More Than a Band-Aid: Diagnosing & Treating Pediatric Pain

AUGUST 17, 2012
Virginia Bartok, RPh

When it comes to pediatric pain, the patient's anxiety and immature communication skills can make pain more challenging to diagnose and treat. Pharmacists can help children and their parents understand the causes and severity of pain as well as navigate the options for alleviating it.

Childhood is perceived to be a carefree time for fun and games, but it is a high-risk time for pain. Children experience musculoskeletal pain from injuries such as falls, bicycle crashes, cuts, and burns. They also experience numerous painful minor illnesses such as ear infections and headaches. In fact, children are less likely than adults to be adequately medicated for pain, so they may experience more pain than adults.1,2

Part of the problem is that most clinicians poorly understand children’s pain. Clinicians may fear adverse events more than they should; have legal concerns about unlikely abuse and diversion; or believe parents when they say, “Ah! He’s making it up!”—but in truth, the child is in pain. A lingering myth is that children, especially young children, do not experience pain like adults do. Researchers have debunked this myth; at around 30 weeks’ gestation, a fetus can recognize pain signals, and his or her cerebral cortex will organize and direct systemic physiologic changes. From before birth, children can feel pain and suffer as a result.1,3

Since treating pain depends on patients’ability to communicate, which is subjective, young children’s limited communication skills can restrict their ability to report or describe pain. Children’s pain is also influenced by their past pain experiences—which is especially important when the child has chronic pain—as well as their current coping skills. A child who has been subjected to a painful procedure will fear other necessary procedures.3,4

Additionally, many pharmacists have also observed firsthand how a parent’s panicky, anxious reaction to a child’s pain induces subsequent anxiety in the child, creating a vicious cycle of pain, anxiety— and more pain for the child. Helping parents calm down can remove some anxiety from the mix. The best way to do this is to remain calm and reassuring for both the parents and the child. If necessary, pull the parent aside and ask them to use a quieter, more confident tone for the child.4-6

Where Does It Hurt?

Mainly due to a heightened awareness of pain and its appropriate treatment after a campaign by The Joint Commission, pain now accompanies temperature, pulse, blood pressure, and respiratory rate as a fifth vital sign (VS). 5 Unlike the other 4 VSs, no exact measuring tool exists for pain. Clinicians can choose from a good selection of pain assessment tools to help determine the location and magnitude of a child’s pain (Table 1). To be used effectively, clinicians need to understand which tool is best based on the child’s developmental level, the context of the pain experience, and the child’s prior experiences.

The pain scales used for adults (“Rate your pain on a scale of 1 to 10, where 1 is no pain and 10 is the worst pain imaginable…”) are too sophisticated for most children because they lack the numerical reasoning, cognitive ability, or magnitude estimation/seriation skills required to use a numeric scale. Children up to 12 years of age will think dichotomously, focusing on the scales’ extremes, so they’ll report either no pain or severe pain using an adult scale.8,9

In the youngest of children, caregivers can assess pain by examining the child’s nonverbal communication—for example, ear-tugging in the case of otitis media or crying and flailing and screaming when the child has severe postoperative pain. It is always useful to compare parental, caregiver, and medical staff assessments of the child’s pain. By age 4, many children are able to use pain scales that use simple cartoon faces depicting how they might feel. With better language skills, children are more able to use words to express their pain’s quality and intensity in greater detail. Scales that use specific words as anchors (eg, “Is the pain more sharp or dull?”; “Constant or shooting?”), however, may still significantly influence an adolescent’s pain ratings.8,9

Children of all ages will develop and use their own unique behavioral and cognitive coping strategies to manage their pain. For younger children, these strategies will be simple, like avoiding the activity that causes the pain. As children age, they start to assert control. They may hide pain if they think it will interfere with something they want to do, or they may use self-distraction methods. A clinician may interpret a quiet, unruffled adolescent as being pain free, but the adolescent may in fact be suffering silently. As adults, the child’s report of the pain should be considered the gold standard of his/her pain measure; if a patient reports pain, the patient has pain.5-7 In all children, regardless of age, clinicians should assume children have pain if they have medical conditions and/or procedures that are typically painful.4

Treatment for Common Types of Pain

In children, the general principles of pain management apply:
  • Anticipate and prevent pain
  • Adequately assess pain
  • Use multi-modal approach
    • Involve the entire health care team
    • Involve parents and patients
    • Use psychology, physiotherapy, and pharmacology
  • Follow the World Health Organization’s Pain Relief Ladder, using agents approved for children
    • Start with 1 drug
    • Schedule doses around the clock if pain is moderate to severe or will persist
    • Add additional doses or another drug for breakthrough or unresponsive pain
    • Anticipate and manage drug side effects, especially when opioids are prescribed
Treating pain in children, just like in adults, will depend on the causative factor(s). Acute pain lasts only a few days, and often can be treated with PRN medication. Four types of chronic pain are most common in children: headaches, abdominal pain, chest pain, and limb pain. Parents and children will need to have analgesics ready in the event the pain recurs.

