Definition and Categories of Pain

Pain is defined by the International Association for the Study of Pain (IASP) as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” The important elements of this definition to be emphasized are (1) pain encompasses both peripheral physiologic and central cognitive/emotional components and (2) pain may or may not be associated with real tissue damage—pain may exist in the absence of demonstrable somatic pathology.

Table 71-1 specifies important pain categories commonly treated (somatic, visceral, and neuropathic) and defines the elements and characteristics of nociception, the peripheral physiologic aspect of pain perception (Fig. 71-1). Nociception refers to how specialized fibers (largely but not exclusively the A delta and C fibers) in the peripheral nervous system transmit nerve impulses (often originating from peripheral mechanoreceptors and chemoreceptors) through synapses in the spinal cord’s dorsal horn through (but not exclusively through) the spinothalamic tracts to the brain’s higher centers, where nociception is converted to pain with all of its cognitive and emotional ramifications.

Table 71-1 PAIN CATEGORIES AND CHARACTERISTICS

Figure 71-1 The typical neural pathways of nociception, also showing higher projection of nociception to the cortex, where the sensation of nociception is translated to the conscious and emotional phenomenon of pain. DLPT, dorsolateral pontine tegmentum; PAG, periaqueductal gray; RF, reticular formation.

The Assessment and Measurement of Pain in Children

Assessing pain entails much more than merely quantifying it. Whenever feasible, the physician should ask the patient about the character, location, quality, duration, frequency, and intensity of the pain. Some children may not report pain because of fears (often well-founded), of talking to strangers, disappointing or bothering others, receiving an injection if they report pain, returning to the hospital if they admit to pain, and other negative reinforcers. For infants and nonverbal children, their parents, pediatricians, nurses, and other caregivers are constantly challenged to interpret whether the children’s distressed behaviors represent pain, fear, hunger, or a range of other perceptions or emotions. Therapeutic trials of comfort measures (cuddling, feeding) and analgesic medications may be helpful in clarifying such a situation.

Behavior and physiologic signs are useful, but they can be misleading. A toddler may scream and grimace during an ear examination because of fear rather than pain. Conversely, children with inadequately relieved persistent pain from cancer, sickle cell disease, trauma, or surgery may withdraw from their surroundings and appear very quiet, leading observers to conclude falsely that they are comfortable or sedated. In these situations, increased dosing of analgesics may make the child become more, not less, interactive and alert. Similarly, neonates and young infants may close their eyes, furrow their brows, and clench their fists in response to pain. Adequate analgesia is often associated with eye opening and increased involvement in the surroundings. A child who is experiencing significant chronic pain may play normally as a way to distract attention from pain. This coping behavior is sometimes misinterpreted as evidence of the child’s faking pain at other times.

Age-Specific and Developmentally Specific Measures

Because infants, young children, and nonverbal children cannot express the quantity of pain they experience, several pain scales have been devised in an attempt to quantify pain in these populations (Fig. 71-2; Table 71-2).

Figure 71-2 Clinically useful pain assessment tools.

(Adapted from Burg FD, Ingelfinger JR, Polin RA, et al, editors: Current pediatric therapy, ed 18, Philadelphia, 2006, Saunders/Elsevier, p 16; and Hicks CL, von Baeyer CL, Spafford P, et al: The Faces Pain Scale—revised: toward a common metric in pediatric pain measurement, Pain 93:173–183, 2001.)

Table 71-2 PAIN MEASUREMENT TOOLS

The Newborn and Infant

There are a range of behavioral distress scales for the infant and young child, mostly emphasizing the patient’s facial expressions, crying, and body movement. Facial expression measures appear most useful and specific in neonates. Autonomic and vital signs can indicate pain, but because they are nonspecific, they may reflect other processes, including fever, hypoxemia, and cardiac or renal dysfunction.

