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Management of Chronic Pain in Adolescents and Children

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A special issue of Children (ISSN 2227-9067). This special issue belongs to the section "Pediatric Neurology & Neurodevelopmental Disorders".

Deadline for manuscript submissions: closed (25 November 2022) | Viewed by 35425

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Special Issue Editor

Dr. Laura Papetti

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Department of Neuroscience, Pediatric Headache Center, Bambino Gesù Children Hospital in Rome, Piazza di Sant’Onofrio 4, 00165 Rome, Italy
Interests: headache; paediatric neurology; migraine; pain
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Special Issue Information

Dear Colleagues,

The experience of pain is likely to be distressing for both the child and their family when it is not well understood. Chronic pain conditions in paediatric patients include several disorders such as headache, low back pain, hypermobility, chronic fatigue, abdominal pain, fibromyalgia, and complex regional pain syndrome.

Each of these conditions can be a diagnostic and therapeutic challenge. Recognition of pain conditions and contributing factors to chronic pain is a fundamental point for the management of these patients. A key element in chronic pain management is providing information about pain to patients, their families and their treating physicians, including a biopsychosocial picture and basic concepts of pain neurobiology. There are, however, many questions about how to best share information with young people and their families so that pain-related outcomes are understood and improved. The treatment of chronic pain usually requires a multidisciplinary approach that integrates pharmacological and non-pharmacological strategies. For pharmaceutical treatments, we have little evidence tested in the paediatric age and the use of drugs for pain is very often based on observations and experience on adult patients. Regarding drugs, it is often necessary to combine other approaches such as nutrition, acupuncture, psychological and physical therapy and mind–body strategies (i.e., yoga, biofeedback and mindfulness). In particular, the integration with a rehabilitation approach is very important because for some children with chronic pain, the pain leads to signiﬁcant disability, often resulting in missed school, extracurricular activities, and age-appropriate activities, such as chores and dating. These programs typically include both patients and parents and use a cognitive behavioural therapy model. The focus is primarily on helping the patient return to age-appropriate functioning rather than reducing pain.

The goal of this Special Issue in Children is to highlight recent advances in information provision and preparation in the context of children’s pain management. We welcome reviews and original research considering novel approaches, as well as identifying gaps in knowledge. We also encourage submissions that explore how social and cultural factors, past pain experiences, and individual differences can affect the experience of pain.

I look forward to receiving your contributions.

Dr. Laura Papetti
Guest Editor

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Keywords

Pain
Chronic pain
Headache
Children
Adolescents

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Published Papers (13 papers)

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Research

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14 pages, 299 KiB

Open AccessArticle

Predicting the Need for Transition from Pediatric to Adult Pain Services: A Retrospective, Longitudinal Study Using the Electronic Persistent Pain Outcome Collaboration (ePPOC) Databases

by Joel Champion, Matthew Crawford and Tiina Jaaniste

Children 2023, 10(2), 357; https://doi.org/10.3390/children10020357 - 10 Feb 2023

Cited by 2 | Viewed by 1853

Abstract

A proportion of youth with chronic pain do not respond to interdisciplinary pain management and may require transition to adult pain services. This study sought to characterize a cohort of patients referred to pediatric pain services who subsequently required referral to an adult pain service. We compared this transition group with pediatric patients eligible by age to transition but who did not transition to adult services. We sought to identify factors predicting the need to transition to adult pain services. This retrospective study utilized linkage data from the adult electronic Persistent Pain Outcomes Collaboration (ePPOC) and the pediatric (PaedePPOC) data repositories. The transition group experienced significantly higher pain intensity and disability, lower quality of life, and higher health care utilization relative to the comparison group. Parents of the transition group reported greater distress, catastrophizing, and helplessness relative to parents in the comparison group. Three factors significantly predicted transition: compensation status (OR = 4.21 (1.185–15)), daily anti-inflammatory medication use (OR = 2 (1.028–3.9)), and older age at referral (OR = 1.6 (1.3–2.17)). This study demonstrated that patients referred to pediatric pain services who subsequently need transition to adult services are a uniquely disabled and vulnerable group beyond comparative peers. Clinical applications for transition-specific care are discussed. Full article

