i. A Primer in Paediatric Pain Management ii. Providing a Specialist Service

Sachin RastogiConsultant in Pain Medicine and Anaesthesia, RVI October 2014

Contents

• Introduction to Paediatric (chronic) pain

• 2 case vignettes

• Specialist commissioning guidelines

Myths that have complicated the management of pain in children

• Infants have immature nervous systems and do not feel pain

• Untreated acute pain has no long-term adverse effects

• Children are at a higher risk of drug addiction when they receive opioids for pain control

• Health professionals cannot accurately measure pain in children

• Children do not suffer from chronic pain

Development of pain systems

• The pain systems develop and function by 23rd week of gestation

• The ‘loudest’ part of pain networks (A-∂ fibres) develops first

• The descending mechanisms to modulate that pain appear last

How does children’s pain experience differ from those of adults?

• Children’s nociceptive system has increased plasticity

• Their pain perception depends on developmental level and previous pain experiences

• They report stronger pain for stimuli that evoke moderate tissue damage in comparison to adults

Chronic Pain in Children - Significance

• An estimated 25% of children and adolescents suffer with recurrent or chronic pain, 5-8% develop pain-related disability, girls > boys

• Impact on all aspects of child’s life – mood, sleep, school attendance, grades, participation in sports, socialisation

• Often under recognized and undertreated by clinicians

Chronic pain conditions in children

• Headache• Abdominal pain• Musculoskeletal pain• Complex regional pain syndrome• Phantom limb pain • Cancer pain • Sickle cell pain• Cerebral palsy related pain• Chronic post-surgical pain

Biopsychosocial model of Pain

Nociception

Pain

Suffering

PainBehaviour

Management

• No single discipline has the expertise to assess and manage chronic pain independently

• Flexible, child-centred programme

• Multidisciplinary team: 3P approach Pharmacology / Physical / Psychological

• “Embarrassing lack of data” (Ecclestone, BMJ 2003)

• Controlled trials are urgently needed

Case #1: History

• 10 year old female• Left ankle pain• Fall playing with dog 3

months ago• Swelling, no #• On crutches• Protective of foot

• Pain– Sharp– ‘knife-like’– Tingling– Sensitive+++– Score 10/10– Worse with movement /

touch– No alleviating factors

Backstory• Mood – hopeless, tearful• Sleep – keeps foot in a box at

night• School – intelligent, high

achieving, bullying• FH – mental illness in family

(ADHD, depression)

• Meds – NSAIDs, paracetamol unhelpful

• Beliefs - Accused of ‘faking it’ by teachers and pupils

Examination• Mildly swollen, red left ankle

• Temperature L=22.5, R=34.5oC

• Severe allodynia, exam aborted due to extreme distress after light touch

• Diagnosis?CRPS Type 1

• Neuropathic pain

• Treatment–Gabapentin 300mg tds–Physio: desensitisation and strength–Psych: to address stress and fear avoidance

Follow up : 2 months later

• Pain score 0/10• Physical function: active, karate, running• Mood: happy, positive

• Gabapentin weaned, no F/U

Case #2:“MY LEGS DON’T WORK”

14 year old female

Presenting complaint

• Lower back pain / spasm• Lower limb paralysis• ‘Piercing’ pain lower back• 7-10/10• Acute onset overnight• No trigger

Past medical history

• Right lung agenesis• Dextrocardia• Scoliosis fusion 2001• Back brace worn till 2011• Back pain ‘all life’

• Examination– Afebrile– Normal upper limbs– No movement proximal

legs, knees, ankles, only toes

– No light touch to waist– Normal proprioception,

vibration, reflexes to lower limbs

• Investigations– Bloods– MRI lower back– SSEPs– EMG– NCS

• Services involved– Paeds / Ortho / Neuro /

APS / Chronic pain / Neurosurg / Psych

Yellow flags

• IVF baby, only child• Born 32 weeks ECS• NICU 1 month• Over solicitous parents• Separation anxiety• No friends at school• Bullying

• Health anxiety• Fear avoidance• Hurt=harm beliefs• Seeking ‘medical or surgical’

answer / diagnosis

• Diagnosis?

– Idiopathic acute onset paraplegia– Mechanical lower back pain compounded by

significant anxiety and fear avoidance– Medically unexplained pain / symptoms– Conversion disorder

Management

• Simple analgesics• Daily physio – very slow progress• Refused psych meds• Required intensive daily physio / psych• Pain management programme for children• Bath

Paediatric Chronic Pain- Management and referral from Primary Care in North West England

Anaesthesia 2012 67(S1): 36

Chronic pain services for children

• Gold standard: interdisciplinary team comprising:– Physician– Physical therapist– Psychologist– Specialist nurse– (Occupational therapist)