How should chronic pain in children be approached?

There is limited research on the effectiveness of pharmacotherapy in treating in children with chronic pain. So what is the best approach and how can pharmacists help?

Approximately 25% of children and adolescents will experience chronic pain at some time during their childhood or adolescence, with around 5% describing this pain as debilitating. While pharmacotherapy is often the first-line treatment option in chronic pain in adults, a recent systematic review and meta-analysis found that there is little evidence for its efficacy and safety in children with chronic non-cancer pain (CNCP).¹

The authors of the review paper indicated that this is partially due to the lack of clinical trials in children with chronic pain. There are ethical considerations to withholding medications from children experiencing pain, however analgesics are often prescribed to children with CNCP or chronic cancer-related pain (CCRP) – relying on evidence from adult-based studies.

Researchers analysed reviews from the Cochrane Database of Systematic Reviews, Medline, EMBASE and DARE up until March 2018. In total 23 systematic reviews investigating children with CNCP and CCRP were included for analysis. Of the seven reviews included, six trials involved children with CNCP; there were no randomised controlled trials relating to the reduction of CCRP. Although there is a lack of evidence, the authors acknowledged that children with CNCP or CCRP should not be denied potential pain relief.¹

The authors suggested that there is a need to establish national or transnational registries focusing on analgesic medicines specific to patients with chronic pain to better capture benefits, harms and harm reduction. Furthermore, they recognise that barriers to evidence production in childhood chronic pain need to be better understood and that clinical trials, including alternative randomised controlled trial methods, need to be better integrated into routine clinical care.¹

Pain management in practice

Debbie Rigby, Consultant Clinical Pharmacist and Chair of the NPS MedicineWise Board Audit and Risk Committee, said that when faced with a lack of evidence, pharmacists should consult the best available evidence such as Australian Medicines Handbook Children’s Dosing Companion and the Therapeutic Guidelines.

Ms Rigby conceded that it can be difficult to ethically and morally conduct randomised controlled trials in children and that there are challenges in terms of the relatively high placebo effect when treating CNCP (30–50% in adults).

Pharmacist and pain expert Joyce McSwan said that because of the high potency of medicines, the exposure rate in children tends to be relatively low. Conducting an evidence trial in itself is also difficult in terms of subject selection.

‘We don’t yet know the pharmacodynamics [of all medicines in] …children – how they are going to react to medications or whether their genetic make-up has an impact,’ Ms McSwan said. ‘Because you have a very tender subject, it makes it hard to collect that sort of information.’

In terms of treatment, Ms McSwan said that – particularly in children – a non-pharmacological approach is firstline. 

‘Of course this is not to deny pharmacological management, either with opioids or simple analgesics, if necessary – but reducing the use of opioids is optimum. Simple analgesics are the frontline pharmacological treatment for chronic pain in children.’

Advice for pharmacists

Children who experience chronic pain need specialist help, Ms McSwan said. 

‘They need to enter pain programs specifically designed for children. It’s not something I think primary healthcare can treat very well. Intensive allied health support via public or private hospital care is really important here.’ 

These programs are under-resourced, however, with only 12 services available across Australia. 

Ms McSwan said pharmacists should be aware there are specialist services at the Royal Children’s Hospital (RCH) in Melbourne or SKiP programs (support kids in chronic pain) – started by a paediatric pain specialist – which run holiday education camp programs for young chronic pain sufferers. Online resources such as Pain, Pain, Go Away: Helping Children With Pain can also help.

If pharmacists see that patients are using too much simple analgesia, taking antihistamines to sleep or being prescribed pain medicine copiously, they should identify why, she said.

The pharmacist and mother

Ruth Parker is a pharmacist who is also the mother of a daughter with chronic pain and knows firsthand the struggles faced by children and parents alike. 

‘My daughter has CRPS (complex regional pain syndrome). She had a fracture when she was four, she’s now 11. The manifestations of the CRPS didn’t actually come out until about three years after the injury. Her foot changed colour, the sensation of hot and cold was skewed, and it was painful even to the lightest touch.’

When the symptoms appeared, Ms Parker sought clinical care. 

‘We saw the children’s hospital and they diagnosed her with CRPS. Initially she began treatment on gabapentin as a trial which I wasn’t that comfortable with, not knowing how she would react, as children don’t react in the same way as adults to medication. 

‘I was interested in other methods for treating the pain, so with the help of an occupational therapist (OT) and physiotherapist, we used mirror box therapy. There’s a lot of psychosocial elements associated with pain, particularly in children where it often comes about through an emotional state.’

Ms Parker said they relied more on psychological rather than pharmacological treatment to treat her daughter’s pain. 

‘She only stayed on gabapentin for a short period of time before we realised it wasn’t really changing her condition and she responded best to behavioural therapy. 

‘We also tried a technique called craniosacral therapy (CST), an osteopathy technique that gently manipulates the central nervous system, which helps to settle the trauma and the child to relax.’

In terms of pharmacist advice to patients, Ms Parker said that validation is key. If the child is showing behavioural signs of being in pain, it’s important for parents to validate, but not catastrophise, the pain – which could actually set off the child.

She said that pharmacological treatment should be offered where appropriate, but it’s important to let parents know that there are many other options available. 

Collaborative pain groups in hospitals such as the RCH incorporate a psychiatrist, psychologist an OT and physiotherapist. 

‘They all sit down and consult with you on the same day, gather all the information and formulate the best strategy,’ Ms Parker said. ‘It’s best to refer complex patients onto pain clinics that specialise in paediatrics.’

Discussing the benefits of behavioral therapy for children is also key. Children are the perfect candidates for this method of treatment, Ms Parker said, as they learn faster and are more open to new experiences than adults, whose belief system can be a limitation.

‘Encourage parents to be compassionate to both themselves and the child, because it can be quite a terrifying situation,’ she said.  

‘While my daughter is not going through pain now, we are acutely aware that when she does, it can go from 1–10 very quickly unless we go back through the techniques that we’ve learned.’

References

1. Eccleston C et al. Pharmacological interventions for chronic pain in children: an overview of systematic reviews. The Journal of the International Association for the Study of Pain. June 2019. At: https://journals.lww.com/pain/Abstract/publishahead/Pharmacological_interventions_for_chronic_pain_in.98682.aspx