Parent / Caregiver Frequent Questions
Who should treat pain in children?
Most common painful conditions of childhood have been and should continue to be managed by pediatricians and family practitioners. Occasionally, a child will develop a pain that does not resolve with time or simple interventions. The pain that results from cancer or other complicated medical problems can also be difficult to control and need special expertise. For those times, a pediatric pain clinic can provide more comprehensive pain care.
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What is a pediatric pain clinic?
Pediatric pain clinics are places that have health care workers who have special training and experience in taking care of pain in children. Children differ from adults in many ways. They are not mature yet. They have a more limited understanding of life and why things happen the way they do. Their bodies are still growing.
Medications may have different effects on them. Lastly, pediatric pain problems often have different prognoses and patterns than the similar ones in adults.
A clinic designed for children has specialists in physical therapy, nursing, behavioral medicine and pain medicine that can take all of these differences into account when treating children with pain. The term “multi-disciplinary” is often used to describe this team of experts, and is an important criterion to look for when selecting a pain treatment clinic for your child. We were honored to receive the Clinical Center of Excellence from the American Pain Society for our multi-disciplinary pain program in 2007.
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How can I have my child seen by the Pain Team?
If your child is coming to the hospital for an operation, or has a painful problem while in the hospital, ask your medical doctor or surgeon about calling the Pain Service for assistance. Many times, we will automatically see you and your child before a major operation, so that we can set up the best plan for comfort from the very beginning.
If your child has an ongoing or long-term pain problem, ask your pediatrician about referring him or her to the Pain Clinic at Cincinnati Children's. You can help us help your child by asking your doctor to send information about X-rays and lab tests to us ahead of time. We can then see the information and use it to help our diagnosis and treatment planning. If your doctor cannot send information ahead of your visit, then bringing it with you is also very helpful. If you live far away, feel free to contact us for help in finding a pain clinic closer to you. If there is no clinic near to you, we will work with you and your local doctor on the best possible way to help your child.
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Who can I ask questions when my child is being treated in the pain clinic?
All of our staff are available to answer questions. Our advance practice nurses, however, are the people you will speak with the most. They are specially trained and have years of experience working with children and families regarding pain problems. They can help you adjust medications, monitor side effects, answer general questions about a pain condition and advise you about making changes in the treatment plan.
Our secretary will usually be the first person you speak with, and will refer you to the proper team member. She will take care of most of your scheduling and medical record keeping needs.
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Are nerve blocks used for pediatric pain problems?
Sometimes nerve blocks can help diagnose the cause of a pain and sometimes they can relieve the pain. For some pain conditions, epidurals can allow the child to undergo physical therapy that they would not otherwise be able to tolerate. We use nerve blocks most often to help control pain after surgery.
Nerve blocks to treat chronic pain generally are done less frequently in children than adults for three reasons:
- Nerve blocks should never be the only approach to pain, even in adults.
- Nerve blocks only help in selected types of pain and for specific purposes.
- Most children require sedation or general anesthesia due to fear of needles and an inability to hold still (movement during some blocks could cause severe complications).
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Why is a psychologist involved?
Pain is not just physical. It causes stress and it causes suffering. Depression and anxiety can result from pain or make it worse.
The family is always involved in the stress and suffering, because of the love the family has for its children. Taking care of these issues is very important. Often pain does not go away quickly, and coping skills training helps the child and the family to go on with life until the pain resolves.
Finally, there are pathways in the brain and spinal cord whose job it is to suppress pain. There are several ways the psychologist can help the child harness these neurologic defenses to actually feel less pain.
Treatments that are available include biofeedback, relaxation training, coping skills training and psychotherapy. All of our patients have at least an evaluation by our pain psychologist when they first come to clinic.
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Why is a physical therapist involved?
Pain affects the way the body functions. Whether they know it or not, people may change the way they walk, sit, use their legs or arms, or hold their head. They may simply become "out of shape."
Our physical therapist is an expert in assessing these changes and designing a course of therapy to optimize the body's function. There are actually severe pain conditions that seem to improve because of physical therapy as much as everything else put together!
The TENS unit that you may use also is done under the supervision of our physical therapist. One thing to know is that the increase in activity that may be recommended often briefly increases the pain before it helps.
We can help with this, but it is to be expected and you will need to help your child stick with the program in order to get the long-term benefits from it.
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What is a TENS unit?
TENS stands for Transcutaneous Electrical Nerve Stimulation. It is a pain-relief device that uses two small patches that stick to the skin, providing a tapping or tingly sensation to the painful area. The nervous system handles sensation on a "first-come, first-serve" basis. The sensation provided by the TENS unit travels faster than pain sensations and helps the spinal cord block out the pain.
The TENS device can be worn under clothing for use at work or school, and it is very safe. TENS units are provided by our physical therapist, with a prescription from the doctor.
