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Pain Treatment in Pediatrics
It is generally accepted that infants and children can and do feel pain comparable to that in adults. Research into the nature, assessment, and treatment of pediatric pain has grown rapidly, and numerous drug and non-drug interventions have been developed and tested in a variety of clinical populations and settings. However, inadequate prevention and relief of pediatric pain are still widespread.
Physical and psychological responses to pain not only affect children’s health directly, but also may predispose them to develop chronic pain in adulthood. The large number of available interventions may be a source of confusion when it comes to selecting the best for each child and situation. This section focuses on providing the most appropriate, cost effective, and evidence-based treatments, taking into account all components of the child’s pain experience.
Researchers/reviewers: Winnie Dawson, MA, RN, BSN; Stewart B. Leavitt, MA, PhD.
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Current Practice and Recent Advances in Pediatric Pain Management
By: Chiaretti A, Pierri F, Valentini P, et al. European Review for Medical and Pharmacological Sciences. 2013;17(Suppl 1):112-126. Access checked 5/23/13.
PDF available here: http://www.europeanreview.org/wp/wp-content/uploads/112-126.pdf
This paper reviews the literature for recent evidence-based pediatric pain assessment and treatment approaches. The authors present the biological and developmental rationale for pain management differences between adult patients and those within the pediatric age range. Consideration of pain assessment techniques includes a discussion of tools addressing physiological and behavioral elements, like those in the Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS) and the Objective Pain Scale. Pharmacological characteristics, pediatric dosing and administration considerations, and adverse events are reviewed for non-opioid analgesics, adjuvant drugs, and opioid agents. Specific concerns related to the use of topical analgesic agents and patient-controlled analgesia in children 8 years and older are explored.
Psychosocial Perspectives in the Treatment of Pediatric Chronic Pain
By: Carter BD, Threlkeld BM. Pediatric Rheumatology. 2012;10(1):15. Access checked 1/3/13.
PDF available for download: http://www.ped-rheum.com/content/pdf/1546-0096-10-15.pdf
Caring for children and adolescents with chronic pain requires an understanding of the cognitive, affective, family, and social dynamics that can impact the effective management of pain. The authors provide a review of chronic pediatric conditions — including both medically defined and medically unexplained — that present in young patients. A literature review complements the discussion of the influence of family dynamics on the pain experience and highlights the impact of parental fears on the child's coping abilities. Cognitive behavioral therapy, hypnotherapy, and physical activity coupled with strategies for improving sleep and academic attendance have been shown to offer benefits for children coping with chronic pain and functional disability. The Children's Health and Illness Recovery Program (CHIRP) model for multimodal outpatient intervention is explained and the benefits of inpatient interdisciplinary treatment for severe cases are briefly reviewed.
2011 American College of Rheumatology Recommendations for the Treatment of Juvenile Idiopathic Arthritis: Initiation and Safety Monitoring of Therapeutic Agents for the Treatment of Arthritis and Systemic Features
By: Beukelman T, Patkar NM, Saag KG, et al. Arthritis Care & Research. 2011(Apr);63(4):465-482. Checked 4/23/11.
PDF available for download: http://www.rheumatology.org/practice/clinical/guidelines/ACR_2011...pdf
Juvenile idiopathic arthritis (JIA) is a chronic disease that can affect joints in any part of the body. However, appropriate treatment can reduce the risk that the disease will interfere with a child's normal growth and development. These recommendations from the American College of Rheumatology are based on evidence and consensus with the goal of providing a reference for the safe initiation and monitoring of the pharmacologic treatment of JIA. Researchers reviewed more than 200 studies and evaluated 1500 clinical scenarios to identify a wide range of therapeutic agents — nonsteroidal anti-inflammatory drugs (NSAIDs), intra-articular glucocorticoid injections, biologic and nonbiologic disease-modifying antirheumatic drugs (DMARDs), and systemic glucocorticoids — used to treat patients with JIA. Scientific evidence of treatment benefit versus risk was evaluated using a quality assessment method and resulted in treatment strategy algorithms for 5 clearly defined JIA groups. These recommendations have been endorsed by the Arthritis Foundation.
Neuropathic Pain in Children: Special Considerations
By: Walco GA, Dworkin RH, Krane EJ, et al. Mayo Clinic Proceedings. 2010(Mar);85(3 Suppl):S33-S41. Access checked 2/1611.
