For Children with Chronic Pain, Evaluation Requires a Biopsychosocial Model

PALM SPRINGS, CA—Increasing survival rates for premature infants—in which pain in neonates can change the developing sensory nervous system, increasing the risk for long-term chronic pain—and increasing survival of children with genetics diseases both contribute to chronic pain in children, Lonnie K. Zeltzer, MD, David Geffen School of Medicine at UCLA, Los Angeles, CA, told those attending the 2012 American Academy of Pain Medicine Annual Meeting.

Children with complex chronic pain often have co-morbid symptoms such as anxiety, depression, pervasive developmental disorder, learning disabilities, and multiple pain problems, she noted, with 15–30% of children in studies from the United States, Canada, Australia, the United Kingdom, Germany, and Holland reporting chronic pain; most commonly, headaches and abdominal pain.

Common pain syndromes in children include irritable bowel syndrome and functional abdominal pain, chronic daily headache, chronic myofascial pain (eg, neck, back, and extremity pain), complex regional pain syndrome, and fibromyalgia, Dr. Zeltszer said.

She outlined several ways in which it may be possible to prevent development of adult chronic pain: good perioperative care, prevention/reduction of medical procedure pain, good pain management in the emergency department, and appropriate treatment of chronic pain. Central pain network that may affect perceptions of controllability of pain among children include learned responses from parents, coping style, anticipation of pain, arousal/anxiety, memory, attention, genetics, nociception.

“Chronic pain typically does not have a single cause and evaluation requires a biopsychosocial model,” said Dr. Zeltzer. An evaluation history for a child with chronic pain includes a history of the pain, emotional history, other physical symptoms, and school history.

She reviewed a case history of a 12-year-old girl who was seen by a primary care provider for a viral gastroenteritis with abdominal pain, nausea, and diarrhea. Despite referrals to two gastroenterologists and consistently negative test outcomes, the child continued to have chronic pain for more than seven weeks, missing school and frustrating her parents. Treatment with amitriptyline 10mg was ineffective.

Subsequent referral to a child psychologist and a pain medicine specialist resulted in diagnoses of irritable bowel syndrome, sleep problems/insomnia, generalized anxiety disorder, obsessive-compulsive disorder, history of separation disorder, and math learning disability. Treatment with citalopram 10mg and melatonin 3mg was initiated; the child also underwent neuropsychological testing with a psychoeducational plan, and psychotherapy with cognitive behavioral therapy. A school reintegration plan was developed in conjunction with her parents.

Education of both the child and parents are required, Dr. Zeltzer said. The child should understand that “the pain is real and biological,” with the pain caused by nerve signals that became “out of balance.” In addition, the medical tests were negative because they did not examine nerve signaling; nerve signals causing the pain can get back in balance “if you help them with some things you can do with your mind and some things with your body,” the child is told.

In turn, parents should help her develop good sleep habits and to learn not to ask the child about pain, because it causes a focus on the pain, contributing to more pain. Also explained is that risk factors exist for why the child developed pain and that treatment will be focused on those treatable factors. Finally, “the mind and body work together to cause pain and a mind-body treatment is the best way to get rid of the pain and increase function,” they are told.