PAIN
Paediatric chronic pain
Paul M Rolfe
Abstract
Many children and adolescents experience chronic pain at some point
in their childhood. While the majority may be successfully supported
by their local services, some may develop persistent pain-related func-
tional disability that should prompt referral to a multidisciplinary paedi-
atric pain service for assessment. These teams work with the family to
provide a framework for promoting rehabilitation and restoration of
function based on the biopsychosocial model. Mental health diffi-
culties including psychological trauma are often a significant factor.
Individualized therapeutic work is core to the pain management
pathway. Medications and therapeutic injections are used less
frequently in children compared to adult practice but may have a
role in facilitating rehabilitation as part of a multidisciplinary approach.
Keywords Chronic pain; paediatric pain; pain assessment
Royal College of Anaesthetists CPD Skills Framework: Pain
Introduction
Although there are many similarities in terms of the assessment
and management of children with persistent pain when compared
to adult practice, children and adolescents are a distinct group that
present different challenges to professionals involved in their care.
Persistent pain in the paediatric population is common, particu-
larly in girls. It is important to state that vast majority of these
patients are managed outside of specialist paediatric pain clinics,
both in primary and secondary care, making it essential for a wide
range of professionals, including pain physicians with a predom-
inant adult practice, to have an appreciation and understanding of
pain management principles in this group.
There is a wide variation in the availability and provision of
specialist paediatric pain services nationally within the UK. This is
common amongst many other developed healthcare systems.
Centralization of specialized paediatric services often means there is a
significant geographical distance for the family, to a suitable place of
treatment which may be a significant barrier to progress if there is no
access to suitable local services. Consequently, untreated persistent
pain may lead to significant pain-related disability, emotional distur-
bance and poor school attendance. Referral to a specialist clinic should
be prompted if a child fails to respond to local therapy provision.
Pain presentation in children and assessment
While children may develop chronic pain related to a long-term
condition such as juvenile idiopathic arthritis or present with
features of a specific pain diagnosis such as complex regional
Paul M Rolfe MA MB BChir FRCA FFPMRCA is a Consultant in Paediatric
Anaesthesia and Pain Medicine at Addenbrooke’s Hospital,
Cambridge University Hospitals NHS Foundation Trust, Cambridge,
UK. Conflicts of interest: none declared.
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Learning objectives
After reading this article, you should be able to:
C explain the multidisciplinary assessment of chronic pain in
children
C outline non-pharmacological therapies used to treat chronic pain
in children
C discuss the potential benefits and limitations of medications
used to treat chronic pain in children
pain syndrome (CRPS), most children present with symptoms
which are not readily explained in terms of examination findings
or investigations. The most common examples are persistent
headache, functional abdominal pain and generalized musculo-
skeletal pain frequently accompanied by fatigue.
These children are sometimes categorized as ‘medically
unexplained symptoms’ in the paediatric literature. However, by
using a biopsychosocial framework, our understanding of
chronic pain pathways and central sensitization, it is possible to
offer an explanation which the child and their family may un-
derstand. Children have often consulted with multiple specialists
and had repeated investigations to find a biomedical explanation
for their pain.
An acceptance of this explanation and move from a bio-
medically orientated understanding to a biopsychosocial model is
fundamental to engagement with a pain management approach.
The recent adoption of pain-specific International Classification
of Diseases (ICD-11) codes such as chronic primary pain may aid
the explanation and acceptance of pain as the primary diagnosis.
The components of an initial multidisciplinary consultation
are shown in Box 1. This primary assessment usually requires
more than 1 hour. The team will typically consist of a pain
physician, paediatrician, physiotherapist, clinical psychologist,
specialist pain nurse and an occupational therapist. It may be
potentially daunting for the child and their family to meet so
many professionals at one appointment, but this can be mitigated
by clear written information provided in advance which explains
the importance of a multidisciplinary assessment and followed
up with a friendly telephone call shortly before the appointment
to answer any questions. In our centre children and their families
are sent several health-related quality of life (HRQOL) ques-
tionnaires which are repeated at intervals throughout the
pathway to track progress. These are also used to quantify the
impact of intervention by the clinic which is also important in
commissioning and funding the service. Typical examples of
HRQL questionnaires are shown in Table 1.
The multidisciplinary clinics are not only a means to obtain a
careful history looking at potential drivers for pain but create a
therapeutic opportunity in themselves. Frequently children with
pain-related disability have had a long journey and the family have
retold their story many times often with little improvement in their
symptoms. Families may have felt that their concerns have been
dismissed when investigations are reassuring. This encounter cre-
ates an opportunity for the family to feel listened to and supported.
A key component is the initial explanation of chronic pain and
agreeing on a way forward. It is important that all necessary in-
vestigations and opinions have been completed. Further search for a
511 Ó 2022 Published by Elsevier Ltd.