Headaches are the most common pediatric pain syndrome, and once more malignant conditions are ruled out, the primary causes are tension and migraine. After puberty, tension headaches are more common. Migraines are more likely to occur in girls with a family history, and in 70% of cases, they will also have abdominal pain. For about 13% of adolescents, migraines will continue to be a problem into adulthood.10

Abdominal pain with no apparent organic cause is also common, occurring in up to 10% of children.11 It is more likely to develop in girls and its incidence peaks in middle school. Occurring on average 3 times monthly, these episodes can limit activity, cause or be caused by school avoidance (when a child fears school, he or she may develop abdominal pain), and may be accompanied by somatic complaints such as headache or fatigue.

Often, family stress contributes to this problem, but pediatricians will need to rule out appendicitis, constipation, Giardia infection, gastroesophageal reflux disease, lactose intolerance, and abdominal migraine.11 Table 2 lists key interventions for medical conditions that cause abdominal pain. Children who have abdominal pain due to psychological distress will need help from a mental health specialist. For them, the most important treatment is reassurance that they are not “crazy” or imagining the pain.

Recurrent chest pain is most common in children older than 10 years, and is often caused by costochondritis (inflammation at the junction of a rib and its cartilage) trauma, or musculoskeletal pain. Children rarely experience chest pain of cardiac origin.7

“Growing pains,” although they may sound imaginary, are real. They can cause limb pain in children aged 2 to 12 years, as can stress fractures. Growing pains are a benign condition, and usually need no treatment. If they persist, nonopioid analgesics can help. Stress fracture requires medical attention, rest, and an analgesic.12,13

Drug Selection and Dosing

Some special considerations apply to children. Clinicians should use the least invasive routes possible. Oral dosing is less traumatic than intravenous administration, and intramuscular dosing should be avoided whenever possible.5 In most cases of mild pain, a non-opioid analgesic (acetaminophen, ibuprofen, naproxen, or ketorolac) will provide relief. In moderate to severe pain where opioids are needed, pharmacists should work with the health care team to anticipate and manage side effects (especially constipation, but also respiratory depression, nausea or vomiting, pruritis, and urinary retention).

Nonpharmacologic Intervention

Children, like adults, can benefit from simple interventions. Relaxation can help, which can take many forms, eg, a parent reading a book, a favorite cartoon, or a gentle massage. Applying heat or ice to the painful area can relieve some pain. Exercise as tolerated is also appropriate. Alternative therapies and massage, when used with the treatment team’s knowledge, can also be helpful.

Some children will need help to develop coping strategies, especially if the pain becomes chronic. In this case, the goal of treatment is not total elimination of pain, but teaching the child coping strategies so he or she can be more active and perhaps resume normal activities.6


Treating pain successfully in children requires trust between all involved parties. Many kids who have recurrent pain have been led to believe it’s all in their heads due to well-intended advice by friends and family and conflicting advice from professionals. Clinicians need good communication skills, especially the ability to empathize and listen. Pain is very scary for children, and can become an indelible memory—past pain will influence and shape future pain. Pharmacists should note that children can have pain, describe or react to it, and help choose the therapies that they think or know will help.

This article gives an overview of pediatric pain, and pharmacists should consult specialty texts for specific types of pain (eg, sickle cell, cancer, osteopathic). Treatment guidelines for critically ill children, procedure-related pain, headaches, and emergencies are available at current_guidelines.php#pediatricpain.

Ms. Bartok is a medical writer who lives in eastern Connecticut.

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11. Vlieger AM, Benninga MA. Chronic abdominal pain including functional abdominal pain, irritable bowel disease, and abdominal migraine. In: Kleinman, et al. (eds.): Walker’s Pediatric Gastrointestinal Disease: Physiology, Diagnosis, Management. 5th edition. PMPH-USA. 2008: 715–28.
12. Pavone V, Lionetti E, Gargano V, Evola FR, Costarella L, Sessa G. Growing pains: A study of 30 cases and a review of the literature. J Pediatr Orthop. 2011;31:606-9.
13. Harel L. Growing pains: Myth or reality. Pediatr Endocrinol Rev. 2010;8:76-8.

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