5 questions: Krane on children's pain
Whether it's a skinned knee or a split chin, parents hate to see their children in pain. But while some tears can be stopped with Band-Aids and kisses, more severe instances can require medical intervention. Elliot Krane, MD, the head of the Department of Anesthesia at Lucile Packard Children's Hospital, recently published a book for parents called Relieve Your Child's Chronic Pain: A Doctor's Program for Easing Headaches, Abdominal Pain, Fibromyalgia, Juvenile Rheumatoid Arthritis, and More. Krista Conger, a writer for Medical Center Report, talked with Krane, who is also a professor of anesthesia and pediatrics, about the ins and outs of chronic pain.
1. It seems that we've been hearing about pain in children more often lately. Is chronic pain becoming more common in children?
Krane: Many more children are surviving or living longer with once-fatal diseases such as childhood cancers or cystic fibrosis. Because these diseases are frequently associated with pain, the number of children with chronic pain is indeed increasing. But these patients account for a very small percentage of children with chronic pain. Most children have problems that are no more common now than decades ago, such as reflex sympathetic dystrophy, migraine headaches, chronic abdominal pain or arthritis.
2. So what's the difference between chronic and acute pain?
Krane: Acute pain occurs when there is an injury of some sort — such as that caused by surgery, trauma or infection, for example—to an organ or to tissue in the body. Generally, the pain persists until healing occurs, then stops. Chronic pain persists for three months or more, and has two main causes: a nervous system abnormality that occurs in response to tissue damage that has since healed, and ongoing tissue damage arising from a chronic disease such as cancer or an inappropriate autoimmune response.
Many people are surprised to learn how common chronic pain is in our society, and still more surprised to learn how prevalent it is in children. One study found that about one-quarter of all children have some type of chronic pain: 19.5 percent of boys and 30.4 percent of girls. About 8 percent of children experience "very frequent and more intense pain," such as frequent and intense abdominal pain or headaches.
3. Do children experience pain differently than adults?
Krane: Children do experience pain differently than adults, partly because of their still-developing brains and partly because they have fewer life experiences on which to draw to put the pain into context. They are also likely to have a greater fear of strangers, including health professionals.
Untreated or inadequately treated pain takes a severe toll on an individual, both physiologically and psychologically. Whether early painful experiences result in developmental changes is a subject of active research. We know that a painful experience as simple and short-lived as neonatal circumcision produces behavioral changes that persist for six months or more and that these changes are mitigated when adequate analgesia and anesthesia are used during the procedure. We also know that brain imaging shows brain shrinkage in adults with chronic pain when compared to normal adults.
Therefore we can intuitively conclude that chronic pain would have a profound effect on a child's developing brain and personality, although more specific information on children is lacking at this time.
4. How can parents and health professionals help a child with chronic pain?
Krane: It is important for parents to remember that pain is a subjective experience. Although it is impossible to measure or objectively quantify, children rarely concoct reports of pain. Therefore, pain is what the child says it is. It is also very important for parents not to discount the mind-body connection; the way that the brain interprets pain signals from the body can either amplify or modulate the pain experienced by children. Conversely, it is important to realize the negative impact that pain can have on a child's emotional health.
There are many treatments for chronic pain. Generally, pharmacologic treatment revolves around the use of conventional analgesics such as acetaminophen, steroidal and non-steroidal anti-inflammatory drugs, local anesthetics for nerve blocks and opioid medications such as codeine and morphine.
It's also becoming clear that non-conventional analgesics such as anti-epileptic drugs, antidepressant drugs, antiarrhythmic drugs and some antihypertensive drugs can also be useful. There are also a wide variety of very effective non-pharmacologic techniques that should always be included in the therapeutic "package": acupuncture, hypnosis, mental imagery, biofeedback, massage and physical therapy, to name a few.
I believe it is almost always impossible to adequately treat pain pharmacologically while ignoring the mental health of the child.
5. Do you run into doctors who expect the child (and their family) to just tough it out?
Krane: Mo st pediatricians are more than capable of recognizing chronic pain and accepting parents' and children's reports of pain. Few are trained to treat the condition.
I have seen many physicians, unaware of the many effective and safe treatment options available, under-treat pain. Others who have tried everything they can think of may attribute the pain to a psychiatric disorder or to malingering.
Fortunately, many physicians who have been unsuccessful in treating their patient's chronic pain will refer them to pain specialists. Treating a child in pain is very stressful, but fortunately we have techniques and tools that work, and the personal reward of helping a child overcome pain is immense.