Kids in Pain

Pediatric pain

Research is showing how kids hurt—and how to help. Image credit: syntika82/123RF Stock Photo.

Parents try to protect kids from getting hurt, but unfortunately pain is an inevitable part of growing up. While most kids’ painful experiences are limited to vaccinations, scraped knees and the occasional broken bone, some children suffer from unexplained chronic pain. In addition, prematurely born or sick infants can undergo up to a dozen painful medical procedures and needle pokes per day, with unknown effects on development of the nervous system. The experience of pain in adults is shaped by what happens early in life; childhood pain can sow the seeds for chronic pain in adulthood.

Researchers are increasingly turning their attention to how they can better understand and treat pain in kids in a variety of settings. And they’re finding that, at all ages, parents can play a crucial role in how children face pain.

Historically, pediatric pain has been overlooked and undertreated. Though it seems unimaginable now, as recently as the 1980s infants received surgery without anesthesia. Doctors were justifiably concerned about the dangers of anesthesia—particularly in preterm babies—but there was also a pervading idea that babies did not feel pain, at least not in the same way that adults do, because their brains are not fully developed.

Today, children’s pain is understood to be essentially the same as the pain adults feel: a whole-brain, complex experience that engages thought and emotion along with physical sensation. That said, how kids experience pain depends on their developmental stage and the context of the pain.

The youngest patients
Ruth Grunau, a pediatric pain researcher at the University of British Columbia, Vancouver, Canada, says that anesthesia for surgery and appropriate medications for severe pain have long been standard practice for premature and sick babies. But how they are cared for in the hospital overall has undergone major changes in the last decade or so, with a new emphasis on parents’ involvement in care.

“There has been a huge shift from thinking of a preterm baby as primarily needing assisted breathing, to understanding that human interaction and more developmentally supportive care is really key,” Grunau says.

Each day, prematurely born babies, and babies with illnesses, have to undergo multiple necessary painful medical procedures including needle pokes. Research is showing that these painful procedures pose significant risks for the immature brain at a critical time of development, perhaps affecting the brain’s stress system, a neural and hormonal signaling network that interacts with pain signals. So minimizing pain during these procedures has been a high priority.

About 20 years ago, researchers discovered that a drop of sweet sucrose solution calmed babies and appeared to relieve their pain. The practice of treating babies with sugar water during heel pokes and other painful procedures spread rapidly, and today is common practice in hospitals.

Sucrose became very popular because it works very well to dampen pain behavior. Babies love it,” Grunau says.

The evidence shows that the strategy is effective in reducing babies’ outward signs of pain. But Grunau warns that it may not alleviate the harmful neurophysiological effects of pain—including an adverse impact on the brain’s stress response.

Moreover, she says, the treatment could have unintended consequences. There have been very few studies of the effects of long-term or repeated use of sucrose to quell pain, but one study found that babies who received oral sucrose at least ten times per day during the first week of life were more likely to show poor attention and motor development in the months after leaving the hospital. Metabolism, too, might be altered by repeated sucrose treatment in babies, which add up to a significant dose of sugar.

“From the nutrition research literature, we know that there are big concerns that high sugar early in life is associated with metabolic disease later on, but we have no studies of the long-term effects” of sucrose treatment in infants, according to Grunau.

The good news, she says, is that evidence now shows that hands-on soothing by a parent or another caregiver “is just as effective as sucrose in lowering pain scores, and more effective in improving physiological regulation,” without any risk of side effects.

It doesn’t have to hurt
Soothing may be good treatment for kids of all ages when it comes to acute pain like that caused by needle shots and injuries, says Christine Chambers, a pediatric pain psychologist and researcher at Dalhousie University, Halifax, Canada. A major goal is to avoid poorly managed procedures, which Chambers says can trigger a lifelong fear of needles and even interfere with kids’ getting important vaccinations or proper treatments.