PDF available for download: http://www.ncbi.nlm.nih.gov/pmc/.../pdf/mayoclinproc_85_3_Suppl_004.pdf
While adult neuropathic pain conditions tend to be uncommon in children, pediatric neuropathic pain has been recognized more often during the past 20 years. It is important to note that several rare pain syndromes are actually unique to children, such as toxic neuropathies, hereditary neurodegenerative disorders, mitochondrial disorders, and primary erythromelalgia. The authors review treatment strategies for several conditions — complex regional pain syndromes, nerve injuries, Guillain-Barre syndrome, plexus avulsion and phantom limb pain — because the pediatric course of the condition is frequently unlike that experienced by adults. A brief discussion of Fabry disease, a pain syndrome caused by a genetic metabolic disorder, includes past study data and the use of enzyme replacement therapy. The authors explore research barriers that have resulted in a lack of review articles and systematic studies in pediatric neuropathic pain conditions, and they suggest ways that practitioners and researchers can improve the clinical trials in this population.
Review for the Generalist: Evaluation of Pediatric Foot and Ankle Pain
By: Houghton KM. Pediatric Rheumatology Online Journal. 2008 (Apr 9);6:6. Access checked 1/15/09.
PDF available for download: http://www.ped-rheum.com/content/pdf/1546-0096-6-6.pdf (350 KB)
This review of common causes of foot and ankle pain in children is written for the family practitioner. Following a review of foot and ankle anatomy, the most effective assessment techniques are described in detail. In addition to useful methods for reproducing the pain, the author explains essential biomechanical evaluations of the patient’s gait, spine, hip, and knee. Five special tests are provided as additional methods of assessment. Overuse injuries, stress fractures, inflammatory disorders, plus several developmental and congenital conditions are described. A brief discussion of the prevalence of accessory bones — also called ossicles and considered to be normal anatomic variants — includes characteristic signs that indicate the presence of symptomatic changes in specific populations of children. The review does not include acute traumatic fractures; some recommendations for consultation with a specialist practitioner are provided.
Headache: Pediatric Perspective
From: eMedicine by WebMD. Authors: J. Ivan Lopez, MD; John F. Rothrock, MD. 10 pages. Updated June 2008. Access checked 1/15/09.
See HTML article at: http://www.emedicine.com/neuro/topic528.htm
This eMedicine topic review begins with a brief discussion of the prevalence and classification of pediatric headache. Because migraine headache is the most common headache seen by the pediatric neurologist, a more detailed examination of the diagnostic criteria for migraine is presented. Secondary causes of headache and the rationale for neuroimaging in cases when an underlying structural pathology is suspected are discussed briefly. Recommendations are made for pharmacologic (abortive and prophylactic) and nonpharmacologic treatment of primary headache in children.
Evaluation of Back Pain in Children and Adolescents
By: Bernstein RM, Cozen H. American Family Physician. 2007(Dec);76(11);1669-1676. Access checked 1/15/09.
PDF available for download: http://www.aafp.org/online/etc/medialib/aafp_org/documents/news_pubs/afp
/access/20071201-1669.Par.0001.File.tmp/20071201-1669.pdf (20 KB)
This report reviews the common and uncommon epidemiological causes of pediatric back pain. While studies on back pain etiology in children who present to primary care practitioners are few, data from existing studies have demonstrated that a high percentage of pediatric patients with back pain will have identifiable underlying pathology. A table of acute and chronic pain symptoms, as well as an evaluation algorithm and techniques for the diagnostic testing for specific back disorders, will aid in the differential diagnosis of back pain in children and adolescents.
Treatment of Chronic Pain in Pediatric Rheumatic Disease
By: Kimura Y, Walco GA. Nature Clinical Practice Rheumatology. 2007;3(4);210-218. Access checked 1/15/09.
