Who should treat pain in children?

Most common painful conditions of childhood have been and should continue to be managed by pediatricians and family practitioners. Occasionally, a child will develop a pain that does not resolve with time or simple interventions. The pain that results from cancer or other complicated medical problems can also be difficult to control and need special expertise. For those times, a pediatric pain clinic/specialist can provide more comprehensive pain care.

Why is a psychologist involved?

Pain is not just physical. It causes stress and it causes suffering. Depression and anxiety can result from pain or make it worse.

The family is always involved in the stress and suffering, because of the love the family has for its children. Taking care of these issues is very important. Often pain does not go away quickly, and coping skills training helps the child and the family to go on with life until the pain resolves.

Finally, there are pathways in the brain and spinal cord whose job it is to suppress pain. There are several ways the psychologist can help the child connect these neurologic defenses to actually feel less pain.

Treatments that are available include biofeedback, relaxation training, coping skills training and psychotherapy. All of our patients have at least an evaluation by our pain psychologist when they first come to clinic. This can also be provided as an inpatient service if needed.

Why is a physical therapist involved?

Pain affects the way the body functions. Whether they know it or not, people may change the way they walk, sit, use their legs or arms, or hold their head. They may simply become “out of shape.”

Our physical therapist is an expert in assessing these changes and designing a course of therapy to optimize the body’s function. There are actually severe pain conditions that seem to improve because of physical therapy as much as everything else put together!

One thing to know is that the increase in activity that may be recommended often briefly increases the pain before it helps.

We can help with this, but it is to be expected and you will need to help your child stick with the program in order to get the long-term benefits from it.

What is a TENS unit?

TENS stands for Transcutaneous Electrical Nerve Stimulation. It is a pain-relief device that uses two small patches that stick to the skin, providing a tapping or tingly sensation to the painful area. The nervous system handles sensation on a “first-come, first-serve” basis. The sensation provided by the TENS unit travels faster than pain sensations and helps the spinal cord block out the pain.

The TENS device can be worn under clothing for use at work or school, and it is very safe.

Can children become addicted to pain medications?

We use opioid (narcotic) pain medicines for certain pain conditions, especially after surgery and for patients with cancer pain. The number of children who become addicts is extraordinarily small.

Most people of any age will become tolerant to opioid medications. They may need more and more to get the same effect; they may say “this medicine doesn’t work for me any more.”

They may have withdrawal if they stop the medicine suddenly (withdrawal can be avoided by following a medication schedule provided by the pain service). This is a physical phenomenon that happens to almost everyone and is different from addiction.

As a matter of policy, though, we do have patients and parents sign a “controlled substances contract” when these medicines are prescribed through the pain clinic for non-cancer pain and enforce the rules strictly, but problems are rare.

Isn’t methadone for drug abusers?

Methadone is a long-acting opioid medication that is the same strength as morphine. Because it does not cause a “high” and because it is long acting, it is used in drug clinics to keep former users off of heroin.

In our pain practice, it is a very useful medication because it works well for pain, lasts a long time, comes as a liquid (for those who cannot take pills), and has special properties as a pain medicine that other opioids do not. It often has fewer side effects for those patients who have had problems with other medications.

Lastly, we often use methadone to help prevent withdrawal symptoms in patients who are discontinuing opioid medications after taking them for a long time. We monitor the use carefully, including obtaining electrocardiograms.

Why are medications used to treat seizures and depression used to treat pain?

An interesting thing about pain is that many of the same chemicals the body uses to transmit or block pain signals are the same as those that seem to be out of balance when a person becomes depressed. Other sorts of pain act a bit like seizures, where nerves fire at times and in ways that are inappropriate.

Antidepressants and anticonvulsants have been shown to help many different pain conditions. They also help with sleep (which is often disturbed by pain) and have a helpful effect on mood. They do have side effects (like almost everything), and we monitor their use carefully, including obtaining electrocardiograms and blood tests, depending on the medication.

What is RSD (Reflex Sympathetic Dystrophy)?

RSD (now called Complex Regional Pain Syndrome Type I) is a type of neuropathic (relating to nerves) pain that is infrequent in adults and children, and can be very severe.