In the worst-case scenario, she says, “a kid may have an exaggerated stress response, and nurses or parents will hold the child down—that ends up being very, very traumatic.”

Instead, parents can use age-appropriate soothing techniques including skin-to-skin contact or breastfeeding for younger children. Adequate preparation can also help.

“Depending on their children’s age, parents should think about how much notice to give kids about a painful procedure. When anxious parents don’t tell kids what’s coming at all, that causes stress and trust issues,” Chambers says.

Parents are understandably searching for guidance in how to help kids weather pain. Although research has provided new clues about the best ways to reduce and treat pain, there can be a gap of up to 17 years before new research reaches the clinic. Chambers is trying to bridge that gap by putting information directly into parents’ hands. With a project called It Doesn’t Have to Hurt, Chambers and others are reaching out to hundreds of thousands of parents across Canada and the globe through social media and other outlets with evidence-based information about what parents can do to help ease kids’ pain. As a four-year-old girl explains in this short video, parents can help by distracting kids from shots with a game or song, taking deep breaths together, and using a topical anesthetic.

In a second, related project in partnership with the Cancer Knowledge Network, called Making Cancer Less Painful for Kids, Chambers and colleagues are aiming to directly inform doctors and parents about evidence-backed tools to alleviate pain associated with cancer, such as medications, distraction and relaxation techniques.

Kids with an adult disease
Chronic pain may seem like an adult problem, but surprisingly the same proportion of kids as adults suffer from chronic pain—about one in five.

“Even within the pain field, people don’t realize that kids have chronic pain at rates comparable to adults,” says Anna Wilson, a pediatric psychologist at Oregon Health and Science University in Portland, US.

The types of pain kids describe varies, she says, with younger kids aged eight to ten often presenting with gastrointestinal pain, and teenagers—particularly girls—more affected by headaches and pelvic pain. When children have chronic pain, it can disrupt school and play, which Wilson calls “the work of childhood.”

“We’ve seen pain get in the way of kids being able to go to school and do physical activities, to just have fun. This can throw social development off track,” she says.

Rachael Coakley, a pain psychologist at Boston Children’s Hospital, US, and author of When Your Child Hurts, also works with kids with chronic pain. When it comes to caring for them, “chronic pain is a whole different ball of wax,” compared to acute pain like a sprained ankle, she says. For example, “the doting, loving, nourishing parenting behaviors, such as giving your child extra treats or special privileges that may be appropriate for acute pain, can end up being counter-productive for kids with chronic pain.”

Kids with chronic pain may miss school, quit sports and activities, and become socially isolated, but the best treatment for them is to stay as active and engaged as possible, Coakley says.

“This may feel counter-intuitive to parents and kids. Asking parents to support their child’s return to school—that’s a tough sell for parents when kids are hurting,” according to Coakley.

She says that the aim is to help families understand that working to stick with kids’ normal routine as much as they possibly can is best for their recovery, “even when it’s painful or hard.”

“Parents are on the front lines,” when it comes to caring for kids with chronic pain, says Wilson. “They have to push kids to go to school, do their physical therapy, and get to their activities. So a big role of psychology in pediatric pain is to support parents so that they can behaviorally and emotionally support their kids.”

While parents might be hesitant to force a reluctant child in pain to be active, Wilson says, research has shown that “when parents are overly protective, it is not helpful for kids. They tend to experience more disability and more pain intensity.”

More than a physical sensation
Pain is a warning signal that alerts us to potential harm in the body, and that’s how we interpret it. But with chronic pain, the sensation persists even when an injury has already healed.

A big part of chronic pain treatment is education, and one facet of that is teaching kids and parents that pain doesn’t always signal ongoing damage in the body. Pain involves the whole brain, and experts now agree that addressing mental health is an important part of treating chronic pain.

“There is so much evidence for the role of psychology in pain management. We want to help families understand that,” says Coakley. “But that doesn’t imply that pain is purely a psychological problem.”