Components of initial multidisciplinary (MDT)
consultation
Parent and child questionnaires prior to meeting, e.g. PedsQL, PI-ED.
Introductions of the team and family.
Explanation of MDT meeting and process of assessment and pain
management plan.
Detailed pain history from child and family (using age-appropriate
language):
C site, character, intensity, radiation, associated symptoms
C aggravating and relieving factors
Identification of pain-associated disability:
C poor sleep, reduced activity and social interactions, anxiety,
low mood
Assessment of coping skills, e.g. identify repeated attendances to
emergency department.
Other relevant medical history and a developmental history as
appropriate.
Investigations and specialist consultations to date.
Establish which therapeutic modalities, including medications have
been tried.
Current medications and allergies.
Family structure/domestic situation.
Current school and educational performance/attendance.
Identify other agencies involved e.g. social worker, Child and
Adolescent Mental Health Services, school nurse.
(It is useful to seek permission for sharing of information at this
point).
Examination of the child by doctor and physiotherapist.
It is sometimes useful for parents to have an opportunity to speak to
a member of the team away from the child, which can often be done
before the team discussion).
MDT meeting without family:
C Confirm all necessary investigations/opinions are complete
C Agree initial pain management plan
MDT meeting with family:
C Initial pain explanation
C Each member of the team will discuss their contribution to pain
management plan
C Family input into plan
C Answer any outstanding questions or concerns
Box 1
biomedical explanation and a potential cure often undermines a
pain management approach later. It should be explained that this
approach aimed at restoration of function is an active process that
requires engagement and ‘buy in’ to be helpful.
Treatment of chronic pain in children
Effective pain education sessions are the foundations on which
to build. A clear understanding of chronic pain provides an
opportunity to look at how potential changes in behaviour and
thought processes may lead to improvement. These sessions
should include topics such as pacing, goal setting, sleep hygiene,
fear avoidant behaviour and management of pain flares. A clear
plan for managing pain flares is important in helping to reduce
the incidence of presentation to hospital and the reinforcement of
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PAIN
a biomedical model that has previously failed. Attendance at the
emergency department or admission often leads to escalation of
treatment, particularly opioids which do not provide a sustain-
able or helpful solution.
Broadly speaking, treatment options for chronic pain can be
classified into pharmacological, physical and psychological treat-
ments as summarized in Table 2. It should be emphasized that
medical interventions such as medications or interventional pro-
cedures likely benefit only a small proportion of children. The core
work is therapy based, building on the work done in pain education.
Pharmacological strategies
Much of the evidence for medication use in children with chronic
pain is extrapolated from our experience with adults and many
medications are used outside of their license. Commonly used
drugs and appropriate doses are summarized in Table 3. The
prescriber should ensure that there is a robust assessment of the
efficacy of any analgesic medication given with a plan to wean
and discontinue if there is no clear benefit. Adverse effects from
medication such as sleepiness and impaired cognitive ability may
have a further significant impact on performance and attendance
at school, which in turn may compound existing pain related
disability and social isolation from peers.
Anti-neuropathic drugs such as the tricyclic antidepressants
(TCA) and gabapentinoids may be useful for neuropathic pain.
Some of the causes of neuropathic pain in children are listed in
Table 4. There is also some evidence for the use of TCA in non-
neuropathic conditions such as functional abdominal pain. TCA
are particularly helpful for their sedative properties and may help
restore sleep, but the timing of the dose is important to reduce
somnolence; a once-daily dose taken approximately 4 hours
before bedtime is a sensible starting point. Common side effects
such as dry mouth may be less prevalent when the secondary
amine nortriptyline is taken instead of amitriptyline due to less
anticholinergic effects, although the former is not widely avail-
able as a liquid and is significantly more expensive. Amitriptyline
is well established in paediatric practice for several indications
such as enuresis and is generally well tolerated, although sudden
death has been reported due to the risk of prolongation of the
QTc interval. Some centres routinely perform an ECG prior to
commencement of treatment.
Gabapentin has also been widely used in children for epi-
lepsy, neuropathic pain and neuro-irritability. Although pre-
gabalin has a similar effect to gabapentin, the pharmacokinetics
of the two drugs are significantly different, allowing twice-daily
dosing. Employing such prescribing strategies may prevent
medication being required during the school day, which can aid
compliance and normalize activities whilst at school. Although
liquid preparations exist for both gabapentinoids, the contents
of the capsules are readily dissolvable in water to allow accurate
dosing.
Lidocaine 5% medicated plasters are a non-systemic topical
treatment for neuropathic pain, which is very acceptable to children
and provides a physical barrier to the area of pain for the 12 hours
they are applied each day. They are useful for peripheral neuro-
pathic pain conditions such as CRPS or post-surgical scar pain.
Opioids should generally be avoided in non-malignant pain
without specialist advice. Although children and their families
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 PAIN

