Chronic Pain Management in Children

Key Points

• Chronic pain, or pain that persists or recurs for 3 to 6 months, is relatively common in children and can be associated with significant functional impairments
• Although evidence is lacking for individual aspects of treatment, interdisciplinary care is considered the best treatment approach for children with chronic pain, including medical, psychological, and physical or occupational therapy treatments
  • Medical treatment can include daily medications, as-needed medications, and potentially procedural interventions
  • Focus physical and occupational therapy on function, movement, and pacing
  • Psychological treatment centers on pain education and CBT (cognitive behavioral therapy), with potential for acceptance-and-mindfulness-based treatments
• In children with severe pain and disability that does not improve outpatient, IIPT (intensive interdisciplinary pain treatment) can improve pain intensity and function

Background Information

• Chronic pain, or pain that persists or recurs for 3 to 6 months, is relatively common in children and can be associated with significant functional impairments
• The WHO and the International Association for the Study of Pain created a classification system for chronic pain^1,2
  • Chronic primary pain syndromes describe persistent or recurrent pain that is associated with significant emotional distress or functional disability and is not a result of another primary diagnosis or painful condition^1,2
  • Chronic secondary pain syndromes evolve from a symptom of an associated diagnosis to a distinct problem that may persist beyond treatment of the associated diagnosis²
• Approximately 6% to 38% of children have chronic pain during childhood, including headache, abdominal pain, musculoskeletal pain, and widespread pain^3,4
• As many as 5% of children have significant pain-associated functional disability.⁵ Such disability can include⁶
  • School dysfunction
  • Peer and social dysfunction
  • Sleep problems
  • Parental burden
• Children with significant pain-associated disability have frequent absences from school and can struggle with academic performance⁶
  • Parents of such children also have significant distress and increased burden of care⁶
• Prevalence is higher in women, older children/adolescents, and those with socioeconomic risk factors (eg, lower income, use of public insurance, parental educational attainment)⁴