The Older Child

Children 3-7 yr old become increasingly articulate in describing the intensity, location, and quality of pain. Pain is occasionally referred to adjacent areas; referral of hip pain to the leg or knee is common in this age range. Self-report measures for children this age include using drawings, pictures of faces, or graded color intensities. Children age 8 yr and older can usually use verbal scales or visual analog pain scales (VASs) accurately (see Fig. 71-2). Verbal numerical ratings are preferred and considered the gold standard; valid and reliable ratings are for children 8 yr and older. The Numerical Rating Scale (NRS) consists of numbers from 0 to 10, in which 0 represents no pain and 10 represents very severe pain. There is debate about the label for the highest pain rating, but the current agreement is NOT to use the worst pain possible, because children can always imagine a greater pain. In the USA, regularly documented pain assessments are required for hospitalized children and children attending outpatient hospital clinics and emergency departments. Pain scores do not always correlate with changes in heart rate or blood pressure.

The Cognitively Impaired Child

Measuring pain in cognitively impaired children remains a challenge. Understanding pain expression and experience in this population is important, because behaviors may be misinterpreted as indicating that cognitively impaired children are more insensitive to pain than cognitively competent children. Children with trisomy 21 may express pain less precisely and more slowly than the general population. Pain in children with autism spectrum disorders may be difficult to assess because they may be both hyposensitive and hypersensitive to many different types of sensory stimuli, and they may have limited communication abilities. Although self-reports of pain can be elicited from some children who are cognitively impaired, observational measures have better validation among these children. The Non-communicating Child’s Pain Checklist—Postoperative Version is recommended for children up to 18 yr. Maladaptive behavior and reduction in functions may also indicate pain. Children with severe cognitive impairments experience pain frequently, mostly not because of accidental injury. Children with the fewest abilities experience the most pain.

The Treatment of Pain

Both pharmacologic and nonpharmacologic approaches to pain management should be considered for all pain treatment plans. Many simple interventions designed to promote relaxation and patient control can be expected to work synergistically with pain medications for optimal relief of pain and related distress. Psychologic and developmental comorbidities affect the child’s experience of pain and ability to tolerate and cope with it. Thus, it is important to assess a child for evidence of situational anxiety and/or anxiety disorders, such as generalized anxiety disorder, post-traumatic stress disorder, social anxiety, separation anxiety, panic disorder, and obsessive-compulsive disorder (Chapter 23). Depression assessment should include current suicidal ideation and intent as well as past history of suicidal gestures or attempts (Chapters 24 and 25). Developmental assessment includes evaluating for specific learning disorders, Asperger disorder, and evidence of pervasive developmental disorders in general, including autism spectrum disorders (Chapter 28). All psychologic and developmental comorbidities should be determined and addressed, to adequately treat the child in pain or to reduce the risk of the child’s developing ongoing pain after surgery, trauma, or even invasive medical procedures.

FDA, U.S. Food and Drug Administration; IV, intravenous(ly): NSAIDs, nonsteroidal anti-inflammatory drugs; PDD, pervasive developmental disorder; PDR, Physicians’ Desk Reference; QTc, corrected QT interval on an electrocardiogram; SSRI, selective serotonin reuptake inhibitor.

Acetaminophen, a generally safe, nonopioid analgesic and antipyretic, has the advantage of rectal and oral routes of administration, is expected to be available soon also as an intravenous (IV) preparation in the USA, as it is now in Europe. Acetaminophen is not associated with the gastrointestinal or antiplatelet effects of aspirin and NSAIDs, making it a particularly useful drug in patients with cancer. Unlike aspirin and NSAIDs, acetaminophen has only mild anti-inflammatory action. Acetaminophen toxicity can result from either, large single doses or cumulative, excessive dosing over days or weeks (Chapters 58 and 355). A single, massive overdose overwhelms the normal glucuronidation and sulfation metabolic pathways in the liver, whereas long-term overdosing exhausts supplies of the sulfhydryl donor glutathione, leading to alternative cytochrome P-450 catalyzed oxidative metabolism and the production of the hepatotoxic metabolite N-acetyl-p-benzoquinone imine (NAPQI). Toxicity manifests as fulminant hepatic necrosis and failure in infants, children, and adults. Drug biotransformation processes are immature in neonates, very active in young children, and somewhat less active in adults. Young children are more resistant to acetaminophen-induced hepatotoxicity than adults as a result of metabolism differences: Sulfation predominates over glucuronidation in young children, leading to a reduction in NAPQI production.