Examples of questionnaires, including health-related quality of life (HRQOL) and physical function measures
Name Notes

Paediatric Quality of Life Inventory (PedsQL)
Child Health Assessment questionnaire (CHAQ)
Bath Adolescent Pain questionnaire (BAPQ)
Pain Experience Questionnaire (PEQ)
Revised Anxiety and Depression Scale (RCADS)
Timed walk
Number of sit-to-stand movements in 1 minute
Designed for paediatric medical populations. Validated between 0 and 18 years old.
Four domains: physical, psychological, social and school functioning
Well established and widely used. Long questionnaire.
Designed specifically for children with chronic pain.
Designed for children with chronic pain and based on the Multidimensional Pain
Inventory.
May be used in children over 7 years old.
Self-reporting in children 8e18. Long version contains 47 items in subscales including
separation anxiety disorder, social phobia, general anxiety disorder, panic disorder,
obsessive compulsive disorder and low mood (major depressive disorder). Used in Child
and Adolescent Mental Health Services

Table 1

may report an initial benefit, this is frequently short lived and
problems of tolerance, escalating doses and dependence occur.
Adverse effects often compound the problem resulting in a more
difficult situation than if the opioids were never started. A pre-
ventative approach of not initiating inappropriate medication
will provide the best circumstances for a child to engage in
rehabilitation. Weaning and discontinuation of unhelpful medi-
cation is more common in the paediatric setting than initiating
new drugs.
Physical treatments
Table 2 outlines the wide range of modalities that fall under this
category, which range from desensitization therapy and the use
of therapeutic exercises to invasive interventions such as nerve
blocks under anaesthesia.
It is common for children with chronic pain to develop reduced
mobility, poor exercise tolerance and reduced physical function.
The reasons are multifactorial but may include the development of
fear-avoidance patterns of behaviour and general de-conditioning
due to lack of exercise. For instance, physiotherapists may help
children reach their goal of improved movement and function
through therapeutic exercises or general conditioning activities.
They may also employ specialized rehabilitative techniques such
as graded motor imagery and mirror box therapy.
Transcutaneous electrical nerve stimulation (TENS) is a safe
inexpensive treatment with no systemic side effects, which some
children find extremely useful in managing their pain, especially
as it is a form of pain relief that they can control and administer
themselves. Other physical treatments such as hot and cold packs
and acupuncture are sometimes used.

