Dr Schanbergs visit is sponsored by

Treating Pediatric
Chronic Pain:
Myths and Misconceptions
Laura E. Schanberg, MD
Professor of Pediatrics
9/23/2010

and

Pediatric Rheumatic Disease

Research Laboratory

PAIN is'
is '

1Healthy children don

dont

An unpleasant sensory and emotional

experience associated with actual or
potential tissue damage, or described in
terms of such damage.

have pain.

Internation al Association for the Stu dy of Pain

Musculoskeletal Pain
5-20% in healt hy children

(Goodman 1991, Perquin

Prevalence Rates of
Chronic Pain

2000)

Females and older children (Sherr y 1991; Mi kkels on

1998; Perqui n 2000)

gender differences at puberty

teenage girls highest r isk

Associated with significant impairment

(Mikkelson et al., 1997; Egger et al., 1999)

depression and anx iety

social difficulties
school absenteeis m
5

Perquin et al, Pain 2000

Hypermobility Syndrome

Incidence of Growing Pains

%
Aple y and Naish (UK 1955)
4
Brenning (Swede n, 1960)
14
Oster and Nielson (Denmark, 1972) 18 F, 12 M
Tedford (USA, 1976)
4

Up to 10% of normal population

Arthralgias, back pain common
Beighton score defines hypermobility
Injuries common
www.arc.org.uk/about_arth/booklets/6019/60 19.htm
dislocations
meniscal tears
tendon injuries

MV prolapse
Genetically
determined

Do growi ng pai ns predi spose to chroni c pai n

syndromes i n adulthood?
7

1 point

1 point
each side

Beighton Sc al e

Pain Assessment

2I can tell if my patient

is in pain.

Pain Behavior
Diagnosis

10

Pain
Gender

Beh avior
Suffering
Perception

Provider
Pain Ratings

Nociception

Physical
Characteristics

Affect
Ethnicity

Loeser JD, Cousins MJ. 1990

11

12

Child Pain Behavior

So,
Self report is gold standard

Children cope differently than adults.

Pain behavior and language varies
from child to child.
Classic pain behavior often not present.
May be subtle changes
sleeping more
sad
change in ac tiv ity level
decreased appetite
clingy

13

14

Developmental Factors

3Children can
can t selfself-

Newborns and small children cant selfreport - OBSERVA TION

A voidance behavior observed by 6 months
Consistency of facial and cry response
demonstrated in neonates and infants
Children 3-5 years able to use self-report
measures and localize pain

report pain.

15

Self Report Pain Tools

16

4Young children don

don t
remember painful
experiences.

17

18

Pain in Neonates

Pain Memory
Neonatal surgery in mice effe cts adult
responses to pain stimuli. (Sternberg 2005)

By 26 w ks, anatomical
and neurochemical
capabilities for nociception
present.
By 29 w ks, cortical and
sub-cortical centers for
pain perception including
pain modulation present.

Circumcised infants show stronger pain

response to routine va ccination. (Taddio 1997)
Young children gi ven placebo for pre vious
procedures had consistently higher pain
scores
than children with proper pro cedural
The pai n itself may not be consciously
analgesia. (Weisman, Bernstein, Schechter 1998)

remember ed, but the painful experienc e impacts

secondinnocence.blogspot.com

Pain sensiti vity i n neonates may b e heightened

compar ed to older indi viduals (less effective at
19
blocking
stimuli)!
Revie wed Grunau, Holsti,
Peters 200 painful
6

Children
exposed
repeated
painfulin age
wiring of
the paintosensing
pathways
procedures experience
dependent increasing
manner. pain and
anxiety with procedures. (Zeltzer 1990)

20

Simple Pain Pathway

5Chronic pain is a
psychiatric disease.

21

22

Biobehavioral Model of Pain

Pain Pathways

Environmental

Behavioral

Biologic
DeLeo 2 006
23

24

Childhood Pain Syndromes

6Children do not

25% of new patients seen by

pediatric rheumatologists
75% female
Average age of onset 12
DIFFICULT TO TREAT !

develop pain
syndromes.

25

Spectrum of Disorders

26

Juvenile Fibromyalgia

Add light spectrum

Fibromyalgia
Chronic fatigue
syndrome
Migraine
Irritable bowel
syndrome
TMJ disorders
CRPS

Functional
abdominal pain
Chronic pelvic
pain
Premenstrual
Syndrome
Myofascial pain
syndromes

Widespread
musculoskeletal
pain for 3 months
Well defined tender
points
1-6% prevalence
depending on study
27

Childhood CRPS (RSD)

Incidence unknown (under diagnosed)

Girls 6:1
Lower extremities 5:1
Delayed diagnosis (1 yr)
Neuropathic descriptors
Autonomic dysfunction

29

28

7All pain has to be

treated with medicine.

30

Pain Variance Accounted for by Coping,

Age, Disease Duration and Activity
60

% Variance
*
p<0.0 5
** p<0.0 1
*** p<0.0 0

Pain Coping
Disease Act ivit y
Disease Dur ation

***

***
40

Ag e

***

***

Role of Stress and Mood

0
Ouch er

Pain
Locat ions
Schanber g 1997

Fati g ue ()

14.26**

20.84**

Increased daily
stressful events

0.65*

0.35

0.96*

Increased negative daily mood was associated with

increased daily symptoms of daily pain, fatigue, &
stiffness.
Increased daily stress was also associated with
increased daily pain & fatigue.