(This article belongs to the Special Issue Management of Chronic Pain in Adolescents and Children)

10 pages, 242 KiB

Open AccessArticle

Demographics, Diagnoses, Drugs, and Adjuvants in Patients on Chronic Opioid Therapy vs. Intermittent Use in a Tertiary Pediatric Chronic Pain Clinic

by James A. Tolley, Martha A. Michel and Elisa J. Sarmiento

Children 2023, 10(1), 37; https://doi.org/10.3390/children10010037 - 24 Dec 2022

Viewed by 1888

Abstract

Anywhere from 11.6% to 20% of pediatric and adolescent patients treated for chronic pain are prescribed opioids, but little is known about these patients. The purpose of this study was to determine the characteristics of patients on chronic opioid therapy (COT) and what therapies had been utilized prior to or in conjunction with COT. The study was a retrospective chart review of all chronic pain patients seen during 2020 with those patients on COT separated for analysis. A total of 346 unique patients were seen of which 257 were female (74.3%). The average age was 15.5 years. A total of 48 patients (13.9%) were identified as being on COT with an average age of 18.1 years. Of these, 23 (47.9%) were male which was significantly more than expected. The most common reason for patients to be receiving COT was palliative (13/48), and the second most common was sickle cell anemia (10/48). Patients on COT were significantly more likely to be male, be older, and to be concurrently prescribed benzodiazepines. Concurrent opioid and benzodiazepine therapy is a risk factor for respiratory depression and overdose. Further investigation into the increased proportion of males and benzodiazepine usage in patients on COT is warranted. Full article

(This article belongs to the Special Issue Management of Chronic Pain in Adolescents and Children)

13 pages, 259 KiB

Open AccessArticle

Aligning with Patients and Families: Exploring Youth and Caregiver Openness to Pediatric Headache Interventions

by Allison M. Smith, Zoë J. Schefter and Hannah Rogan

Children 2022, 9(12), 1956; https://doi.org/10.3390/children9121956 - 13 Dec 2022

Cited by 1 | Viewed by 1228

Abstract

Primary headache disorders are common yet underestimated in youth, resulting in functional disability, decreased quality of life, and caregiver burden. Despite the ubiquity of options, adherence remains challenging for families. One potential factor impacting willingness to engage in recommended treatments is openness. This study explored openness to multidisciplinary headache interventions and the relationships with demographic, pain-related, and psychological variables, among youth and their caregivers. Participants (n = 1087) were youth/caregiver dyads presenting for initial headache evaluation. They completed assessments of openness to headache treatments, medical information, functional disability, and pain-related distress. Overall openness was moderately high for youth and caregivers, and highly correlated between them (r = 0.70). Relationships between youth/caregiver openness to specific interventions were moderate–high (r = 0.42–0.73). These were stronger for interventional techniques but weaker for lifestyle changes. In hierarchical regression models predicting youth and caregiver openness, we found that counterpart openness accounted for the largest portion of variance in their own openness (31–32%), beyond demographic (3%), pain-related (10%), and psychological variables (2–3%). Our findings highlight the importance of involving caregivers in pediatric headache management, given their influence on youth openness and potential involvement in adherence. Awareness of youth/caregiver openness may guide clinicians providing recommendations. Full article

(This article belongs to the Special Issue Management of Chronic Pain in Adolescents and Children)

9 pages, 525 KiB

Open AccessArticle

Evaluating Providers’ Prescription Opioid Instructions to Pediatric Patients

by Denise D. Tran, Patrick C. M. Brown, Corrin Murphy, Diana Ho, Karen A. Hudson, Anna C. Wilson and Sarah W. Feldstein Ewing