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Can children become addicted to pain medications?
We use opioid (narcotic) pain medicines for certain pain conditions, especially after surgery and for patients with cancer pain. The number of children who become addicts is extraordinarily small.
Most people of any age will become tolerant to opioid medications. They may need more and more to get the same effect; they may say "this medicine doesn't work for me any more."
They may have withdrawal if they stop the medicine suddenly (withdrawal can be avoided by following a medication schedule provided by the pain service). This is a physical phenomenon that happens to almost everyone and is different from addiction.
As a matter of policy, though, we do have patients and parents sign a "controlled substances contract" when these medicines are prescribed through the pain clinic for non-cancer pain and enforce the rules strictly, but problems are rare.
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Isn't methadone for drug abusers?
Methadone is a long-acting opioid medication that is the same strength as morphine. Because it does not cause a "high" and because it is long acting, it is used in drug clinics to keep former users off of heroin.
In our pain practice, it is a very useful medication because it works well for pain, lasts a long time, comes as a liquid (for those who can not take pills), and has special properties as a pain medicine that other opioids do not. It often has fewer side effects for those patients who have had problems with other medications.
Lastly, we often use methadone to help prevent withdrawal symptoms in patients who are discontinuing opioid medications after taking them for a long time.
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Why are medications used to treat seizures and depression used to treat pain?
An interesting thing about pain is that many of the same chemicals the body uses to transmit or block pain signals are the same as those that seem to be out of balance when a person becomes depressed. Other sorts of pain act a bit like seizures, where nerves fire at times and in ways that are inappropriate.
Antidepressants and anticonvulsants have been shown to help many different pain conditions. They also help with sleep (which is often disturbed by pain) and have a helpful effect on mood. They do have side effects (like almost everything), and we monitor their use carefully, including obtaining electrocardiograms and blood tests, depending on the medication.
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What is Complex Regional Pain Syndrome (formerly Reflex Sympathetic Dystrophy [RSD])?
Complex Regional Pain Syndrome (CRPS) is a type of neuropathic (relating to nerves) pain that is infrequent in adults and children, and can be very severe.
There are several differences in pediatric CRPS from that in adults. Most children recover from it. It is most common in active (athletes, dancers) female adolescents of high-achievement oriented families. It tends to occur in the lower legs and feet and usually does not progress to the "crippled up," withered appearance that can occur in adults with the syndrome.
CRPS in children appears to respond well to aggressive physical therapy, medication and behavioral medicine. Sometimes nerve blocks are used to interrupt the pain cycle or to allow physical therapy to be done if it is otherwise too painful.
We stress that the information available on the Internet is predominantly related to adults and often paints a picture that does not apply to children with this pain syndrome.
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What causes pelvic pain?
Pelvic pain is more common in adolescent girls than once thought. Often endometriosis is the cause. Endometriosis is a condition in which the clusters of cells that usually form the lining of the uterus come to be lodged in the pelvis and abdomen and cause pain.
Other causes of pain include menstrual cramps, ovarian cysts, venereal diseases, pelvic floor dysfunction and adhesions from surgery. Sometimes extensive testing reveals no obvious cause.
Treatment involves medications (often including oral contraceptive pills), TENS, physical therapy, behavioral medicine and other non-traditional treatments such has acupuncture.
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What causes recurrent abdominal pain?
Pain is assumed to be a natural part of having cancer; it is one reason why cancer is so feared as a disease. In addition, many of the treatments and tests for cancer are painful.
Fortunately, we have many things to offer for controlling cancer pain, as well as the pain and fear that result from the tests and treatments. We believed very strongly that cancer pain should be brought under control to the greatest degree possible for all children, regardless of the prognosis.
We established the Pediatric Palliative and Comfort Care Team (PACT) to provide consistent, compassionate and up-to-date pain and symptom management for our cancer patients. We use a combination of medications, behavioral medicine techniques to reduce stress, and nerve blocks to relieve cancer-related pain. We have the training and experience to utilize advanced procedures and the latest innovations to relieve cancer pain that does not respond to conservative measures.
For patients having the common, but painful tests (such as bone marrow aspirations), we have a Procedural Management service. We provide sedation and anesthesia for patients when they have these procedures. In partnership with the Cancer and Blood Diseases Institute we established a procedure room and recovery room right in the Hematology-Oncology clinic, so the children feel comfortable in their surroundings, and recognize the friendly faces of their clinic nurses when they wake from anesthesia.
We make ourselves available around the clock to all our cancer pain patients and are involved in the StarShine Hospice program for children based here at the Cincinnati Children's Hospital Medical Center.
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What can be done for cancer pain in children?
Pain is assumed to be a natural part of having cancer; it is one reason why cancer is so feared as a disease. In addition, many of the treatments and tests for cancer are painful.