Cognitive-behavioral therapy (CBT) has been shown effective, and Coakley says it should be used to teach specific skills related to pain management.

For example, kids can learn to recognize that negative thoughts, such as “My pain will never end,” actually increase pain intensity, and they can learn to shift toward positive thoughts, like “I know I can make it through this hard day.” Self-regulation skills, biofeedback, and relaxation strategies can also help with the goal of returning to activities like social events, school, and sports.

Treating mental health in kids with chronic pain is a good investment, too, because they are at three times greater risk of future psychological conditions, including anxiety and depression, than their peers without pain. Some research suggests that kids who develop chronic pain have an “anxious temperament,” implying they’re more susceptible to mental health issues to begin with. “But in the context of chronic pain,” Coakley says, “with all the medical evaluation, testing and treatments, kids can develop anxiety or depression, particularly if they are not engaged in their normal activities, are socially isolated, and missing school,” all risk factors for mental illness. “So the risk of mental health difficulties can both preclude pain or develop in response to pain,” Coakley says.

Parents play an influential role in how kids deal with pain at any age, and their own pain can be a big factor. Wilson is currently conducting a study on intergenerational pain, to see what effect a mom’s chronic pain condition has on her kids. “Clearly there is some genetic risk,” she says, but that doesn’t entirely account for the finding that kids with a parent with chronic pain have a higher likelihood of developing chronic pain.

“We want to identify the psychosocial pathways to risk, hopefully to figure out who is most at risk and how to intervene,” she says.

Wilson says there is a lot to learn from kids about chronic pain. “People don’t turn into adults with chronic pain overnight. Patients have often had pain begin when they were much younger, frequently in the teen years. We need to look at chronic pain as a whole-life event.”

Changing the memory of pain
Because painful events early in life have a large impact on the future experience of pain, some researchers are working to understand how pain memories are formed, and how tweaking them might lessen or prevent future pain.

“What we remember about pain in the past is one of the biggest predictors of future pain,” says Melanie Noel, a pediatric pain psychologist at the University of Calgary, Alberta, Canada.

Bad experiences such as a nurse making several attempts at a needle procedure, or—in what Noel calls the worst-case scenario—a panicking child being held down, can create traumatic memories that cause fear and worsen subsequent painful experiences. The good news, she says, is that such memories are not set in stone.

“The malleability, the changeability of the memory—we can harness that,” to reduce future pain.

Kids often don’t accurately remember painful experiences, Noel says, and some people have a tendency to remember things as worse over time. One strategy to help kids make less-scary pain memories is to gently correct them when they exaggerate how bad an experience was. For example, if a child recalled crying for ten minutes, a parent or psychologist might remind them that they actually only cried for two minutes.

“We can help kids through language to see they have control over their pain experience, before helplessness and anxiety can take over,” Noel says.

Three studies hint that employing this strategy might help to dampen future pain-related anxiety. Kids that underwent either a dental procedure, a lumbar puncture (spinal tap), or a vaccine shot had a short chat with a researcher after recovery from the initial procedure. The researcher emphasized positive aspects of the experience, which led kids to form more positive and accurate memories, and reduced their anxiety.

“These studies emphasize how powerful the past is, and how talking about it can reframe your memories,” Noel says. “It’s not about pretending a painful experience was all wonderful and butterflies, but [this approach] can offset the tendency for memories to get worse.”

What can parents do to help reduce the risk of pain in kids? “Basically, talk about it,” says Noel.

The ideal time to look back and talk about a painful experience is later, after the stress of it has passed, she adds. And focusing on negative aspects such as how painful or scary it was should be avoided. Instead, “emphasize anything positive that happened. Maybe someone was helpful and kind. Maybe the child cried, but they calmed down fast.” Anything that helps kids and parents realize that they do have some control over the experience of pain helps set kids up for a better future, says Noel.

Stephani Sutherland, PhD, is a neuroscientist, yogi, and freelance writer in Southern California.