Children 2022, 9(5), 707; https://doi.org/10.3390/children9050707 - 11 May 2022

Cited by 1 | Viewed by 3250

Abstract

Receiving an opioid prescription during childhood increases the risk of hazardous prescription opioid (PO) use during emerging adulthood. Instruction on how to safely use POs plays an essential role in pediatric patients’ capacity to utilize as well as to discontinue POs appropriately. This study aimed to evaluate pediatric PO label instructions provided to a large sample of pediatric outpatients. Data were extracted from the electronic healthcare records system identifying pediatric patients who received a PO between 2016 and 2019 from pediatric outpatient medical clinics were affiliated with a northwestern United States medical center and children’s hospital. Pediatric patients (n = 12,613) between 0–17 years old who received a PO during outpatient care were included. Patients with chronic health conditions (e.g., cancer) or who received their PO from an inpatient medical setting were excluded. Patient demographics, medication instructions, associated diagnoses, and other prescription information (e.g., name of medication, dose, and quantity dispensed) were examined using automated text classification. Many label instructions did not include any indication/reason for use (20.8%). Virtually none of the POs (>99%) included instructions for how to reduce/wean off POs, contact information for questions about the POs, and/or instructions around how to dispose of the POs. Efforts are needed to ensure that pediatric PO instructions contain essential elements to improve comprehension of when and how to use POs for pediatric patients. Full article

(This article belongs to the Special Issue Management of Chronic Pain in Adolescents and Children)

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14 pages, 1476 KiB

Open AccessArticle

Sensitivity to Pain Traumatization and Its Relationship to the Anxiety–Pain Connection in Youth with Chronic Pain: Implications for Treatment

by Larah Maunder, Maria Pavlova, Jaimie K. Beveridge, Joel Katz, Tim V. Salomons and Melanie Noel

Children 2022, 9(4), 529; https://doi.org/10.3390/children9040529 - 8 Apr 2022

Cited by 2 | Viewed by 2393

Abstract

The bidirectional relationship between anxiety and chronic pain in youth is well-known, but how anxiety contributes to the maintenance of pediatric chronic pain needs to be elucidated. Sensitivity to pain traumatization (SPT), an individual’s propensity to develop responses to pain that resemble a traumatic stress response, may contribute to the mutual maintenance of anxiety and pediatric chronic pain. A clinical sample of youth (aged 10–18 years) with chronic pain completed a measure of SPT at baseline and rated their anxiety and pain characteristics for seven consecutive days at baseline and at three-month follow-up. Multiple linear regression analyses were conducted to model whether SPT moderated the relationship between baseline anxiety and pain intensity, unpleasantness, and interference three months later. SPT significantly moderated the relationship between anxiety and pain intensity. High anxiety youth with high SPT reported increased pain intensity three months later, while high anxiety youth with low SPT did not. High anxiety youth who experience pain as potentially traumatizing are more likely to report higher pain intensity three months later than high-anxiety youth who do not. Future research should examine whether children’s propensity to become traumatized by their pain predicts the development of chronic pain and response to intervention. Full article

(This article belongs to the Special Issue Management of Chronic Pain in Adolescents and Children)

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13 pages, 504 KiB

Open AccessArticle

Exploring the Mechanisms Underlying the Effectiveness of Psychosocial Aftercare in Pediatric Chronic Pain Treatment: A Qualitative Approach

by Meltem Dogan, Almut Hartenstein-Pinter, Susanne Lopez Lumbi, Markus Blankenburg, Michael C. Frühwald, Rosemarie Ahnert, Sarah Braun, Ursula Marschall, Boris Zernikow and Julia Wager

Children 2022, 9(3), 407; https://doi.org/10.3390/children9030407 - 13 Mar 2022

Cited by 2 | Viewed by 2084

Abstract

A newly developed specialized psychosocial aftercare program (PAC) for pediatric patients with chronic pain following an intensive interdisciplinary pain treatment (IIPT) was found to be significantly more effective than IIPT alone. This qualitative study aimed to gain further insight into the mechanisms and prerequisites for the effectiveness of this specialized aftercare program. We conducted structured telephone interviews with patients, parents, and health care professionals conducting PAC. A total of 16 interviews were conducted—seven interviews with parents, six interviews with patients, and three interviews with health care professionals—and transcribed verbatim. Data were analyzed using reflexive thematic analysis. Four major themes consisting of 20 subcategories were identified, namely (1) frame conditions, (2) person factors, (3) stabilization and (4) catalyst. The foundations of treatment success are frame conditions, such as flexibility or constancy, and person factors, such as respect or expertise. Based on these foundations, stabilization is achieved through security, mediation, orientation and support. Altogether, these components of PAC reveal their potential as catalysts for further improvement even after discharge from IIPT. Overall, patients and their families emphasized widespread personal relevance and acceptance of the PAC program. The findings of this study may be employed in the development of other aftercare programs or interventions involving families in the context of psychotherapeutic and psychosocial health care. Full article

