Evidence Based Strategies: Pediatric Chronic Pain Initial Assessment and Management: What Every Pediatric Clinician Should Know

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.

Assessment and Associated Conditions

Pain should be assessed through a combination of pain history provided by both patient and family and the use of a validated pain assessment tool, such as the Numerical Rating Scale or revised Face Legs Activity Cry and Consolability scale. Moreover, factors such as patient satisfaction with their analgesic regimen, observations by family and nursing staff, and physiological parameters should be used to contextualize the pain.³ “Red flag” symptoms must be ruled out, or, if present, trigger further workup and specialist consultation. When pain persists longer than the expected timeframe for healing (or, longer than three months, a commonly used definition), it is deemed chronic, and a more in-depth assessment is required. While this comprehensive assessment is best performed in a pediatric pain clinic, an initial inquiry into the patient’s physical and psychosocial functioning⁴ may warrant expediting a pediatric pain clinic referral. Certain health conditions are frequently seen in patients suffering from chronic pain, such as anxiety and depression,⁵ and it is important to screen for and address these conditions as part of the multidisciplinary treatment approach. Many risk factors are associated with pediatric chronic pain, including psychological disorders, chronic illnesses, sleep disturbances, hypermobility, significant early life pain exposure, adverse childhood experiences, and family dynamics. While this list is not comprehensive, the presence of one or more risk factors should prompt both addressing that risk factor and raising the index of suspicion for coexisting chronic pain.⁶

Initial Management

Evidence-based management of chronic pain is based on the biopsychosocial conceptualization of chronic pain. This model posits that the pain experience is composed of biological factors (e.g., tissue injury, inflammation), psychological factors (e.g., the patient’s conceptualization and thought patterns regarding their pain), and social factors (e.g., food insecurity, trauma) interacting with each other in complex ways to create the pain experience.⁷ All these factors should be addressed for optimal results. While this may not be possible until the patient is established in a pediatric pain clinic, a few core recommendations can and should be made, provided an organic cause of pain has been ruled out. These recommendations focus on increasing daily movement (e.g., Physical Therapy referral, daily aerobic activity), optimizing healthy habits (diet, hydration, exercise, sleep, social connection), and continuing to function (especially going to school) even if modifications need to be made. In addition, careful attention must be paid to how a patient’s pain is discussed. Patients with chronic pain frequently feel ignored or brushed off and can be made to feel “it’s all in their head.” Validating a patient’s pain experience is important, as is pivoting to discussing a concrete action plan to turn things around. Over-the-counter analgesics may be helpful depending on the etiology of the pain and are acceptable insofar as they help improve function.

When to Refer to a Pediatric Pain Clinic or Pain Rehabilitative Program

When functional impairment is present, initial treatments and analgesic regimens are ineffective, or chronic pain is coexisting with or exacerbating mental health conditions, referral to a pediatric pain clinic is indicated. Patients with more severe functional impairments who have failed outpatient management may be good candidates for pain rehabilitation programs such as the Rehabilitation for Amplified Pain Syndrome (RAPS) program at Children’s Mercy.

Resources for Patients

The following resources can help patients and families better understand chronic pain and may increase buy-in to the treatment approach.

YouTube videos

- Tame The Beast – It's time to rethink persistent pain

- The mysterious science of pain – Joshua W. Pate (TED-Ed)

- Elliot Krane: The mystery of chronic pain (TED talk)

Books

- The Chronic Pain & Illness Workbook for Teens by Rachel Zoffness, PhD

- Tell Me Where It Hurts by Rachel Zoffness, PhD

- Conquering Your Child’s Chronic Pain: A Pediatrician’s Guide for Reclaiming a Normal Childhood by Lonnie K. Zeltzer, M.D., and Christina Blackett Schlank

- Zoe and Zak’s Pain Hacks Book Series

Online Resources

- The Comfort Ability program (www.thecomfortability.com)

- Fibroline (app)

- iCanCope with Pain (app)

- Power over Pain Portal for Youth

- WebMAP Mobile (Meg Foundation)

References:

1. Chambers CT, Dol J, Tutelman PR, et al. The prevalence of chronic pain in children and adolescents: a systematic review update and meta-analysis. Pain. 2024;165(10):2215-2234. doi:10.1097/j.pain.0000000000003267
2. Cohen SP, Vase L, Hooten WM. Chronic pain: an update on burden, best practices, and new advances. Lancet. 2021;397(10289):2082-2097. doi:10.1016/S0140-6736(21)00393-7
3. Gai N, Naser B, Hanley J, Peliowski A, Hayes J, Aoyama K. A practical guide to acute pain management in children. J Anesth. 2020;34(3):421-433. doi:10.1007/s00540-020-02767-x
4. Fillingim RB, Loeser JD, Baron R, Edwards RR. Assessment of chronic pain: domains, methods, and mechanisms. J Pain. 2016;17(9 Suppl):T10-20. doi:10.1016/j.jpain.2015.08.010
5. Soltani S, Kopala-Sibley DC, Noel M. The co-occurrence of pediatric chronic pain and depression: a narrative review and conceptualization of mutual maintenance. Clin J Pain. 2019;35(7):633-643. doi:10.1097/AJP.0000000000000723
6. McKillop HN, Banez GA. A broad consideration of risk factors in pediatric chronic pain: where to go from here? Children (Basel). 2016;3(4):38. doi:10.3390/children3040038
7. Nicholas, MK. The biopsychosocial model of pain 40 years on: time for a reappraisal? Pain. 2022;163(S1):S3-S14. doi:10.1097/j.pain.0000000000002654