by Brian S. Carter, MD, FAAP. Children’s Mercy Bioethics Center

“Of pain you could wish only one thing: that it should stop. Nothing in the world was so bad as physical pain. In the face of pain there are no heroes.” ~ George Orwell, 1984

Throughout the 20th century, many misperceptions—and even myths—existed regarding pain in children. It was believed that they experienced pain with less intensity than did adults. Clinicians assumed differences in pain response were related to an immature perception of pain rather than an immature response to it.

In the last 20 years, studies across the broad domains of pain perception and responsiveness revealed that pain is not a single, objective, physiological phenomenon. Pain perception and processing varies among different origins—e.g., tissue damage (laceration, broken bone), the stretching of an internal organ (bowel, bladder), or nerve injury (neuropathic pain)—and occurs in a social context. Each patient may express or interpret pain differently and requires an individualized response by healthcare professionals.

The World Health Organization recognized that a child’s pain is a subjective phenomenon in 1998. It led investigators to determine improved ways to understand the child’s own experience of pain, and the realization that children experience pain at least as intensely as adults. New understandings of pain processing in the central nervous system (CNS) and how inhibitory pathways, neurotransmitters, and psychological components of the pain response in children have been gained. We understand better now how early experiences of pain affect subsequent perception, tolerance, and adaptation by children.

But old myths die hard; resistance to the treatment of infants and children with pain persists; some clinicians still believe that a child’s immature central nervous system (CNS) means that pain is less intensely sensed than in adults; and others think that pain in infancy or childhood is not registered in memory. Nothing could be farther from the truth, as we now know that recurrent, and untreated, pain and its associated stress greatly impact behavior and child development—and even responses to subsequent pain. Yet fears of a child or adolescent developing tolerance, dependence, or even addiction to strong pain medications such as opioids persist—leading to painful procedures still being performed on conscious children without local anesthetics or post-procedural analgesics despite the availability of safe and effective anesthesia/analgesia. Why? Likely because adults often trivialize pain in children, consider analgesia to be unnecessary, or even dangerous.

Chronic pain is likely to be the most poorly understood of pain conditions in children. It may be experienced by children with certain disease states (juvenile arthritis, fibromyalgia, sickle cell disease, cancer); or simply be an isolated chronic (generally agreed upon as greater than 3 months in duration) symptom such as headache, abdominal pain or lower back pain. Chronic pain often interrupts sleep, daily activities at home and school, and a child’s desires to participate in sports or hobbies. In contrast to past practices, dividing pain syndromes into organic (disease-based) and functional (psychological bases) is not presently considered helpful. Indeed most pain syndromes have a psychological, social, and behavioral component—and consequently stand to be treated more comprehensively with both pharmacologic and behavioral interventions. For chronic pain, these may include a variety of cognitive behavioral interventions, biofeedback, massage, and relaxation therapy in addition to the use of adjunctive medications such as antidepressants.

Recognizing pain in a child isn’t easy for healthcare professionals and sometimes not for parents. But the child’s family or consistent caregivers may more accurately identify pain-related behaviors than physicians and others with more limited contact. The principle activities of childhood include eating, sleeping, school and play, and altered behavior might be a valuable clue to a child’s pain. Hence, pain should always be among things considered amid a child’s diminished (e.g., reduced spontaneous movement of an extremity or a child that becomes distressed when moved). Even subtle changes may be important, such as the avoidance of normal social interaction—which may appear like depression. A simple rule of thumb is to ask oneself, “How do I act when I’m in pain?” Given that it isn’t always possible to reliably exclude pain in a child, a therapeutic trial of analgesia may be justified. Or, in considering an event or incident where pain is questioned, ask, “Would I be in pain if it were me?” If pain is likely, adequate analgesia should be provided, regardless of whether or not a child is capable of verbalizing pain. And we should not forget to reassess for pain after such a treatment.

There are challenges in diagnosing pain in pre-verbal or cognitively impaired children, but numerous pain scales have been developed and validated across the pediatric age spectrum—including for newborns and non-verbal children. Their use lends objective, standardized measures that generally incorporate physiologic components (heart rate, blood pressure, muscle tone and movement, oxygen saturation, and quality of breathing or even crying) and behavioral components (restlessness, facial expression, responsiveness).

In summary, the diagnosis of pain in children can be difficult. Some children can clearly detect and describe their pain. Others, especially non- or pre-verbal children may only give clues by their change in behavior. Healthcare professionals must respect the knowledge of daily caregivers, particularly the family. A therapeutic trial of analgesia is a simple way to distinguish pain from other causes of distress. The use of standardized age-appropriate pain scales is advisable in order to bring objectivity and consistency in treating individual patients. More remains to be learned about children’s quality of life when in pain—particularly if it is chronic pain or when terminally ill.