Fortunately, we have many things to offer for controlling cancer pain, as well as the pain and fear that result from the tests and treatments. We believed very strongly that cancer pain should be brought under control to the greatest degree possible for all children, regardless of the prognosis.
We use a combination of medications, behavioral medicine techniques to reduce stress, and nerve blocks to relieve cancer-related pain.
We have the training and experience to utilize advanced procedures and the latest innovations to relieve cancer pain that does not respond to conservative measures.
We make ourselves available around the clock to all our cancer pain patients and are involved in the StarShine Hospice program for children based here at the Cincinnati Children's Hospital Medical Center.
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What can be done for the pain of surgery in children?
Children hurt after surgery. That seems so obvious, but for a long time, children received much less pain control after surgery than adults did. We have an active acute pain service to advocate for the children who need special pain care.
We use epidural catheters (see below) for a wide range of operations, both in the operating room and afterwards. Epidurals can be used from the day a child is born up through adulthood. Peripheral nerve blocks and catheters (see below) are another way to provide pain relief for certain operations. For children age 7 and up, Patient Controlled Analgesia (PCA) pumps can be very effective (see below).
For children who are either too young to use a PCA or are handicapped and cannot use a PCA, we will sometimes teach parents to use the PCA pump, although this is done on a case-by-case basis.
Treatment of pain goes beyond the traditional, morphine-type medications. Medicines such as anti-seizure drugs, anti-depressants, anti-inflammatory medications can all be helpful for pain. Music therapy, physical therapy, psychological treatments can all be helpful to children going through the experience of a big operation.
Even with the latest advances on medicine and technology, we cannot promise that there will be no pain after surgery. We do promise to do our best to keep the pain to the least possible amount. We also look after side effects and have safety guidelines that are used throughout the hospital for the patients on our service.
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What is a PCA (Patient-Controlled Analgesia) pump?
PCAs are computerized pumps that can be set to deliver a specific amount of medication when a button is pushed by a patient. Children as young as 4 years old have used PCAs effectively, although generally we only offer it to children over the age of 7.
Safety settings include limits on how often the pump will deliver the medication, how much is given at a time, and how much can be given over a four-hour period. Several medications can be used this way. Only the patient is allowed to press the button, so that if they become too sleepy, they fall asleep and do not press the button.
Pressing the button while a patient is asleep is a dangerous thing to do (no matter how old the patient is) and we prohibit that, a policy we strictly enforce.
In specific cases, we may allow a parent or nurse to use the button on behalf of the child. Because this carries extra risk, we reserve the right to limit who receives this treatment. We will discuss the options with you, and decide if your child is a candidate for this treatment. While we are named the Pain Service, our primary focus is safety, and all decisions are based on what is the safest way to care for your child.
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What is an epidural?
Most people know of epidural analgesia as a way to keep women comfortable during childbirth. The epidural is a length of thin tubing that is placed in a space between the bones of the spine and the spinal cord. Medications can be given as an infusion to keep people comfortable after surgery.
Children are generally quite afraid of needles and would move during catheter placement (which could be dangerous), so we place the catheter while the child is asleep under general anesthesia. Abdominal, chest, hip and leg surgery are the types of surgery most appropriate for an epidural. Epidurals can be used from the first day of life through adulthood. An epidural can be left to work for up to a week after surgery, if needed. We will check on the catheter every day. If there is any suspicion of infection or other problem, we will remove the cathether. Again, safety is our bottom line.
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What is a peripheral nerve block?
Peripheral nerve blocks are a way to give local anesthesia to a specific nerve. We use a needle to inject the numbing medicine close to a nerve, using either an electronic stimulation device or ultrasound to guide the proper placement of the needle. This allows the medicine to work only on one set of nerves, so a small area of the body is numbed. This way, a patient can be comfortable, without some of the side effects of numbness in a bigger area. The numbness usually lasts for 4-18 hours.
The advantage of these blocks is that a person needs less of the other types of pain medicine, and so can be comfortable without so much sleepiness, nausea or other side effects. Sometimes, the increase in blood flow can be helpful to healing in some surgeries.
One thing to be aware of with peripheral nerve blocks is that when they wear off, one needs to be very alert to giving the fist dose of prescribed pain medicine, so that pain does not get out of control. Also, patients and families have to be aware that the area of the body will be very numb, and to protect it from things that could do damage because the person will not feel something that would otherwise hurt (for instance, leaning of a radiator and getting burned without knowing it). Most of the time, nerve blocks are used for surgery on the hand, foot, arm, leg shoulder or hip, but there are many types of blocks for other surgeries as well.
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What is a peripheral nerve catheter?
Peripheral nerve catheters are very similar to peripheral nerve blocks, but instead, we place a thin tubing right next to the nerve. The catheter can be left in place for up to three days, providing continuous comfort. Extensive surgery on the arm or leg, or surgeries requiring skin or muscle grafting are common reasons for this technique to be used.
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