Approach to Treatment

• An ideal treatment model for chronic pain in children includes an interdisciplinary team offering a range of treatment options
  • This model integrates clinical practice with research and education⁷ (Figure 1)^8,9. This includes:
    • Psychology: psychological interventions have more supportive evidence than any other individual modality for chronic pain in children, although the overall quality of evidence is still low^10,11,12.
      • CBT (cognitive behavioral therapy), relaxation strategies, and biofeedback have the most evidence¹³
    • Physical or occupational therapy: an important role for physical and occupational therapies is to teach pacing to encourage function^14,15
      • Strategies that have been proposed for the treatment of chronic pain in children include^16,17
        • Cardiovascular conditioning
        • Aerobic exercise
        • Functional training
        • Postural training
        • Biomechanics education
    • Other services (eg, acupuncture, massage, nutrition, school services)
      • Integrative medicine is frequently used by children with pain through specialized diets, herbal supplements, manual therapies, and acupuncture
      • Such approaches are often a part of pediatric pain clinics in the United States^18,19
  • Biomedical interventions (eg, medications, procedures) have limited evidence for ongoing benefit and have potential for significant side effects including increased health care utilization.^20,21,22 Instead, interdisciplinary rehabilitation focuses on adaptive functioning with an expectation that function will improve before pain intensity²³
• The first opportunity to emphasize this model of treatment is initial feedback with a child and family
  • Include validation of symptoms, diagnosis with explanation, education, and emphasis of interdisciplinary care in feedback²⁴
  • Although an interdisciplinary team is the ideal treatment model for pediatric pain, most patients are initially seen in primary care settings, and it can be challenging for primary care physicians to discuss chronic pain or determine a treatment plan^25,26
• The Pediatric Pain Screening Tool has been developed to triage services that would be most helpful for individual children²⁷
  • This tool has 9 patient-reported items, 8 yes/no questions, and 1 rating from "not at all" to "a whole lot"
  • These items are divided into 2 subscales:
    • Psychosocial subscale, which includes items like the following:
      • "I worry about my pain a lot"
      • "I do not have as much fun as I used to,"
    • Physical subscale, which includes items like the following:
      • "My pain is in more than 1 body part"
      • "It is difficult for me to be at school all day"
  • A child’s score on each subscale and for the overall tool can guide referrals to physical therapy, psychology services, or a multidisciplinary pain clinic²⁷
• Evidence for pharmacologic management of pain in children is limited, with few studies of relatively low quality, extrapolation of adult data, and concerns for side effects^20,22
  • However, children are often prescribed multiple medications and report high use of OTC medications (eg, acetaminophen, ibuprofen)^28,29
  • Medications for chronic pain in children can be divided into daily medications that decrease pain intensity overall and as-needed medications for worst episodes of pain
    • Daily medication
      • Daily medications can include²⁰
        • Antiepileptics (eg, gabapentin, pregabalin)
        • Tricyclic antidepressants (eg, amitriptyline)
        • Serotonin-norepinephrine reuptake inhibitors (eg, duloxetine)
      • These medications have been shown effective in some conditions, although evidence is of low quality and borrowed from adult literature for other conditions^{30,31,32,33,34,35,36}
    • As needed medication
      • As-needed medications including relatively safe and commonly used OTC options (eg, acetaminophen, ibuprofen)^37,38,39
      • Prescription options include other NSAIDs and muscle relaxing medications^20,38,40
      • Opioid medications are not considered first-line treatment of chronic pain, but may be an option for severe acute pain as part of an interdisciplinary plan^41,42,43
  • Commonly used medications are summarized in Table 1, including side effects and summary of evidence^20,44,45,46
• Procedural treatment
  • Interventional procedures may be recommended for certain diagnoses (eg, epidural injections for radiculopathy, trigger point injections in myofascial pain)
  • Evidence for procedures is borrowed from adult literature²¹
  • As part of interdisciplinary care, include interventional procedures rather than choosing between procedures and other care
• Outpatient care
  • Outpatient pediatric pain clinics are typically interdisciplinary, with physicians, nurses, physical therapists, and psychologists incorporating medication management, CBT, relaxation training, and pacing-focused treatments⁷
  • Although such clinics require significant resources, they are shown to be cost effective for both hospitals and insurance companies⁴⁷
  • While outpatient interdisciplinary treatment is effective, it can be difficult for families to access services and adhere to recommendations^7,48
• Intensive interdisciplinary pain treatment
  • Some children continue to have severe pain-associated functional impairments despite appropriate outpatient treatment. Those children may benefit from either rehabilitation through IIPT (intensive interdisciplinary pain treatment) or an inpatient or day hospital program that incorporates at least 3 treatment disciplines^49,50
  • Overall, IIPT programs have shown significant improvement in functional disability with smaller improvements in pain intensity⁴⁹
  • These improvements occur regardless of pain intensity or pain distribution at the onset of program and can persist for multiple years following the end of intensive treatment^51,52
  • IIPT can also improve depression, anxiety, sleep, school performance, and parental factors^49,53,54
  • Due to the importance of parental factors, there has been increased focus on incorporating parent-focused treatment into IIPT to improve parents’ mental health, behaviors, and problem-solving skills^55,56,57

In addition to IIPT, which is resource-intensive and requires a large team, lower intensity outpatient programs have been introduced to address chronic pain in children.^58,59 Such lower intensity options may provide a lower cost alternative for some children or help to bridge the gap between traditional outpatient management and IIPT

• NSAIDs, nonsteroidal anti-inflammatory drugs; GI, gastrointestinal; TCAs, tricyclic antidepressants; QTc, QT interval corrected for heart rate; SNRIs, serotonin-norepinephrine reuptake inhibitors.

  Table 1. Commonly used medications for chronic pain in children.

