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Pediatric Update


Pediatric Update

Spring 2006

Multiple Modalities Relieve Chronic Pain in Children

“Pediatricians can do a lot by understanding the mechanisms of chronic pain and how anxiety, for example, can actually increase the volume of pain signals and make the pain worse.” —Lonnie K. Zeltzer, M.D.

Nationwide, between 15 percent and 30 percent of school-age children struggle with chronic pain, ranging from headaches and stomachaches to fibromyalgia, irritable bowel syndrome and other chronic pain syndromes. When not properly addressed, chronic pain can dramatically affect children’s school attendance and performance, social activities and relationships, sleep, appetite, and mental health.

Unlike acute pain, which should be treated vigorously with medication or with psychological techniques like hypnosis, chronic pain requires a focus on helping the child learn to function and cope while efforts are undertaken to soothe the nervous system and reactivate the body’s natural pain control mechanisms, says Lonnie K. Zeltzer, M.D., director, Pediatric Pain Program at Mattel Children’s Hospital at UCLA.

“If a child has surgery or is in the emergency room with a broken bone that needs setting, we focus on turning off the pain with good analgesia or anesthesia,” says Dr. Zeltzer. “With hronic pain, so many systems are involved that using opioids to get rid of the pain is typically not helpful. What’s more important is to help the child begin to spiral back up through incentives and coping strategies that help him or her sleep better, stay in school, and engage in social activities, while also focusing on ways to reduce the pain.”

Chronic pain involves a complex interplay between biology, psychology and environment, Dr. Zeltzer notes. “There is no pain that is either psychological or physical,” she says. For example, tressors at school can activate the child’s central nervous system, which in turn affects neural signals that make the child more vulnerable to a particular chronic pain syndrome. In addition, research has recently shown that exposure to significant acute pain as early as the newborn period can shape the development of the sensory nervous system, making children more prone to pain vulnerability throughout their childhood. Children who experience undertreated acute pain can also develop post-traumatic stress disorder, contributing to chronic pain after the acute pain period has passed.

Dr. Zeltzer notes that children with nerve signaling problems who are sent to one specialist after another in an effort to determine the cause of their chronic pain often end up with more sensitive nervous systems from all of the tests, adding to their problems. Such repeated testing, when it yields little new information, can also lead children to feel that no one believes they are really in pain.

 “Pediatricians can do a lot by understanding the mechanisms of chronic pain and how anxiety, for example, can actually increase the volume of pain signals and make the pain worse,” Dr. Zeltzer says. She notes that it is also important to help parents and their children understand that negative test results do not mean that the pain isn’t real. “If the child has myofacial headaches or irritable bowel syndrome, explain that the problem is in the wiring system and the signaling, and that now that we have ruled out other possibilities, we can focus on rebalancing the nerve signaling so that the pain control system can start working normally again,” Dr. Zeltzer explains.

The most common types of chronic pain in childhood are headaches and stomachaches. “Children with intractable headaches should be evaluated by a pediatric neurologist, especially if there are other symptoms such as neurologic signs or early-morning vomiting,” Dr. Zeltzer notes. “But many children are suffering from myofacial headaches, in which there is a chronic muscle spasm in the head, neck or shoulders.”

Myofacial pain can be diagnosed by feeling for tenderness at muscle insertion points in front of the ears, or other tender points in the muscles along the back of the neck and between the shoulder blades. For children with recurrent abdominal pain, a good history will determine whether the child has a functional bowel disorder or should be referred to a pediatric gastroenterologist for further testing. A functional bowel disorder means that the braingut nervous system is dysregulated or out of balance. The child may just have recurrent abdominal pain or may also have other gastrointestinal symptoms, such as diarrhea, constipation, nausea or bloating. Typically, medical evaluations for children with abdominal pain related to functional bowel syndromes do not show serious problems. When children are told that there is “nothing wrong” or that they have pain “because of stress,” they feel that the doctor does not believe them or thinks the pain is imaginary, but their belly is hurting.

“The stomach and intestines can become hypersensitive,” says Dr. Zeltzer, “and these children may feel pain from gas, swallowing food, stomach-wall stretching or having a bowel movement. In these children, the problem isn’t in the intestines themselves but rather the nerve signals to and from the intestines, and that is what needs to be addressed.”

Other types of chronic pain problems include fibromyalgia and complex regional pain syndrome. Fibromyalgia is a condition of widespread pain, with tender points along areas of the back, neck, chest and extremities. It is not uncommon for children with fibromyalgia to also have headaches and irritable bowel syndrome, Dr. Zeltzer says. Complex regional pain syndrome, previously referred to as reflex sympathetic dystrophy, is characterized by extreme sensitivity and pain in a part of the body, sometimes accompanied by vascular changes such as swelling or discoloration.

The problem with treating children who have chronic pain with opioids, Dr. Zeltzer notes, is that the drugs block the body’s pain control system. The rehabilitation effort generally should begin with helping the child learn how to function and cope with the pain until it moves from the foreground to the background and then dissipates, Dr. Zeltzer says. Non-medication strategies include physiotherapy, psychotherapy and complementary therapies such as acupuncture, meditation, Iyengar yoga and art therapy, as well as biofeedback and hypnotherapy. “Any of these modalities can be helpful in restoring balance to the body’s central nervous system,” Dr. Zeltzer notes.

Beyond treatment, pediatricians can contribute a great deal by working with parents to develop behavioral incentive plans to assist the child in gradually increasing function. Parents should also be counseled not to constantly ask their children about the pain. “Parents can empathize when the child brings it up, but always asking about it causes the child to focus on the pain,” Dr. Zeltzer explains.

When parents are particularly anxious about their child’s pain or their own chronic pain, it can also exacerbate matters. “The caregivers need to take care of themselves, because children with chronic pain are often very sensitive to their parents’ feelings,” Dr. Zeltzer says. “If the parents are feeling stress or guilt, that can further rev up the child’s nervous system and cause more pain. Children learn how to cope, function and remain calm by observing their parents; therefore, parents who care for themselves teach children how to feel better.”

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