Many Barriers Still Interfere With Adequate Pain Management in Pediatric Patients

LAS VEGAS, NV In a live symposium at PAINWeek 2012, Deborah Ward, PharmD, BCOP, BCPS, clinical pharmacy specialist, of St. Jude Children's Research Hospital, Memphis, TN, told clinicians and pain specialists that a major barrier to helping pediatric patients deal with chronic and acute pain includes limited FDA testing in children. In addition, healthcare providers are aware of treatment steps they must take that only add to the child's pain.

Describing pediatric patients as “a vulnerable population,” Dr. Ward explained that children often receive inadequate treatment for pain, as is the case with some elderly patients and minorities. The lack of comparable randomized trials and few published meta-analyses of analgesic use in pediatric patients poses a challenge to providing adequate pain relief. While the situation has improved greatly — considering that in earlier years, “kids underwent surgery with inadequate analgesia and sedation,” — she noted that things have improved with the advent of childhood advocates. However, a continuing problem is that while FDA mandates exist for newer products, there are few or none for older drugs.

Pain assessment also can be challenging in younger patients because of such shortcomings as the false perception that infants and children do not feel pain, or if they did, this would not have serious consequences. Another barrier is lack of assessment or inadequate pain assessment in children. Frequently added to this is a lack of knowledge of how to treat pain in pediatric patients, as well as concerns about side effects. Some feel that pain management in children is too time-consuming and requires excessive effort. 

There is also fear of using effective agents because of the possible adverse effects, such as respiratory depression in younger children and the potential for habituation in adolescents. Society can foster misuse, she added, noting that “pharm parties” are a newer problem among adolescents.

The patient, even if young, is the best and most accurate source of information about his or her pain, if he has verbal and cognitive skills. For pediatric patients, Dr. Ward's group uses verbal analogue scales, including the Wong-Baker FACES Pain Scale. But even with older children and adolescents, cultural differences may interfere with expression of concerns or of the extent of pain. An example is the teen who is in much pain but doesn't want to discuss it because the parents are in the room. The teen may be trying to spare the parents  the stress of knowing and worrying about the pain. There are obviously cognitive developmental barriers, she said, although by age 2, a young patient can point to the source of pain, and by age 5, he can rate the severity of pain.

Dr. Ward is a strong proponent of telling young patients exactly what is happening, and she said that the fear of the unknown is often greater than the pain itself — children are often aware of much of what is going on. At St. Jude, child life specialists work closely with the kids, and use approaches such as guided imagery, songs, and dolls; also, no procedures are performed in the young patient's room.

In these very ill patients, Dr. Ward advises, “Be careful of daily cumulative doses” of ibuprofen, and she feels that NSAIDs are not safe for many children. As with all medications, she stresses weighing the benefits versus the possible risks.