(This article belongs to the Special Issue Management of Chronic Pain in Adolescents and Children)

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16 pages, 964 KiB

Open AccessArticle

Exploring the Outcomes That Matter Most to Young People Treated for Chronic Pain: A Qualitative Study

by Rhiannon Joslin, Maggie Donovan-Hall and Lisa Roberts

Children 2021, 8(12), 1170; https://doi.org/10.3390/children8121170 - 10 Dec 2021

Cited by 12 | Viewed by 5603

Abstract

Global and national policies state that all children and young people should be part of decision making and that outcomes that matter to them should take priority, yet patient-centred outcomes have been identified as a gap in the paediatric chronic pain literature. This study gave youths experiencing chronic pain a platform to have their views heard. Using novel methods, twenty-one young people, aged 11 to 18 years old, completed a semi-structured interview in which they constructed a timeline drawing to symbolise their treatment. They identified when aspects of their life changed (outcomes) and described the importance of these changes. Thematic analysis identified four themes that emerged at different stages of the treatment: “perfect storm”; “turning points”; “disconnect”; and; “free”. “Turning points” were points in time when the narrative of the young person took a turn in a different direction. At these points, the outcomes important to them also changed. Youths initially prioritised outcomes related to pain, then during treatment the focus became their emotional functioning, with role functioning and “going out” becoming the focus at the end. The stage of treatment as perceived by the young person impacted which outcomes mattered most. Full article

(This article belongs to the Special Issue Management of Chronic Pain in Adolescents and Children)

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8 pages, 410 KiB

Open AccessArticle

Fifteen-Years Follow-Up in a Cohort of Children with Functional Gastrointestinal Disorders: Prevalence and Risk Factors to Develop Neuropsychiatric Disorders and Other Comorbidities

by Chiara Zanchi, Stefano Pintaldi, Grazia Di Leo, Luca Ronfani, Giulia Zamagni, Marialuisa Viel, Egidio Barbi and Giorgio Cozzi

Children 2021, 8(10), 838; https://doi.org/10.3390/children8100838 - 24 Sep 2021

Cited by 5 | Viewed by 2090

Abstract

Background: Functional gastrointestinal disorders (FGIDs) are chronic and recurrent disorders, which affect up to 23% of children and adolescents and represent 50% of gastroenterological accesses. The association between FGIDs diagnosed at paediatric age and the onset of migraine or headache and neuropsychiatric diseases in adolescence and adulthood is widely reported in the literature. However, there is still limited knowledge about the long-term prognosis and risk factors for neuropsychiatric pathologies and other comorbidities. Aim: The aim is to assess the prevalence and persistence of FGIDs as well as the occurrence of migraine or headache and neuropsychiatric disorders in a cohort of patients diagnosed with FGIDs 15 years ago compared with a control group of peers. Materials and methods: We enrolled a group of patients diagnosed with FGIDs at paediatric age, at least 10 years ago (FGIDs group, n = 79; median age 23), and control subjects (control group, n = 201; median age 23). In both groups, an online questionnaire created explicitly for the study was submitted in order to investigate the presence of chronic intestinal diseases, migraine, headache or neuropsychiatric disorders. Results: 45.6% (36 out of 79) of patients previously diagnosed with FGIDs still suffer from FGIDs versus 12% (24 out of 201) of healthy controls (p < 0.0001). The prevalence of chronic organic gastrointestinal disorders was comparable in the two groups (2.5% in FGIDs group versus 1% in healthy group, p = 0.3). Thirty-three percent (26 out of 79) of FGIDs patients reported headache or migraine versus 13% (26 out of 201) of healthy peers (p < 0.001). No differences were found regarding the prevalence of anxiety and depression. Conclusion: The outcome at 15 years of FGIDs was characterized by a high prevalence of persisting functional symptoms along with a significant incidence of headaches and migraines. Abbreviation: FGIDs: Functional gastrointestinal disorders; IBS: Inflammatory Bowel Syndrome. Full article

