1. What types of pain do children experience?

Like adults, children can experience many different types of pain throughout their lives: acute pain caused by disease or trauma; acute pain and heightened emotional distress caused by repeated invasive medical procedures; recurrent episodes of headache, stomachache, or limb pain unrelated to disease; and chronic pain caused by injury, disease, psychological factors, or of unknown etiology.

However, the prevalence of certain types of pain is different for adults and children. For example, chronic back pain is a major problem for adults but not for children. Common pain problems for children include chronic headache, complex regional pain syndrome–type 1, and variants of pain and somatization disorder. Although the prevalence of these pains increases throughout childhood, few epidemiological studies have been conducted on chronic pain in children. Thus, little is known about the pathophysiology and the prevalence of different types of chronic pain; the children most vulnerable to develop chronic pain according to age, sex, ethnicity, personality; and individual risk and prognostic factors.

2. How do children’s pain experiences differ from those of adults?

Results from neurodevelopmental studies in animals and clinical studies in humans show clear developmental differences in pain sensitivity because of the increased plasticity of children’s nociceptive systems. Newborn infants are more sensitive to painful stimuli than adults. Children report stronger pain for stimuli that evoke moderate tissue damage in comparison to adults.

Also, children’s pain perceptions differ from those of adults because of developmental changes in their understanding and previous pain experiences. As children mature they experience a wider diversity of pains varying in location, intensity, and quality. Like adults, the nature and diversity of children’s pain experience form their frame of reference for perceiving any new pain and for evaluating its aversive significance. Yet, unlike adults who have generally a wide frame of reference of pain experience, children’s frames of reference change considerably as they mature and sustain more diverse types of tissue damage. Thus, even a mild level of tissue damage may evoke strong pain if the type of tissue damage is a new pain experience for a child or the maximum that the child has experienced.

3. What is plasticity?

Like adults, children can experience pain without tissue injury or any apparent injury at all. They can also sustain injury without experiencing pain and can experience very different pains from the same type of tissue damage. Children’s nociceptive systems are plastic in that they have the capacity to respond differently to the same amount of tissue damage.

We now know that children’s perceptions of pain depend on complex neural interactions. Impulses generated by tissue damage are modified both by ascending systems activated by a noxious stimulus (e.g., touch) and by descending pain suppressing systems activated by various situational factors, such as a child’s expectations about what he or she will feel.

4. What myths have complicated our management of children’s pain?

The following myths have complicated our management of children’s pain:

5. How do you assess pain in infants?

From birth, infants exhibit an array of distress behaviors (e.g., cries, facial expressions, withdrawal behaviors) and physiological reactions (e.g., changes in heart rate, blood pressure, oxygen level) in response to tissue damage. Health care providers assess pain by carefully monitoring these distress indices.

Several pain scales that can be used for children, including infants (Table 30-1 and Figs. 30-1 and 30-2), comprised of itemized lists of the various distress behaviors, have been designed to more specifically assess pain intensity. Clinicians complete these scales by observing infants for a specified period, noting which behaviors occur, and ranking their intensity on a 0-4 scale. The greater the number and intensity of distress signals, the greater the pain level.

TABLE 30-1. Verbal Descriptor Scales To Assess Pain Intensity For Children

Figure 30-1 Facial affective scale to assess pain affect.

(From McGrath PA: Pain in children: nature, assessment and treatment, New York, 1990, Guilford Press, with permission.)

Figure 30-2 Visual (A) and shaded (B) analogue scale to access pain intensity. The numbers are on the reverse side of the shaded gradation.

6. How do you assess pain in children?

Several behavioral pain scales have been designed for children, as well as infants. The majority are more appropriate for use with children aged 6 to 10 than with adolescents, because adolescents usually display different and more subtle distress behaviors. Because a child’s pain behaviors naturally vary in relation to the type of pain experienced, different behavioral scales must be used for children with acute, recurrent, and chronic pain. Children who are physically or developmentally impaired can be assessed using behavioral scales composed of the subtle cues that parents recognize; these scales are under development.

By the age of 5, most children can differentiate a wider range of pain intensities and can use many analogue, facial, and verbal rating scales (see Figs. 30-1 and 30-2) to indicate the strength of their pain. Children choose a level on the scale that best matches the strength of their own pain. These scales are easy to administer, requiring only a few seconds once children understand how to use them. Many of these scales yield pain scores on a scale of 0 to 10.

7. What role does self-report play in assessing pain in children?

Self-report pain measures potentially provide the most comprehensive information about children’s pain. Children can provide essential information about their pain in their own words. Children begin to understand pain through their own hurting experiences; they learn to describe the different characteristics of their pains (intensity, quality, duration, and location) in the same way that they learn specific words to describe different sounds, tastes, smells, and colors. Toddlers begin to communicate the presence of pain, using words learned from their parents to describe the sensations they feel when they hurt themselves. They can point to its general location. Gradually, they learn to distinguish three different levels of pain intensity, such as “a little,” “some or medium,” and “a lot.” Children under age 5 can use facial scales (children’s faces depicting different levels of distress) or concrete physical scales (object graded in size, poker chips that represent one to four pieces of hurt) to show how much pain they have.

