Pain is one of the most common reasons for a parent or caregiver to seek medical attention for their child. Children experience pain for a wide variety of reasons, many that are similar to if not exactly the same as causes of adult pain, but historically pediatric patients have been grossly undertreated. I am 37-years-old and, sadly, if I had undergone a surgical procedure as an infant there would have been a significant chance that I would have received no analgesia at all. Things are better now, but there remains a large gap between what is recommended and how pediatric pain management is practiced in the real world.
The appropriate management of a child’s pain is a vital aspect of compassionate and high quality care, and it is simply the right thing to do. Failing to treat pain effectively is ethically no different than purposefully causing pain in a child, and it can have serious repercussions. Poorly controlled pain can interfere with a child’s recovery because of the negative impact of catecholamine surges and other stress-related chemicals, and impair the ability to take part in physical or occupational therapy. It can also make future encounters with health care professionals more challenging because of anxiety and mistrust.
Untreated pain can interfere with deep breathing, potentially leading to prolonged need for supplemental oxygen and increased risk of pneumonia. It can prevent restful sleep, which has myriad health consequences beyond just cognitive impairment. Pain can interfere with the family unit by significantly increasing parental or caregiver anxiety, which can lead to neglect, abuse, and increased utilization of healthcare resources. Poorly-managed acute pain can increase the likelihood of a patient, even a child, developing chronic pain. There is even good evidence in neonates (my next post I think), that poorly managed acute pain can lead to increased sensitivity and an increased pain response to future occurrences of procedural pain, such as routine immunizations.
Multiple reports throughout the 1970′s and 1980′s revealed that pediatric patients received substantially less pain treatment compared to adults for equivalent conditions, such as broken bones and hernia repair. Despite steady improvement in pain management in kids over the past few decades, we still have a long way to go. Though appropriate anesthesia is now standard of care in children of all ages, many physicians are uncomfortable with evaluating and treating acute pain (chronic pain is another topic) in children. And many parents are resistant to the use of safe and effective pain medications.
Even with physicians that might profess their comfort with recognizing and treating pediatric pain, my admittedly personal experience is that many still allow kids to be in pain at times for a variety of reasons. However, it isn’t that these physicians and caregivers are heartless or enjoy watching their patients, or their children if it is a parent putting up a roadblock, suffer. Even knowing a child is in pain can sometimes be challenging. And there are many misconceptions regarding pain in children that interfere with appropriate treatment. The bulk of these misconceptions involve the use of opioids. All of these misconceptions and false beliefs should be amenable to education and increased awareness of science-based guidelines.
Pediatric pain is a challenging entity. So much so that many institutions have pediatric pain teams. My wife is an expert on pediatric pain and spends her days, and often nights, as a palliative care pediatrician helping to manage pain and other symptoms in children who are approaching the end of life. Her insights and expertise on this topic have been invaluable in my own encounters with pain as a pediatric hospitalist. Her experience, like mine, is that even at major academic institutions pain management is regularly not approached systematically, nor based on the best available evidence.
So what is pain exactly, and how is it assessed in kids?
A brief primer on pain
At its core, pain is an unpleasant sensation or emotional experience that can occur when there is tissue injury, when we expect tissue injury to occur, or when we think there has already been tissue injury. It is entirely subjective and personalized. Each individual learns over time, through their own personal experiences, what sensations and emotions to label as pain and how to express the severity of that pain verbally once they have achieved that stage of cognitive development. There are many ways that this process can get tripped up, leading to chronic pain even after any tissue injury has healed, but that deserves its own discussion so I will stick to acute pain. Of course children with chronic pain can have acute pain as well. It’s complicated.
We generally break pain down into two categories, nociceptive and neuropathic, and nociceptive is further broken down into somatic and visceral pain. The label nociceptive pain is given to pain initiated by otherwise-healthy pain receptors present in injured or inflamed tissue. Somatic describes pain associated with skin, soft tissue, muscle and bone while pain from our internal organs is visceral. The difference clinically is that with visceral pain it is hard for patients to describe a specific location of their dull- or cramping-type pain, while somatic pain is sharp, throbbing and they can point right to it. Neuropathic pain involves damaged sensory nerves rather than specific pain receptors and is typically more of a burning, tingling, or shooting pain.
