Chronic pain in children and adolescents, more than just a pill.

Introduction and Epidemiology It was in 2022 that well-known researchers involved in pediatric pain made a statement for more attention for pediatric pain in general, and where more research concerning pediatric pain was needed, using the motto: make pain matter, make pain understood, make pain visible and make pain better (Eccleston et al., 2021). Currently there are gaps in knowledge of validated criteria for certain pediatric pain conditions, adequate treatment protocols, adequate dosing of medication for all age groups and an absolute lack of evidence for invasive interventions (Boulkedid et al., 2018; Shah et al., 2016). And despite things are improving the amount of publications related to pain in children was in 2023 around one tenth of the amount related to pain adults (Krane 2023).

Chronic pain in children and adolescents is a common problem with a prevalence cited between 11% and 38% of the general population (King et al., 2011). Between 2004 and 2010 an increase was observed of 831% in the amount of pediatric pain patients presenting with chronic pain in 43 tertiary centers in the United States (Coffelt et al., 2013). This may be caused by an enhanced detection and awareness but an increase in prevalence of chronic pain cannot be excluded.

Risk Factors As risk factors for chronic pain are considered: female sex, age around 12-14 years, children with anxiety or depression, other chronic health conditions, low socio-economic status but also additional neurodevelopment disorders like autism or attention deficit hyperactivity disorder (ADHD) (King et al., 2011; Lipsker et al., 2018). Furthermore adverse child experiences like child abuse or bullying at school are considered as risk factors as well as an immigration background, the last especially in younger children (Abrahamyan et al., 2024; Roman-Juan et al., 2024; Solé et al., 2024).

Consequences of Chronic Pain in Childhood Consequences of pain in childhood or adolescence can be more anxiety and depression with sometimes suicidal ideation, sleep disturbances, social isolation, school absence and therefore a lower school achievement, an impaired athletic performance and generally a lower quality of life. In addition, there is the burden through involvement of parents and siblings. So adequate treatment of these chronic pain disorders in childhood or adolescence is eminent. Not just because of the actual burden but also because around two third of children with chronic pain in childhood or adolescence might present themselves in an adult pain center in adulthood (Kashikar-Zuck et al., 2014; Walker et al., 2010).

Presentations of Pediatric Pain Now what kind or pain conditions are generally seen in a pediatric pain center ? This may vary from one pediatric pain center to another, by country and how care is arranged. Generally it concerns musculoskeletal and limb pain (e.g. complex regional pain syndrome), headache, abdominal pain, back pain, chronic postsurgical pain, pain that comes with chronic diseases like sickle cell anemia or neurofibromatosis and more general; pain like functional pain. Furthermore there is pain in palliative care situations.

Overlooking the different types of pain, next to nociceptive pain which is most of the time acute pain, chronic pain contains often neuropathic pain, a pain type that is often overlooked and for which specific diagnostic questionnaires are not validated for children. Also the causes of neuropathic pain in children are often different from those in adults (Howard et al., 2014; Kachko et al., 2014). Since a few years there is a new descriptor, that involves pain not caused through tissue damage or disease or damage of the somatosensory system but through altered pain processing: nociplastic pain. This new descriptor can help us to elucidate the often used explanation for their pain complaints to patients an parents: Functional pain, or better dysfunctional pain (Schechter 2014).

Assessment and Treatment Chronic pediatric pain assessment and treatment according a bio-psycho-social model by a multi- or interdisciplinary team is generally considered state of the art nowadays. Again, depending on how care is organized by center, regionally or nationally (Liossi et al., 2019; Miró et al., 2017).

Generally such interdisciplinary team consists of a pediatric pain specialist, psychologist and physiotherapist (3 P’s) with eventually complementary therapists like occupational or music therapists. This way each team member has treatment modalities from their own professional background (Rolfe 2016).

First step, and crucial in assessment and treatment should be connection with and feedback to the patient and parents in the so called ‘Golden Half Hour’ (Schechter et al., 2021). One should validate symptoms, emphasize a multi- or interdisciplinary treatment plan and give education. Diagnostic uncertainty in patients or parents might otherwise lead to more catastrophizing and higher pain scores (Neville et al., 2020).

Furthermore the target in treatment is in the first place; recovery of function with the restoration of daily activities and sleep rhythm, next to reduction of pain. In such a treatment program physiotherapy has proven it’s benefit, for example through a graded exposure or graded activity plan, not only in the treatment of musculoskeletal pain but also in abdominal pain or tension headache.

Psychologic therapies, like cognitive behavioral therapy (CBT) or acceptance and commitment therapy (ACT), have proven to be efficient, also to elucidate pain-maintaining factors (Fisher et al., 2018). Additionally, for the treatment of chronic pain after a traumatic injury, trauma therapy like eye movement desensitization an reprocessing (EMDR) and hypnosis techniques can be incorporated in the armament of the psychologist. Pending assessment in the clinic, some types of therapy may already be offered via the internet but the evidence up till now is low (Fisher et al., 2019; Murray et al., 2020).

Furthermore, pain medication can be offered by the physician of the interdisciplinary team as treatment by itself but also to make physiotherapy more feasible. Most used medications for the treatment of chronic pain are non-steroid anti-inflammatory drugs (NSAID’s), Cox-2-inhibitors, gabapentinoids, tricyclic antidepressants (TCA’s), and selective serotonin reuptake inhibitors (SSRI’s). For the use of opioids there is only place in special pain conditions and palliative care (Cooper et al., 2017). Most evidence for the use of medication as well as doses advices are abstracted from literature in adults. In daily practice hardly treatment protocols are used and one must keep in mind that generally the evidence for the use of medication in chronic pediatric pain is very low (de Leeuw et al., 2020; Eccleston et al., 2019).

As an extra tool transcutaneous electric nerve stimulation (TENS) could be used. It hardly has any side effects and has the advantage that it gives patients a way of self-control in their pain treatment. On the contrary there is no robust evidence for invasive interventions in the treatment of chronic pediatric pain (Shah et al., 2016; Zernikow et al., 2012). A drawback is further that these interventions in children have to be performed under sedation or general anesthesia.

The format of interdisciplinary treatment programs varies from clinic to clinic, as does the way of reimbursement for such treatments, which is regulated differently from country to country. Often it is provided by means of an outward patient program but clinics can also offer an internal intensive rehabilitation program. Such an intensive rehabilitation program may offer better results than a program in an outward patient setting (Claus et al., 2022; Dekker et al., 2020; Hechler et al., 2015; Simons et al., 2013; Wager et al., 2021) A list of clinics with a pediatric pain program worldwide can be found under: http://childpain.org/index.php/resources/

Conclusion Chronic pain in children and adolescents is an increasing problem in Western Europe and North America, but an increased prevalence cannot be excluded in the Non-Western world (Coffelt et al., 2013; McCarthy and de Leeuw 2019).

Assessment of chronic pain and treatment of chronic pain in children and adolescents is time consuming and needs great commitment from the treatment team. Trust and bonding of the patient and parents with the treatment team are essential and since often these patients are frequently referred from one professional to another without satisfying result, this might be difficult to achieve and should be priority during the first assessment (Schechter et al., 2021).

The recently published study of Pico showed that chronic pain in children is still underdiagnosed and undertreated mainly due to a lack of knowledge of health care professionals (mainly pediatricians in this study) of mechanisms contributing to persistence of chronic and adequate management of chronic pain (Pico et al., 2023). Education, treatment protocols and up to date guidelines and programs are mandatory, just as adequate guidelines where and by whom (preferably pediatric pain specialists) these children should be treated (McCarthy and de Leeuw 2019; Miró et al., 2017).

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