Aspirin (ASA) is indicated for certain rheumatologic conditions and for inhibition of platelet adhesiveness, as in the treatment of Kawasaki disease. Concerns about Reye syndrome have resulted in a substantial decline in pediatric aspirin use (Chapter 349).

The NSAIDs are used widely to treat pain and fever in children. In children with juvenile rheumatoid arthritis, ibuprofen and aspirin are equally effective, but ibuprofen is associated with fewer side effects and better compliance. NSAIDs used adjunctively in surgical patients reduce opioid requirements (and therefore opioid side effects) by as much as 35-40%. Although NSAIDs can be useful postoperatively, they should be used as an adjunct to, not as a substitute for, opioids in patients with moderate to severe pain.

Ketorolac, an IV NSAID, is useful in treating moderate to severe acute pain in patients who are unable or unwilling to swallow oral NSAIDs. Intravenous ibuprofen is approved in the USA for the management of pain and fever for 5 days or less, although there is no pediatric indication in the package labeling. In Europe, IV ibuprofen is used to treat pediatric pain.

Adverse effects of NSAIDs are uncommon, but they may be serious when they occur. They include gastritis with pain and bleeding; decreased renal blood flow that may reduce glomerular filtration and enhance sodium reabsorption, in some cases leading to tubular necrosis; hepatic dysfunction and liver failure; and inhibition of platelet function. Although the overall incidence of bleeding is very low, NSAIDs should not be used in the child with a bleeding diathesis or at risk for bleeding or when surgical hemostasis is a prominent concern, such as after tonsillectomy. Renal injury from short-term use of ibuprofen in euvolemic children is quite rare; the risk is increased by hypovolemia or cardiac dysfunction. The safety of both ibuprofen and acetaminophen for short-term use is well established (see Table 71-3).

Opioids

Opioids are analgesic substances either derived from the opium poppy (opiates) or synthesized to have a similar chemical structure and mechanism of action (opioids). The older, pejorative term narcotics should not be used for these agents, because it connotes criminality and lacks pharmacologic descriptive specificity. Opioids are administered for moderate and severe pain, such as acute postoperative pain, sickle cell crisis pain, and cancer pain. Opioids can be administered by the oral, rectal, oral transmucosal, transdermal, intranasal, IV, epidural, intrathecal, subcutaneous, or intramuscular route. Historically, infants and young children have been underdosed with opioids for fear of significant respiratory side effects. With proper understanding of the pharmacokinetic and pharmacodynamics of opioids, children can receive effective relief of pain and suffering with a good margin of safety (Tables 71-4 to 71-7).

Table 71-6 MANAGEMENT OF OPIOID-INDUCED ADVERSE EFFECTS

* Avoid in patients taking monoamine oxidase inhibitors.

^† May be associated with extrapyramidal side effects, which may be more commonly seen in children than in adults.

Modified from Burg FD, Ingelfinger JR, Polin RA, et al, editors: Current pediatric therapy, ed 18, Philadelphia, 2006, Saunders/Elsevier, p 16.

Opioids act by mimicking the actions of endogenous opioid peptides, binding to receptors in the brain, brainstem, spinal cord, and peripheral nervous system and thus leading to inhibition of nociception. Opioids have dose-dependent respiratory depressant effects, and they blunt ventilatory responses to hypoxia and hypercarbia. These respiratory depressant effects can be increased with co-administration of other sedating drugs, such as benzodiazepines or barbiturates. What was once thought to represent infants’ particular sensitivity to the opioids’ respiratory depressant effects we now understand to be due to infants’ lower metabolic clearance of opioids and higher blood levels with frequent dosing.