Pediatric pain assessment basics
The key to appropriately managing pain in a child involves deciphering the clues obtained from a thorough history taking and physical exam, in order to assess the type of pain, where it is coming from and the severity. We use self-reporting methods when we can, but obviously it often isn’t as simple as just asking the patient to rate their pain on a 1 to 10 scale. There are behavioral observational scales validated on pediatric patients, such as young infants and toddlers, who are unable to self-report but we must frequently rely on details provided by caregivers. These caregivers, no different than the rest of us, can fall prey to stress and cognitive biases that alter their memory and perception. Also, there is always concern that observational assessment may underestimate pain compared to self-report.
We must also frequently deal with adolescent patients whose ability to reliably rate their own pain using a numerical scale is suspect because of psychiatric conditions, maladaptive responses to stress, and even malingering, though this isn’t common. In general, it is considered best practice to take the patient’s word for their pain severity, at least until you have a good relationship with them and ample evidence that their pain reporting is unreliable. Not treating pain is unacceptable and I would rather treat a thousand kids for pain unnecessarily, but safely, than allow one child to suffer needlessly.
As in the adult world, we are called upon to assess neurologically impaired patients that might be in pain or may simply be agitated for some other reason. These children, who are unable to communicate because of neurological impairment, are particularly challenging. The best practice is to make use of observational clues and to trust the caregiver, who is usually quite familiar with the patient’s typical patterns of behaviors and vocalizations when facing regular day-to-day stresses. They are best able to point out when these patterns have changed or are inconsistent with other possible etiologies for the concerning changes. The parent of a severely cognitively impaired 15-year-old boy may be able to tell us, for instance, that a particular period of moaning, grunting, change in muscle tone or posture, or other behavior is not what is typical for him when he is merely hungry or has a cold. That being said, this population of pediatric patients still are often victims of untreated pain.
Pediatric pain management pearls
Compared to when I was an infant in the late 1970′s, the options for treating pain in children have only improved a little. There are few new pharmaceutical agents and there has been an expansion of adult approaches to pain into the pediatric sphere. These improvements, whether talking about the use of an old drug in a new way like methadone for pain in kids or transdermal fentanyl patches, are typically only used by experts like my wife. It is not even entirely clear that these newer approaches are better.
The bulk of the improvement in pediatric pain management, and again there is plenty of room for improvement, is that we somewhat more reliably treat kids who are in pain that would have suffered through it in the past. A physician doesn’t need to be an expert, and to be comfortable using every drug in the book, to be able to provide good care for most children with pain. The key for managing pediatric pain effectively is to become familiar with the use of just a few drugs, to not be afraid to use them when appropriate, to make use of non-pharmaceutical methods of pain control and to be consistent and systematic in our approach. Our goal should always be to control and prevent acute pain.
Decades ago, the World Health Organization (WHO) developed guidelines for treating pain and an analgesic ladder of pain management that has now been adjusted for use in pediatric patients. It entails a stepwise approach to pain based on the severity and response to any intervention. I’ll give you the quick and dirty version of the WHO guidelines:
- Assess for pain, and severity of pain, regularly in injured or sick kids.
- Use non-pharmaceutical methods like massage, play therapy, distraction techniques and cognitive psychotherapy in addition to drugs, especially with painful procedures like blood draws and abscess drainage if not sedated. (Please don’t get me started on acupuncture.)
- With anything more than minor pain, schedule pain medication around the clock instead of waiting until they are hurting.
- Use oral pain medications whenever possible and avoid uncomfortable intramuscular or rectal administration.
- Anticipate and treat side effects.
- Use non-analgesic medications when appropriate to treat neuropathic pain, anxiety, or swelling that might be adding to the perception of pain.
The 2-step pediatric analgesic ladder essentially amounts to using big drugs for big pain and little drugs for little pain, as my wife likes to say. We generally use non-opioid medications like acetaminophen and ibuprofen on step one (little pain) and opioids on step two (big pain) or when little pain doesn’t respond to the step one approach. Non-analgesic medications can be given on any step depending on the circumstances, and non-pharmaceutical measures should always be put into use.
I like the QUEST approach as a framework for a physician learning about pain management to build on:
Question the child
Use a pain scale
Secure parent involvement
Take cause of pain into account
Take action and evaluate results
Comfortable children or: How you should learn to stop worrying (too much) and love morphine
No pharmaceutical intervention is risk free. But, as has been pointed out time and time again on SBM, the poison is typically in the dose. Dosed appropriately based on a child’s weight, and used appropriately based on science-based guidelines, opioid medications are extremely safe and effective in the treatment of pain in children of any age. They are just one piece of the puzzle, but unfortunately they are most often the missing piece.
