdominal pain typically develops slowly, over a period of weeks to months
  • This can be differentiated from the acute pain that follows an obvious injury
  • There are typically psychological, societal, and familial factors to consider

The most common type of functional pain is abdominal. This is a chronic, ongoing, and episodic pain that can be brought on by a number of different factors. Common triggers of functional abdominal pain in children include:

  • The anxiety that comes with performing publicly
  • Nervousness about going to school
  • Hesitance at trying something new or stepping outside of the child’s comfort zone

It is important not to criticize the child for these feelings. Instead, it is important to validate his or her concerns and offer encouragement. The goal of the treatment of functional abdominal pain is not to completely eliminate the pain but to control it to the point that the child can return to his or her routine. It is vital to address the obstacles to school attendance so that the child does not get behind on his or her schoolwork.

Sickle Cell Disease
Sickle cell disease is another common cause of chronic pain in children. There are lots of different types of sickle cell disease, including:

  • Hemoglobin SS disease
  • Hemoglobin SC disease
  • Hemoglobin S Beta Thalassemia

These are only a few of the many variants. Those with sickle cell disease often have the most severe symptoms, marked by frequent and recurrent pain crisis. From a young age, children with sickle cell disease learn what their triggers are. Some of the common ones include:

  • Altitude changes
  • Temperature changes
  • Dehydration
  • Illnesses, including the common cold

When these children are stressed, their blood vessels vasoconstrict and their blood cells start to sickle, leading to a vaso-occlusive crisis. This can be incredibly painful and, for most children, they know what their sickle cell pain is and where it occurs. Because pain itself is stressful, this is a positive feedback loop that exacerbates their pain. Therefore, it is vital to get on top of this pain and get it under control before it becomes intractable. Some of the important points in the management of a sickle cell pain crisis include:

  • Hydration is vital to prevent pain crises from occurring
  • Children should be educated to try oral pain medication (such as hydrocodone)
  • If this fails, they need to come to the emergency department for IV pain medication

Once these children reach the emergency department:

  • If there is a fever, blood cultures need to be drawn to rule out sepsis
  • If there are respiratory symptoms, a chest x-ray is required to rule out acute chest syndrome
  • Toradol is used to relieve inflammation
  • Morphine is typically first-line for pain medication
  • The starting dose is usually around 0.2 mg/kg q2-4h
  • Pain should be re-evaluated every 30 minutes and the dose repeated if necessary

If, after three rounds of IV pain medication, the pain is still not under control, these children should be admitted for management by a trained pediatric hematologist.

Pediatric Rheumatoid Arthritis
Rheumatoid arthritis is another common cause of chronic pain. Juvenile Rheumatoid Arthritis is another serious cause of chronic pain in children. Like functional pain, the goal isn’t to eliminate this pain completely but to allow the child to return to school. Some of the treatment points include:

  • NSAIDs are a cornerstone of treatment to relieve inflammation, acute pain, and swelling. Examples include Motrin, Advil, and Toradol
  • Disease-modifying agents (DMARDs) are used to prevent pain. Examples include methotrexate.
  • Biologic agents include tumor necrosis factor blockers, such as Humira, which help prevent long-term joint damage.
  • Intractable pain often requires steroids, such as prednisone, to control symptoms to the point that these above agents become effective.

Pediatric rheumatoid arthritis (also called Juvenile Rheumatoid Arthritis and Juvenile Idiopathic Arthritis) are is difficult to manage. Consultation with a pediatric rheumatologist is essential.

Chronic Pain is Challenging
Chronic pain is difficult to manage in children and it is important for you to involve the entire family in its management. And it is critical to think about the possible medical emergencies so that these are not missed. Often, children do not want to take medicine because they are worried that it will affect their personality or that they could become addicted. It is vital for healthcare providers to provide just as much education as medical management. This will help improve compliance with medication regimens and prevent the development of dangerous sequelae down the road.

Last updated on 9/25/19.

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