(This article belongs to the Special Issue Management of Chronic Pain in Adolescents and Children)

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10 pages, 2744 KiB

Open AccessArticle

Incidence of Acute and Chronic Post-Thoracotomy Pain in Pediatric Patients

by Giuliano Marchetti, Alessandro Vittori, Fabio Ferrari, Elisa Francia, Ilaria Mascilini, Emiliano Petrucci, Simone Piga, Valerio Pardi, Marco Cascella, Giorgia Contini, Franco Marinangeli, Alessandro Inserra and Sergio Giuseppe Picardo

Children 2021, 8(8), 642; https://doi.org/10.3390/children8080642 - 27 Jul 2021

Cited by 11 | Viewed by 2363

Abstract

We studied acute and chronic pain in pediatric patients who underwent thoracotomy for benign disease with a follow-up of at least three months. A telephone interview investigated about the presence of pain and the analgesic therapy in progress. The results were compared with the anesthetic technique, postoperative pain and the adequacy of pain therapy, both during the first week after surgery and at the time of interview. Fifty-six families consented to the study. The mean age of the children at surgery was 2.9 ± 4.5 years, while at the time of the interview was 6.5 ± 4.4 years. We performed different anesthetic strategies: Group A: general anesthesia (36 pts); Group B: general anesthesia and thoracic epidural (10 pts); Group C: general anesthesia and intercostal nerve block (10 pts). During the immediate postoperative period, 21 patients (37.5%) had at least one painful episode. At the time of interview, 3 children (5.3%) had moderate chronic neuropathic (burning) pain on surgical scar. There was no statistically significant difference between the type of anesthesia and the incidence and severity of acute post-operative pain. Despite its limitations, this study confirms the low incidence of chronic post-thoracotomy pain syndrome in children. Full article

(This article belongs to the Special Issue Management of Chronic Pain in Adolescents and Children)

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Review

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8 pages, 1416 KiB

Open AccessEditor’s ChoiceReview

VOSviewer-Based Bibliometric Network Analysis for Evaluating Research on Juvenile Primary Fibromyalgia Syndrome (JPFS)

by Alessandro Vittori, Marco Cascella, Marianna Leonardi, Federica Monaco, Davide Nocerino, Arturo Cuomo, Alessandro Ottaiano, Francesco Perri, Ilaria Mascilini, Elisa Francia, Emiliano Petrucci, Franco Marinangeli and Sergio Giuseppe Picardo

Children 2022, 9(5), 637; https://doi.org/10.3390/children9050637 - 28 Apr 2022

Cited by 22 | Viewed by 3383

Abstract

Background: Juvenile primary fibromyalgia syndrome (JPFS) is a chronic musculoskeletal pain syndrome that affects children and adolescents. Methods: A VOSviewer-based bibliometric network analysis was performed by scanning the global literature on JPFS in the Web of Science (WOS) online database. The search string applied to identify the closest matching articles was “juvenile primary fibromyalgia syndrome (all field)”. Results: A total of 67 articles on JPFS were published from 1985 to March 2022, in the WOS. Regarding article types, 39 were research manuscripts, 16 reviews, 8 meeting abstracts, 2 letters, 1 book chapter, 1 correction, and 1 proceeding paper. The Quartile analysis demonstrated that 44% of papers were published in Q1, 37% in Q2, 8% in Q3, and 11% in Q4. Conclusions: Our analysis highlights that more efforts are warranted to increase the production of quality papers and enhance the connections between the various research groups. JFPS represents a research field still to be explored and which deserves greater investments to obtain quality scientific evidence. Full article

(This article belongs to the Special Issue Management of Chronic Pain in Adolescents and Children)