Optimal use of opioids requires proactive and anticipatory management of side effects (see Table 71-6). Common side effects include constipation, nausea, vomiting, urinary retention, and pruritus. The most common, troubling but treatable side effect is constipation. Stool softeners and stimulant laxatives should be administered to most patients receiving opioids for more than a few days. Constipation also remains a problem with long-term opioid administration. A peripherally acting opiate µ receptor antagonist, methylnaltrexone, promptly and effectively reverses opioid-induced constipation in patients with chronic pain who are receiving opioids daily. The side effect of nausea typically subsides with long-term dosing, but it may require treatment with antiemetics, such as a phenothiazine, butyrophenones, antihistamines, or a serotonin receptor antagonist such as ondansetron or granisetron. Pruritus and other complications during patient-controlled analgesia (PCA) with opioids may be effectively managed by low-dose IV naloxone (see Table 71-6).

One of the potent barriers to effective management of pain with opioids is the unrealistic fear of addiction held by many prescribing pediatricians and parents. Pediatricians should understand the phenomena of tolerance, dependence, withdrawal, and addiction (see Table 71-5) and should know that the rational short- or long-term use of opioids in children does not lead to a predilection or risk of addiction in a child not otherwise at risk by virtue of genetic background and social milieu. It is important for pediatricians to realize that even patients with recognized substance-abuse diagnoses are entitled to effective analgesic management, which often includes the use of opioids. When there are legitimate concerns about addiction in a patient, then safe, effective opioid pain management is often best managed by specialists in pain management and/or addictionology.

There is no longer a reason to administer opioids by intramuscular injection. Continuous IV infusion of opioids is one, effective option that permits more constant plasma concentrations and clinical effects than intermittent IV bolus dosing, without the pain associated with intramuscular injection. The most common approach in pediatric centers is to administer a low-dose basal opioid infusion, while permitting patients to use a PCA device to titrate the dosage above the infusion (Chapter 70; Fig. 71-3). Compared with children given intermittent intramuscular morphine, children using PCA reported better pain scores. PCA has several other advantages: (1) dosing can be adjusted to account for individual pharmacokinetic and pharmacodynamic variation and for changing pain intensity during the day, (2) psychologically, the patient is more in control, actively coping with the pain, (3) overall opioid consumption is lower, (4) fewer side effects occur, and (5) patient satisfaction is generally much higher. Children as young as 5-6 yr can effectively use PCA. The device can be activated by parents or nurses—the latter practice known as PCA-by-proxy (PCA-P); PCA-P produces analgesia in a safe, effective manner for children who cannot activate the PCA demand button themselves because they are too young or intellectually or physically impaired. PCA overdoses occur when well-meaning, inadequately instructed parents pushed the PCA button in medically complicated situations with or without the use of PCA-P, highlighting the need for patient and family education, the use of protocols, and adequate nursing supervision.

Figure 71-3 Patient-controlled analgesia is more likely to keep blood concentrations of opioid within the “analgesic corridor” and allows rapid titration if there is an increase in pain stimulus requiring higher blood levels of opioid to maintain the analgesia.

(From Burg FD, Ingelfinger JR, Polin RA, et al, editors: Current pediatric therapy, ed 18. Philadelphia, 2006, Saunders/Elsevier, p 16.)