8. Which pain assessment tools should be incorporated into routine clinical practice?

Pain assessment is an integral component of the diagnosis and treatment for children with pain. A thorough medical history, physical examination, and assessment of pain characteristics and contributing factors are necessary to establish a correct clinical diagnosis. Always ask a child directly about his or her pain experience, and obtain objective information about the pattern, intensity, and quality of pain to facilitate an accurate diagnosis. A few structured questions can be easily incorporated within the regular clinical interview. Children can be asked to describe their pain according to its similarity to other sensations they have experienced. In addition, ask children to rate their pain during the course of their medical treatment, using a simple validated scale.

No one pain measure is equally appropriate for all children or for all types of pain. Health care providers who treat a wide range of children’s pain problems need a flexible pain measurement inventory consisting of a brief pain interview for general use, a few pain scales (for younger and older children) that children can use in the clinic and at home, and a comprehensive interview (for children with recurrent and chronic pain) to evaluate the factors that can trigger pain episodes, exacerbate pain, or prolong pain-related disability.

9. Is there a basic treatment algorithm that covers pain control in children?

Yes. There is a basic treatment algorithm that covers pain control in children. It provides a brief summary of the steps to controlling pain in children (Fig. 30-3). The first step is to assess the child with pain, evaluating not only the primary sensory characteristics of the pain (its quality, intensity, location, duration, and aversive component) but also the extent to which situational factors (cognitive, behavioral, and emotional) may be influencing the child’s pain. Direct appropriate physical and medical examinations not only at the primary source of pain but also at secondary sources.

Figure 30-3 A treatment algorithm for controlling children’s pain.

(From McGrath PA, Brown SC: Pain control in paediatric palliative care. In Doyle D, Hanks GW, MacDonald N, editors: Oxford textbook of palliative medicine, 3rd ed, Oxford, in press, Oxford University Press, with permission.)

Once a differential diagnosis has been made, the treatment plan for most pains consists of analgesics, adjuvant analgesics, or anesthetic interventions, plus cognitive, physical, and behavioral interventions, to address all of the factors that contribute to the pain.

Children and parents should receive specific feedback on causes and contributing factors as well as the rationale for the treatments selected. Treatment includes measuring children’s pain regularly, evaluating the effectiveness of interventions, and revising the plan as necessary. Because the factors that influence a child’s pain are dynamic, not static, adjustments must be made to treatment regimens for children who will be experiencing recurrent or long-term pain.

10. What are the basic guidelines for selecting and administering traditional analgesic drugs?

Four simple concepts should be followed when administering analgesics to children: (1) by the ladder; (2) by the clock; (3) by the child; (4) by the mouth.

11. What does “by the ladder” mean?

“By the ladder” refers to a three-step approach for selecting progressively stronger traditional analgesic drugs (acetaminophen, codeine, or morphine) according to a child’s level of pain (mild, moderate, or strong). The approach is based on our scientific understanding of how analgesics affect pain of nociceptive origins. If the child’s pain persists despite use of the appropriate drug and recommended dosing schedule, the clinician moves up the ladder to the next most potent analgesic. Even when children require opioid analgesics, they should continue to receive acetaminophen (or nonsteroidal antiinflammatory drugs, if appropriate) as supplemental analgesics.

Recently, attention has focused on “thinking beyond the ladder” and using adjuvant analgesics as the first step for children whose pain has neuropathic origins. Adjuvant analgesics include a variety of drugs with analgesic properties that were initially developed to treat other health problems, such as convulsions and depression. These drugs more specifically target neuropathic mechanisms and are critical analgesics for certain types of pain.

12. Explain the term “by the clock.”

“By the clock” refers to the timing for administering analgesic medications. Analgesics should be administered on a regular schedule, e.g., every 4 or 6 hours, based on the drug’s duration of action and the severity of the child’s pain, not on an as-needed (PRN) basis, unless a child’s episodes of pain are truly intermittent and unpredictable. When PRN dosing is used, children must first experience pain before they can obtain pain relief. These breakthrough episodes of pain can cause serious problems for children who fear that their pain cannot be controlled. Unlike adults, who generally realize that they can demand more potent analgesic medications or demand more frequent dosing intervals, children have little control and little awareness of alternatives, and fear that their pain cannot be controlled. As a result, they may become progressively frightened and upset, so that their pain increases. Moreover, the doses of opioids required to relieve existing or breakthrough pain are higher than those required to prevent the recurrence of pain. Thus, it is essential to establish and maintain a therapeutic window of pain relief for children.

13. What does “by the child” mean?

“By the child” refers to the need to base analgesic doses on each child’s individual circumstances. No one analgesic dose will reliably relieve pain for all children who have a similar medical condition or similar level of pain. Instead, children vary with respect to how much of a drug or what type of a drug is required to control their pain. The goal is to select a dose that prevents children from experiencing pain before they receive the next dose. It is essential to monitor a child’s pain regularly and adjust analgesic doses as necessary.

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