The Link - July 2026

Chronic pain affects approximately 1 in 5 children and adolescents, with a higher prevalence in girls. The most common types are headache, gastrointestinal and musculoskeletal pain. Chronic pain is often associated with functional impairment, and children with chronic pain are at higher risk for anxiety, depression, social isolation and a lower quality of life.¹ The pain can be nociceptive (due to tissue injury), neuropathic (due to nerve injury), nociplastic (due to a sensitized nervous system), or can have a mixed phenotype.² This article seeks to answer the question of how to initially assess, recognize and manage pain that is chronic or becoming chronic.

Substance use and substance use disorders (SUDs) are frequently underrecognized and associated with significant psychiatric, neurocognitive and social sequelae. According to a 2022 survey of 13-year-olds, 8% reported cannabis use, 17% nicotine use and 23% lifetime alcohol use. Worryingly, earlier initiation is associated with higher rates of psychiatric comorbidity and more rapid progression to SUD.¹ This article aims to emphasize the importance of substance use screening, resources for substance use assessments and prevention, as well as protective support for children and adolescents.

Medical decision-making in pediatrics relies on shared decision-making (SDM) between parents/caregivers and the medical team, and at times the child as well. In most cases, SDM allows all parties to effectively share and understand information, discuss goals and values, and agree to a reasonable plan of care. However, disagreements do arise, and such conflict is becoming a recognized challenge within pediatrics as public mistrust in health care rises.

Parent-clinician disagreements typically take one of two forms. The first type of disagreement occurs when parents decline a recommended intervention. In such cases, there is a widely agreed upon process for resolving the disagreement: the clinician must determine whether the refusal (1) significantly increases the likelihood of imminent serious harm to the patient and, hence, permits state intervention on the child’s behalf¹ or (2) falls within “the zone of parental discretion,” which refers to “the ethically protected space where parents may legitimately make decisions for their children, even if the decisions are sub-optimal for those children (i.e., not absolutely the best for them).”² The second type of disagreement occurs when parents request treatment for their child that is not medically recommended and potentially nonbeneficial. In those cases, the physician must evaluate the benefits and burdens of treatment and balance parental authority with responsible therapeutics, all while acknowledging and seeking to mitigate the risk of bias.

Children with gastrointestinal motility disorders frequently experience years of symptoms before receiving a diagnosis. This is especially true with motility disorders of the esophagus, which often cause varied symptoms in the pediatric population such as vomiting, dysphagia, feeding difficulties, pain and weight loss. These symptoms are often progressive and debilitating.

Diagnostic workup for esophageal dysmotility was historically limited in pediatrics. Endoscopy is helpful to identify structural and mucosal abnormalities; however, it offers limited insight into the gastrointestinal tract function and motility. High-resolution manometry is the gold standard for evaluating esophageal motility, although it has several practical limitations in our young patient population. High-resolution esophageal manometry requires patient cooperation; hence, it is not always feasible in younger patients or those with developmental delays. It is also not readily available in every pediatric gastroenterology practice.

The first hepatitis B vaccine, Heptavax, was plasma-derived and was approved by the Food and Drug Administration (FDA) in 1981. It was used in targeted populations of high-risk individuals, including infants born to infected mothers. In 1986, the FDA approved the first recombinant vaccine, Recombivax HB. This vaccine was derived from yeast and was used for the same high-risk populations. In 1989, a second recombinant vaccine was approved, Engerix-B. Unfortunately, the targeted vaccination strategy did not have an impact on reducing the overall incidence of the disease. Efforts to identify high-risk individuals were further complicated by data that showed 35%-65% of hepatitis B surface antigen (HBsAg) positive mothers had no identifiable high-risk factors. Vertical (mother-to-child) transmission was the most common route of infection. Approximately 90% of babies born to mothers with hepatitis B become infected, and an estimated 25%-40% die prematurely in adulthood due to complications such as cirrhosis or hepatocellular carcinoma.¹ This led the Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP) to recommend the vaccine for all newborns, starting in 1991.