PDF available for download: http://www.nature.com/ncprheum/journal/v3/n4/pdf/ncprheum0458.pdf (236 KB)
The pain associated with childhood rheumatic disease is common, but treatment guidelines for pediatric patients with rheumatic disease do not exist and management can be complicated. This report reviews the multiple mechanisms responsible for pediatric rheumatic pain and inflammation. Additionally, a summary of the important factors in pediatric rheumatic pain assessment precedes a discussion of pharmacological and nonpharmacological treatment options. The authors suggest more aggressive pain therapy for patients with unmanaged chronic pain. A brief checklist of the biological, psychological, and social factors that could influence a child’s pain experience is included. Note: the CME activity associated with this report has expired.
Chronic Musculoskeletal Pain in Children
From: American Academy of Family Physicians. July 2006. Access checked 1/15/09.
Part I. Initial Evaluation - PDF available at: http://www.aafp.org/afp/20060701/115.pdf (20 KB)
Part II. Rheumatic Causes - PDF available at: http://www.aafp.org/afp/20060715/293.pdf (21 KB)
This 2-part report on pediatric musculoskeletal pain presents a synthesis of concepts reviewed at the American Academy of Family Physicians 2006 Annual Clinical Focus on care for children and adolescents. Part I of this report includes a basic algorithm of evidence-based diagnostic recommendations and a table of pain characteristics that differentiate benign conditions from serious musculoskeletal disorders in children. Part II provides a summary table of common pediatric rheumatic conditions with associated clinical and physical history findings for each pain disorder. The criteria for juvenile rheumatoid arthritis is reviewed and nonrheumatic causes of musculoskeletal pain are examined briefly.
Psychological Interventions for Acute and Chronic Pain in Children
From: International Association for the Study of Pain (IASP), 2006, 10 pages. Access checked 1/15/09.
PDF available for download: http://www.iasp-pain.org/AM/Template.cfm?Section=Resources1&
Template=/CM/ContentDisplay.cfm&ContentID=2271 (108 KB)
Acute and chronic pain in children are frequently complicated by the complex psychological components of pain perception. In addition to the practical complications of treatment, emotional trauma is thought to predispose children to the development of chronic pain in adulthood. The authors of this report from IASP reviewed the evidence for effective interventions and found a high level of evidence for guided imagery, relaxation, and cognitive-behavioral therapy in acute pain, postoperative pain management, and chronic pain (including headache). Recommendations for future studies include interventions that can be implemented by the child or parents and, therefore, potentially becoming more practical and cost-effective options.
Complementary and Alternative Medicine Approaches for Pediatric Pain: A Review of the State-of-the-Science
By: Tsao JCI, Zeltzer LK. Evidence-based Complementary and Alternative Medicine. 2005;2(2);149-159. Access checked 1/15/09.
PDF available for download: http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1142204&blobtype=pdf (110 KB)
With the increasing use of complementary and alternative medicine (CAM) in children with chronic conditions, reviewers from the David Geffen School of Medicine at UCLA in California evaluated the existing evidence for CAM interventions for pain symptoms in pediatric populations. CAM modalities — as reported in studies that treated chronic, acute, or procedural pain — were evaluated according to the American Psychological Division 12 Task Force on Promotion and Dissemination of Psychological Procedures. Only one combined intervention, self-hypnosis/guided imagery/relaxation for recurrent pediatric headache, qualified as efficacious. Several treatments that were identified as promising interventions included: acupuncture for chronic pain, biofeedback for tension headaches, homeopathy for ear pain, and massage for juvenile rheumatoid arthritis. The authors reviewed the limitations of existing research and made recommendations for future investigations.
Relief of Pain and Anxiety in Pediatric Patients in Emergency Medical Systems
By: Zempsky WT, Cravero JP, Committee on Pediatric Emergency Medicine and Section on Anesthesiology and Pain Medicine. Pediatrics. 2004;114(5);1348-1356. Access checked 1/15/09.
PDF available for download: http://pediatrics.aappublications.org:80/cgi/reprint/114/5/1348 (270 KB)
This report considers both pain management and stress relief as vital components in the care of children with pain who enter acute care settings. The authors recommend a systematic approach to eliminating barriers to the effective management of pediatric pain and anxiety and achieving optimal patient comfort. Ethnic considerations related to the need to address cultural variations in pain perception and consistency of treatment are encouraged for each provider organization. Staff and procedural development, including an evaluation of employee bias and attitudes, should be assessed and revised as needed to improve pain and anxiety relief. Thorough attention to parental education on the administration of analgesic medications is encouraged.
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