Local Anesthetics

Local anesthetics are widely used in children for topical application, cutaneous infiltration, peripheral nerve block, epidural neuraxial blocks, intrathecal infusions, and IV infusions (Chapter 70; Table 71-8). Local anesthetics can be used with excellent safety and effectiveness. Excessive systemic concentrations can cause seizures, central nervous system (CNS) depression, arrhythmia, or cardiac depression. Unlike opioids, local anesthetics require a strict maximum dosing schedule. Pediatricians should be aware of the need to calculate these doses and adhere to guidelines. Topical local anesthetic preparations can reduce pain in diverse circumstances: suturing of lacerations, placement of peripheral IV catheters, lumbar punctures, and accessing of indwelling central venous ports. The application of tetracaine, epinephrine, and cocaine (TAC) results in good anesthesia for suturing wounds, but TAC should not be used on mucous membranes. Combinations of tetracaine with phenylephrine and lidocaine-epinephrine-tetracaine are equally as effective as TAC, eliminating the need to use a controlled substance (cocaine). EMLA, a topical eutectic mixture of lidocaine and prilocaine used to anesthetize intact skin, is commonly applied for venipuncture, lumbar puncture, and other needle procedures. EMLA is generally safe for use in neonates, but it has been associated with prilocaine-induced methemoglobinemia. In circumcision, EMLA is more effective than placebo in providing analgesia, but probably less effective than ring block of the penis. EMLA should be used cautiously for circumcision, because its use may cause redness and blistering on the penis. A small area should be tested for hypersensitivity before EMLA is more widely applied. Lidocaine cream, 5%, has replaced EMLA in many pediatric centers. Lidocaine is the most commonly used local anesthetic for cutaneous infiltration. Maximum safe doses of lidocaine are 5 mg/kg without epinephrine and 7 mg/kg with epinephrine. Although concentrated solutions (2%) are commonly available from hospital pharmacies, more dilute solutions such as 0.25% and 0.5% are as equally as effective as 1-2% solutions. The diluted solutions cause less burning discomfort on injection and permit use of larger volumes without achieving toxic doses. In the surgical setting, cutaneous infiltration is more often performed with bupivacaine 0.25% or ropivacaine 0.2% because of the much longer duration of effect. The maximum dose of these long-acting amide anesthetics is 2 to 3 mg/kg.

Table 71-8 CLASSES OF LOCAL ANESTHETIC DRUGS

Modified from Macintyre PE, Ready LB: Acute pain management: a practical guide, ed 2, Philadelphia, 2001, WB Saunders, p 19.

Neuropathic pain often responds well to the local application of a lidocaine topical patch (Lidoderm) for 12 hr per day (Table 71-9). Peripheral neuropathic pain may also respond well to IV lidocaine infusions, which may be used in hospital settings for refractory pain, complex regional pain syndromes, and pain associated with malignancies or the therapy of malignancies, such as oral mucositis following bone marrow transplantation. In these instances, 1 to 2 mg/kg/hr should be administered, and the infusion titrated to achieve a blood lidocaine level in the 2 to 5 µg/mL range, with use of twice daily therapeutic blood monitoring. Approaches to central neuropathic pain are listed in Table 71-10.

Table 71-10 TREATMENT RECOMMENDATIONS FOR CENTRAL NEUROPATHIC PAIN ADAPTED FROM CURRENT EVIDENCE-BASED LITERATURE

* Second or third (no specification).

From Freynhagen R, Bennett MI: Diagnosis and management of neuropathic pain, BMJ 339:b3002, 2009.

Unconventional Medications in Pediatric Pain

Unconventional analgesic medication refers to a wide number of drugs that were developed for other indications but that have been found to have analgesic properties. These drugs include some antidepressants, antiepileptic drugs (AEDs), and neurotropic drugs.

The unconventional analgesics are generally used to manage neuropathic pain conditions, migraine disorders, fibromyalgia syndrome, and some forms of functional chronic abdominal pain syndromes, but they are generally not used to manage surgical, somatic, or musculoskeletal pain. Figure 71-4 presents a decision-making tree that will help the physician select the appropriate analgesic category for various types of pain.

Figure 71-4 A decision tree for the selection of conventional and nonconventional analgesics. APAP, acetaminophen; CDH, chronic daily headaches; CRPS, complex regional pain syndromes; NSAIDs, nonsteroidal anti-inflammatory drugs.

Although several unconventional analgesics have been approved by the U.S. Food and Drug Administration (FDA) for analgesic uses, few have been specifically approved for use in youth with chronic pain. Thus, they should be used with caution, with a focus on mitigating pain to allow a child to participate effectively in therapies and return to normal activity as soon as possible. The use of psychotropic medications should be guided by the principles applied to pharmacologic treatment of any symptom or disease. Target symptoms should be identified, and medication side effects monitored. To determine dosing regimens, the physician should consider the child’s weight and the effects that medical condition and other medications, such as psychotropic drugs, may have on the child’s metabolism. When available, therapeutic blood level monitoring should be performed. Side effects should be addressed in detail with both parent and child, and specific instructions given for responding to possible adverse events. It may be necessary to directly address concerns about addiction, dependence, and tolerance in order to decrease treatment-related anxiety and improve compliance.

