Examples of childhood problems that can result in pain include arthritis, sickle cell anaemia, cancer, headaches, and burns. These conditions and the treatments for pain associated with them are discussed on this page.
Arthritis pain
Arthritis is commonly thought of as a disease affecting older rather than younger people. However, it is the fifth most common chronic illness in children, affecting about 130 kids out of every 100,000. There are seven different types of JIA. The most common symptoms of arthritis are pain and stiffness in the joints, and fatigue.
There is currently no cure for arthritis. However, between 30% to 50% of children experience a long-lasting remission during which they experience few symptoms. The pain intensity experienced is not always in proportion to the amount of joint damage. Most children with this illness report mild to moderate pain.
Pain management starts with an assessment of the child's condition. Children's pain from arthritis is managed with a variety of strategies. These include medicines such as non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen (Tylenol), psychological coping strategies, and physical therapy. They may also be treated with oral steroids or methotrexate, a medication that has anti-inflammatory properties and can be given orally or by subcutaneous injection. Corticosteroids can also be injected into painful swollen joints. Newer disease-modifying drugs such as etanercept and infliximab are also used. However, these are reserved for severe cases that involve many joints and for children who have not responded to other treatments.
All treatments need ongoing evaluation to assess their effectiveness in reducing pain and other symptoms and improving the child's quality of life.
Sickle cell pain
Children and adults with sickle cell disease suffer from an inherited disorder of the red blood cells. In North America, this condition is most commonly found in people of African descent. In sickle cell disease, the red blood cells contain an abnormal type of haemoglobin that sometimes causes the red blood cells to become sickle-shaped, like a crescent.
These sickle-shaped cells do not pass through small blood vessels as well as normal round red blood cells. This can reduce or block the blood supply to tissues in many different parts of the body. When the oxygen carried inside the red blood cells cannot get to the tissues, the result is a painful "vaso-occlusive" crisis.
An animation showing how sickle cells stick together and block blood flow.
These painful episodes can begin as early as six months of age. Each episode may last from a few hours to several days. If the pain is severe and not controlled with simple pain medicines, the child may require hospitalization to help manage the pain. Children tend to have shorter episodes of pain than adults. The factors or triggers that may cause the changes in the red blood cells include:
- infection
- lack of oxygen
- dehydration
- fatigue
- strenuous exercise
- exposure to cold
- stress
The type of pain experienced by your child due to sickle cell disease may include both acute (short-lived) and chronic (long-standing) pain. Caring for your child will start with assessing the pain and then deciding on a plan to manage it. As with other types of pain, treatment may focus on:
- medicines for pain relief
- physical therapies such as heat
- psychological therapies, for example, distraction or deep breathing
Although applying cold, such as an ice pack, to the affected area can work for some types of pain, it is not a good idea to use it for sickle cell pain. Indeed, it can worsen the pain.
Specific management of sickle cell pain may include ensuring that your child is drinking enough fluids. If the pain is mild, children may need only simple pain medicines such as acetaminophen or ibuprofen.
Children with this disorder may experience many episodes of pain throughout their lives. This means that it is important that you and your child learn how to manage the pain. If sickle cell pain is not successfully managed at home with a combination of pain-relieving medicines and physical and psychological strategies, then your child may need to come to the hospital for assessment and help. If the pain is severe and difficult to control with oral medicines at home, your child may need to receive pain medicines through an intravenous line at the hospital. This is usually inserted in the back of your child's hand. The medicines used for severe pain caused by sickle cell disease include opioids such as morphine.
Cancer-related pain
Cancer-related pain can be caused by the cancer itself or by the treatment of cancer. Pain from the cancer itself usually improves following treatment. Whether the pain comes from the cancer or from its treatment, your child will be assessed and a plan of care developed. The plan will include medicines, physical therapies, and psychological treatments.
Medicines prescribed for cancer-related pain may include mild, moderate, and severe pain control medicines. The pain medicines that are recommended depend on the severity of your child's pain. Children who are receiving chemotherapy may not be given acetaminophen (Tylenol) because it may hide a fever, which is a warning sign of infection in your child. Your child also may not be able to use NSAIDs such as ibuprofen because these drugs can interfere with the blood clotting system, which may already be affected by chemotherapy. Strong opioid pain medicines such as morphine are very helpful for moderate to severe pain.
Cancer treatment-related pain
Treatment related pain may arise from chemotherapy, radiotherapy, or surgery. Procedural pain may occur during investigations and treatments for the cancer. If your child has surgery they may have some pain afterwards. If this type of pain is frequent and severe, some changes may be made to your child's care. Your child may continue to receive strong pain medicines until the cancer causing their pain is fully treated. As the pain lessens, the doses of the pain medicines will be decreased.
During the course of treatment, your child may undergo procedures that cause pain. These may include lumbar puncture or bone marrow aspiration. Every effort will be made to minimize the pain of these procedures using medicines and psychological and physical therapies. Your child may be given medicine for pain relief or to help them relax. Depending on the procedure, a local anaesthetic may be used to freeze the area. Sometimes children will receive conscious or deep sedation for these procedures. There will also be some procedures, such as putting and intravenous line and giving medications by needle, that will cause your child some discomfort. Often, local anesthetic applied on the skin is used to reduce this procedural pain.