Treatment modalities for chronic pain in children

Pharmacological strategies Physical treatments Psychological interventions

Tricyclic antidepressants (TCA) Physiotherapy Pain education

C therapeutic exercise Activity pacing
C hydrotherapy Goal setting
C Graded motor imagery Sleep hygiene
C Mirror box therapy
C Breathing exercises
Gabapentinoids Occupational therapy Relaxation
C Gabapentin Distraction
C Pregabalin
Topical treatments TENS heat/cold packs Cognitive-behavioural therapy (CBT)
e.g. Lidocaine 5% medicated plasters
Opioid medication Acupuncture/acupressure Acceptance and commitment therapy (ACT)
Paracetamol Interventional procedures, Mindfulness
Non-steroidal anti-inflammatory drugs e.g. sympathetic nerve blocks for complex
regional pain syndrome
Eye movement desensitisation and
reprocessing (EMDR)

Table 2

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 PAIN

Some commonly prescribed medications for children with chronic pain

Drug name Dosage guidance Comments

Amitriptyline An initial dose 0.1 mg/kg taken once in the Anticholinergic and antihistaminic side effects
Nortriptyline evening. Slowly titrated to a usual frequently cause dry mouth and sedation.
maintenance dose 0.2e0.5 mg/kg. Daytime somnolence reduced by taking earlier
in evening. Reduced side-effect profile with
secondary amines. May prolong QTc interval.
Gabapentin Maintenance dose range 30e70 mg/kg/day in Active absorption across gut is saturable
three divided doses. reducing bioavailability at higher doses.
Pregabalin Author uses target maintenance dose range 1 Twice daily dosing may aid compliance
e2 mg/kg twice daily
Lidocaine 5% medicated plaster One to three plasters may be applied to the Very low systemic absorption.
painful area for 12 hours each day followed by ‘Cooling effect’ on application.
12 hours without. Provides physical barrier.
May cause skin reaction.

Table 3

The role of interventional procedures in children is less Psychological interventions

clear than in adult practice. Invasive treatments such as
An assessment of the child’s mental health and an understanding
lumbar sympathetic nerve blocks or continuous local anaes-
of their environment including physical and mental health of
thetic infusion catheters are sometimes used to facilitate
family members is extremely important. For instance, anxiety
physiotherapy by providing an ’analgesic window’ in some
may be a significant driver in amplifying the pain response.
children with CRPS. Personally, I believe these interventions
Similarly unprocessed traumatic events may respond to eye
do have a place in the management of a limited number of
movement desensitization and reprocessing (EMDR) therapy.
children who require pain relief to perform their physical
Cognitive-behavioural therapy (CBT) is the most well-known
therapy and are otherwise engaged in multidisciplinary
psychological therapy for treatment of chronic pain. This is a
treatment. Each individual case must be considered carefully,
time-limited therapy that focusses on linking how a person’s
particularly as the child will usually require general anaes-
thoughts and beliefs affect how they feel and the way that they
thesia to perform the block.
behave. Acceptance and commitment therapy (ACT) is a more
recent form of psychotherapy used in some centres. Rather than
placing an emphasis on controlling or changing the pain expe-
rience it uses acceptance and mindfulness techniques to develop
Causes of neuropathic pain in children and young people
an acceptance of pain and live life according to the person’s core
Category Examples values.
A pain management programme, which may involve resi-
Central neuropathic Spinal cord injury dential treatment for several weeks is an option for children some
pain Stroke children who fail to make progress. A
Multiple sclerosis
Tumours, e.g. neurofibromatosis
Trauma/surgery Complex regional pain syndrome
Post-surgical scar pain FURTHER READING
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Chemotherapy-induced neuropathy values-based treatment of adolescents with chronic pain:
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