Nonpharmacologic Treatment of Pain

Numerous psychologic and physical treatments for relieving pain, fear, and anxiety as well as enhancing functioning have excellent safety profiles and proven effectiveness. Cognitive-behavioral treatments for childhood chronic headaches are more effective than many pharmacologic treatments, especially because children can apply their learning to new situations, increasing their sense of mastery. In addition, a combination of distraction, cognitive-behavioral interventions, and hypnosis has large effects in children. Psychologic interventions may also be effective for children with musculoskeletal and recurrent abdominal pain.

Nonpharmacologic treatments of pain may be generalized to other treatment needs. A child with cancer who learns self-hypnosis to reduce distress from lumbar punctures may successfully apply this skill to other stressful medical and nonmedical situations. When deciding whether to use nonpharmacologic techniques to treat pain, the practitioner should: (1) pay attention to the patient’s environment, optimal positioning, and physical comfort; (2) because nonpharmacologic techniques alone may not work for some children, not withhold appropriate analgesics; (3) give children (and family members) developmentally and situationally appropriate information as to what to expect, given the child’s medical condition, procedures, and treatments; (4) include patients and their families in decision-making to ensure an appropriate treatment choice and to optimize adherence to treatment protocols; and (5) above all, develop a communication plan among the different therapists, typically with the pediatrician as the case manager, so that the messages to the child and parent are consistent and the modes of therapy are organized into an integrative team approach.

Relaxation techniques promote muscle relaxation and reduction of anxiety, which often accompanies and increases pain. Controlled breathing and progressive muscle relaxation are commonly used relaxation techniques for preschool-aged and older children. Asking the child to focus on the breath and pretend to be blowing up a big balloon, while pursing the lips and exhaling slowly, may help induce controlled breathing.

Distraction helps a child of any age shift attention away from pain and onto other activities. Common attention sustainers in the environment include bubbles, music, video games, television, the telephone, conversation, school, and play. Asking children to tell stories, or asking parents to read to the child, and even mutual story-telling can be helpful distracters. Being involved with social, school, physical, or other activities helps the child in chronic pain regain function.

Hypnotherapy helps a child focus on an imaginative experience that is comforting, safe, fun, or intriguing. Hypnotherapy captures the child’s attention, alters his sensory experiences, reduces distress, reframes pain experiences, creates time distortions, helps the child dissociate from the pain, and enhances feelings of mastery and self-control. Children with chronic pain can use metaphor, for example, imagining they have overcome something feared because of pain in real life. As the child increases mastery of imagined experiences, the enhanced sense of control can be used during actual pain rehabilitation. Hypnotherapy is best for children of school age or older.

Biofeedback involves controlled breathing, relaxation, or hypnotic techniques with a mechanical device that provides visual or auditory feedback to the child when the desired action is approximated. Common targets of actions include muscle tension, peripheral skin temperature through peripheral vasodilation, and anal control through rectal muscle contraction and relaxation. Biofeedback also enhances the child’s sense of mastery and control, especially for the child who needs more “proof” of change than that generated through hypnotherapy alone.

Iyengar yoga was developed to achieve balance in mind, body, and spirit. This form of therapeutic yoga is especially effective for treating chronic pain; improving mood, energy, and sleep; and reducing anxiety. Iyengar yoga involves a series of asanas (body poses) oriented to the specific medical condition or symptoms. It uses props, such as blankets, bolsters, blocks, and belts, to support the body while the patient assumes more healing poses. Yoga promotes a sense of energy, relaxation, strength, balance, and flexibility and, over time, enhances a sense of mastery and control. In more advanced yoga, the child may learn certain types of breathing (pranayama) for added benefit.