First off, with rare exception, non-opioid medications like acetaminophen and ibuprofen should always be used for mild pain and in conjunction with opioids for more severe pain. They are safe when dosed right and very effective. For some causes of pain, ibuprofen is preferred over acetaminophen because of its anti-inflammatory properties. And because I’m a pediatrician, I’m compelled to mention that aspirin should never be given to a child less than 19 years of age unless directed to do so by a physician because of the association with Reye syndrome, a sometimes deadly encephalopathy that can injure multiple organs systems.
Now the good stuff. There are many options for using opioid medications and they can be given by the IV, oral, transmucosal (fentanyl lollypops), and transdermal (fentanyl patch) route. Generally IV morphine is the first-line opioid for severe pain, but hydromorphone (dilaudid) is also commonly used in kids, as is fentanyl, although it is used mostly when sedation is desired along with pain control during an invasive procedure. Children with moderate acute pain are typically given oral agents such as oxycodone or tramadol, at least they should be, but are often given combination products containing acetaminophen and codeine or hydrocodone (lortab). I’ll explain why this is not a good idea.
Historically combination drugs like acetaminophen and codeine, or acetaminophen and hydrocodone, have been given to people of all ages for moderate pain, often after surgical procedures for use at home while recovering. In the pediatric population, which is all I can really speak for, we have been trying to move away from their use, and especially the use of codeine, for years. Unfortunately it is still commonplace to see these drugs prescribed by non-pediatric surgeons and dentists, and I do still see them used by some pediatricians.
What’s the problem with these medications? Why should codeine in particular be wiped from the minds of anyone with the ability to prescribe it? Because the potential risks far outweigh the potential benefit. Here’s why.
In August of 2012 the FDA, which had been made aware of 3 pediatric deaths in children receiving standard doses of codeine for analgesia after having their tonsils and/or adenoids surgically removed, and one case of severe respiratory suppression, issued a warning. A few months later they issued a stronger “boxed warning” for inclusion on product labeling. Many pediatricians stopped using it and pediatric hospitals began removing it from their formularies in droves.
It shouldn’t have taken these deaths to get to this point though, because we have better options available. But codeine had developed a reputation as a good choice when a weak opioid was needed. People thought it was safer than just giving lower doses of what are commonly thought of as stronger drugs like oxycodone and morphine. It isn’t.
The way codeine provides analgesia is by its conversion to morphine in our bodies. The problem is that in some people, around 1-2%, this conversion is more robust than would be expected. In these hyper-metabolizers, the body doesn’t have to time to return to baseline before the next dose is given. So over multiple doses, this can lead to a stacking of adverse effects, primarily respiratory suppression and sedation, without an improvement in analgesia.
Another problem with codeine is that a larger percentage of the population doesn’t metabolize it much at all. They won’t stop breathing, assuming an appropriate dose is given, but they aren’t protected from the side effects. And they will get no analgesia except from the added acetaminophen if there is any. There are also a number of medications that interfere with the conversion to morphine, thus limiting its ability to provide pain relief. Remember this the next time a physician tries to prescribe codeine for you or your child for pain or cough, which it doesn’t work for either!
Why don’t we like combination pain medications that don’t include codeine? They aren’t a good option either in most situations, but it’s because of the acetaminophen, not the weak opioid. With combination products, we lose the ability to safely change dosing on the fly, such as taking two pills when the pain is worse instead of the prescribed single pill. In some circumstance, the acetaminophen can accumulate and lead to potentially-fatal toxicity. We also lose the ability to give acetaminophen if there is an associated fever. Finally, many people take OTC products that contain acetaminophen without even realizing it. Again, we have better options, so why take the risk in kids.
Speaking of risks
Naturally it isn’t all sunshine and daisies with opioids. There are risks and side effects. But when dosing is done with care and based on the child’s weight, the risk of serious adverse events is very low and far outweighed by the benefits. And when side effects are anticipated, they can almost always be managed safely and effectively when they arise. These include sedation, respiratory depression, constipation, nausea, urinary retention, itching, and rarely, repetitive involuntary twitching of some muscle groups. Tolerance to these effects tends to occur within a couple of days so most patients can get by with symptomatic treatment (medication for nausea or itching) but not with constipation. This is why it is a good idea for anyone on an opioid to also be on a stool softener.