There are also psychological treatments that may be very helpful, through which your child can learn to control their pain. Deep breathing and imagery are among the suggested techniques that may help during the treatment. Progressive muscle relaxation may be useful prior to the procedure to reduce stress and anxiety.
While every effort will be made to make the procedure as pain-free as possible, it is important not to promise your child that "it will not hurt" or that "everything will be okay." Researchers have found that the best approach is to be honest with your child and to remain calm. They should be encouraged to develop strategies that will allow them to take control of their situation.
Mucositis
Some chemotherapy causes inflammation of the cells that protect the lining of the mouth, throat, stomach, intestines, and rectal areas. This is called mucositis. It can cause moderate to severe pain that may interfere with eating, talking, and swallowing. The treatments for this condition include mouthwashes, antiviral drugs, and strong pain-relief medicines such as morphine. These strong pain medicines are usually administered through a continuous intravenous infusion or patient-controlled analgesia (PCA).
Headaches
Most children have an occasional headache. In a Canadian survey of children's pain experiences, 85% of children aged between five and seven years had experienced a headache. This proportion increased to 100% for adolescents aged 14 to 16 years. Many had a headache within the last month. Children typically described headache as lasting a few hours and rated the pain intensity at six out of 10. Up to 40% of children and adolescents reported that recurring headaches are a major cause of suffering and disability.
Tension-type headache and migraine are the most commonly reported type of headache. Tension-type headaches cause a dull, diffuse, and persistent pain that may last for hours, days, months, or even years. Migraine headaches create a throbbing more localized pain and are often accompanied by nausea, vomiting, and sensitivity to light and sound. Such episodes usually last several hours. Most children who have headaches experience a mixed pattern of tension-type and migraine headaches.
Other types of headache include:
- chronic daily headache
- cluster headache
- basilar artery migraine
- epilepsy equivalent
- sinus headache
It is important that your child be assessed comprehensively by a health-care professional. Typically, several environmental or situational factors contribute to the development of headache, but these factors may vary for different children. An assessment will help to reveal which factors are important for your child. Stress is a common trigger. Particular sources of stress include a child's inability to resolve problems with school, social relationships, sports, or family situations. There is little evidence that foods, weather conditions, and activities are common triggers for headache in children.
Burns
Burn and scald injuries are common in children, especially under the age of four years. Typically, it is a scald caused by hot liquids rather than burns caused by fire that cause the injury. Very young children are at risk because of their curious nature and stage of development. Burns and scalds mostly occur in the home, especially in kitchens and bathrooms. They cause injury to the skin and the layers underneath and can be very painful.
Burns can be life-threatening and should not be underestimated. If your child is admitted to an emergency department with a severe burn, the focus may initially be on life saving rather than pain relief. Once the life-threatening injuries are dealt with, more focus can be placed on pain management.
Pain intensity is affected primarily by burn thickness, and secondarily by the size of the burn. Deep burns, also called full-thickness or third-degree burns, penetrate through to the nerve endings. Deep burns destroy nerve endings which prevent the nerves from transmitting pain messages to the brain and are therefore less painful than superficial burns. However, children rarely receive only a third-degree burn. Usually they will have mixed-thickness burns and may have severe pain as a result. The pain from burns is often described as burning, aching, or an intermittent sharp pain.
Burn pain may get more severe over time from repeated dressing changes, physiotherapy, and procedures such as skin grafting. Procedural pain and breakthrough pain may be an issue in addition to the background pain. This is especially so after dressing changes and exercise. Some children may experience neuropathic pain that involves burning, tingling, numbness, or shooting pain. Children and their parents may also experience a form of post-traumatic stress disorder (PTSD) following the burn injury. Symptoms associated with PTSD include nightmares, memory impairment, and a "flat affect" involving a numbing of emotions. These symptoms may hinder pain assessment and treatment.
Pain management begins with a careful assessment of the child's condition. A child recovering from a burn may require strong opioid medicine to help relieve the constant pain. This will involve continuous dosing through an intravenous infusion or regular oral medication. Additionally, prior to burn dressing changes, children may receive pain and sedation medicines to help prevent pain and distress associated with these procedures. Some children may need general anaesthesia in the operating room during extensive dressing changes or treatments.
Psychological strategies can be very helpful in reducing anxiety and procedural pain associated with a burn. Parents or a health-care professional can encourage, and be involved with, the use of such strategies. See the "Psychological Treatments for Pain Management" link above. Many hospitals have staff you can approach to help you with these types of pain relief strategies.
Along with pain, children can experience a distressing itch as the burn heals. Some antihistamine medicines may be helpful in these cases, and again psychological strategies may be used to help to distract or relax the child. Ongoing chronic pain is not common in children who have recovered from a burn injury.