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Cincinnati Children's answers questions for patients and families about Pediatric Pain Management:
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. Chronic pain can become a complicated medical, psychological and social problem that can also be difficult to control and need special expertise. For those situations, a pediatric pain clinic can provide more comprehensive pain care.
Pediatric pain clinics have healthcare workers with special training and experience in managing pain in children and young adults. Children differ from adults in many ways. They are not mature yet. They have a more limited understanding of life and why things happen. Their bodies are still growing. Medications may have different effects. And pediatric pain problems often have different prognoses and patterns than similar problems in adults.
A clinic designed for children has specialists in physical therapy, nursing, behavioral medicine and pain medicine that can take these differences into account when treating children with pain. The term “inter-disciplinary” is often used to describe this team of experts, and is an important factor to consider 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 inter-disciplinary pain program in 2007.
If your child is coming to the hospital with a painful problem, or has pain that is difficult to control while in the hospital, you can ask your child’s doctor about calling the Medical Pain Service for assistance.
If your child has an ongoing or long-term pain problem, ask your pediatrician about referring him 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 use that information to help our diagnosis and treatment planning. If your doctor cannot send information ahead of your visit, please bring it with you. 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 child’s primary care physician on the best possible way to help your child.
All of our staff is available to answer questions. Our administrative assistant 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. Our pain management nurses, however, are the people you are most likely to speak with. They are specially trained and have years of experience working with children and families in the pain clinic. They can help you adjust medications, monitor side effects, answer general questions about pain conditions and advise you about making changes in your child’s treatment plan.
Nerve blocks and other injections are sometimes used as a part of a pain treatment plan. Nerve blocks to treat chronic pain are typically done less frequently in children than adults for three reasons:
Pain is not just physical. It causes stress and suffering, and depression and anxiety can result from pain or make it worse. All of our patients have at least an evaluation by our pain psychologist when they first come to the clinic to determine if treatments such as biofeedback, relaxation training, coping skills training or psychotherapy may help with pain management.
The entire family is affected by this stress, and addressing this issue is important to your child’s recovery. Often pain does not go away quickly, and coping skills training can help the entire family manage until the pain resolves.
In addition, there are pathways in the brain and spinal cord whose job it is to suppress pain. Our psychologists can help your child harness these neurologic defenses to reduce and manage his pain.
Pain affects the way the body functions. Whether they know it or not, children may change the way they walk, sit, use their legs or arms, or hold their head due to pain. 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. In fact, there are some severe pain conditions that seem to improve because of physical therapy as much as through other therapies.
A TENS unit that you may use is conducted under the supervision of our physical therapist. Keep in mind 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 to get long-term benefits.
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.
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 addicted to these medications is extraordinarily small.
People of any age can become tolerant to opioid medications. They may need more and more to get the same effect, and 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 agreement” when these medicines are prescribed through the pain clinic . We strictly enforce the rules, and perform urine drug screening to promote safe use and problems are rare.
Methadone is a long-acting opioid medication similar to morphine. Because it does not cause a “high” and is long acting, it is used in drug clinics to keep former users off of heroin.
In our pain practice, methadone is a useful medication because it works well for pain, lasts a long time, comes as a liquid (for those who cannot take pills), and has special properties as a pain medicine that other opioids do not. It often has fewer side effects for patients who have had problems with other medications. We also often use methadone to help prevent withdrawal symptoms in patients who are discontinuing opioid medications after taking them for a long time.
An interesting feature of 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 types of pain act a bit like seizures, where nerves fire at inappropriate times and in inappropriate ways.
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 the patient’s mood. They do have side effects, and we monitor their use carefully.
Complex Regional Pain Syndrome (CRPS) is a rare type of neuropathic (relating to nerves) pain that can be severe. Although it can be miserable, most children recover from it. It is most common in active female adolescents (athletes, dancers) from high-achievement oriented families. It tends to occur in the lower legs and feet, and usually does not progress to the 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.
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 become 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.
A PCA is a computerized pump that can be set to deliver a specific amount of medication when your child pushes a button. Children as young as 7 years old can use PCAs effectively. For younger children, parents or nurses can help push the button to relieve pain.
Safety settings limit 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; pressing the button while a patient is asleep is dangerous (no matter how old the patient is) and we prohibit it in 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.