**

Pain
Therm om eter

Stiffne ss ()

20.60**

* p < .0 2, ** p < .000 1

20

Pain ( )
Increased
negative mood

Schanberg 2005
31

32

Education

Multidisciplinary Treatment
Education
Graduated
aerobic e xercise
Sleep h ygiene
Pain coping
skills training
Stress reduction
Counseling
School

Medica tion
Blocks
Acupuncture
Massage
Other

Fatigue

Effectively treats fatigue

(Cochrane review)

Inactivity

Lack of
control

Stress

Isolat ion

Vicious Cycle

33

34

Sleep Hygiene
http:/ /bos ton.k 12.ma.us /baldwinelc /programs /s pec ial.htm

30 minutes daily
Short bouts (Schachter 2003)
Walking/home-based
program (Valim 2003)

Anxiety

Poor
sleep

Exercise
Graduated aerobic
program (Richards 2002)
Aerobic component
improves symptoms

Low
mood

No naps
Sleep at night
Regular bedtime and awake time
No distractions
Relaxation techniques
Tricyclics if needed

36

Pain Coping Strategies

Activity/rest
cycling
Cognitive
restructuring
Imagery
Relaxation
Distraction

Pain coping skills

Problem solving
Sleep hygiene
Autogenic
training
Pleasant
activities
Life planning

physical
triggers

emotional
triggers
PAIN

thoughts

feelings

behavior

Pain coping skills

37

Non--Pharm Rx: Infants

Non

5Children can
can t effectively

use nonnon-pharmacologic
interventions for pain.

Positioning
Swaddling
Rocking
Pacifier (sucrose)
Soft music/voice
Touch

Dim light
Reduce noise
Visual distraction
Access to parents
Cuddling

39

Non--Pharm Rx: 1Non

1- 6 yrs

Medical play
Music
Security objects
Soothing voice
Bubbles
Holding a hand
Dim light

38

40

Non--Pharm Rx: > 6 yrs

Non

Reduce noise
Visual distraction
Access to parents
Cuddling/rocking

41

Medical
preparation
Music (headset)
Security objects
Breathing
techniques
Guided imagery

Video games
Holding a hand
Distraction (books,
TV, etc)
Acce ss to parents
Visual focusing

42

Pharmacotherapies

6Pain medicines are not

Local anesthetics
Non Steroidal Anti-inflammatory
Agents (NSAI DS)
Opioids
Adjunctive agents

safe in children.

Antiepileptic drugs
Antidepressants

43

44

Treatment Approach
By the ladder
By the clock

Opioids
Underused
Avoid codeine,
propoxyphene , meperidine
Utilize long-acting
preparations as appropriate
Use to maintain function
Use with non-pharm
treatments
Avoid using for depression,
sedation, etc

By the mouth
By the person

SEDATION
ANALGESIA
PAIN

45

Ad dicti o n is a prima ry, chronic,

neurobiologic DISEASE with
genetic, psychosocial, and
enviro nmental facto rs influencing
its developmen t and
manifestations.

46

Addiction and Children

Addiction
Dependence
Withdrawal

AAP M, APS, ASA M 2001

Less than 1% of children treated with

opioids for PAIN develop addiction (Foley,

Physical dep en den ce is a state

of adaptation that is manifested
by a d rug class specific
withdra wal synd rome that can b e
produced by abru pt cessation,
rapid dose reduction, dec reasing
blood level of t he drug, and /or
administration of an antago nist.

1996)

Consider diversion!
Use opioid contract
www.Ini.wa.gov

AAP M, APS, ASA M 2001

With dra wal is a syndro me ofte n
not a sign of addiction but of
medical mismanagement!
47

48

8I can
cant treat chronic
pain in children
effectively.

YES, you can'

can'

But not alone!

49

Multidisciplinary Team

Barriers to Success
Passive, sick role
Anticipated failure
Poor
communication
Fear of addiction
Fear of side effects
Noncomplicance

50

Lack of resources
Anticipated failure
Poor
communication
Fear of addiction
Knowledge deficits
Opioid underuse

Pain spec ialist

Local c are prov ider
Soc ial w orker
Teac her
Psychologist
Psychiatr ist
Phys ical
ther apist

Alter native medicine

providers
Par ents

Patient

Nurse Clinic ian

Other s ubs pec ialty
physic ians

Phar macist
Pati ent

Physi ci an

51

52

NO MAGIC BULLET

Heat her van Mater, M D

Stacy Ardoin, M D
Carl von Baeyer, PHD

Patient education and empowerment

Family engagement
Utilize team approach
Use pharmacologic
and
non-pharmacologic
treatments together
Be patient!

Thanks!

Karen Gil, PHD

Maggie Brom berg, MA
Mark Connelly, PHD
Kelly Anthon y, PHD
Lindsey Franks, BS

53