There are several differences in pediatric RSD from that in adults. Most children recover. It is most common in active (athletes, dancers) female adolescents of high-achievement oriented families. It tends to occur in the lower legs and feet and usually does not progress to the “crippled up,” withered appearance that can occur in adults with the syndrome.

RSD in children appears to respond well to aggressive physical therapy, medication and behavioral medicine. Sometimes nerve blocks are used to interrupt the pain cycle or to allow physical therapy to be done if it is otherwise too painful.

We stress that the information available on the Internet is predominantly from adults and often paints a picture that does not apply to children with this pain syndrome.

What causes pelvic pain?

Pelvic pain is more common in adolescent girls than once thought. Often endometriosis is the cause. Endometriosis is a condition in which the clusters of cells that usually form the lining of the uterus come to be lodged in the pelvis and abdomen and cause pain.

Other causes of pain include menstrual cramps, ovarian cysts, venereal diseases and adhesions from surgery. Sometimes extensive testing reveals no obvious cause.

Treatment involves medications (often including oral contraceptive pills), TENS, physical therapy, behavioral medicine and other non-traditional treatments such has acupuncture.

What causes recurrent abdominal pain?

This is one of the more frustrating kinds of pain in children not only because it is extremely common (even Peanuts lead character Charlie Brown complains, “my stomach hurts”), but also because the reason for the pain is often unknown.

Sometimes conditions such as lactose intolerance, visceral hyperalgesia, intestinal pseud-obstruction, pancreatitis, diabetes and gallbladder disease may explain the pain.

As with most complex pain in children, a multidisciplinary approach is required to manage the pain.

What can be done for cancer pain in children?

Pain is assumed to be a natural part of having cancer; it is one reason why cancer is so feared as a disease. In addition, many of the treatments and tests for cancer are painful.

Fortunately, we have many things to offer for controlling cancer pain, as well as the pain and fear that result from the tests and treatments. We believed very strongly that cancer pain should be brought under control to the greatest degree possible for all children, regardless of the prognosis.

We use a combination of medications, behavioral medicine techniques to reduce stress.

We make ourselves available around the clock to all our cancer pain patients.

What can be done for the pain of surgery in children?

Children hurt after surgery. That seems so obvious, but for a long time, children received much less pain control after surgery than adults did. We have an active acute pain service to advocate for the children who need special pain care.

We use epidural catheters for a wide range of operations, both in the operating room and afterwards. For children age 5 and up, PCA pumps can be very effective.

For children who are either too young to use a PCA or are handicapped and cannot use a PCA, we have other means of making sure all patients on our service receive the proper pain medications. Even with the latest advances in medicine and technology, we cannot promise that there will be no pain after surgery. We promise to do our best to keep the pain to the least possible amount. We also look after side effects and have safety guidelines that are used throughout the hospital for the patients on our service.

What is a PCA (Patient-Controlled Analgesia) pump?

PCAs are computerized pumps that can be set to deliver a specific amount of medication when a button is pushed by a patient. Children as young as 4 years old have used PCAs effectively, although generally we only offer it to children over the age of 5.

Safety settings include limits on how often the pump will deliver the medication, how much is given at a time. Several medications can be used this way. Only the patient is allowed to press the button, so that if they become too sleepy, they fall asleep and do not press the button.

Pressing the button while a patient is asleep is a dangerous thing to do (no matter how old the patient is) and we prohibit that, a policy we strictly enforce.

With proper education, an identified parent/caregiver can be instructed on how and when to push the pca button for extra medication. Instruction will also be given about signs and symptom that should be reported to the nurse.

What is an epidural?

Most people know of epidural analgesia as a way to keep women comfortable during childbirth. The epidural is a length of thin tubing that is placed in a space between the bones of the spine and the spinal cord. Medications can be given as an infusion to keep people comfortable after surgery.

Children are generally quite afraid of needles and would move during catheter placement (which could be dangerous), so we place the catheter while the child is asleep under general anesthesia. Abdominal, chest, hip and leg surgery are the types of surgery most appropriate for an epidural. Epidurals can be used after surgery on patients from the first day of life and through adulthood.

 

1 Children’s Way, Slot 203
Little Rock, Arkansas
Phone: 501-364-2933
Fax: 501-364-2939