Massage therapy involves the therapist’s touching and applying varied degrees of pressure on the child’s muscles. This massage is very useful for children with chronic pain and especially helpful for those with myofascial pain. There are several types of massage, including craniosacral therapy. For young children, it can be helpful to have parents learn and perform brief massage on their children before bedtime.

Individual psychotherapy can be used to address the cognitive, behavioral, and psychologic contributors to pain and pain behaviors. Assessing and treating such contributors—maladaptive coping, anxiety, depression, learning disorders, social problem-solving deficits, communication problems, relationship issues, unresolved grief or trauma, school avoidance, and other identified problems—can reduce acute distress and chronic stress load on the CNS, thereby reducing excessive arousal and pain.

Family education and/or psychotherapy, particularly cognitive-behavioral family approaches, has been shown to be effective for treating chronic pain. It may help family members to better cope with their child’s and their own distress. They can learn the mechanisms and appropriate treatment of pain and alter family patterns that may inadvertently exacerbate pain. A key goal is to develop a plan for the child to manage his/her own symptoms and increase independent functioning. Parents and teachers may need guidance on developing a behavioral incentive plan to help the child return to school, gradually increase attendance, and receive tutoring, after a prolonged, pain-related absence.

Physical therapy can be especially useful for children with chronic, musculoskeletal pain and for those deconditioned from inactivity. Exercise appears to specifically benefit muscle functioning, circulation, and posture, also improving body image, body mechanics, sleep, and mood. The physical therapist and the child can develop a graded exercise plan for enhancing the child’s overall function.

Acupuncture involves the placement of needles at specific acupuncture points along a meridian, or energy field, after a diagnosis of excess or deficiency energy in that meridian as the primary cause of the pain is made by the acupuncturist. Acupuncture is a feasible, popular part of a pain management plan for children with chronic pain. Acupuncture alleviates chronic nausea, fatigue, and several chronic pain states, including migraine and chronic daily headaches, abdominal pain, and myofascial pain. Acupuncture also has efficacy in adults with myofascial pain, primary dysmenorrhea, sickle cell crisis pain, and sore throat pain. The acupuncturist must relate well to children so that the experience is not traumatic, because added stress would undo the benefits gained.

Transcutaneous electrical nerve stimulation (TENS) is the use of a battery-operated tool worn on the body to send electrical impulses into the body at certain frequencies set by the machine. TENS is believed to be quite safe and can be tried for many forms of localized pain. Children often find TENS helpful and effective, but there are no randomized clinical trials of TENS for pain in children.

Music and art therapy can be especially helpful for young and nonverbal children who would otherwise have trouble with traditional talk psychotherapies. Also, many creative children can more easily express fears and negative emotions through creative expression and, with the therapist’s help, learn about themselves in the process.

Dance, movement, pet therapies, and aromatherapy have also been used and may be very helpful but have not been studied in children for pain control.

Invasive Interventions in Treating Pain

Interventional neuraxial and peripheral nerve blocks provide intraoperative anesthesia, postoperative analgesia (Chapter 70), treatment of acute pain (e.g., long bone fracture and the pain of acute pancreatitis), and contribute to the management of chronic pain (e.g., headaches, abdominal pain, complex regional pain syndromes [CRPS], and cancer pain).

Regional anesthesia provides several benefits: (1) it is an alternative to or augmentation of opioid-based pain control, thereby minimizing the opioid side effects nausea, vomiting, somnolence, respiratory depression, pruritus, and constipation; (2) it generally provides better quality pain relief because it interrupts nociceptive pathways and more profoundly inhibits endocrine stress responses; (3) it results in earlier ambulation in recovering surgical patients; (4) it helps prevent atelectasis in the setting of severe chest pain; and (5) it usually results in earlier discharge from the hospital.

Regional anesthesia is considered safe and effective if performed by trained staff with the proper equipment. Most nerve blocks are performed by an anesthesiologist or pain management physician; a few are easily performed by a non-anesthesiologist with appropriate training.

Considerations for Special Pediatric Populations