Sometimes the side effects, like itching or nausea, or simply not tolerable to the patient. We will typically try a different opioid when this occurs, and in many cases that does the trick. Another drug to add to the list of opioids best forgotten is meperidine (demerol). Reasonable increases in the dose of most opioids in response to poorly controlled pain do not tend to lead to an increased risk of adverse effects if a patient is tolerating the drug. Meperidine is an exception because of unique products of its metabolization, which can lead to severe toxicity with dose increases. It’s a bad drug.
Pediatric pain misconceptions and some counterarguments
So what are the many barriers to effective management of pain, which includes the appropriate use of opioid medications? There are a lot of them unfortunately, and the patient, their caregivers, and the treating nurses and physicians can all fall prey to them. Patients may be reluctant to report their pain for fear of being labelled a drug seeker, concern over poorly-managed side effects, or because of social issues at home. What happens when mom needs to sell them to pay the light bill, or is taking them herself because she is addicted? The patient or caregiver may be afraid of the development of an addiction, or physical dependency on the medication.
Medical professionals may be afraid of harming their patient, or worried about the development of addiction or misuse. They may be concerned about prescribing controlled substances. Many physicians are uncomfortable with children nearing the end of life, and the possibility of contributing to their death by prescribing an opioid. The most common barrier is simply inadequate training in pain management and the lack of skills needed to assess pain in children however.
These barriers are, for the most part, understandable but unfounded. The key to removing them is education and developing a good approach to pain management. As stated above, severe side effects are uncommon when doses are appropriate and the others are generally able to be dealt with or subside after a few days. There is no difference between lower dosing of a stronger opioid and a weaker opioid when it comes to side effects. Dependence on opioids is rare as well. So is drug-seeking. Pediatric patients seeking a higher dose are considerably more likely to be doing so because of undertreatment or the development of tolerance than to be drug seeking. And the use of opioids in a patient that is receiving end-of-life care does not contribute to their death when used appropriately.
There are a number of misconceptions regarding pain in children that are not so understandable, but still should respond to education. Children do not always scream or cry when they are in pain. Sometimes they just shut down. This is where a thorough history and physical should come in very handy. If a 15-month-old who just had a hernia repair is clingy, or curled up with their eyes closed refusing to interact with anyone, they are likely in pain even if there are no tears. This is especially true after a lengthy period of undertreated pain. Think of it as learned helplessness.
Children who would be expected to have significant pain because of an injury, illness, or surgical procedure should be treated for pain. A common issue I have with nursing is when scheduled pain medications are not given because the child is asleep. A child who just had a broken femur screwed back together is sleeping because the pain management has thus far been effective. Waiting until they are awoken by pain is cruel. The point of scheduling pain medications rather than giving them as needed is to prevent pain, which is every bit as important as treating pain once it occurs. As my brilliant wife likes to say, PRN = Patient Receives Nothing.
Pain is never good for kids. There is never a benefit to pain, no lesson to be learned from it. Treating pain will not impair a physician’s ability to do a physical exam, it will only improve it. A common misconception that I’ve personally encountered a number of times, although not typically when a pediatric surgeon is involved, is that a child’s pain should not be treated if there is suspicion of a surgical process, typically appendicitis, until the surgeons arrive to assess them. This is cruel and simply untrue.
This discussion is far from comprehensive. Pain management in kids is complex and this just scratches the surface. There are even plenty of misconceptions about pediatric pain management that I left out so this wouldn’t drag on too much. But I believe that this is a good overview, perhaps more of a deep scratch or gouge into the surface of the thing that I hope will lead to better pain management should a reader find themselves in need of it for their own child or for the child of a friend or family member. If you don’t think that a child is being treated appropriately, speak up.
It can’t be said enough that the best way to approach pediatric pain is consistently and systematically. Pain is one of the few instances where kids and adults should be thought of as equivalent. We all feel pain, even premature infants, and we all deserve to be treated for it. There are adult patients with neurological impairment that are non-communicative just as there are in pediatrics. Both populations have psychiatric issues that increase the complexity of treatment. Both adult and pediatric practitioners must rely on caregiver report at times. The drugs used to manage acute pain are the same, though the doses sure are different, and we all can be helped with non-pharmaceutical interventions. Although an adult is perhaps less likely to respond to a bubble machine and a Dora the Explorer video in quite the same way as a young child.