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Other

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7 pages, 514 KiB

Open AccessCase Report

A Rare Case of Idiopathic Painful Nervus Intermedius Neuropathy in a 13-Year-Old Female: A Case Report and Discussion in the Context of the Literature

by Diego Fernandez-Vial, Linda Sangalli and Cristina Perez

Children 2022, 9(8), 1234; https://doi.org/10.3390/children9081234 - 15 Aug 2022

Viewed by 2485

Abstract

(1) Background: Painful nervus intermedius neuropathy involves continuous or near-continuous pain affecting the distribution of the intermedius nerve(s). The diagnosis of this entity is challenging, particularly when the clinical and demographic features do not resemble the typical presentation of this condition. To the best of our knowledge, only three case reports have described the occurrence of nervus intermedius neuropathy in young patients. (2) Case Description: A 13-year-old female referred to the orofacial pain clinic with a complaint of pain located deep in the right ear and mastoid area. The pain was described as constant, throbbing and dull, with an intensity of 7/10 on numerical rating scale, characterized by superimposed brief paroxysms of severe sharp pain. The past treatments included ineffective pharmacological and irreversible surgical approaches. After a comprehensive evaluation, a diagnosis of idiopathic painful nervus intermedius neuropathy was given, which was successfully managed with the use of gabapentin. (3) Conclusions and Practical Implications: The diagnosis and treatment of neuropathic pain affecting the nervus intermedius can be challenging due to the complex nature of the sensory innervation of the ear. The diagnosis can be even more challenging in cases of atypical clinical and demographic presentations, which in turn may result in unsuccessful, unnecessary, and irreversible treatments. Multidisciplinary teams and constant knowledge update are fundamental to provide good quality of care to our patients and not to overlook any relevant signs or symptoms. Full article

(This article belongs to the Special Issue Management of Chronic Pain in Adolescents and Children)

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9 pages, 1177 KiB

Open AccessViewpoint

A Pragmatic Approach to Assessment of Chronic and Recurrent Pain in Children with Severe Neurologic Impairment

by Simone Benvenuto, Andrea Trombetta and Egidio Barbi

Children 2022, 9(1), 45; https://doi.org/10.3390/children9010045 - 2 Jan 2022

Cited by 3 | Viewed by 1800

Abstract

The term “severe neurologic impairment” (SNI) is used to describe a group of disorders of the central nervous system which arise in childhood, resulting in motor impairment, cognitive impairment and medical complexity. As a result, much assistance is required with activities of daily living. Since these patients are often unable to self-report pain, or they may exhibit uncommon behaviors when suffering, pain manifestations may go unrecognized. In this article, the basic principles of how to approach pain in children with SNI are discussed. Full article

(This article belongs to the Special Issue Management of Chronic Pain in Adolescents and Children)

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6 pages, 850 KiB

Open AccessCase Report

Somatic and Abdominal Acupuncture for Pain Treatment in Adolescent Complex Regional Pain Syndrome (CRPS) of the Upper Limb: A Case Report

by Giuliano Marchetti, Alessandro Vittori, Ilaria Mascilini, Elisa Francia, Antonella Insalaco, Fabrizio De Benedetti and Sergio Giuseppe Picardo

Children 2021, 8(12), 1187; https://doi.org/10.3390/children8121187 - 16 Dec 2021

Viewed by 3027

Abstract

Complex regional pain syndrome (CRPS) is still poorly understood. It is a pain disorder in which pain is disproportionate to the initial stimulus. There is no specific therapy for CRPS, but it can be managed by a combination of treatments. We report a 13-year-old girl with CRPS of the upper limb treated with somatic and abdominal acupuncture. She described a severe, pulsating pain in the left wrist and hand, with hypersensitivity, allodynia, a marked reduction in strength, and swelling and sweating at the level of the fingers. Pain began three months previously, after a trauma to the left wrist. The diagnostic tests performed were negative. At the first visit we recommended oral tramadol. During the first two sessions we used somatic acupuncture. At the third session, the girl reported suffering intolerable pain in the affected limb during the previous sessions, so we decided to use abdominal acupuncture. After 8 sessions of abdominal acupuncture the pain completely disappeared. Acupuncture could be a potential alternative when conservative therapy with physical and medical treatment fails, but more often parents and adolescents prefer this therapy since other comorbidities are often present in pediatric populations and abdominal acupuncture could be a valuable alternative aid. Full article

(This article belongs to the Special Issue Management of Chronic Pain in Adolescents and Children)

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