  Class	Example medications	Indications	Side effects	Evidence per Cochrane Review
  As-needed medications
  Acetaminophen	Acetaminophen	Acute pain, adjunctive treatment	Hepatic injury	No eligible studies to include
  NSAIDs	Ibuprofen, naproxen	Acute pain, inflammatory conditions, abortive headache treatment	GI effects, kidney injury, bleeding disorders, hypertension	Small number of studies, insufficient data for analysis
  Muscle relaxants	Methocarbamol, cyclobenzaprine, tizanidine, badofen	Myofascial pain, spasmodic pain	Sedation, nausea, dizziness, serotonin syndrome for cyclobenzaprine	No review performed
  Opioids	Morphine, oxycodone, hydromorphone	Acute pain, postsurgical pain	Sedation, nausea, dependence, addiction	No eligible studies to include
  Daily medications
  Antiepileptics	Gabapentin, pregabalin, oxcarbazepine	Neuropathic pain, widespread pain, primary pain disorders	Somnolence, altered mood, weight gain	Small number of studies, insufficient data for analysis
  Antidepressants	Amitripyline and other TCAs Duloxetine and other SNRIs	Neuropathic pain, headache prophylaxis, abdominal pain, widespread pain, primary pain disorders Neuropathic pain, widespread pain, primary pain disorders	Somnolence, altered mood, dry mouth, prolonged QT interval (QTc), risk of serotonin syndrome Altered mood, nausea, risk of serotonin syndrome	Small number of studies, insufficient data for analysis

Nondrug and Supportive Care

• Psychological interventions
  • CBT: skill-based treatment that includes relaxation training, distraction techniques, and activity pacing, with little evidence on which aspect of CBT is more effective¹¹
    • CBT typically starts with pain education and establishing a rationale for psychological intervention
      • Pain education alone is an effective intervention in adults but has not been studied in children^11,60
    • In addition to pain education, CBT addresses altering maladaptive behavioral responses, challenging negative cognitions, and developing pain coping skills
  • Other psychological interventions effective for some populations include problem solving training, acceptance-based strategies, mindfulness, and positive psychology^61,62
    • ACT (acceptance and commitment therapy) is the name of an acceptance-based psychological therapy shown to improve pain, function, and engagement in activities of value in children with chronic pain⁶¹
    • ACTs overlap with aspects of traditional CBT, including the use of similar behavioral techniques
    • However, although CBT emphasizes the use of behaviors to reduce symptoms, ACT and other acceptance-based therapies emphasize accepting symptoms while continuing to engage in activities
  • In addition to cognitive-behavioral and acceptance focused treatments, family-focused and parent-focused problem-solving skills training is effective at reducing distress and improving function^63,64
    • Because families of children with chronic pain have poorer family functioning and a child’s function relates to parental distress and behaviors, parent-focused psychology is also important^65,66
• Integrative medicine
  • Acupuncture, the most common integrative option offered in interdisciplinary clinics in the United States, is suggested to be safe and potentially effective in children^18,67
• Physical and occupational therapy
  • Physical and occupational strategies that have been proposed for the treatment of chronic pain in children include^16,17
    • Cardiovascular conditioning
    • Aerobic exercise
    • Functional training
    • Postural training
    • Biomechanics education
  • An important role for physical and occupational therapies is to teach pacing to encourage function^14,15
    • Pacing is most helpful when focused on consistency and proactive decisions around amount of activity, rather than symptom-based strategies for stopping^68,69
      • One proposed strategy for mindful use of pacing is STAR (stop, think, act or ask, resume)⁷⁰
        • Stop: the child should stop or modify an activity during a planned pacing break
        • Think: this is an opportunity for the child to actively identify physical, mental, and emotional feelings that keep them from participating in an activity. Children with chronic pain can struggle to identify and name feelings other than pain, so this can be challenging
        • Act or Ask: the child should use a skill or strategy to address the feelings in the previous step or ask a designated person for help to identify a strategy. Strategies could include hydration, stretching, breathing, or another coping skill
        • Resume: after utilizing a skill or strategy, the child then resumes their activity as they were doing earlier or with appropriate adjustments

Drug Therapy

• Provide recommended drug(s), dosage(s), duration

Treatment Procedures

• Describe treatment procedures and surgical interventions, when applicable
• Include indications, contraindications

Monitoring

• Include specific measures (eg, clinical assessment, labs, imaging) and frequency if such recommendations have been defined