Chronic pain in children should be viewed as more than just a biomedical disease, according to the new World Health Organization (WHO) guidelines.1 Instead, the selection of appropriate pain treatments should include a holistic view of the patient and biopsychosocial factors such as the child’s age, social environment and cultural background 2
Range of pain in children
“Chronic pain in children is a major public health problem worldwide and a leading cause of morbidity in children that negatively impacts their emotional, physical and social development and function,” the guideline authors write. “The lives of families and carers are also seriously affected.”
Managing chronic pain in adults can be challenging. Treating pain in children adds complexity – especially given the current lack of quality research studies that focus on treatment interventions and management approaches. Within the small portion of the published literature, study populations vary according to age, sample size, and definition of pain, and data from low and middle income countries are largely lacking.
The studies currently available suggest that between a quarter and a third of children have chronic pain. Approximately 1 in 20 children will have moderate to severe pain and pain-related disabilities. Data on adolescent pain, including headache, back, abdominal, musculoskeletal, and multisite pain indicate significant variability in prevalence.
“Early exposure to chronic pain can affect the incidence, severity, and duration of chronic pain and be associated with long-term, maladaptive neurological changes,” the guideline authors wrote, citing imaging studies in children with acute pain that suggests pointed out that chronic pain may be associated with changes in the structure, function and chemistry of the nervous system “which correlate with subsequent cognitive, behavioral and somatosensory outcomes”.
Goals and obstacles
The aim of the WHO guidelines is to provide evidence-based recommendations for the management of chronic pain in pediatric patients. They were developed through a systematic review of currently available evidence on the benefit, harm, feasibility, and acceptance of recommendations, as well as equity and resource considerations.
“There are a number of barriers to adequate access to pain management strategies … for vulnerable populations such as children,” the authors wrote. “These barriers include the focus of the medical community and policy makers on life extension and productivity, opiophobia (prejudice and misinformation about the appropriate medical use of opioids), limited global awareness of non-communicable diseases, lack of knowledge on the part of the world Healthcare Professionals and Concerns About Non-Medical Use of Controlled Substances. “
According to the WHO, these guidelines are intended for children between the ages of 0 and 19 who require primary or secondary chronic pain treatment. Particular attention is paid to physical, psychological and pharmacological pain relief measures.
The Guideline Development Group has outlined three basic principles that serve as best practice statements and “guide all aspects of caring for children with chronic pain”. These basic principles can be summarized as follows:
- Access to pain management is a basic human right
- Children have the right to enjoy the highest possible standard of health
- Health care providers should ensure that children, families and carers are aware of their rights to self-determination, non-discrimination, confidentiality and adequate and accessible health services
Recommended course of action
The Guideline Development Group also produced 10 best practice statements on the clinical treatment of chronic pain in children. These statements apply to all aspects of clinical care, including the planning, implementation, and implementation of physical, psychological, and pharmacological interventions. These statements are summarized below:
- Children and their families and / or carers must be cared for from a bio-psychosocial point of view. Pain shouldn’t be treated just as a biomedical problem.
- A comprehensive bio-psychosocial assessment is essential for pain management and planning. Healthcare providers should use age, context and culturally appropriate tools to monitor pain intensity and the impact on quality of life.
- Children must undergo a thorough evaluation of all underlying conditions and receive treatment for those conditions as well as appropriate pain management. Comorbidities that affect social and emotional wellbeing require simultaneous management.
- Children with chronic pain should be assessed by health care providers who have knowledge and experience in the assessment, diagnosis, and management of chronic pain.
- Whatever the methodology, management should be tailored to the child’s health, taking into account the underlying conditions, developmental skills, and social and emotional needs.
- Care for children with chronic pain should be child- and family-oriented. That is, it should be tailored and organized around the health needs, preferences and expectations of the child and their family. Be tailored to the values, cultural preferences and resources of each family; and encourage active involvement of the whole family in childcare.
- Families need timely and accurate information. Joint decision-making and clear communication are essential for good clinical care. Patient-centered communication should be tailored to the patient’s cognitive, developmental and language skills.
- Patients and their families should receive comprehensive and inclusive care. Cognitive, emotional, and physical health, as well as educational, cultural, and social needs and goals should be included in the care management plan.
- An interdisciplinary, multimodal approach should be chosen and tailored to the needs and wishes of the child as well as the family and caregivers.
- In addition to families and carers, policy makers, program managers and health care providers need to consider opioid stewardship to ensure the “rational and prudent” use of opioids. Opioids should only be used for appropriate indications and prescribed by trained providers with a clear plan for continuation, tapering, or withdrawal.
Recommendations and their reasons
The guideline creation process involved a systematic review of studies across the three types of intervention (physical, psychosocial and pharmacological). Quantitative data were reviewed for all areas and used to provide guidelines for the management of chronic pain in children. These recommendations are summarized below.
Recommendation 1. Children with chronic pain can be treated with physiotherapy either alone or in combination with other treatments. This recommendation is conditional and based on evidence with very little certainty.
Recommendation 2. (A) Psychological management through cognitive behavioral therapy and related interventions – such as acceptance and engagement, behavioral and relaxation therapy – can be applied. (B) Psychological therapy can be delivered either face-to-face or remotely, or via a combined approach. These recommendations are conditional and based on evidence with moderate certainty.
Recommendation 3. Appropriate pharmacological management tailored to specific indications and conditions may be used to treat this patient population. This recommendation is conditional and based on low certainty evidence.
Recommendation 4. (A) Under the principles of opioid stewardship, appropriate pharmacological management may include the use of morphine for end-of-life treatment. (B) Children with chronic pain from life-limiting conditions (e.g., illnesses for which there is no cure and for which early death is expected) can also receive morphine, which is distributed by appropriately trained health care providers. These recommendations are conditional on evidence with very little certainty.
Eye on the future
Research gaps were also identified by the Guideline Development Group. Addressing these gaps in future studies will help provide future evidence-based guidelines for direct decision-making. Areas for future studies include large multicenter studies examining individual and multimodal therapies in variable settings, analysis of children’s responses to interventions at different stages of treatment or disease at the individual level, reporting on characteristics of the study population, the catalog of validated ones Pain assessment tools and a standardized set of patient- and family-centered outcomes. Long-term follow-up data are also needed.
“The WHO steering group will continue to monitor research developments in the treatment of chronic pain in children, particularly in interventions where the evidence level has been found to be low or very low,” the study’s authors wrote.
“Treating pain requires a broad, multimodal and interdisciplinary approach that addresses its physical, psychosocial and social dimensions,” they concluded. “Children, including adolescents, have the right to adequate treatments … for the management of pain, and policy makers and providers must ensure adequate access to treatment strategies while minimizing the potential harms of inappropriate use in society.”
- World health organization. Guidelines for the Management of Chronic Pain in Children. December 22, 2020. Accessed March 30, 2021.
- Kühn BM. New WHO guideline for the management of chronic pain in children. JAMA. 2021; 325 (11): 1031. doi: 10.1001 / jama.2021.2976.
This article originally appeared on Clinical Pain Advisor